Epistaxis

Last revised in August 2010

Epistaxis - Summary
Epistaxis is bleeding from the nose, caused by damage to the blood vessels of the nasal mucosa.
Most epistaxis is self-limiting and harmless, and often the cause of damage to the blood vessels is
not identified.
Local causes of damage to the blood vessels include trauma, inflammation, topical drugs, surgery,
vascular causes (such as hereditary haemorrhagic telangiectasia, Wegener's granulomatosis), or
tumours (such as squamous cell carcinoma).
More general causes of damage include hypertension; atherosclerosis; increased venous
pressure from mitral stenosis; haematological disorders such as thrombocytopenia, leukaemia,
and haemophilia; environmental factors such as temperature, humidity, or altitude; systemic drugs
such as anticoagulants and antiplatelets; and excessive alcohol consumption.
Complications of epistaxis are rare, and include hypovolaemia, anaemia and complications from
nasal packing treatment.
If the person is haemodynamically compromised, epistaxis should be managed as an emergency,
and immediate transfer to hospital arranged.
If the person is haemodynamically stable, epistaxis can usually be managed with first aid measures:
the person should sit with their upper body tilted forward and their mouth open; the soft part of the
nose should be pinched firmly and held for 1015 minutes.
If a posterior bleed is suspected (bleeding is profuse, from both nostrils, and the bleeding site
cannot be identified on examination), admission to hospital may be necessary.
If bleeding stops with first aid measures, a topical antiseptic such as Naseptin (chlorhexidine and
neomycin) cream may be applied to prevent re-bleeding.
If bleeding does not stop after 1015 minutes of pressure, nasal cautery or nasal packing (if
available) may be used to stop the bleeding, otherwise immediate admission to Accident and
Emergency is recommended
Investigations are rarely needed in primary care following acute epistaxis but may include:

A full blood count if bleeding has been heavy or recurrent, or anaemia is suspected.
Coagulation studies, only if a clotting diathesis is suspected or the person is on warfarin therapy.
Management of a person with recurrent epistaxis includes:
Topical antiseptic treatment such as Naseptin (chlorhexidine and neomycin) cream to reduce
crusting and vestibulitis, or
Nasal cautery (if available).
Referral to an ear, nose, and throat specialist if epistaxis is recurrent despite treatment, or there is
a high risk of a serious underlying cause.

Definition
What is it?
Epistaxis is bleeding from the nose.
Epistaxis mostly (8090%) originates from Little's area on the anterior nasal septum, which
contains the Kiesselbach plexus of vessels [Crown and Criner, 2004; Schlosser, 2009].
Less commonly, epistaxis originates from branches of the sphenopalatine artery in the posterior
nasal cavity [Pashen and Stevens, 2002; Wormald, 2002; Schlosser, 2009].

Causes
What causes it?
Blood vessels in the mucosa (particularly in Little's area) are superficial and therefore easily
damaged, causing bleeding [Crown and Criner, 2004; Schlosser, 2009]. Most epistaxis is self-limiting
and harmless, and the cause of damage to the blood vessels is not identified [Pope and Hobbs,
2005; Schlosser, 2009].
Local causes of damage to the blood vessels include:
Trauma injury from nose-picking, nasal fractures, septal ulcers or perforations, foreign body,
blunt trauma (such as falls in children).
Inflammation infection (for example chronic sinusitis), allergic rhinosinusitis, nasal polyps.

Topical drugs for example cocaine, topical decongestants.

Vascular for example hereditary haemorrhagic telangiectasia, Wegener's granulomatosis.
Post-operative bleeding for example following: ear, nose, and throat surgery; maxillofacial
surgery; or ophthalmic surgery.
Tumours benign (such as angiofibroma), malignant (such as squamous cell carcinoma). Older
people are more likely to have epistaxis associated with cancer.
Nasal oxygen therapy causes drying of the nasal mucosa.
More general causes of damage include:
Hypertension (although this is controversial).
Atherosclerosis.
Increased venous pressure from mitral stenosis.
Haematological conditions such as thrombocytopenia, platelet dysfunction, and conditions such
as leukaemia and haemophilia.
Environmental factors temperature, humidity, altitude.
Systemic drugs including anticoagulants and antiplatelet agents (for example aspirin,
clopidogrel).
Excessive alcohol consumption.
[McGarry et al, 1994; Pashen and Stevens, 2002; Wormald, 2002; Crown and Criner, 2004; Kucik
and Clenney, 2005; Pope and Hobbs, 2005]

Prevalence
How common is it?
Epistaxis is common.
Up to 60% of the population have experienced an episode of epistaxis, but only 6% have sought
medical attention for it [Kucik and Clenney, 2005; Daudia et al, 2008].
The incidence of epistaxis changes with age.

