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Epistaxis (nosebleeds)
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Exam Tips
- In OSCEs, first demonstrate correct first aid (lean forward + pinch soft nose for 10-15 minutes) and state why pinching nasal bones is ineffective.
- Posterior epistaxis clues: older patient, profuse bleeding from both nostrils, blood down throat, no anterior point visible.
- Always screen for red flags and safeguarding issues: spontaneous epistaxis in children under 2 years is unusual and may indicate trauma/non-accidental injury.
- Warfarin users with difficult-to-control bleeding need INR assessment; check haemodynamic status early and escalate urgently if compromised.
- Do not cauterise the same septal area bilaterally due to septal perforation risk.
Definition
Epistaxis is bleeding originating from the nasal mucosa, presenting from the nostril(s), nasal cavity, or tracking posteriorly into the nasopharynx. Most episodes are anterior bleeds from Little’s area (Kiesselbach’s plexus) on the anterior septum, while posterior bleeds are less common but typically heavier, harder to localise, and more clinically significant in older adults.
Pathophysiology
The nasal septal mucosa contains a dense superficial arterial anastomotic network; in Little’s area, thin mucosa over Kiesselbach’s plexus is easily disrupted by minor trauma, dryness, inflammation, or topical irritants. Posterior epistaxis usually arises from branches of the sphenopalatine system and tends to be higher-flow, with blood passing to both nostrils and the pharynx. Systemic contributors (anticoagulants/antiplatelets, inherited or acquired coagulopathies, platelet disorders, alcohol excess, vascular fragility in older age) reduce haemostatic reserve and increase recurrence/severity. See figure of Kiesselbach’s plexus and lateral nasal wall arterial supply in core ENT anatomy texts.
Risk Factors
- Digital trauma (nose-picking), facial/nasal trauma, septal ulceration or perforation, nasal foreign body
- Nasal inflammation (allergic rhinitis, chronic rhinosinusitis, infection, nasal polyps)
- Topical irritants/drugs (intranasal decongestants, intranasal corticosteroids if misused, cocaine)
- Systemic drugs (aspirin, clopidogrel, warfarin, DOACs, other anticoagulants/antiplatelets)
- Coagulopathy or haematological disease (von Willebrand disease, thrombocytopenia, haemophilia, leukaemia)
- Environmental dryness/low humidity, cold weather, irritant exposure (dust, chemicals, smoke), oxygen cannula mucosal drying
- Older age (especially posterior bleeds), atherosclerotic vascular disease
- Hereditary haemorrhagic telangiectasia or vasculitic/vascular pathology
- Post-operative state (ENT/maxillofacial/ophthalmic procedures)
- Excess alcohol use
Clinical Features
Symptoms
- Visible nasal bleeding (usually unilateral initially in anterior bleeds)
- Blood in throat, metallic taste, or swallowing blood
- Profuse bilateral bleeding or persistent throat blood suggesting posterior source
- Light-headedness, presyncope/syncope if significant blood loss
- Recurrent brief episodes, especially in children
Signs
- Small anterior septal bleeding point on speculum exam (often in Little’s area)
- Active bleeding obscuring source; clots in nasal cavity
- Tachycardia, pallor, hypotension in haemodynamic compromise
- Blood in oropharynx despite limited anterior findings (possible posterior bleed)
- Features of underlying cause (telangiectasia, septal perforation, tumour red flags such as unilateral obstruction/cervical nodes)
Investigations
Focused clinical assessment (including ABCDE where indicated) and nasal examination with good light/speculum:Identifies severity, haemodynamic stability, and whether an anterior bleeding point is visible; inability to localise with heavy bilateral bleed suggests posterior epistaxis
Full blood count:Usually normal in minor bleeds; may show anaemia after heavy/recurrent blood loss or thrombocytopenia
Coagulation screen (PT/INR, aPTT) when indicated:Raised INR in over-anticoagulated warfarin users or abnormal clotting profile if coagulopathy
Medication review and targeted history:Anticoagulant/antiplatelet exposure or intranasal irritant use contributing to persistence/recurrence
Management
Lifestyle Modifications
- First aid: sit forward with mouth open, avoid lying flat unless faint, pinch soft cartilaginous nose continuously for 10-15 minutes
- Spit out blood rather than swallowing; avoid repeated checking before 10-15 minutes
- After control: avoid nose-picking, heavy exertion, hot drinks/alcohol, and forceful nose blowing for 24-48 hours; maintain humidification/emollient care
Pharmacological Treatment
Antifibrinolytic (selected severe cases before transfer)
- Tranexamic acid 1 g oral single dose (major haemorrhage while awaiting emergency transfer, per local protocol)
Use only when benefits outweigh risks and according to local major haemorrhage pathways; caution in history of thrombosis, haematuria/upper urinary tract bleeding, or seizure risk.
