Key Facts

Epistaxis is bleeding from the nasal cavity. It is one of the most common ENT emergencies. Most cases are anterior, self-limiting, and easily managed, but posterior epistaxis can be severe and life-threatening, requiring urgent intervention.

Epidemiology

• 60% of people experience epistaxis at some point in their life
• 6-10% require medical attention
• Bimodal age distribution: children (2-10 years, nose picking) and elderly (>65 years, anticoagulants, hypertension)
• More common in winter months (dry air, URTIs)
• Male predominance in adult presentations

Aetiology

• Local causes: digital trauma (nose picking — most common in children), mucosal drying, nasal fracture, nasal surgery, foreign body, septal perforation, nasal tumours, hereditary haemorrhagic telangiectasia (HHT/Osler-Weber-Rendu)
• Systemic causes: anticoagulants (warfarin, DOACs, heparin), antiplatelets (aspirin, clopidogrel), hypertension (may prolong bleeding), coagulopathies (haemophilia, von Willebrand disease, thrombocytopenia, liver disease), leukaemia
• Idiopathic: most common overall

Pathophysiology

• Little's area (Kiesselbach's plexus) on the anterior nasal septum is the most common site (90%)
  • Anastomosis of anterior ethmoidal, superior labial, greater palatine, and sphenopalatine arteries
  • Thin mucosa, exposed location, trauma-prone
• Posterior epistaxis: branches of sphenopalatine artery (posterior nasal septum and lateral nasal wall)
  • Higher flow, harder to control, more likely to require intervention
• Hypertension does not directly cause epistaxis but makes bleeding harder to control

Anterior Epistaxis

• Bleeding from one or both nostrils
• Patient can usually identify the bleeding side
• Visible bleeding point on anterior septum (Little's area)
• Usually self-limiting
• Common in children and young adults

Posterior Epistaxis

• Bleeding from back of nose, often bilateral or into throat
• Patient may swallow blood (presenting with haematemesis, melaena)
• Often profuse, continuous
• More common in elderly patients, those on anticoagulants
• May cause haemodynamic compromise

Red Flags

• Haemodynamic instability (tachycardia, hypotension)
• Signs of significant blood loss (pallor, dizziness)
• Known coagulopathy or anticoagulant use
• Bilateral epistaxis or blood in oropharynx (posterior source)
• Recurrent epistaxis requiring medical attention
• Unilateral nasal mass or obstruction (tumour)
• Multiple mucocutaneous telangiectasiae (HHT)

Bedside

• ABC assessment: if significant bleeding
• Blood pressure measurement
• Anterior rhinoscopy: identify bleeding point
• Nasendoscopy: if anterior source not identified

Bloods

• FBC: haemoglobin, platelets
• Coagulation screen: PT/INR, APTT (essential if on anticoagulants)
• Group and save / crossmatch: if significant ongoing blood loss
• U&Es: if significant blood loss

Imaging

• Not routinely required for epistaxis
• CT/MRI sinuses: if recurrent epistaxis with no identifiable source, suspected tumour
• CT angiography: if considering embolisation for refractory posterior epistaxis

Special Tests

• Von Willebrand factor assay, factor levels: if recurrent epistaxis suggesting coagulopathy
• Genetic testing: if HHT suspected (Curaçao criteria met)

Non-pharmacological

• First aid (ABCDE approach):
  1. Sit patient forward, mouth open
  2. Pinch soft part of nose continuously for 15-20 minutes
  3. Spit out blood (swallowed blood causes nausea/vomiting)
  4. Ice pack to nasal bridge (minimal evidence but widely used)
  5. Avoid nose blowing, sneezing with mouth closed, hot drinks for 24 hours

Pharmacological

• Topical vasoconstrictor: phenylephrine or xylometazoline spray before examination
• Cautery: silver nitrate (75%) applied to visible bleeding point for 5-10 seconds after topical anaesthesia (co-phenylcaine or lidocaine/phenylephrine)
  • Only cauterise ONE side of septum at a time (risk of septal perforation if bilateral)
• Naseptin cream (chlorhexidine/neomycin) or Vaseline: to anterior septum BD for 2-4 weeks after cautery or for recurrent minor epistaxis
• Tranexamic acid: 1g IV or topical (soaked gauze) as adjunct for significant bleeding
• Reverse anticoagulation: vitamin K (phytomenadione), prothrombin complex concentrate, fresh frozen plasma as indicated by INR/APTT

Surgical/Interventional (Escalation Pathway)

1. Anterior nasal packing: Rapid Rhino (inflatable) or Merocel (expandable) — leave for 24-48 hours
2. Posterior nasal packing: Foley catheter or posterior balloon tampon + anterior packing
3. Sphenopalatine artery ligation (endoscopic): definitive treatment for refractory posterior epistaxis; success rate >95%
4. Anterior ethmoidal artery ligation: for bleeding from anterior ethmoidal territory
5. Angiographic embolisation: alternative to surgical ligation in high-risk patients

Referral Criteria

• ENT assessment: all patients requiring nasal packing
• Emergency ENT: posterior epistaxis, haemodynamic compromise, failed anterior packing
• ENT follow-up: recurrent epistaxis, post-packing review
• Haematology: suspected coagulopathy

• >90% of anterior epistaxis controlled with first aid and/or cautery
• Anterior packing success rate: 70-80%
• Posterior packing success rate: 60-70%
• Sphenopalatine artery ligation: >95% success rate for posterior epistaxis
• Recurrence after cautery: 10-30% (higher in children due to nose picking)
• Posterior epistaxis in anticoagulated elderly patients carries significant morbidity
• HHT: lifelong recurrent epistaxis; may require multiple interventions
• Mortality from severe epistaxis is rare (<0.01%) with modern management

Epistaxis Management Escalation

Curaçao Criteria for HHT (≥3 = definite)

Blood Supply to Little's Area