Epistaxis
Epistaxis, commonly known as a nosebleed, refers to bleeding from the nasal cavity. It is a symptom or presentation, rather than a condition.
This updated UKMLA guide to epistaxis is based on NICE CKS, which covers anterior vs posterior epistaxis, causes, assessment, and management.
Classification
| Type | Implicated vessel | Description |
|---|---|---|
| Anterior epistaxis | Kiesselbach plexus (Little’s area of the anterior nasal septum) | 80-95% cases
Bleeding is less severe and the bleeding site can often be identified on examination |
| Posterior epistaxis | Branches of the sphenopalatine artery in the posterior nasal cavity | Usually seen in older patients
Features suggestive of posterior epistaxis:
|
Causes
Most episodes of epistaxis are self-limiting and harmless, and the cause of damage to the blood vessels is not identified.
Local causes of damage to blood vessels:
- Trauma
- Nose picking (common)
- Nasal fractures / blunt trauma (e.g. falls in children)
- Foreign body
- Vascular causes
- HHT
- GPA
- Tumours (e.g. nasopharyngeal carcinoma, angiofibroma)
- Inflammation (e.g. chronic sinusitis, nasal polyps)
- Cocaine abuse – classically causes septal ulceration +/- perforation
- Post-operative bleeding (e.g. following ENT, maxillofacial, ophthalmic surgery)
- Nasal oxygen therapy (esp. long-term use)
General causes of vessel damage (non-specific):
- Clotting disorder (e.g. vWD, leukaemia, thrombocytopaenia)
- Antiplatelet or anticoagulant use
- Atherosclerosis
- Excessive alcohol consumption
- Environmental factors (temperature, humidity, altitude, exposure to irritants)
Assessment
Examine both nasal passages (ideally with adequate lighting and a nasal speculum)
- Look for a bleeding point
Features suggestive of posterior epistaxis:
- Profuse bleeding from both nostrils
- Bleeding site cannot be identified on examination
- Bleeding first started down the throat
Laboratory investigations are not usually required unless an underlying cause is suspected:
- Consider FBC if bleeding has been heavy or recurrent, or anaemia is suspected
- Only perform coagulation studies if a clotting disorder is suspected or the patient takes warfarin
Management
Acute Epistaxis
Referral criteria:
- Haemodynamically unstable → immediate transfer to A&E
- Posterior epistaxis suspected → admit to hospital
If immediate referral is not necessary:
| Steps | Management | Description |
|---|---|---|
| Step 1 | First aid measures |
If the bleeding did not stop after 10-15 min → proceed to step 2 |
| Step 2 | Nasal cautery or nasal packing | Depends on whether the bleeding point is identifiable:
If nasal cautery and nasal packing are not available in primary care → admit to hospital |
| Step 3 (if the above failed) | Secondary care management | Options include:
|
Complications of Treatment
| Treatment | Potential complications |
|---|---|
| Nasal cautery |
Therefore, avoid performing on both sides of the septum |
| Nasal packing |
|
Management After Resolution
If the bleeding stops with first aid measures:
- Consider Naseptin® (chlorhexidine and neomycin) cream – QDS for 10 days
- If allergic to neomycin / peanuts / soya → consider mupirocin nasal ointment
If the bleeding stops with nasal cautery:
- Dab the cauterised area with a clean cotton bud
- Apply Naseptin® (chlorhexidine and neomycin) cream – QDS for 10 days
- Observe the patient for 15 min to ensure bleeding is controlled
- Advise the person to avoid blowing their nose for a few hours
After nasal packing:
- Admit for observation
Recurrent Epistaxis Management
Advise the person on first aid measures to control bleeding during an acute episode
Determine if there is an underlying cause for epistaxis:
- Consider FBC
- If < 2 y/o → consider referral to a paediatrician as an underlying cause is likely
If an underlying cause is unlikely:
- 1st line: topical Naseptin® (chlorhexidine and neomycin) cream QDS for 10 days
- If allergic to neomycin / peanus / soya → consider mupirocin nasal ointment
- 2nd line: nasal cautery