Peaks in incidence occur in children younger than 10 years of age, and in adults older than
45 years of age [Kucik and Clenney, 2005; Pope and Hobbs, 2005; Schlosser, 2009].
Epistaxis in children younger than 2 years of age is unusual and may be associated with injury or
serious illness [McIntosh et al, 2007; Paranjothy et al, 2009].
Posterior epistaxis is more common in older people compared with younger people [Schlosser,
2009].

Prognosis
What is the prognosis?
Most episodes of epistaxis are self-limiting and do not require medical treatment [Schlosser, 2009].
It is unusual for epistaxis to necessitate a transfusion, although (rarely) massive nasal bleeding can
be fatal [Kucik and Clenney, 2005; Schlosser, 2009].

Complications
What are the complications?
Complications of bleeding (for example hypovolaemia and anaemia).
Complications of nasal packing [Kucik and Clenney, 2005; Schlosser, 2009].
Sinusitis.
Septal haematoma or abscess (due to traumatic packing).
Pressure necrosis (secondary to excessively tight packing).
Toxic shock syndrome (from prolonged packing).
Apnoeic episodes (associated with bilateral anterior or posterior nasal packs).

Overview
Overview of management for acute epistaxis
If the person is haemodynamically compromised, telephone 999 for an emergency ambulance and
advise first aid measures while awaiting its arrival.
If the person is not haemodynamically compromised:

Advise first aid measures.

Assess :
Blood loss.
The site of bleeding (which nostril, and if it is from the anterior or posterior nasal area).
What attempts have been made to stop the bleeding before seeking medical help.
Determine if there is a likely underlying cause or comorbid condition that may influence the
decision to refer the person (for example warfarin therapy).
If bleeding stops with first aid measures, consider topical treatment.
If bleeding does not stop after 1015 minutes of pressure and the appropriate expertise and
facilities for cautery or packing are not available in primary care, send the person to the Accident
and Emergency department immediately.
If bleeding does not stop after 1015 minutes of pressure and the appropriate expertise and
facilities are available in primary care, consider:
Nasal cautery if the bleeding point can be seen.
Nasal packing if nasal cautery is ineffective or the bleeding point cannot be seen.
Consider whether admission is warranted.
Consider referral to an ear, nose, and throat specialist if epistaxis is recurrent despite treatment, or
there is a high risk of a serious underlying cause.
Offer self-care advice after the bleeding has stopped.

First aid measures

What first aid measures should I advise for acute epistaxis?
Advise the person to:
Sit with their upper body tilted forward and their mouth open. They should avoid lying down,
unless they are feeling faint.
Leaning forward decreases blood flow through the nasopharynx, allows spitting out of blood,
and minimizes swallowing blood that drains into the pharynx.

Pinch the cartilaginous (soft) part of the nose firmly and hold it for 1015 minutes without
releasing the pressure, breathing through their mouth.
A common misconception is that compression of the nasal bones will help stop bleeding.

