Recurrent Nosebleeds (Epistaxis)

What Is Epistaxis?

Epistaxis is bleeding from the nasal mucosa. It is one of the most common ENT emergencies and has a bimodal distribution - peaks in childhood and again in older adults (especially over 60). Incidence rises in winter months and colder, drier climates, largely because dry indoor heating desiccates nasal mucosa and impairs coagulation. - Rosen's Emergency Medicine, p. 919

Types: Anterior vs. Posterior

	Anterior	Posterior
Frequency	~90% of cases	~10% of cases
Site	Kiesselbach's plexus (anteroinferior septum)	Sphenopalatine artery territory
Severity	Usually mild, self-limiting	Often severe, requires intervention
Age	Any age, common in children	Predominantly elderly
Bleeding pattern	Flows forward out of nose	Drains down the throat

Rosen's Emergency Medicine, p. 920

Common Causes

Local / Nasal Causes

Nose picking (digital trauma) - the most common cause in children
Upper respiratory infections - mucosal vasodilation and inflammation
Allergies / allergic rhinitis - mucosal fragility
Low home humidity / dry air - desiccation of mucosa
Environmental irritants - smoke, dust, chemicals
Nasal polyps
Foreign body in the nose
Nasal or facial trauma
Chronic nasal decongestant use (rebound congestion)
Cocaine use - vasoconstriction damages mucosa
Post-surgical bleeding

Systemic / Medical Causes

Anticoagulant or antiplatelet therapy (warfarin, aspirin, clopidogrel, DOACs) - patients on warfarin account for 9-17% of epistaxis admissions
Blood dyscrasias (thrombocytopenia, leukemia, myelosuppression)
Liver disease - impaired clotting factor synthesis
Hypertension - elevated BP is commonly seen with epistaxis; while not proven to directly cause it, it is associated with persistent and more severe bleeding
Hereditary Hemorrhagic Telangiectasia (HHT / Rendu-Osler-Weber disease) - a genetic disorder causing fragile abnormal vessels; ~90% of HHT patients have recurrent epistaxis, often from childhood
Vitamin K deficiency
Folic acid deficiency
Chemotherapy
Alcohol use - impaired coagulation

Rosen's Emergency Medicine, Box 58.6; Scott-Brown's Otorhinolaryngology Vol 1, p. 1221

Note: 70-80% of epistaxis cases are idiopathic - no specific cause is found despite investigation. - Scott-Brown's Otorhinolaryngology, p. 1221

First Aid: How to Stop a Nosebleed

Sit upright and lean forward slightly (not backward - prevents blood swallowing)
Pinch the soft part of the nose (cartilaginous portion, not the bony bridge) firmly
Hold for 10-15 minutes continuously without releasing to check
Breathe through the mouth
Two sprays of oxymetazoline 0.05% (Afrin-type nasal spray) into the affected nostril before applying pressure helps constrict vessels and stop bleeding faster
Apply a nose clip if available - shown to be superior to manual pressure alone
Do NOT tilt the head back, stuff cotton deep into the nose, or blow the nose during/immediately after

Medical Treatment (When First Aid Fails)

If bleeding doesn't stop after 15-20 minutes of proper pressure, or recurs frequently, see a doctor. Options include:

Step	Treatment
1st	Chemical cautery (silver nitrate) - most effective for anterior epistaxis; applied from periphery to center, max 15 sec contact; do NOT cauterize both sides of septum
2nd	Topical hemostatic agents - absorbable gelatin sponge (Gelfoam), Surgicel
3rd	Nasal packing - anterior tampon (Merocel sponge) or inflatable balloon (Rapid Rhino)
4th	Topical tranexamic acid - inhibits fibrinolysis; systematic review shows it reduces bleeding at 10 min and re-bleeding at 7-10 days; particularly useful in patients on antiplatelet drugs
Advanced	Posterior packing or arterial ligation/embolization for severe posterior epistaxis

Rosen's Emergency Medicine, p. 920-921

When to Seek Urgent Medical Care

Bleeding that does NOT stop after 20-30 minutes of correct first aid
Very heavy bleeding (soaking through cloths rapidly)
Blood flowing down the throat in large amounts
Associated with head/facial trauma
In a child under 2 years old (rare at this age - may suggest abuse or a bleeding disorder)
On anticoagulant medications
Associated with easy bruising, prolonged bleeding from cuts, or family history of bleeding disorders
Recurring very frequently (multiple times per week)

Prevention of Recurrence

Use a saline nasal spray or gel (e.g., NasoGEL) to keep nasal mucosa moist, especially in dry climates
Use a humidifier at home, particularly in winter
Avoid nose picking
Trim fingernails short
Manage allergies and nasal inflammation promptly
Control blood pressure if hypertensive
Review medications with your doctor (NSAIDs, blood thinners) if nosebleeds are frequent
Avoid excessive use of nasal decongestant sprays

Red Flags Suggesting a Serious Underlying Cause

See your doctor promptly if you also have:

Skin telangiectasias (tiny red dots on lips, fingertips, face) - possible HHT
Family history of recurrent nosebleeds
Spontaneous bruising or prolonged bleeding elsewhere
Unexplained fatigue (possible anemia from chronic blood loss)
A lump or growth visible inside the nose

In summary: Most regular nosebleeds are benign and respond to simple first aid. Recurrent bleeds warrant evaluation to rule out systemic causes (blood pressure, clotting disorders, HHT, medications). A simple ENT assessment with possible chemical cautery often resolves the problem long-term.

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