Overview
Epistaxis (Nosebleed)
1. Clinical Overview
Summary
Epistaxis (Nosebleed) is bleeding from the nasal cavity, a very common condition affecting up to 60% of the population at some point. Most cases are Anterior Epistaxis (~90%), originating from Kiesselbach's Plexus (Little's Area) on the anterior nasal septum, and are easily managed with First Aid (Pinching, Leaning forward, Ice) and Cautery or Packing if needed. Posterior Epistaxis (~10%) is less common but more serious, originating from the Woodruff's Plexus (Posterior lateral nasal wall, Sphenopalatine artery territory) and is more common in Elderly, Hypertensive, and Anticoagulated patients. It may require Posterior Packing, Endoscopic Sphenopalatine Artery Ligation (ESPAL), or Interventional Radiology (Embolisation). Key causes include Trauma, Nose Picking, Dry Air, Hypertension, Anticoagulants, Hereditary Haemorrhagic Telangiectasia (HHT), and Nasal Tumours (Rare). Assessment includes identifying the bleeding source, Haemodynamic status, and Underlying causes. [1,2,3]
Clinical Pearls
"Pinch the Soft Part, Lean Forward": First aid. Pinch the cartilaginous (soft) part of the nose for 15-20 mins. Lean forward (Not back) to prevent swallowing blood.
"Anterior (Easy) vs Posterior (Difficult)": Anterior = Little's area, Visible, Easy to manage. Posterior = Not visible, More severe, Often needs ENT.
"Hypertension and Anticoagulants": Common contributors in posterior epistaxis. Check BP and clotting.
"If Packing Fails, Escalate": Surgical ligation (ESPAL) or Embolisation for refractory cases.
2. Epidemiology
Demographics
| Factor | Notes |
|---|---|
| Prevalence | ~60% of population experience at least one nosebleed. ~6% seek medical attention. |
| Age | Bimodal: Children (Nose picking, Dry air) and Elderly (Hypertension, Anticoagulants, Mucosal atrophy). |
| Sex | Slight male predominance. |
Causes
| Category | Examples |
|---|---|
| Local Causes | |
| - Trauma | Nose picking (Rhinotillexomania), Direct blow, Nasal fracture. |
| - Inflammation | Upper respiratory tract infection, Rhinitis, Sinusitis. |
| - Dryness | Dry air, Oxygen therapy, CPAP. |
| - Foreign Body | Children. |
| - Nasal Tumours | Rare. Juvenile nasopharyngeal angiofibroma (Young males). SCC. Esthesioneuroblastoma. |
| - Septal Pathology | Deviation, Perforation. |
| Systemic Causes | |
| - Hypertension | Associated, ? Causative. |
| - Anticoagulants / Antiplatelets | Warfarin, DOACs, Aspirin, Clopidogrel. |
| - Coagulopathy | Liver disease, Haemophilia, von Willebrand disease, Thrombocytopenia. |
| - Hereditary Haemorrhagic Telangiectasia (HHT) | Osler-Weber-Rendu. Telangiectasia on lips, Tongue, Nasal mucosa, GI. AV malformations. |
3. Anatomy
Blood Supply to the Nose
| Artery | Territory |
|---|---|
| Internal Carotid System | |
| - Anterior Ethmoidal Artery | (Branch of Ophthalmic → Internal Carotid). Upper nasal cavity. |
| - Posterior Ethmoidal Artery | (Branch of Ophthalmic). Upper nasal cavity. |
| External Carotid System | |
| - Sphenopalatine Artery | (Branch of Maxillary). Major supply. Posterior and lateral wall. Woodruff's plexus. |
| - Greater Palatine Artery | Floor and septum. |
| - Superior Labial Artery | (Branch of Facial). Anterior septum. |
Kiesselbach's Plexus (Little's Area)
- Location: Anterior inferior nasal septum.
- Arterial Anastomosis: Superior Labial, Greater Palatine, Anterior Ethmoidal, Sphenopalatine.
- Most Common Site: ~90% of anterior epistaxis.
- Why Vulnerable: Rich vascular supply, Thin overlying mucosa, Exposed to trauma and drying.
Woodruff's Plexus
- Location: Posterior lateral nasal wall, Below posterior end of middle turbinate.
- Arterial Supply: Sphenopalatine artery branches.
- Posterior Epistaxis: Originates here.
