Epistaxis

Last updated: November 1, 2022

Summarytoggle arrow icon

Epistaxis is the medical term for a nosebleed, which is a common presenting concern in the emergency room. The most common site of bleeding is the Kiesselbach plexus, where the vessels supplying the nasal mucosa anastomose, resulting in bleeding from the nostrils (anterior epistaxis). Posterior epistaxis is less common and may not be clinically apparent because blood may flow down the throat. The most common causes of epistaxis include nose picking, a foreign body in the nasal cavity, and a dry nose. Usually, bleeding is self-limited, but severe epistaxis may occur in patients with posterior bleeding sites, systemic conditions such as hypertension or bleeding disorders, and/or following traumatic injury. Hereditary hemorrhagic telangiectasia, which is an autosomal dominant vasculopathy characterized by telangiectasia on the skin and mucosa, may cause recurrent epistaxis. Immediate measures to control epistaxis include elevating the patient's head and tilting it forward and pinching the nose. For continued bleeding from an anterior site, local hemostatic measures (i.e., vasoconstrictors and nasal cautery) are used. If hemostasis cannot be achieved with these measures, the nasal cavity must be packed and the patient referred to an ENT surgeon.

In most cases, the exact cause of epistaxis remains unknown (idiopathic epistaxis). While a single episode of epistaxis usually does not require any investigation, recurrent epistaxis must be investigated for an underlying cause (e.g., a bleeding disorder).

Local causes [1][2]

Systemic causes [1][3]

Classification of epistaxis [4]
Criteria Anterior epistaxis Posterior epistaxis
Clinical features
  • Bleeding from the nostrils
Relative frequency
  • ∼ 90% of cases
  • ∼ 10% of cases
Peak incidence [5]
  • Children < 10 years of age
  • Older individuals (> 50 years of age)
Most common site of bleeding

Posterior epistaxis may be a sign of life-threatening hemorrhages.

To remember the vessels that form the Kiesselbach plexus, think of LEGS: Labial (superior), Ethmoidal (anterior), Greater palatine, and Sphenopalatine arteries.

Immediate management [7][8][9]

Management of ongoing bleeding [7][8][9]

Anterior nasal packing is not sufficient to control posterior epistaxis.

Consult otolaryngology for refractory or recurrent bleeding despite nasal cautery and packing. [8]

Supportive treatment

For patients on anticoagulants or antiplatelets, initiate local treatments prior to withholding or reversing anticoagulants unless there is life-threatening epistaxis. [8][9]

In rare cases, retained nasal packing can cause toxic shock syndrome. [11]

Disposition [7][8][9]

  • Anterior epistaxis
    • Consider discharge after observation if hemostasis is successful.
    • Counsel patients on preventative measures and return precautions.
    • Arrange follow-up and ensure packing removal within 48–72 hours if discharging with nonresorbable packing.
  • Posterior epistaxis
    • Admit patients with posterior packing for monitoring.
    • Consider ICU admission for patients with hemodynamic instability.

  1. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  2. Tunkel DE, Anne S, Payne SC, et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg. 2020; 162 (1_suppl): p.S1-S38. doi: 10.1177/0194599819890327 . | Open in Read by QxMD
  3. Seikaly H. Epistaxis. N Engl J Med. 2021; 384 (10): p.944-951. doi: 10.1056/nejmcp2019344 . | Open in Read by QxMD
  4. Tomaselli GF, Mahaffey KW, Cuker A, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Am Coll Cardiol. 2020; 76 (5): p.594-622. doi: 10.1016/j.jacc.2020.04.053 . | Open in Read by QxMD
  5. Maul X, Dincer BC, Wu AW, et al. A Clinical Decision Analysis for Use of Antibiotic Prophylaxis for Nonabsorbable Nasal Packing. Otolaryngol Head Neck Surg. 2021; 165 (5): p.647-654. doi: 10.1177/0194599820988740 . | Open in Read by QxMD
  6. Shovlin C. Clinical Manifestations and Diagnosis of Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu Syndrome). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-hereditary-hemorrhagic-telangiectasia-osler-weber-rendu-syndrome.Last updated: September 29, 2017. Accessed: February 20, 2018.
  7. Faughnan ME, Palda VA, Garcia-Tsao G, et al. International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. J Med Genet. 2009; 48 (2): p.73-87. doi: 10.1136/jmg.2009.069013 . | Open in Read by QxMD
  8. Yau S. An update on epistaxis.. Aust Fam Physician. 2015; 44 (9): p.653-6.
  9. Japhet M Gilyomacorresponding and Phillipo L Chalya. Etiological profile and treatment outcome of epistaxis at a tertiary care hospital in Northwestern Tanzania: a prospective review of 104 cases. BMC Ear, Nose and Throat Disorders. 2011 .
  10. T W Chiu, J Shaw-Dunn, G W McGarry. Woodruff's plexus. The Journal of Laryngology & Otology. 2008; 122 (10): p.1074-1077. doi: 10.1017/s002221510800176x . | Open in Read by QxMD
  11. Fatakia A, Winters R, Amedee RG. Epistaxis: a common problem.. The Ochsner journal. 2010; 10 (3): p.176-8.
  12. Williams NS, Bulstrode C, O'Connell PR. Bailey & Love's Short Practice of Surgery. CRC Press ; 2013
  13. Alter H. Approach to the adult with epistaxis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis.Last updated: February 2, 2016. Accessed: March 30, 2017.
  14. American Academy of Otolaryngology - Head and Neck Surgery Foundation. Primary Care Otolaryngology. American Academy of Otolaryngology - Head and Neck Surgery Foundation ; 2011

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