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Epistaxis: Complete Clinical Guide

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Vascular Anatomy - The Foundation

• Internal maxillary artery → sphenopalatine artery (posterior septal + posterior lateral nasal branches), descending palatine → greater palatine artery
• Facial artery → superior labial artery

• Ophthalmic artery → anterior ethmoidal artery, posterior ethmoidal artery

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1. Bleeding Site: Anterior vs. Posterior Differentiation

Kiesselbach's Plexus (Little's Area) - Anterior

• Anterior ethmoidal artery
• Sphenopalatine artery
• Greater palatine artery
• Superior labial artery

Woodruff Plexus - Posterior

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2. Causes

Local Causes

Systemic Causes

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3. Risk Factors

• Age: bimodal peaks - children <10 years and adults >35-50 years
• Male sex (estrogen appears to have a protective effect on nasal vasculature)
• Winter/dry climate (nasal mucosal desiccation)
• Anticoagulant or antiplatelet medications
• Hypertension (associated with persistent/severe bleeding, though causation unproven)
• Bleeding disorders (haemophilia, vWD, thrombocytopenia)
• Nasal septal deviation
• Recurrent URTIs
• HHT (family history)
• Chronic liver/renal disease
• Prior nasal surgery (altered anatomy)
• Cocaine use (mucosal damage)

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4. Investigations

Clinical Assessment First

• Airway, breathing, circulation (assess hemodynamic stability)
• Anterior rhinoscopy with nasal speculum (vertical opening to visualize septum)
• Nasendoscopy (rigid or flexible) to identify posterior source
• Ask the patient to blow the nose to clear clots, then apply pressure + oxymetazoline 0.05% spray before examination

Laboratory Investigations

• Severe hemorrhage with haemodynamic compromise
• Anticoagulant/antiplatelet therapy
• Suspected coagulopathy or bleeding disorder
• Advanced liver disease / haematologic malignancy

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5. Emergency OPD Management - Step-by-Step

STEP 1: Initial Assessment and Stabilisation

• Assess airway, breathing, circulation - address haemodynamic instability first
• Sit patient upright, leaning slightly forward (prevents swallowing blood, reduces aspiration risk)
• Large-bore IV access + fluid resuscitation if haemodynamically compromised
• Pulse oximetry, BP monitoring
• Patient is often anxious and hypertensive - address both

STEP 2: First Aid Measures

• Instruct patient to blow nose to clear clots
• Apply 2 sprays of oxymetazoline 0.05% (or xylometazoline) into affected nostril - vasoconstriction facilitates examination and haemostasis
• Apply firm digital pressure on the cartilaginous (soft) part of the nose (not the bony bridge) for 10-15 minutes continuous; a nose clip is superior to manual pressure alone
• Apply ice pack over nose bridge

STEP 3: Local Anaesthesia and Examination

• Apply 2% aqueous lidocaine via mucosal atomisation or soaked pledget (with adrenaline for added vasoconstriction)
• Examine with nasal speculum (opened vertically, floor of nose parallel to floor)
• Identify bleeding source via anterior rhinoscopy or nasendoscopy

STEP 4: Chemical Cautery (if source identified)

• Silver nitrate cauterisation - first-line when bleeding point visible; highly effective with low re-bleeding rate
• Cauterise from periphery to centre, superiorly to inferiorly (blood makes sticks ineffective)
• Contact with mucosa no longer than 15 seconds to prevent septal necrosis
• NEVER cauterise both sides of the septum simultaneously - risk of septal perforation and necrosis
• If cautery fails, apply topical thrombogenic agents: Gelfoam (absorbable gelatin sponge) or Surgicel (oxidised cellulose)

STEP 5: Topical Tranexamic Acid

• 500 mg of IV tranexamic acid solution applied to a nasal pledget or atomised into the nose
• Evidence supports benefit in reducing bleeding at 10 minutes and re-bleeding at 7-10 days
• Superior to anterior nasal packing specifically in patients on antiplatelet drugs
• No significant increase in adverse events

STEP 6: Anterior Nasal Packing (if cautery fails)

1. Merocel (polyvinyl alcohol) nasal tampon - inserted along floor of nose, expands with moisture; may control high-pressure arterial bleeds; remove after 3-5 days
2. Rapid Rhino balloon catheter - coated in procoagulant material, inflated with air along floor of nose; self-lubricating
3. Vaseline-impregnated ribbon gauze - traditional, effective but uncomfortable; layered from floor upwards in accordion fashion
4. Absorbable packs (Nasopore, MeroGel) - dissolve within 1 week; better tolerated but less pressure

• Insert along the floor of the nose in an inferior vector (not superiorly against middle turbinate)
• Moisten before removal to prevent mucosal trauma
• For uncontrolled bleeding despite anterior pack in one naris, insert second anterior pack in opposite naris

STEP 7: Posterior Packing (if anterior packing fails - posterior epistaxis)