4. Classification
By Location
| Type | Location | Notes |
|---|---|---|
| Anterior Epistaxis | Little's area (Anterior septum) | ~90%. Visible on anterior rhinoscopy. Usually self-limiting or easily controlled. |
| Posterior Epistaxis | Woodruff's plexus (Posterior lateral wall) | ~10%. Not easily visible. More severe bleeding. Older patients, Hypertension, Anticoagulants. |
5. Clinical Presentation
History
| Feature | Notes |
|---|---|
| Bleeding Side | Unilateral initially (May become bilateral). |
| Duration | |
| Volume | |
| Recurrence | |
| Trigger | Nose picking, Trauma, Spontaneous. |
| Associated Symptoms | Nasal obstruction (Tumour, Polyps). Rhinorrhoea. |
| Medications | Anticoagulants (Warfarin, DOACs), Antiplatelets (Aspirin, Clopidogrel). Nasal sprays. |
| PMH | Hypertension. Liver disease. Bleeding disorders. Previous epistaxis. HHT. |
| FH | HHT. Bleeding disorders. |
Examination
| Component | Findings |
|---|---|
| Haemodynamic Status | Pulse, BP, Pallor, Capillary refill. Assess for shock. |
| Blood Pressure | Often elevated during acute bleed. |
| Anterior Rhinoscopy | Use Thudichum speculum. Identify bleeding point on septum. |
| Oropharynx | Blood trickling down posterior pharynx = Posterior epistaxis or ongoing anterior. |
| Signs of HHT | Telangiectasia on lips, Tongue, Fingers. |
| Signs of Coagulopathy | Bruising, Petechiae. |
6. Investigation
Laboratory (If Indicated)
| Test | Indication |
|---|---|
| FBC | Significant/Recurrent bleed. Assess Hb (Anaemia). Platelets. |
| Coagulation (PT/INR, APTT) | On anticoagulants. Suspected coagulopathy. Severe bleed. |
| Group and Save / Crossmatch | Severe bleed. |
| LFTs | If liver disease suspected (Coagulopathy). |
Imaging
| Indication | Modality |
|---|---|
| Suspected Tumour | CT Sinuses, MRI. |
| Pre-Embolisation | Angiography. |
7. Management
Management Algorithm
EPISTAXIS
(Active Nosebleed)
↓
INITIAL FIRST AID
┌──────────────────────────────────────────────────────────┐
│ - Sit upright, Lean FORWARD (Not back) │
│ - PINCH the soft, cartilaginous part of nose firmly │
│ - Hold for 15-20 minutes without releasing │
│ - Spit out any blood in mouth (Don't swallow) │
│ - Ice pack to bridge of nose (Optional) │
│ - Breathe through mouth │
└──────────────────────────────────────────────────────────┘
↓
BLEEDING STOPPED?
┌────────────────┴────────────────┐
YES NO
↓ ↓
Advice: SEEK MEDICAL ATTENTION
- Avoid nose blowing, (ED or ENT)
Picking, Hot drinks ↓
for 24h
- Nasal lubricant (Vaseline,
Naseptin)
- If recurrent → GP
↓
MEDICAL/HOSPITAL MANAGEMENT
┌──────────────────────────────────────────────────────────┐
│ **RESUSCITATION (If needed)** │
│ - ABC approach. IV access. Fluids. │
│ - Correct shock. │
│ - Crossmatch if severe. │
│ - Reverse anticoagulation (Vitamin K, Prothrombin │
│ complex, Idarucizumab for Dabigatran, etc.) │
└──────────────────────────────────────────────────────────┘
↓
IDENTIFY BLEEDING SITE
- Anterior rhinoscopy (Thudichum speculum)
- Suction to clear clots
- Topical vasoconstrictor + Local anaesthetic
(e.g., Co-phenylcaine spray, Lidocaine + Adrenaline)
┌────────────────┴────────────────┐
ANTERIOR EPISTAXIS POSTERIOR EPISTAXIS
(Visible bleeding point (No visible source,
on septum) Blood in oropharynx)
↓ ↓
**ANTERIOR MANAGEMENT** **POSTERIOR MANAGEMENT**
↓
ANTERIOR EPISTAXIS MANAGEMENT
┌──────────────────────────────────────────────────────────┐
│ **STEP 1: Chemical Cautery** │
│ - Silver Nitrate stick applied to bleeding point │
│ - 5-10 seconds. One side at a time (Risk septal │
│ perforation if bilateral same sitting) │
│ │
│ **STEP 2: Anterior Nasal Packing (If Cautery Fails)** │
│ - Nasal sponge (Merocel, Rapid Rhino) │
│ - Ribbon gauze (BIPP) │
│ - Leave 24-48 hours │
│ - Prophylactic antibiotics (Co-amoxiclav) to prevent │
│ toxic shock syndrome │
│ │
│ **STEP 3: Electrocautery (Under Endoscopy)** │
│ - If chemical cautery fails. ENT. │
└──────────────────────────────────────────────────────────┘
↓
POSTERIOR EPISTAXIS MANAGEMENT
┌──────────────────────────────────────────────────────────┐
│ **POSTERIOR NASAL PACKING** │
│ - Foley catheter (Inflate in postnasal space) │
│ - Posterior pack (Brighton Balloon, Rapid Rhino │
│ posterior) │
│ - Requires admission, Monitoring (Hypoxia, Cardiac │
│ effects in elderly) │
│ │
│ **SURGICAL (If Packing Fails)** │
│ - **ESPAL (Endoscopic Sphenopalatine Artery Ligation)** │
