creation date: 2026-05-12 19:32
tags: Pathologies
Epistaxis
Background
Definitions
Epistaxis, commonly referred to as a nosebleed, is a common issue patients deal with but rarely seek medical conditions for. Regardless, epistaxis is a still a common otolaryngologic cause for seeking medical treatment.
Epistaxis occurrence has a bimodal distribution with most causes occurring either:
- Before age 10
- Between ages 45-65
Anatomy
Anterior bleeds
These are the more common bleed which are generally self-limited. Up to 90% of nosebleeds occur within the vascular watershed area of the nasal septum known as Kiesselbach’s plexus which is where the anastomosis of three primary vessels occur:
- Septal branch of anterior ethmoidal artery
- Lateral nasal branch of the sphenopalatine artery
- Septal branch of the superior labial branch of the facial artery
Posterior bleeds
These are less common and occur from the posterolateral branches of the sphenopalatine artery or branches of the carotid artery.
Etiology and Risk Factors
Anterior bleeds are often due to mucosal trauma or irritation:
- Nose picking
- Low moisture content in air (causing mucosal dryness and irritation)
- Mucosal hyperemia due to allergic or viral rhinitis
- Presence of foreign body (especially when associated with purulent discharge)
- Chronic excoriation
- Facial trauma
Both anterior and posterior bleeds may be caused by or associated with a number of conditions:
- Anticoagulation
- Bleeding disorders
- Vascular conditions (eg. aneurysm of carotid artery)
- Neoplasm
- Aspirin use
- Hypertension
- Alcohol use
- Intranasal preparations for seasonal allergies
- Heart failure
Clinical Presentation
Signs & Symptoms
Epistaxis is the loss of blood from the nasal cavity.
History & Physical Exam
History should address:
- Conditions that may predispose bleeding (tumours, coagulation disorders)
- Recent trauma or surgery
- Medications
In regards to the epistaxis, the timing, frequency, and severity should be assessed.
Physical exam should ensure there isn’t:
- Airway compromise
- Hypovolemic shock
An examination of the nares should be done without extension of the neck while scrunching the nose for. Inspect the Kiesselback’s plexus for:
- Bleeding
- Ulceration
- Erosion
Other points of inspection include nasal vestibule, septum, and turbinates.
Note that some anesthesia with a swab may be needed to comfortably examine.
- Lidocaine with epinephrine
Diagnosis
Criteria
Diagnosis is made clinically.
Differentiating between anterior and posterior bleeds can be difficult. In general, major bleeding and/or bleeds that do not stop with anterior packing are more likely to be posterior.
Work-up
Direct visualization
May be made using nasal speculum. This may require consultation of ENT.
Laboratory studies
While not typically required, labs may include:
- CBC
- Type and cross match
- Coagulation studies
Differential
Differential includes other causes of bleeding or discharge:
- Coagulation disorders
- Nasal tumour
- Warfarin toxicity
- Foreign body in nose
- Rhinitis
Red Flags / Complications
Complications include:
- Synechiae (intranasal adhesions)
- Aspiration
- Hypovolemia
Complication of treatment include:
- Toxic shock syndrome (16 per 100,000 nasal packings; 0.016%)
Management
Anterior Bleeding
Treatment follows a stepwise algorithm until hemostasis is achieved.
Conservative measures
Initial tamponade involves:
- Patient blowing nose to remove blood and clot
- Nares are sprayed with oxymetazoline (nasal decongestant and vasoconstrictor)
- Patient pinches the alae tightly against the septum and holds for 10 minutes
If the bleed stops, observation for 30 minutes should be done for recurrent rebleeding. If bleeding has stopped, patients can be discharged with antibiotic ointment to coat mucosa TID x 3d.
Chemical or electrical cautery
If an anterior bleeding source is visualized, cautery can be used.
Chemical cautery consist of silver nitrate.
- Apply topical anesthesia and vasoconstrictive agent (or manual pressure; must be bloodless)
- Apply silver nitrate stick for few seconds (no longer than 10 seconds), starting at the periphery and moving towards the centre of the bleed
- Wipe excess with cotton swab
Similarly to conservative measures, antibiotics should be given for home use once bleeding stops.
Anterior nasal packing
Several packing options are available.
Nasal tampons:
- Pretreat with topical anesthetic (2% lidocaine) and vasoconstrictor (oxymetazoline)
- Coat tampon with bacitracin ointment
- Insert catheter along the floor of the nasal cavity until the proximal fabric ring of the plastic is within the naris
- If one tampon is too small, a combination of pediatric + adult, or two adult tampons can be used
- Expand the tampon by infusing 10 mL of saline or bacitracin solution
Nasal balloon catheter (Rapid Rhino):
- Pretreat as above
- Confirm the balloon functions with a 20 mL syringe; ensure pilot cuff correlates to balloon
- Soak the catheter in sterile water for 30 seconds (not saline or lubricants)
- Insert catheter along the floor of the nasal cavity until the proximal fabric ring of the plastic is within the naris
- Inflate the catheter with air using a syringe, stopping once pilot cuff is firm and round
- After 10-15 minutes, reassess; add air if pilot cuff is no longer round and firm
- Tape pilot cuff to the patient’s cheek
Other treatments
A number of foams and gels may be available. Additionally, evidence for tranexamic acid (used with a nasal tampon in lieu of saline) is growing but there is risk of systemic thrombosis.
Posterior Bleeding
The treatment of a posterior bleed involves balloon catheters. These are double-balloon catheters with a large anterior balloon and smaller posterior balloon.
- Pretreat as above
- Advance the catheter along the floor of the nasal cavity until the retention ring reaches the entrance of the naris
- Inflate the posterior balloon with 10 mL of sterile water
- Retract the catheter gently until it lodges against the posterior choana in the nasopharynx
- Once seated, inflate the anterior balloon with 30 mL of sterile water; deflate if severe pain or septum deviation
Most patients with posterior bleeding require hospitalization.