Background

Epistaxis, or bleeding from the nose, is a common complaint. It is rarely life threatening but may cause significant
concern, especially among parents of small children.[1] Most nosebleeds are benign, self-limiting, and spontaneous, but
some can be recurrent. Many uncommon causes are also noted.
Epistaxis can be divided into 2 categories, anterior bleeds and posterior bleeds, on the basis of the site where the bleeding
originates (see the image below).

Posterior epistaxis from the left sphenopalatine artery.

The true prevalence of epistaxis is not known, because most episodes are self-limited and thus are not reported. When
medical attention is needed, it is usually because of either the recurrent or severe nature of the problem. Treatment
depends on the clinical picture, the experience of the treating physician, and the availability of ancillary services. [2, 3, 4, 5]
Anatomy
The nose has a rich vascular supply, with substantial contributions from the internal carotid artery (ICA) and the external
carotid artery (ECA).
The ECA system supplies blood to the nose via the facial and internal maxillary arteries. The superior labial artery is one
of the terminal branches of the facial artery. This artery subsequently contributes to the blood supply of the anterior nasal
floor and anterior septum through a septal branch.
The internal maxillary artery enters the pterygomaxillary fossa and divides into 6 branches: posterior superior alveolar,
descending palatine, infraorbital, sphenopalatine, pterygoid canal, and pharyngeal.
The descending palatine artery descends through the greater palatine canal and supplies the lateral nasal wall. It then
returns to the nose via a branch in the incisive foramen to provide blood to the anterior septum. The sphenopalatine artery
enters the nose near the posterior attachment of the middle turbinate to supply the lateral nasal wall. It also gives off a
branch to provide blood supply to the septum.
The ICA contributes to nasal vascularity through the ophthalmic artery. This artery enters the bony orbit via the superior
orbital fissure and divides into several branches. The posterior ethmoid artery exits the orbit through the posterior ethmoid
foramen, located 2-9 mm anterior to the optic canal. The larger anterior ethmoid artery leaves the orbit through the
anterior ethmoid foramen.
The anterior and posterior ethmoid arteries cross the ethmoid roof to enter the anterior cranial fossa and then descend into
the nasal cavity through the cribriform plate. Here, they divide into lateral and septal branches to supply the lateral nasal
wall and the septum.
The Kiesselbach plexus, or Little’s area, is an anastomotic network of vessels located on the anterior cartilaginous septum.
It receives blood supply from both the ICA and the ECA.[6] Many of the arteries supplying the septum have anastomotic
connections at this site.
Pathophysiology
Bleeding typically occurs when the mucosa is eroded and vessels become exposed and subsequently break.
More than 90% of bleeds occur anteriorly and arise from Little’s area, where the Kiesselbach plexus forms on the
septum.[7, 8] The Kiesselbach plexus is where vessels from both the ICA (anterior and posterior ethmoid arteries) and the
ECA (sphenopalatine and branches of the internal maxillary arteries) converge. These capillary or venous bleeds provide a
constant ooze, rather than the profuse pumping of blood observed from an arterial origin. Anterior bleeding may also
originate anterior to the inferior turbinate.
Posterior bleeds arise further back in the nasal cavity, are usually more profuse, and are often of arterial origin (eg, from
branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx). A posterior source presents a greater
risk of airway compromise, aspiration of blood, and greater difficulty controlling bleeding.
History
Controlling significant bleeding or hemodynamic instability should always take precedence over obtaining a lengthy
history.
Ask specific questions about the severity, frequency, duration, and laterality of the nosebleed. Determine whether the
bleed occurs after exercise or during sleep or is associated with a migraine. Determine whether hematemesis or melena
has occurred because posterior bleeding in particular may present in this fashion.
Inquire about precipitating and aggravating factors and methods used to stop the bleeding. Most nosebleeds are reported
as spontaneous events and are frequently related to nose picking or other trauma; therefore, investigate the various
possibilities.
Foreign bodies inserted in the nose may also present with epistaxis, but bleeding may be less and accompanied by foul or
purulent discharge if the object has been retained for some time. A unilateral nasal discharge suggests the presence of a
foreign body.
Children easily can insert small batteries from electronic devices (eg, calculators, watches, handheld video games) into
their nostrils. Not only can local irritation and bleeding result, but these can leak and cause a chemical alkali burn that
may result in local tissue necrosis. Severe complications (eg, nasal stenosis) can result from batteries. Removal is a
