Classification of nosebleeds

Currently, the most common classification is that of I.A. Kurilin and A.N. Vlasyuk, which is based on the pathophysiological principle. Considering that this classification was proposed in 1979, a number of its provisions are outdated, so some adjustments were made to it taking into account the achievements of modern hematology. However, at present, no matter what classifications are considered in terms of the etiological causes of nosebleeds, they all have their advantages and disadvantages.

• Nosebleeds caused by changes (disturbances) in the vascular system of the nasal cavity.
  • Injuries.
  • Dystrophic changes in the mucous membrane of the nasal cavity.
  • Deviated nasal septum.
  • Anomalies in the development of the vascular system of the nasal cavity.
  • Neoplasms in the nasal cavity and paranasal sinuses (bleeding polyp of the septum, angiomas, angiofibromas).
• Nosebleeds as a manifestation of disorders of the blood coagulation system.
  • Decreased activity of plasma factors of the blood coagulation system:
    • violation of the 1st phase of coagulation (hemophilia A, B, C);
    • violation of the 2nd phase of coagulation (dysprothrombia);
    • disruption of phase 3 coagulation (afibrinogenemia or hypofibrinemia, dysfibrinogenemia or production of abnormal fibrinogen);
  • Decreased activity of platelet factors of the blood coagulation system - thrombocytopathy;
  • Increased activity of the blood anticoagulant system:
    • increased concentration of circulating direct anticoagulant (heparin);
    • increase in the concentration of indirect anticoagulants;
  • Hyperfibrinolytic conditions.
• Nosebleeds caused by the combined effect of changes (disturbances) in the vascular system of the nasal cavity and the coagulation properties of the blood;
  • Dystrophic lesions of the endothelium or endothelial dysfunction in atherosclerosis, arterial hypertension, etc.
  • Hemorrhagic diathesis:
    • immune (in typhoid, sepsis, scarlet fever, measles, malaria, brucellosis, influenza, parainfluenza, adenoviral diseases, etc.) and autoimmune vasculitis (both primary diseases and manifestations of systemic autoimmune pathological processes);
    • neurovegetative and endocrine vasopathies (juvenile; senile; associated with menstrual irregularities, with the use of glucocorticoids);
    • hypovitaminosis C and P;
    • immune and autoimmune thrombocytopathy;
    • von Willebrand disease;
    • hemorrhagic angiomatosis (Rendu Osler disease),
  • Chronic liver diseases:
    • hepatitis;
    • cirrhosis;
  • Chronic inflammatory diseases of the nose and paranasal sinuses:
    • purulent rhinosinusitis;
    • allergic rhinosinusopathy.
  • Blood diseases (acute and chronic hemoblastoses - leukemia; polycythemia; aplastic and megaloblastic anemia; lymphoproliferative diseases; acute radiation sickness).

Nosebleeds are also classified according to the location of their source.

• Nosebleeds from the vessels of the nasal cavity.
  • From the anterior parts of the nasal cavity.
  • From the posterior parts of the nasal cavity:
    • the source of bleeding is located above the middle nasal concha;
    • the source of bleeding is located below the middle nasal concha.
• Nosebleeds from vessels located outside the nasal cavity.
  • Bleeding from the paranasal sinuses, nasopharynx.
  • Bleeding from intracranial vessels:
    • from intracarotid aneurysm of the internal carotid artery;
    • from the vessels of the dura mater in case of a fracture of the cribriform plate.

The division of nosebleeds by the localization of their sources into anterior and posterior is explained by the difference in tactical approaches to these forms. In anterior nosebleeds, the bleeding vessel is usually located in the Kiesselbach zone. The diagnosis of posterior nosebleed is made in this case if it is impossible to determine its source during anterior rhinoscopy, if the bleeding cannot be stopped by anterior tamponade, or the patient experiences blood flowing into the pharynx without anterior nosebleeds,

When the source of bleeding is detected, its location in relation to the middle turbinate should be determined, especially in the case of post-traumatic nosebleeds. If the source of bleeding is above the middle turbinate, then the cause of bleeding is most likely damage to the ethmoid arteries, which belong to the internal carotid artery system. The location of the bleeding vessel below the middle turbinate indicates damage to the branches of the internal maxillary artery.

The source of bleeding may be located outside the nasal cavity, for example in the paranasal sinuses, nasopharynx, and also in the cranial cavity. Blood may flow from the nose in the case of esophageal, gastric, and pulmonary bleeding, which should be differentiated from nasal bleeding. The bleeding vessel may be located in the cranial cavity, as is the case with ruptures of posttraumatic and non-traumatic (infectious) intracavernous aneurysms of the internal carotid artery, and with fractures of the ethmoid plate.

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