Assessment
How should I assess a person with acute epistaxis?
Assess the person's airway, breathing, pulse, and blood pressure.
If any are compromised, telephone 999 for an ambulance and advise first aid measures while
awaiting its arrival.
Usually, the person's airway, breathing, pulse, and blood pressure are not compromised.If the
person is otherwise well, ask:
When the bleeding started, and from which side.
How much blood has been lost. This is difficult to estimate, but establish whether the bleeding is
light or heavy. If bleeding is heavy, ask the person how many cups (each equates to approximately
250 mL) they think they have lost. Significant blood loss may necessitate admission to hospital.
Whether a temporary pack (such as cotton wool) has been used before seeking medical help.
These are not always easily visible, and formal nasal packing can push foreign bodies further into
the nose.
About any previous episodes of epistaxis and how they were treated.
Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
If the nose is still bleeding, advise the person to blow their nose to remove clots (several big blows
may be required). Old blood is usually darker and runs out in a gush with formed clots, then stops.
Fresh bleeding is bright red and drips steadily when the person leans forward.
Look for a bleeding point. Bleeding points which have stopped look like a small red dot (less than
1 mm).
Suspect a posterior bleed if bleeding is profuse, from both nostrils, and the bleeding site cannot be
identified on speculum examination.
Determine if there is an underlying cause, particularly in children younger than 2 years of age as
epistaxis is unusual in this group.

Laboratory investigations are not usually required unless an underlying cause is suspected.
A full blood count should be considered if bleeding has been heavy or recurrent, or anaemia is
suspected.
Coagulation studies should be requested only if a clotting diathesis is suspected or an INR
(international normalized ratio) is required to determine if warfarin treatment needs adjusting.

Identifying an underlying cause

How should I identify an underlying cause for acute epistaxis?
Determine whether an underlying cause is likely, by asking about:
A history of surgery or recent trauma (consider the possibility of non-accidental injury).
Symptoms suggestive of a tumour (benign or malignant) including nasal obstruction,
rhinorrhoea, facial pain, or evidence of cranial neuropathy (for example facial numbness or double
vision).
Current medications (for example aspirin and warfarin, nasally-administered drugs).
If the person is taking warfarin, check the INR (international normalized ratio) or admit to
hospital if bleeding is difficult to control.
Conditions predisposing to bleeding (such as haemophilia or leukaemia).
Family history of bleeding disorders.
Features of hereditary haemorrhagic telangiectasia that may be evident on examination include
telangiectasia on the lips, mucous membranes, and fingers.
Environmental factors (such as humidity and allergens).
Have a low threshold for referral in children younger than 2 years of age (underlying cause likely).

Topical treatment
What topical treatment should I advise for acute epistaxis?
If acute epistaxis settles with first aid measures, consider applying a topical antiseptic
preparation, particularly in children for whom cautery is not an option.

Prescribe Naseptin (chlorhexidine and neomycin) cream first-line. Advise that the cream should
be applied to the nostrils four times daily for 10 days. If compliance is a problem, experts suggest
it can be used twice daily for up to 2 weeks.
Do not prescribe Naseptin for people known to be allergic to peanut as it contains arachis oil
(peanut oil).
If the person is allergic to peanut or neomycin, consider prescribing mupirocin nasal ointment.
Advise that it should be applied to the nostrils two to three times a day for 57 days.

Nasal cautery
How should I perform nasal cautery for acute epistaxis?
Consider nasal cautery in primary care if:
First aid measures have not worked, and
The appropriate expertise and facilities are available (good lighting, topical anaesthetic spray, and
nasal speculum).
Prior to cautery
Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. This
may restart the bleeding.
Use topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with
phenylephrine Co-phenylcaine) prior to cauterizing the area. Wait for 34 minutes for the full
effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off the bleeding
may start again.
To cauterize the bleeding point
Identify the bleeding point it looks like a small red dot (less than 1 mm) and may not be actively
bleeding.
Lightly apply the silver nitrate stick to the bleeding point for 310 seconds, until a grey-white
colour develops.
Only cauterize one side of the septum to avoid nasal septal perforation.
Avoid touching areas which do not need treatment (for example facial skin, nasal alae).
After cautery

Dab the cauterized area with a clean cotton bud to remove excess chemical or blood.
Apply antibiotic ointment to the area.
Use Naseptin (chlorhexidine and neomycin) cream first-line, applied to the nostrils four times
daily for 10 days. Do not prescribe Naseptin for people known to be allergic to peanut as it
contains arachis oil (peanut oil).
If the person is allergic to peanut or neomycin, consider using mupirocin nasal ointment. This
should be applied to the nostrils two to three times a day for 57 days.
Do not routinely pack the affected side.
Offer self-care advice.