priority; removing the batteries within 4 hours of insertion is best.
In addition to obtaining a head and neck history with an emphasis on nasal symptoms, elicit a general medical history
concerning relevant medical conditions, current medications, and smoking and drinking habits.
Inquire about previous epistaxis, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding
after minor surgical procedures. A history of frequent recurrent nosebleeds, easy bruising, or other bleeding episodes
should make the clinician suspicious of a systemic cause and prompt a hematologic workup. Obtain any family history of
bleeding disorders or leukemia.
Children with severe epistaxis are more likely to have required nasal cauterization, an underlying coagulopathy, a positive
family history of bleeding, and anemia. Although unusual, children with bleeding disorders (eg, von Willebrand disease)
can occasionally have normal coagulation profiles. More than 1 sample may be required to notice the abnormality due to
biologic variability throughout the day.
Use of medications—especially aspirin, NSAIDs, warfarin, heparin, ticlopidine, and dipyridamole—should be
documented, as these not only predispose to epistaxis but make treatment more difficult. Particularly in children, include
investigation of suspicion of accidental ingestion (eg, accidental ingestion of rat poison in toddlers).
Physical Examination
Before evaluating a patient with epistaxis, have sufficient illumination, adequate suction, all the necessary topical
medications, and cauterization and packing materials ready. Remove all packings, even though bleeding may not be
active. The importance of obtaining adequate anesthesia and vasoconstriction if time permits cannot be overemphasized.
A comfortable patient tends to be more cooperative, allowing for better examination and more effective treatment.
Perform a thorough and methodical examination of the nasal cavity. Blowing the nose decreases the effects of local
fibrinolysis and removes clots, permitting a better examination. Application of a vasoconstrictor (eg, 0.05%
oxymetazoline) before the examination may reduce hemorrhage and help to pinpoint the precise bleeding site. A topical
anesthetic (eg, 4% aqueous lidocaine) reduces pain associated with the examination and nasal packing. Clots are then
suctioned out to permit a thorough examination.
Gently insert a nasal speculum (see the image below) and spread the naris vertically. Begin the examination with
inspection, looking specifically for any obvious bleeding site on the septum that may be amenable to direct pressure or
cautery. This permits visualization of most anterior bleeding sources. Anterior bleeds from the nasal septum are most
common type, and the site can frequently be identified if bleeding is active.
 Nasal speculum.
If an anterior source cannot be visualized, if the hemorrhage is from both nares, or if constant dripping of blood is seen in
the posterior pharynx, the bleeding may be from a posterior site. After placement of an anterior pack, and, if bleeding is
noted in the pharynx with the anterior pack in place, strongly consider a posterior bleed.
Massive epistaxis may be confused with hemoptysis or hematemesis. Blood dripping from the posterior nasopharynx
confirms a nasal source. Approximately 90% of nosebleeds can be visualized in the anterior portion of the nasal cavity.
Fiberoptic endoscopy may be performed with a flexible or (preferably) rigid endoscope to inspect the entire nasal cavity,
including the nasopharynx. The rigid endoscope is preferred because of its superior optics and its ability to allow
endoscopic suction and cauterization.
Examine the skin for evidence of bruises or petechiae that may indicate an underlying hematologic abnormality.
Assess vital signs. Although high blood pressure rarely, if ever, causes epistaxis on its own, it may impede clotting. Check
blood pressure, and complete a workup if high blood pressure is present. Persistent tachycardia must be recognized as an
early indicator of significant blood loss requiring intravenous (IV) fluid replacement and, potentially, transfusion.
Complications
Complications of epistaxis may include the following:
 Sinusitis  Vasovagal episode
 Septal hematoma/perforation  Balloon migration
 External nasal deformity  Aspiration
 Mucosal pressure necrosis
Diagnostic Considerations
Recurrent epistaxis in children could be caused by a foreign body, especially if the nosebleeds are accompanied by
symptoms of unilateral nasal congestion and purulent rhinorrhea. Delayed epistaxis in a trauma patient may signal the
presence of a traumatic aneurysm.
Other conditions to be considered include the following:  Coumarin Plant Poisoning
 Chemical irritants  Disseminated Intravascular Coagulation in
 Hepatic failure Emergency Medicine
 Leukemia  Emergent Treatment of Endometriosis
 Thrombocytopenia  Nasal Foreign Bodies
 Heparin toxicity  Nonsteroidal Anti-inflammatory Agent Toxicity
 Ticlopidine toxicity  Pediatric Osler-Weber-Rendu Syndrome
 Dipyridamole toxicity  Rodenticide Toxicity