│ - Gold standard surgery. High success ~95%. │
│ - Anterior Ethmoidal Artery Ligation (If needed) │
│ - External Carotid Ligation (Rarely needed) │
│ │
│ **INTERVENTIONAL RADIOLOGY** │
│ - Embolisation of Maxillary/Sphenopalatine artery │
│ - Alternative if surgery contraindicated/Failed │
│ - Risk: Stroke (Internal carotid anastomoses) │
└──────────────────────────────────────────────────────────┘
Anticoagulant Management
| Situation | Action |
|---|---|
| Warfarin | Check INR. If supratherapeutic → Vitamin K. If life-threatening → Prothrombin Complex Concentrate (Beriplex). |
| DOACs | Specific reversal agents (Idarucizumab for Dabigatran, Andexanet Alfa for Factor Xa inhibitors) if life-threatening. Otherwise supportive. |
| Antiplatelets | Platelet transfusion rarely helpful unless severe bleeding. Generally continue for high-risk indications. |
8. Complications
| Complication | Notes |
|---|---|
| Shock | Severe blood loss. |
| Anaemia | Chronic or recurrent bleeding. |
| Aspiration | Blood swallowed → Vomiting. Posterior bleeding → Aspiration. |
| Toxic Shock Syndrome | From nasal packing. Prophylactic antibiotics recommended. |
| Septal Perforation | From bilateral cautery in same sitting. |
| Nasal/Sinus Infection | From packing. |
| Pressure Necrosis | From prolonged or over-inflated packs. |
9. Prognosis and Outcomes
| Factor | Notes |
|---|---|
| Anterior Epistaxis | Excellent prognosis. Usually self-limiting or easily controlled. |
| Posterior Epistaxis | More challenging. May require surgery. Good outcomes with ESPAL. |
| Recurrence | Common. Address underlying factors (BP, Anticoagulation, Nasal hygiene). |
| HHT | Chronic, Lifelong. May need repeated interventions. |
10. Evidence and Guidelines
Key Guidelines
| Guideline | Organisation | Key Recommendations |
|---|---|---|
| Epistaxis | NICE CKS, ENT UK | First aid. Cautery/Packing. ESPAL for refractory posterior. |
11. Patient and Layperson Explanation
What is a Nosebleed?
A nosebleed is bleeding from inside your nose. Most nosebleeds are not serious and stop on their own or with simple first aid.
What causes it?
- Picking or rubbing your nose.
- Dry air.
- Colds or allergies.
- High blood pressure.
- Blood-thinning medications.
- Sometimes no obvious cause.
What should I do?
- Sit upright and lean forward slightly (Don't lean back or lie down).
- Pinch the soft part of your nose firmly (Just below the bony bit).
- Hold for 15-20 minutes without letting go.
- Spit out any blood in your mouth.
- After it stops, Avoid blowing your nose or heavy lifting for 24 hours.
When should I seek help?
- Bleeding lasts more than 20 minutes despite pinching.
- You are on blood thinners.
- You feel faint or have lost a lot of blood.
- Nosebleeds keep happening.
- Bleeding is from the back of the nose (Blood going down your throat).
How is it treated in hospital?
- Cautery (Sealing the bleeding point).
- Nasal packing (A sponge or balloon in the nose).
- Surgery (If packing doesn't work).
12. References
Primary Sources
- Pope LER, Hobbs CGL. Epistaxis: an update on current management. Postgrad Med J. 2005;81(955):309-314. PMID: 15879044.
- Schlosser RJ. Clinical practice. Epistaxis. N Engl J Med. 2009;360(8):784-789. PMID: 19228621.
- ENT UK. Epistaxis: Surgical Management. 2017.
13. Examination Focus
Common Exam Questions
- Common Bleeding Site: "Where does most anterior epistaxis originate?"
- Answer: Kiesselbach's Plexus (Little's Area) on the anterior inferior nasal septum.
- First Aid: "What is the correct first aid for a nosebleed?"
- Answer: Sit upright, Lean forward, Pinch the soft (cartilaginous) part of the nose for 15-20 minutes.
- Posterior Epistaxis Surgery: "What is the gold-standard surgical treatment for refractory posterior epistaxis?"
- Answer: ESPAL (Endoscopic Sphenopalatine Artery Ligation).
- Red Flag Condition: "What inherited condition causes recurrent epistaxis and telangiectasia?"
- Answer: Hereditary Haemorrhagic Telangiectasia (HHT) / Osler-Weber-Rendu Syndrome.
Viva Points
- Woodruff's Plexus: Posterior lateral wall. Source of posterior epistaxis. Sphenopalatine artery.
- Antibiotic Prophylaxis with Packing: To prevent Toxic Shock Syndrome.
- Don't Cauterise Both Sides of Septum Same Sitting: Risk of perforation.
- Assess Haemodynamic Status First: ABC approach in severe cases.
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. Always consult appropriate specialists.