• Indicated when bleeding continues despite properly placed anterior nasal packing
• Options:
  • Double balloon catheter (e.g., Brighton/Epistat balloon): posterior balloon inflated in nasopharynx, anterior balloon in nasal cavity
  • Foley catheter + anterior gauze pack - classical method (14-16 Fr Foley, balloon inflated with 7-10 mL saline in nasopharynx)
  • Gauze postnasal pack under GA in theatre
• Requires inpatient admission with monitoring (risk of hypoxia, eustachian tube dysfunction, pain)
• ENT consultation mandatory

STEP 8: Refractory/Surgical Management

STEP 9: Treat Underlying Cause

• Reverse anticoagulation if clinically appropriate (Vitamin K for warfarin, reversal agents for NOACs)
• Manage hypertension (does not directly cause epistaxis but worsens persistent bleeding)
• Correct coagulopathy, transfuse if Hb <7 g/dL
• Address thrombocytopenia
• Platelet transfusion if count critically low

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6. Age-Wise Approach

Children (< 10 years) - Most Common Age Group

• Predominant cause: Nose picking, trauma, URTIs, low humidity, allergies
• Site: Anterior (Kiesselbach's plexus) in almost all cases
• Severity: Usually mild, self-limiting
• Special considerations:
  • In children <2 years, epistaxis is rare - always consider non-accidental trauma (NAT) and bleeding disorders
  • Exclude nasal foreign body (unilateral, foul-smelling discharge)
  • Exclude juvenile angiofibroma in adolescent boys (unilateral progressive epistaxis, nasal obstruction - do NOT biopsy, pre-op embolisation required)
  • HHT may first manifest in childhood
  • Screen for haematologic malignancy (leukaemia) if associated bruising/pallor
• Management: First-aid pressure, oxymetazoline, silver nitrate cautery under local anaesthesia if source visible; nasal moisturisers for recurrence prevention
• Do NOT routinely perform bilateral septal cautery in children

Young Adults (10-35 years)

• Predominant causes: Trauma, nose picking, septal deviation, substance abuse (cocaine - septal perforation), sports injuries, iatrogenic (post-septal/nasal surgery)
• Site: Usually anterior
• Considerations:
  • Cocaine use causes progressive septal destruction
  • Screen for bleeding disorders (vWD especially in young females with recurrent epistaxis)
  • Pregnancy-associated epistaxis (hormonal mucosal engorgement)
  • HHT presenting with recurrent episodes
• Management: Cautery usually sufficient; address underlying cause

Middle-Aged Adults (35-60 years)

• Predominant causes: Hypertension, antiplatelet medications, septal pathology, rhinitis, chronic alcohol use
• Transition period where posterior epistaxis starts becoming more prevalent
• Considerations:
  • Onset of posterior epistaxis; assess need for posterior packing
  • Screen for systemic comorbidities
  • Exclude sinonasal malignancy in unilateral presentations with nasal obstruction/facial pain
• Management: Address underlying hypertension and coagulopathy; chemical cautery or anterior packing usually sufficient; escalate if posterior bleed suspected

Elderly (> 60-70 years)

• Predominant causes: Hypertension, arteriosclerosis (vessel fragility), anticoagulants (warfarin, NOACs), antiplatelet agents, chronic liver/renal disease
• Site: Frequently posterior; arterial bleeds from sphenopalatine branches
• Severity: More severe, harder to control, higher recurrence and mortality (13.9% recurrence, 3.4% mortality at 30 days in UK nationwide study)
• Special considerations:
  • Multiple comorbidities complicate management (anticoagulation, cardiac disease)
  • Higher risk of aspiration, hypoxia from posterior packing
  • Mucosal atrophy worsens fragility
  • Altered anatomy from prior surgeries
  • Monitor for cardiovascular complications during packing
• Management: Posterior packing more often required; earlier ENT involvement; consider endoscopic SPA ligation over prolonged posterior packing (better tolerated in elderly); reverse anticoagulation carefully with haematology input

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7. Prevention and Discharge Advice

• Saline nasal spray or nasal moisturiser (petroleum jelly to nasal vestibule) - prevents mucosal drying
• Avoid nose picking; cut fingernails
• Use humidifier at home in winter
• Lean forward (not backward) during a nosebleed
• Apply firm digital pressure for 10-15 minutes without interruption
• Avoid hot drinks, alcohol, and strenuous activity for 24-48 hours post-episode
• Review anticoagulant/antiplatelet medications with prescribing physician
• Return to ED if bleeding recurs and does not stop with 20 minutes of pressure

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• Cummings Otolaryngology Head and Neck Surgery, Chapter 47 (Epistaxis)
• Rosen's Emergency Medicine, Chapter 58 (Epistaxis)
• Bailey & Love's Short Practice of Surgery, 28th Ed., Chapter 51
• Roberts and Hedges' Clinical Procedures in Emergency Medicine, Chapter 15