 Trauma  Salicylate Toxicity
 Tumor  Sinusitis Imaging
Differential Diagnoses  Type A Hemophilia
 Allergic Rhinitis  Type B Hemophilia
 Barotrauma  von Willebrand Disease
 Cocaine Toxicity  Warfarin and Superwarfarin Toxicity
Approach Considerations
For the most part, laboratory studies are not needed or helpful for first-time nosebleeds or infrequent recurrences with a
good history of nose picking or trauma to the nose. However, they are recommended if major bleeding is present or if a
coagulopathy is suspected.
Laboratory Tests
Laboratory tests to evaluate the patient’s condition and underlying medical problems may be ordered depending on the
clinical picture at the time of presentation. If the bleeding is minor and not recurrent, then a laboratory evaluation may not
be needed.
If a history of persistent heavy bleeding is present, obtain a hematocrit count and type and cross-match. If a history of
recurrent epistaxis, a platelet disorder, or neoplasia is present, obtain a complete blood count (CBC) with differential. The
bleeding time is an excellent screening test if suspicion of a bleeding disorder is present. Obtain the international
normalized ratio (INR)/prothrombin time (PT) if the patient is taking warfarin or if liver disease is suspected. Obtain the
activated partial thromboplastin time (aPTT) as necessary.
Other Studies
Direct visualization with a good directed light source, a nasal speculum, and nasal suction should be sufficient in most
patients. However, computed tomography (CT) scanning, magnetic resonance imaging (MRI) or both may be indicated to
evaluate the surgical anatomy and to determine the presence and extent of rhinosinusitis, foreign bodies, and neoplasms.
Nasopharyngoscopy may also be performed if a tumor is the suspected cause of bleeding.
Sinus films are rarely indicated for a nosebleed. Angiography is rarely indicated.
Approach Considerations
When medical attention is needed for epistaxis, it is usually because of the problem is either recurrent or severe.
Treatment depends on the clinical picture, the experience of the treating physician, and the availability of ancillary
services.
In most patients with epistaxis, the bleeding responds to cauterization, nasal packing, or both. For those who have
recurrent or severe bleeding for which medical therapy has failed, various surgical options are available. After surgery or
embolization, patients should be closely observed for any complications or signs of rebleeding.
Medical approaches to the treatment of epistaxis may include the following:
 Adequate pain control in patients with nasal packing, especially in those with posterior packing (However, the
need of adequate pain control has to be balanced with the concern over hypoventilation in the patient with
posterior pack.)
 Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock syndrome
 Avoidance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)
 Medications to control underlying medical problems (eg, hypertension, vitamin K deficiency) in consultation with
other specialists
Manual Hemostasis
Initial treatment begins with direct pressure. The nostrils are squeezed together for 5-30 minutes straight, without frequent
peeking to see if the bleeding is controlled. Usually, 5-10 minutes is sufficient.
Patients should keep their heads elevated but not hyperextended because hyperextension may cause bleeding into the
pharynx and possible aspiration. This maneuver works more than 90% of the time.
If direct pressure is not sufficient, gauze moistened with epinephrine at a ratio of 1:10,000 or phenylephrine (Neo-
Synephrine) may be placed in the affected nostril to help vasoconstrict and achieve hemostasis.
Humidification and Moisturization
If bleeding is caused by excessive dryness in the home (eg, from radiator heating), patients may benefit from humidifying
the air with a cool mist vaporizer in the bedroom or, as a simpler alternative, placing a metal basin of water on top of a
radiator to humidify the ambient air.
Nasal saline sprays are useful. Oxymetazoline may also be used, with fewer cardiac adverse effects. To minimize the risk
of rhinitis medicamentosa and tachyphylaxis, these agents should be used for no more than 3-5 days at a time.
The physician may consider local application of bacitracin or petrolatum ointment directly to the Kiesselbach area with a
cotton applicator to prevent further drying (studies recommend 2 wk).
Cauterization
Bleeding from the Kiesselbach plexus (Little’s area) is frequently treated with silver nitrate cauterization. [13] Manage the
vessels leading to the site before managing the actual bleeding site. Avoid random and aggressive cauterization and
cautery on opposing surfaces of the septum.
Electrocauterization with an insulated suction cautery unit can also be used. This method is usually reserved for more
severe bleeding and for bleeding in more posteriorly located sites, and it often requires local anesthesia. The effectiveness
of both cauterization methods can be enhanced by using rigid endoscopy, especially in the case of more posteriorly
located bleeding sites (see the image below).[16]