Topical antiseptic/antibacterial therapy after bleeding control
- Chlorhexidine 0.1% with neomycin 0.5% nasal cream (Naseptin): apply to each nostril four times daily for 10 days (or twice daily up to 14 days if adherence limited)
- Mupirocin nasal ointment: apply to affected nostril(s) two to three times daily for 5-7 days
Do not use chlorhexidine/neomycin cream in neomycin allergy; avoid if peanut or soya allergy per product cautions. Useful for crusting/vestibulitis reduction after acute episode.
Surgical / Interventional
- Silver nitrate cautery of clearly visualised unilateral anterior bleeding point after haemostasis and local preparation
- Anterior nasal packing if first aid/cautery fail
- Posterior packing and urgent ENT admission for suspected posterior bleed
- Definitive refractory management in secondary care: endoscopic sphenopalatine artery ligation or interventional radiology embolisation
Complications
- Hypovolaemia and acute haemodynamic compromise
- Iron-deficiency anaemia after recurrent/heavy bleeding
- Aspiration of blood (including with displaced packs, especially posterior epistaxis)
- Recurrent or recalcitrant epistaxis (higher risk with anticoagulants/coagulopathy)
- Nasal packing complications: sinusitis, septal haematoma/abscess, pressure necrosis, hypoxia/apnoea, toxic shock syndrome if prolonged packing
- Septal perforation risk after cautery (especially bilateral cautery at same septal site)
- Rare mortality, usually in severe bleeding with major comorbidity
Prognosis
Overall prognosis is excellent: most episodes are self-limiting and resolve with first aid alone. Posterior bleeds, frailty, anticoagulant use, and coagulopathy increase admission risk and recurrence; death is rare and usually linked to severe blood loss or treatment-related complications in comorbid patients.
Sources & References
💊BNF Drug References(11)
- Alirocumab[management.pharmacological]
- Amitriptyline hydrochloride[management.pharmacological]
- Atorvastatin[management.pharmacological]
- Bempedoic acid[management.pharmacological]
- Bempedoic acid with ezetimibe[management.pharmacological]
- Colestyramine[management.pharmacological]
- Follitropin alfa[management.pharmacological]
- Follitropin alfa with lutropin alfa[management.pharmacological]
- Menotrophin[management.pharmacological]
- Methylprednisolone[management.pharmacological]
- Urofollitropin[management.pharmacological]
✅NICE Guidelines(1)
- Epistaxis (nosebleeds)[overview]
📖Textbook References(20)
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1812)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1805)[context]
- David Randall PhD MRCP (Editor), John Booth PhD MRCP (Editor), K - Kumar and Clark's Clinical Medicine (2025, American Elsevier Publishing Co.) - libgen.li.pdf(pp. 1804, 1805)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 596)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 596)[context]
- Guyton and Hall Textbook of Medical Physiology (John E. Hall, Michael E. Hall) (Z-Library).pdf(pp. 1007)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 1441, 1442)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 2055, 2056)[context]
- Netter F. Netter Atlas of Human Anatomy. A Systems Approach 8ed 2022.pdf(pp. 2054, 2055)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2992, 2993)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2486, 2487)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 1442, 1443)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2055)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2998, 2999)[context]
- _OceanofPDF.com_Netters_Anatomy_-_8th_edition_-_Frank_H_Netter_MD.pdf(pp. 2480, 2481)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1051)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 970)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 133)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 1050, 1051)[context]
- [Williams, Bailey and Love's Short Practice of Surgery] Norman Williams, Christopher Bulstrode, P Ronan O'Connell - Bailey & Love's Short Practice of Surgery 26E (2013, CRC Press) - libgen.li.pdf(pp. 132, 133)[context]