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Probability diagnosis

Idiopathic: spontaneous from Little’s area

URTI: common cold/flu/sinusitis

Rhinitis: allergic and atrophic


Trauma (incl. nose picking, nose injury)

Drugs (e.g. anticoagulants, aspirin)

Serious disorders not to be missed


  • hypertension and arteriosclerosis


  • systemic febrile illness (e.g. malaria)



  • tumours of nose/sinuses/nasopharynx

  • intracranial tumours

  • leukaemia


  • thrombocytopenia

  • coagulopathy (e.g. haemophilia, liver disease)

Pitfalls (often missed)

Exposure to toxic agents

Vitamin deficiencies: C and K

Septal granulomas and perforations

Foreign bodies (esp. in children)

Cocaine abuse


  • hereditary haemorrhagic telangiectasia

Masquerades checklist

Drugs: anticoagulants, aspirin, nasal sprays Anaemia: aplastic anaemia

Key history

Recent trauma to nose. Significant past history (e.g. hypertension). Drug and alcohol history (e.g. anticoagulants). Bleeding or bruising tendency.

Key examination

  • Nasal airways and sinuses

  • Skin for evidence of purpura or ecchymoses

  • Lymph node areas and abdomen for hepatosplenomegaly

  • Vital signs (esp. blood pressure)

Key investigations

Probably none. Consider:

  • FBE

  • clotting studies

  • sinus X-ray

  • INR

  • CT scan (occasionally).

Diagnostic tips

  • Recent onset of persistent bleeding in elderly points to carcinoma.

  • Severe epistaxis is often caused by liver disease coagulopathy.

  • Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.

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