Epistaxis: Assessment and Management

Introduction

Epistaxis, or nosebleed, is one of the most common ENT presentations to primary care and the emergency department. The great majority are minor, self-limiting, and managed with simple first aid, but a minority - particularly in older adults on anticoagulants, or those with an underlying bleeding disorder - can cause significant blood loss and need urgent intervention.¹

Understanding the anatomy of the nasal blood supply explains both why most bleeds are anterior and easily controlled, and why the less common posterior bleeds are harder to manage and more likely to need specialist input.

Anatomy and classification

Anterior epistaxis

Around 90% of nosebleeds arise from Little's area, a region on the anterior nasal septum where branches of four arteries converge to form a superficial vascular plexus known as Kiesselbach's plexus: the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries. Because this plexus lies directly under a thin, exposed mucosa, it is vulnerable to drying, trauma and minor knocks, which is why anterior bleeds predominate in children and young adults.^1,2

Posterior epistaxis

A smaller proportion of bleeds arise more posteriorly, from Woodruff's plexus near the posterior nasal cavity, supplied predominantly by branches of the sphenopalatine artery. Posterior bleeds are more common in older adults with hypertension and atherosclerosis, tend to bleed more heavily, are harder to visualise directly, and are more likely to require nasal packing or surgical/radiological intervention.¹

Aetiology and risk factors

Causes are usefully split into local and systemic factors, and both should be actively considered, particularly in recurrent or severe presentations:¹

Local causes

• Digital trauma (nose picking), especially in children
• Dry or cold air, and low humidity, which dries and cracks the mucosa
• Upper respiratory tract infection or allergic rhinitis
• Nasal septal deviation or a septal spur
• Nasal foreign body (consider in a young child with unilateral, offensive discharge or bleeding)
• Cocaine use, which is directly damaging to the nasal mucosa
• Nasal or sinus tumours - important to consider in unilateral, persistent or recurrent bleeding in an adult

Systemic causes

• Anticoagulant or antiplatelet medication
• Inherited bleeding disorders (e.g. von Willebrand disease, haemophilia)
• Hypertension, particularly relevant to posterior bleeds
• Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu syndrome) - recurrent epistaxis from childhood with mucocutaneous telangiectasia
• Liver disease, causing an acquired coagulopathy
• Excess alcohol intake

Assessment

As with any bleeding presentation, begin with an assessment of haemodynamic stability (ABCDE) if the bleed is severe or ongoing. Establish the duration, estimated volume of blood loss, and whether blood is being swallowed (suggesting a posterior source), and ask specifically about anticoagulant or antiplatelet use, known bleeding disorders, recurrent nosebleeds, and a family history suggestive of hereditary haemorrhagic telangiectasia.¹

Examination with a good light source and nasal speculum (anterior rhinoscopy) aims to identify a visible bleeding point, most often on the anterior septum at Little's area. Inspect the lips, tongue and skin for telangiectasia if hereditary haemorrhagic telangiectasia is suspected, and check blood pressure.

Investigations

Most minor, self-limiting anterior nosebleeds need no investigation. For recurrent or severe epistaxis, arrange FBC (to assess for anaemia and platelet count), a clotting screen (particularly if on warfarin or a bleeding disorder is suspected), and group and save or crossmatch if blood loss is significant or ongoing.¹ Endoscopic nasal examination by ENT is used when no anterior source is found, to look for a posterior bleeding point or an underlying structural lesion.

Management

First aid

The patient should sit up and lean forward, not tilt the head back, to avoid swallowing blood (which can cause nausea, vomiting and aspiration) and to allow inspection of ongoing bleeding. Firm continuous pressure is applied by pinching the soft, cartilaginous lower part of the nose (not the bony bridge) for a full 10-15 minutes without releasing to check, alongside an ice pack to the nasal bridge or sucking on ice.¹

If first aid fails

If bleeding continues despite adequate first aid, and a bleeding point is visible, chemical cautery with silver nitrate (after topical local anaesthetic) is first line. Only one side of the septum should be cauterised in a single sitting wherever possible, as bilateral cautery carries a meaningful risk of septal perforation from disrupting the blood supply to the cartilage on both sides at the same level.^1,2

If no bleeding point is visible, or cautery fails, anterior nasal packing (e.g. a nasal tampon or inflatable pack) is used, and the patient is usually admitted for observation. Naseptin cream (chlorhexidine and neomycin) can be used for a few days after minor bleeds to reduce crusting and the chance of re-bleeding, but should be avoided in peanut or soya allergy because of its arachis oil base.

Posterior or refractory bleeding

Bleeding that continues despite anterior packing, or is clearly posterior in origin, needs posterior packing and admission under ENT. Options for ongoing refractory bleeding include surgical arterial ligation (e.g. endoscopic sphenopalatine artery ligation) or interventional radiological embolisation. Any anticoagulation should be reviewed with the relevant specialty rather than stopped unilaterally, balancing bleeding risk against the indication for anticoagulation.

Complications

• Hypovolaemia and, rarely, haemorrhagic shock with severe or posterior bleeds
• Aspiration of swallowed blood, particularly if the head is tilted back
• Septal haematoma or perforation, from cautery or prolonged/forceful packing
• Toxic shock syndrome, a rare but recognised complication of prolonged nasal packing
• Recurrent bleeding and iron-deficiency anaemia with frequent episodes

Red flags

Prognosis

The majority of anterior nosebleeds settle with first aid alone or with cautery, and most patients need no further follow-up. Children with recurrent bleeds from Little's area typically improve as they get older and stop picking at the nose, with the mucosa less prone to drying.¹

Recurrence is more likely in older adults with poorly controlled hypertension, ongoing anticoagulation, or an underlying structural or systemic cause, and these patients benefit from addressing modifiable risk factors alongside acute treatment of each episode.