Resolved posterior epistaxis after endoscopic cauterization of the left sphenopalatine artery.
After the bleeding has been controlled, instruct the patient to use nasal saline spray and antibiotic ointment and to avoid
strenuous activities for 7-10 days. NSAIDs are to be avoided if at all possible. Digital manipulation of the nose is to be
avoided. A topical vasoconstrictor may be used if minor bleeding recurs with the dislodging of the eschar.
Nasal Packing
Nasal packing can be used to treat epistaxis that is not responsive to cauterization. Two types of packing, anterior and
posterior, can be placed. In both cases, adequate anesthesia and vasoconstriction are necessary.
A study by Kundi and Raza suggested that in patients with epistaxis, removal of nasal packs after 12 hours leads to a
lower incidence of headache and excessive lacrimation than does removal of packs after 24 hours, with no significant
difference in bleeding recurrence. The study involved 60 patients with epistaxis, evenly divided between the 12-hour and
24-hour groups.[17]
Anterior
For anterior packing, various packing materials are available. Petroleum jelly gauze (0.5 in × 72 in) filled with an
antibiotic ointment is traditionally used (see the image below). Layer it tightly and far enough posteriorly to provide
adequate pressure. Blind packing with loose gauze is to be avoided.

Vaseline gauze packing.

Merocel sponges can be placed relatively easily and quickly but may not provide adequate pressure (see the image below).
They should be coated with an antibiotic ointment and can be hydrated with a topical vasoconstrictor.

Expandable (Merocel) packing (dry).

