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Last reviewed: 4 Sep 2023
Last updated: 26 May 2021



History and exam

Key diagnostic factors

  • blood at both sides of nose
More key diagnostic factors

Other diagnostic factors

  • bleeding starting at the nares
  • recurrent epistaxis
  • septal deviation
  • tachycardia
  • bleeding starting in the throat
  • hypotension
  • syncope
  • dizziness or lightheadedness
  • pallor
  • hypoesthesia and pain in the distribution of the second branch of the trigeminal nerve
Other diagnostic factors

Risk factors

  • 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
  • barotrauma
  • ulceration secondary to infection (e.g., herpes zoster, or bacterial infection)
  • forceful coughing
  • sinonasal neoplasm
  • chronic granulomatous disease
More risk factors

Diagnostic investigations

1st investigations to order

  • clinical diagnosis
More 1st investigations to order

Investigations to consider

  • CBC
  • coagulation studies (prothrombin time, activated partial thromboplastin time, platelet function tests)
  • BUN, serum creatinine
  • LFTs
  • 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
More investigations to consider

Treatment algorithm


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.

Peer reviewers

Ethan Cumbler, MD

Assistant Professor

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

Los Angeles

Medical Director

Health Disaster Management/Emergency Medical Services

Orange County Health Care Agency

Santa Ana



SJS declares that he has no competing interests.

Janet Wilson, BSc, MD, FRCSEd, FRCSEng

Professor of Otolaryngology - Head and Neck Surgery

Newcastle University

Honorary Consultant Otolaryngologist

Freeman Hospital




JW declares that she has no competing interests.

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