Summary
Definition
History and exam
Key diagnostic factors
- blood at both sides of nose
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
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
Diagnostic tests
1st tests to order
- clinical diagnosis
Tests 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
Treatment algorithm
active epistaxis: initial measures
active epistaxis: persistent bleeding precluding identification of bleeding site
active epistaxis: bleeding site visible
quiescent but recurrent epistaxis
Contributors
Authors
Darren Pinder, BSc(Hons), MB BChir, MSc(Med Ed), FRCS(ORL)
Consultant ENT Surgeon
Royal United Hospital Bath NHS Trust
Bath
UK
Disclosures
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
Denver
CO
Disclosures
EC declares that he has no competing interests.
Samuel J. Stratton, MD, MPH
Professor
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
CA
Disclosures
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
Newcastle-Upon-Tyne
UK
Disclosures
JW declares that she has no competing interests.
Peer reviewer acknowledgements
BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.
Disclosures
Peer reviewer affiliations and disclosures pertain to the time of the review.
References
Key articles
Tan L, Calhoun K. Epistaxis. Med Clin North Am. 1999 Jan;83(1):43-56. Abstract
Perretta L, Denslow B, Brown C. Emergency evaluation and management of epistaxis. Emerg Med Clin North Am. 1987 May;5(2):265-77. Abstract
Santos P, Lepore M. Epistaxis. In: Bailey B, Healy G, Johnson J, et al., eds. Head & neck surgery-otolaryngology. Philadelphia: Lippincott, Williams & Wilkins; 2001:415-28.
Massick D, Tobin E. Epistaxis. In: Cummings C, Flint P, Harker L, et al., eds. Otolaryngology-head and neck surgery. Philadelphia: Elsevier Mosby; 2005:942-61.
Santos P, Lepore M. Epistaxis. In: Bailey B, Healy G, Johnson J, et al., eds. Head & neck surgery-otolaryngology. Philadelphia: Lippincott, Williams & Wilkins; 2001:415-428.
Massick D, Tobin E. Epistaxis. In: Cummings C, Flint P, Harker L, et al., eds. Otolaryngology-head and neck surgery. Philadelphia: Elsevier Mosby; 2005:942-961.
Tunkel DE, Anne S, Payne SC, et al. Clinical practice guideline: nosebleed (epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162(1 suppl):S1-S38.Full text Abstract
Pond F, Sizeland A. Epistaxis: strategies for management. Aust Fam Physician. 2000 Oct;29(10):933-8. Abstract
Randall DA. Epistaxis packing. Practical pointers for nosebleed control. Postgrad Med. 2006 Jun-Jul;119(1):77-82. Abstract
Ruddy J, Proops DW, Pearman K, et al. Management of epistaxis in children. Int J Paediatr Otorhinolaryngol. 1991 Apr;21(2):139-42. Abstract
Reference articles
A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.
Differentials
- Hemoptysis
- Hematemesis
More DifferentialsGuidelines
- Clinical practice guideline: nosebleed (epistaxis)
- Clinical guideline: epistaxis
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