Epistaxis (nosebleed) is a common condition with a bimodal age distribution, occurring more frequently in the young and the old.
90% arise at Little's area of the anterior septum, the location of the Kiesselbach plexus.
Precipitating factors include dry weather and other causes of nasal mucosal inflammation or hyperemia, such as allergy, viral rhinitis, bacterial rhinosinusitis, dust, or chemicals. Although rare, neoplasm may also cause nosebleed.
Topical anesthesia and vasoconstriction are essential for initial treatment of active bleeding. If initial measures fail, almost all episodes may be controlled with anterior or anterior-posterior packing techniques.
Bleeding may be refractory in the presence of coagulopathy.
History and exam
Key diagnostic factors
- blood at both sides of nose
Other diagnostic factors
- bleeding starting at the nares
- recurrent epistaxis
- septal deviation
- bleeding starting in the throat
- dizziness or lightheadedness
- hypoesthesia and pain in the distribution of the second branch of the trigeminal nerve
- dry weather and low humidity
- prior nasal or sinus surgery
- nasal cannula oxygen or continuous positive airways pressure (CPAP)
- nasal and other facial fracture
- other nasal trauma
- topical nasal drugs
- primary coagulopathy (e.g., hemophilia)
- medication (e.g., aspirin, anticoagulant, antiplatelet, nonsteroidal anti-inflammatory drugs)
- familial hereditary hemorrhagic telangiectasia
- juvenile nasal angiofibroma
- chronic kidney or liver disease
- septal deviation
- nasal foreign body
- environmental irritants
- ulceration secondary to infection (e.g., herpes zoster, or bacterial infection)
- forceful coughing
- sinonasal neoplasm
- chronic granulomatous disease
1st investigations to order
- clinical diagnosis
Investigations to consider
- coagulation studies (prothrombin time, activated partial thromboplastin time, platelet function tests)
- BUN, serum creatinine
- autoimmune screen/autoantibodies
- CT scan of paranasal sinuses
- MRI of head
- internal and external carotid angiography
- nasal endoscopy and nasopharyngoscopy
- plain nasal or sinus x-ray
active epistaxis: initial measures
active epistaxis: persistent bleeding precluding identification of bleeding site
active epistaxis: bleeding site visible
quiescent but recurrent epistaxis
Darren Pinder, BSc(Hons), MB BChir, MSc(Med Ed), FRCS(ORL)
Consultant ENT Surgeon
Royal United Hospital Bath NHS Trust
DP declares that he has no competing interests.
Ethan Cumbler, MD
Department of Internal Medicine
University of Colorado Health Sciences Center
EC declares that he has no competing interests.
Samuel J. Stratton, MD, MPH
UCLA School of Public Health and David Geffen School of Medicine
Health Disaster Management/Emergency Medical Services
Orange County Health Care Agency
SJS declares that he has no competing interests.
Janet Wilson, BSc, MD, FRCSEd, FRCSEng
Professor of Otolaryngology - Head and Neck Surgery
Honorary Consultant Otolaryngologist
JW declares that she has no competing interests.
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