Epistaxis

Causes

• Idiopathic (approximately 85% of cases)

• Local

  • Digital trauma (nose picking)

  • Dry air (especially during winter)

  • Structural issues (septal deviation), nasal irritants (cocaine, intranasal steroids)

  • Chronic nasal inflammation (recurrent URTI)

  • Tumours (rare)

• Systemic

  • Hypertension

  • Coagulopathies (e.g. liver disease, alcohol misuse, hereditary bleeding disorders)

  • Medications (anticoagulants, NSAIDs, SSRIs)

  • Haematological conditions (leukaemia, thrombocytopenia)

History

• Frequency and duration of nosebleeds

• Medications (NSAIDs, anticoagulants) and over-the-counter remedies

• Signs of bleeding disorder (gum bleeding, easy bruising, menorrhagia)

• Possible triggers (nose picking, illicit substances, heavy alcohol use)

• Unilateral or bilateral bleeding

• Any postnasal drip, haematemesis, or melaena from swallowed blood

• Red flag symptoms (night sweats, weight loss, bone pain)

• Symptoms of anaemia (fatigue, dizziness, pallor)

Examination

• Check vital signs (postural hypotension, tachycardia)

• Look for signs of anaemia (pallor, tachycardia) or chronic liver disease (jaundice, spider naevi)

• Inspect for stigmata of coagulopathy (bruising, petechiae)

• Anterior rhinoscopy

  • Evaluate Little’s area (common site of anterior bleeds)

  • Note excoriations, granulations, or visible vessels

• Bilateral bleeding or prominent postnasal drip suggests posterior source

• Consider nasal endoscopy if bleeding source is unclear

Investigations

• Usually clinical diagnosis for mild, recurrent anterior bleeds

• FBC and coagulation profile if epistaxis is recurrent, severe, or suspected coagulopathy

• LFTs if chronic liver disease is suspected

• CT scan of the sinuses or nasopharynx if structural lesion or tumour is suspected

Management

• Acute

  • Sit patient upright, leaning forward, to prevent blood swallowing

  • Pinch soft part of the nostrils firmly for at least 10 minutes

  • Apply cold packs to the nose or neck to induce vasoconstriction

  • Consider topical vasoconstrictors (phenylephrine) with local anaesthesia (lignocaine) if available

  • If visible bleeding site, cauterise with silver nitrate under good visualisation

  • Anterior nasal packing if bleeding persists or source not clearly identified

  • Posterior packing or balloon catheter if posterior bleed is suspected (often bilateral or heavy bleed)

  • Insert IV cannula if risk of significant blood loss and check bloods including coags

  • Refer to ENT or ED if uncontrolled bleeding, shock, or suspicion of posterior source

• Long-Term and Preventive

  • Avoid nasal trauma (picking, forceful blowing) and reduce aggravating factors (dry air, irritants)

  • Use topical emollients or antibiotic-steroid ointments (e.g. Kenacomb) to keep nasal mucosa moist and prevent crusting

  • Optimise management of systemic factors (control hypertension, review anticoagulants if recurrent bleeds)

  • ENT follow-up for recurrent idiopathic bleeds or suspected anatomical abnormality

  • Consider antibiotic prophylaxis in certain cases of nasal packing to prevent toxic shock syndrome (depending on pack type and clinical risk)

Complications

• Significant blood loss, leading to hypovolaemia or anaemia

• Nasal septal haematoma, which can cause cartilage necrosis if untreated

• Infection, including rare toxic shock syndrome

• Aspiration of blood, particularly with posterior bleeds

• Need for surgical intervention (arterial ligation or embolisation) if conservative measures fail

Key Points

• Most epistaxis arises from Kiesselbach’s plexus in Little’s area (anterior bleeds) and is easily managed with pressure and local cautery

• Posterior bleeds tend to be more severe, often requiring specialist involvement

• Patients on anticoagulants may need dose adjustment or temporary reversal if bleeding is severe or uncontrolled

• Early referral to ENT is indicated for refractory cases, high suspicion of posterior source, or structural lesions