All packings should be removed in 3-4 days. Absorbable materials (eg, Gelfoam, Surgicel, Avitene) may be used in
patients with coagulopathy to prevent trauma upon packing removal. Administer prophylactic antibiotics to all patients
with packing, and instruct them to avoid physical strain for 1 week.
Also see Anterior Epistaxis Nasal Pack.
Posterior
Epistaxis that cannot be controlled by anterior packing can be managed with posterior packing. Classically, rolled gauzes
are used, but medium tonsil sponges can be substituted.
Recently, inflatable balloon devices (eg, 12 or 14 French Foley catheters) or specially designed catheters manufactured by
companies such as Storz and Xomed (eg, Storz Epistaxis Catheter, Xomed Treace Nasal Post Pac) have become popular
because they are easier to place. Avoiding overinflation of the balloon is important because it can cause pain and
displacement of the soft palate inferiorly, interfering with swallowing.
A 2010 study by Garcia Callejo et al determined that gauze packing, despite being slower and more uncomfortable, has a
higher success rate, produces fewer local injuries, and costs less than inflatable balloon packing.[18]
Regardless of the type of posterior pack used, an anterior pack should also be placed. Admit all patients with posterior
packing to the intensive care unit (ICU) for close monitoring of oxygenation, fluid status, and pain control. An antibiotic
should also be given to prevent rhinosinusitis and possible toxic shock syndrome.
Management of packing failure
Packing failure can be caused by inadequate placement resulting either from lack of patient cooperation (especially in the
pediatric age group) or from anatomic factors (eg, deviated septum). In cases of packing failure, a careful endoscopic
examination with the patient under general anesthesia may be considered. Bleeding sites can be cauterized under
endoscopic guidance, a deviated septum can be straightened, spurs can be removed, and meticulous packing can be
placed.[19]
If these steps fail to control the bleeding, arterial ligation (see below) may be performed at the same time.
Arterial Ligation
The choice of the specific vessel or vessels to be ligated depends on the location of the epistaxis. In general, the closer the
ligation is to the bleeding site, the more effective the procedure tends to be.
External carotid artery
Ligation of the external carotid artery (ECA) can be performed with the patient under local or general anesthesia. A
horizontal skin incision is made between the hyoid bone and the superior border of the thyroid cartilage. Subplatysmal
skin flaps are then raised, and the sternocleidomastoid muscle is retracted posteriorly.
Next, the carotid sheath is opened and its contents exposed. The ECA is identified by following the internal carotid artery
(ICA) for a few centimeters and dissecting the ECA beyond its first few branches. After the ECA has been positively
identified, it is usually ligated just distal to the superior thyroid artery. Continued bleeding after ligation may be from
anastomoses with the opposite carotid system or the ipsilateral ICA.
Internal maxillary artery
Internal maxillary artery ligation has a higher success rate than ECA ligation because of the more distal site of
intervention.
Traditionally, the internal maxillary artery is accessed transantrally via a Caldwell-Luc approach. With the help of an
operating microscope, the posterior sinus wall is removed in a piecemeal fashion, and the posterior periosteum is carefully
opened. The internal maxillary artery and 3 of its terminal branches (ie, sphenopalatine, descending palatine, pharyngeal)
are elevated with nerve hooks, then clipped. The posterior sinus wall is then packed with Gelfoam, and the gingivobuccal
incision is closed.
More recently, transoral and transnasal endoscopic approaches have been described. The transoral approach is useful in
patients with midface trauma, hypoplastic antra, or maxillary tumors.
In the transoral approach, the buccinator space is first entered through a gingivobuccal incision. The buccal fat pad is
removed, and the attachment of the temporalis to the coronoid process is identified. This process facilitates the
identification of the internal maxillary artery. The vessel is then doubly clipped and divided. This procedure has a higher
failure rate than the transantral approach because the site of ligation is more proximal.
The transnasal endoscopic method requires skills with endoscopic instruments. A large middle meatal antrostomy is made
to expose the posterior sinus wall. The middle turbinate can be partially resected to ensure adequate exposure. The
remaining steps are similar to those of the traditional transantral approach.
Endoscopic technique can also be used to ligate the sphenopalatine artery at its exit from the sphenopalatine foramen.[20, 21]
An incision is made just posterior to the posterior attachment of the middle turbinate. The mucosal flap is then carefully
elevated to reveal the sphenopalatine artery, which is then clipped and ligated.
Ethmoid artery
If bleeding occurs high in the nasal vault, consider ligation of the anterior ethmoid artery, the posterior ethmoid artery, or
both. These arteries are approached through an external ethmoidectomy incision.
The anterior ethmoid artery is usually found approximately 22 mm (range, 16-29 mm) from the anterior lacrimal crest. If
