Epistaxis

Risk factors

• Local: digital trauma (nose picking), dry air, nasal foreign body, intranasal medications (corticosteroids, cocaine), septal deformity or perforation, nasal/sinus surgery, tumors (juvenile nasopharyngeal angiofibroma in adolescent males)
• Systemic: hypertension (association with severity, not cause), anticoagulants and antiplatelets, inherited bleeding disorders (von Willebrand disease, hemophilia), thrombocytopenia, liver disease/uremia, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu), aspirin/NSAID use, alcohol
• Vascular malformations and tumors as red-flag etiologies

Pathophysiology

Mucosal disruption exposes submucosal vessels. Anterior bleeds arise from anastomotic vessels of Kiesselbach plexus (anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries). Posterior bleeds come from larger branches of the sphenopalatine artery (Woodruff plexus), often arterial and brisk.

Clinical presentation

Differential diagnosis

• Hemoptysis — Blood from lower airway with cough; frothy, bright red; chest pathology; do not confuse with posterior epistaxis dripping into pharynx
• Hematemesis — Vomited blood; coffee-ground or bright red; GI source; swallowed posterior epistaxis can mimic
• Nasal foreign body — Unilateral foul purulent discharge ± blood, often in a young child
• Sinonasal tumor — Unilateral persistent or recurrent bleeding, nasal obstruction, mass on endoscopy or imaging
• Juvenile nasopharyngeal angiofibroma — Adolescent male with recurrent unilateral severe epistaxis and obstruction; vascular mass; biopsy contraindicated, image and refer ENT
• Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu) — Recurrent epistaxis + telangiectases on lips/tongue/fingertips + family history + AVMs (pulmonary, hepatic, cerebral)
• Coagulopathy — Bleeding from multiple sites, easy bruising; check CBC, PT/INR, aPTT, vWF

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Active epistaxis] --> B[ABCs<br/>lean forward<br/>pinch soft nose 10-15 min]
  B --> C{Bleeding stopped?}
  C -->|Yes| D[Identify source<br/>discharge with home care]
  C -->|No| E[Topical vasoconstrictor<br/>oxymetazoline pledget]
  E --> F{Anterior source<br/>identified?}
  F -->|Yes, focal| G[Silver nitrate cautery<br/>one side septum only]
  F -->|Diffuse or persistent| H[Anterior packing<br/>Merocel / Rapid Rhino<br/>24-72 h]
  F -->|No anterior source| I[POSTERIOR bleed]
  I --> J[Posterior balloon pack<br/>or Foley<br/>ADMIT with monitoring]
  J --> K[ENT consult<br/>endoscopic cautery<br/>SPA ligation<br/>or IR embolization]
  G --> L[Discharge with<br/>saline gel + humidifier]
  H --> M{Re-bleed at 24-72 h?}
  M -->|Yes| K
  M -->|No| L

Treatment

Complications

• Hypovolemic shock with substantial blood loss
• Aspiration of blood
• Septal hematoma → septal perforation or saddle nose if not drained
• Septal perforation from bilateral cautery
• Pressure necrosis or toxic shock syndrome from prolonged packing
• Nasovagal reflex with posterior packing (bradycardia, hypotension)
• Vascular complications from embolization (stroke, blindness)

PANCE pearls

• LEAN FORWARD — leaning back causes blood to be swallowed (nausea, vomiting, aspiration) and obscures volume estimation.
• Pinch the SOFT cartilaginous portion of the nose (not the bony bridge) for 10-15 minutes continuously.
• Cauterize ONLY one side of the septum at a time and avoid both sides at the same visit — bilateral cautery risks septal perforation.
• Posterior epistaxis = admit and monitor on telemetry; high risk of hemodynamic instability and nasovagal events.
• In an adolescent male with recurrent unilateral epistaxis + nasal obstruction — suspect juvenile nasopharyngeal angiofibroma. Image first; biopsy can cause catastrophic bleeding.
• Septal hematoma after trauma must be drained urgently or it causes cartilage necrosis (saddle-nose).

References

• AAO-HNS 2020 — Tunkel DE et al. Clinical Practice Guideline: Nosebleed (Epistaxis). Otolaryngol Head Neck Surg 2020;162(1S):S1-S38
• AAFP — Krulewitz NA, Fix ML. Epistaxis. Emerg Med Clin North Am 2019;37(1):29-39