- Clinical science
Epistaxis is the medical term for nosebleed, which is a common presenting complaint in the emergency room. The most common site of bleeding is the Kiesselbach plexus, where the vessels supplying the nasal mucosa anastomose with each other. Bleeding from this region causes blood to flow out through the nostrils (anterior epistaxis). Rarely, epistaxis may not be apparent because blood runs down the throat (posterior epistaxis). The most common causes of epistaxis include nose picking, foreign body in the nasal cavity, and a dry nose. Usually, the bleeding stops on its own, but severe epistaxis may occur with hypertension, bleeding disorders, and/or following severe traumatic injury. Hereditary hemorrhagic telangiectasia, which is an autosomal dominant vasculopathy characterized by telangiectasia on the skin and mucosa, is another cause of recurrent epistaxis. Immediate measures to control epistaxis include elevation of the upper body, application of ice packs, and nose pinching. If bleeding does not subside, the nasal cavity must be packed and the patient must be 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 
- Nasal irritation
- Vascular malformations
- Inflammatory/granulomatous disorders
- Craniofacial trauma
Nasal septal defects
- Deviated nasal septum
- Septal spurs
- Septal perforation
- Tumors of the nasopharynx and/or paranasal sinuses
Systemic causes 
|Classification of epistaxis |
|Criteria||Anterior epistaxis||Posterior epistaxis|
|Clinical features|| |
|Relative frequency|| || |
|Peak incidence || || |
|Most common site of bleeding|
Posterior epistaxis may be a sign of life-threatening hemorrhages.
Immediate measures 
- Begin if the patient is hemodynamically unstable.
- Keep the patient calm .
- Elevate the patient's upper body and bend their head forward .
- Apply cold packs and sustained, direct pressure by pinching the nose at the nostrils for 5–10 minutes in order to occlude the bleeding vessel.
- Apply topical vasoconstrictors (e.g., oxymetazoline, phenylephrine).
If epistaxis continues after 10–15 minutes 
- First-line: cauterization of the bleeding vessel using silver nitrate or electrocautery
- Second-line: nasal packing using gauze impregnated with petrolatum and antibiotics (for Staphylococcus aureus coverage). 
- If epistaxis persists: arterial embolization or endoscopic ligation of the bleeding vessel
Nasal packs can cause toxic shock syndrome if left in place for more than 24 hours.
- Definition: a hereditary, systemic vasculopathy characterized by telangiectasia on the skin and mucosa, particularly in the area of the face (nose, lips, tongue)
- Pattern of inheritance: autosomal dominant
- Pathophysiology: mutations in genes which code for TGF-β receptors (e.g., endoglin or ALK-1) → structural defects in the vessel wall → postcapillary venous pooling → formation of small and large arteriovenous shunts
- Clinical features 
- Diagnosis