clipping the artery does not stop the bleeding, then the posterior ethmoid artery may be ligated. This artery is found
approximately 12 mm posterior to its anterior counterpart. It should be clipped, not cauterized, because it is only 4-7 mm
anterior to the optic nerve.
Embolization
Bleeding from the ECA system may be controlled with embolization, either as a primary modality in poor surgical
candidates or as a second-line treatment in those for whom surgery has failed. Patients considered candidates for
embolization should be transferred to hospitals with interventional radiology capability.[19]
Preembolization angiography is performed to check for the presence of any unsafe communications between the ICA and
ECA systems. Selective embolization of the internal maxillary artery[22] and sometimes the facial artery may be
performed. Postprocedure angiography can be used to evaluate the degree of occlusion. The most common reason for
failure is continued bleeding from the ethmoid arteries.
Palliative Therapy for Hereditary Hemorrhagic Telangiectasia
Management of hereditary hemorrhagic telangiectasia (HHT) is palliative because the underlying defect is not curable.
Options include coagulation with potassium-titanyl-phosphate (KTP) or neodymium:yttrium-aluminum-garnet (Nd:YAG)
lasers, septodermoplasty, embolization, and estrogen therapy
Complications of Treatment
Potential treatment complications include the following :
 Cauterization - Synechia, septal perforation
 Anterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction, scarring of the
nasal ala and columella
 Posterior packing - Synechia, rhinosinusitis, toxic shock syndrome, eustachian tube dysfunction, dysphagia,
scarring of nasal ala and columella, hypoventilation, sudden death
 Transantral internal maxillary artery ligation - Anesthetic risks, rhinosinusitis, oroantral fistula, infraorbital
numbness, dental injury
 Transoral internal maxillary artery ligation - Anesthetic risks, cheek numbness, trismus, tongue paresthesia
 Anterior or posterior ethmoid artery ligation - Anesthetic risks, rhinosinusitis, lacrimal duct injury, telecanthus,
blindness
 Embolization - Facial pain, trismus, facial paralysis, skin necrosis, blindness, stroke, groin hematoma
Dietary Measures
Few dietary measures are indicated. Patients should avoid hot and spicy foods and drink plenty of fluids
Activity Restriction
Patients should avoid strenuous activities, hot showers, and digital trauma. They should use nasal saline spray liberally
and should employ digital pressure and ice packs as needed for minor recurrences.
Prevention of Epistaxis
To the extent possible, patients should avoid the following:
 Strenuous activities - Protection from direct trauma from some sports activities is afforded by the use of helmets
or face pieces.
 Hot and dry environments – The effects of such environments can be mitigated by using humidifiers, better
thermostatic control, saline spray, and antibiotic ointment on the Kiesselbach area.
  Hot and spicy foods
 Digital trauma – In children, nose picking is difficult to deter and should probably be considered inevitable.
Keeping the child’s nails well trimmed may be helpful.
 Nose blowing and excessive sneezing - Instruct patients to sneeze gently with the mouth open.
 Inappropriate or careless use of drugs - Consider drug education relating to use or accidental ingestion of aspirin,
warfarin (eg, rat poison in toddlers), or drug abuse in adolescents.
Medication Summary
Most patients with epistaxis who seek medical attention are likely to be treated with cauterization, anterior packing, or
both. Those with severe or recalcitrant bleeding may need posterior packing, arterial ligation, or embolization.
Pharmacotherapy plays only a supportive role in treating the patient with epistaxis.
Class Summary
Topical vasoconstrictors act on alpha-adrenergic receptors in the nasal mucosa, causing vessels to constrict.
Oxymetazoline 0.05% (Afrin)
Oxymetazoline is applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and causes
vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac
stimulation.
Oxymetazoline can be used in combination with lidocaine 4% to provide effective nasal anesthesia and vasoconstriction.

Anesthetics
Class Summary
When anesthetics are used concomitantly with vasoconstrictors, their anesthetic effect is prolonged and the pain threshold
increased.
Lidocaine 4% (Xylocaine)
Lidocaine decreases permeability to sodium ions in neuronal membranes. This results in the inhibition of depolarization,
blocking the transmission of nerve impulses.
Lidocaine can be used in combination with oxymetazoline 0.05% to provide effective nasal anesthesia and
vasoconstriction.

Class Summary
Antibiotic ointments help prevent local infection and provide local moisturization.
Mupirocin ointment 2% (Bactroban nasal)
Mupirocin ointment inhibits bacterial growth by inhibiting RNA and protein synthesis. It is a compounded medication.
Cauterizing agents
Class Summary
Cauterizing agents coagulate cellular proteins, which can in turn reduce bleeding.

Silver nitrate
Silver nitrate coagulates cellular protein and removes granulation tissue. It also has antibacterial effects.
Dosage Forms & Strengths
Antiseptic Wound Cauterization
Sticks: Apply to mucous membranes and other moist skin surfaces only on area to be treated
Topical solution: Apply a cotton applicator dipped in solution/ointment on the affected area 2-3 times per week for 2-3
weeks