Epistaxis (Nosebleed)

Anatomy & Vascular Supply

Classification

Epidemiology

• Bimodal age distribution: peaks in children and the elderly
• Higher incidence in winter months and cold/dry climates — dry heated air desiccates nasal mucosa and cold affects coagulation
• In children, most common between ages 2–10

Causes

• Nose picking (most common in children)
• Upper respiratory tract infections / rhinitis
• Low humidity / desiccation (rhinitis sicca)
• Allergic rhinitis
• Nasal foreign bodies
• Nasal polyps, septal deviation
• Environmental irritants (cocaine, chronic nasal vasoconstrictors)
• Barotrauma
• Trauma / surgery
• Neoplasms (e.g., juvenile nasopharyngeal angiofibroma in adolescent males — suspect when there is profuse unilateral bleeding with nasal obstruction)

• Anticoagulant or antiplatelet therapy
• Coagulopathies (von Willebrand disease type 1 is the most commonly identified — found in ~⅓ of children with recurrent epistaxis)
• Thrombocytopenia (leukemia, aplastic anemia, chemotherapy)
• Hepatic disease / vitamin K deficiency
• Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) — a congenital vascular malformation causing recurrent, multifocal bleeding
• Hypertension: no proven causal relationship, but elevated BP at presentation is associated with persistent bleeding

Clinical Evaluation

Initial priorities

1. Airway — assess patency, especially in posterior bleeds
2. Hemodynamics — tissue perfusion, signs of significant blood loss
3. History — timing, frequency, severity; trauma; medications; family history of bleeding disorders

Physical examination

• Instruct patient to blow the nose to clear clots
• Apply bilateral pressure on the cartilaginous part of the nose for 10–15 minutes (a nose clip is superior to manual pressure alone)
• Administer 0.05% oxymetazoline (2 sprays) before applying pressure to optimize hemostasis and aid examination
• Tilt head slightly forward (not back) to avoid swallowing blood
• Examine with nasal speculum opened vertically, floor of nose parallel to the room floor

Diagnostics

• Patients on anticoagulants (INR, PT, aPTT, platelets)
• Severe or prolonged bleeding (CBC)
• Underlying liver disease or hematologic malignancy

Management (Stepwise)

Step 1 — Direct pressure + vasoconstriction

• Pinch the cartilaginous nose for 10–15 min
• Topical oxymetazoline or phenylephrine
• Topical anesthetic (2% lidocaine) to facilitate examination

Step 2 — Identify the bleeding site + cautery

• Silver nitrate chemical cautery — most effective when the site is identified
• Apply from periphery → center, superior → inferior (to avoid blood)
• Contact ≤15 seconds; never cauterize both sides of the septum simultaneously (risk of necrosis)

Step 3 — Topical hemostatics

• Absorbable gelatin sponge (Gelfoam)
• Oxidized cellulose (Surgicel)
• Topical tranexamic acid (500 mg IV solution on pledget or atomized): moderate-quality evidence supports reduced bleeding at 10 min and re-bleeding at 7–10 days; superior to anterior nasal packing in antiplatelet users

Step 4 — Anterior nasal packing

• Merocel (polyvinyl acetal nasal tampon) or Rapid Rhino (procoagulant-coated inflatable balloon) inserted along the floor of the nose
• If uncontrolled despite an adequately placed anterior pack → insert a second pack in the opposite naris
• Routine prophylactic antibiotics are not recommended

Step 5 — Posterior packing

• Double balloon catheter (e.g., Epistat): posterior balloon inflated first, device seated by pulling anteriorly, then anterior balloon inflated
• Foley catheter (if commercial device unavailable): 5–7 mL water in balloon, seated in nasopharynx; caution for pressure necrosis
• Requires inpatient monitoring (risk of airway compromise, hypoxia, cardiac events — especially in elderly)

Step 6 — Refractory / definitive

• Endovascular embolization — >80–91% success rate; preferred in coagulopathic patients and those on anticoagulants; requires bilateral selective internal + external carotid angiography; targets sphenopalatine, facial, and ascending pharyngeal arteries
• Surgical ligation — historically the gold standard for intractable bleeds

Special Situations

Disposition

• Anterior epistaxis controlled in ED → discharge with instructions: avoid nose-picking, apply topical antibiotic ointment nightly to lubricate mucosa
• Anterior pack placed → ENT follow-up in 2–3 days for pack removal; no routine antibiotics
• Posterior pack placed → hospital admission for monitoring
• Refractory → urgent ENT consultation for embolization or surgical planning