Nasal packing
How should I perform nasal packing for acute epistaxis?
Consider nasal packing in primary care if:
Nasal cautery has been ineffective or the bleeding point cannot be seen, and
The appropriate expertise and facilities are available (good lighting, topical anaesthetic spray, and
nasal speculum).
Anaesthetize the nasal cavity with topical local anaesthetic spray, preferably with a vasoconstrictor
(such as lidocaine with phenylephrine Co-phenylcaine), if this has not already been done. Wait
for 34 minutes for the full effect.
The decision concerning which product to use is based on availability, cost, and
preference. The available products include:
Nasal tampons (for example Merocel) effective and easy to use.
Inflatable packs (for example Rapid-Rhino) effective, and may be more comfortable to insert
and remove than nasal tampons. They may also be easier for the healthcare professional to use
than nasal tampons.
Ribbon gauze impregnated with Vaseline or bismuth-iodoform paraffin paste packing with
ribbon gauze is not recommended in primary care without specific training.
Insert the packing according to the manufacturers instructions.

Pack the person's nostril whilst they are sitting with their head tilted forwards and holding a
receptacle allowing them to spit out blood, and breathing through their mouth.
Secure the pack (for example Merocel packs have a string attached which can be taped to the
cheek) and ensure there is no pressure on the cartilage around the nostril as this can cause a
cosmetic defect.
Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen,
consider packing the other side to increase pressure on the bleeding vessel.
Admit the person to hospital for observation, preferably to an ear, nose, and throat ward.

Referral
When should I refer a person with acute epistaxis?
Admit the person to hospital if:
Epistaxis continues despite efforts to stop the bleeding.
Bleeding from the posterior area of the nose is suspected.
A nasal pack has been inserted in primary care.
Consider admission to hospital if the person is elderly or has a comorbid condition (such as
coronary artery disease, severe hypertension, clotting disorder, or significant anaemia).
Consider referral to an ear, nose, and throat specialist if the person has recurrent episodes
and is at high risk of having a serious underlying cause. Use clinical judgement and consider
referral in the following groups:
Males 1220 years of age angiofibroma is possible (but rare).
Middle-aged people of Chinese origin due to the high incidence of nasopharyngeal cancer.
People older than 50 years of age as nasal, sinus, and nasopharyngeal cancers are more
common (although they usually present with associated symptoms).
People with any symptoms suggestive of cancer such as nasal obstruction, facial pain, hearing
loss, eye symptoms (proptosis or double vision), or palpable neck glands.
People with a family history of hereditary haemorrhagic telangiectasia and suggestive features
upon examination telangiectasia on the lips, mucous membranes, and fingers.

People with occupational exposure to wood dust or chemicals.

Consider referral to a paediatrician for children younger than 2 years of age who present with
epistaxis.

Secondary care treatments

What secondary care treatments are available for epistaxis?
Secondary care treatments for acute epistaxis include:
Resuscitation this may include transfusion to replace blood volume and provide coagulation
factors.
Formal packing (may be under general anaesthetic).
Endoscopic assessment and electrocautery.
Examination under anaesthesia and surgical intervention (such as diathermy, septal surgery,
arterial ligation, laser treatment).
Radiological arterial embolization.
Intravenous or oral tranexamic acid.

Self-care advice
What self-care advice should I provide after an episode of epistaxis?
For 24 hours after bleeding, where practical, advise the person to avoid activities which may
increase the risk of rebleeding. These include:
Blowing or picking the nose.
Heavy lifting.
Strenuous exercise.
Lying flat.
Drinking alcohol or hot drinks as these can cause the nasal blood vessels to dilate and
increase the risk of bleeding.

If the nose has been cauterized, the person should avoid blowing their nose for a few hours to
prevent staining of the nostril.
If bleeding restarts and does not respond to first aid measures, the person should seek medical
advice.

Scenario : Recurrent epistaxis

Overview
Overview of management for recurrent epistaxis
Assess the person and, if possible, identify any underlying cause.
Offer advice on first aid measures and self-care advice for when an acute episode occurs.
SeeScenario : Acute epistaxis.
Discuss management options for recurrent epistaxis.
Refer the person if treatment in primary care is ineffective, or if a serious underlying cause is
suspected.

Assessment
How should I assess a person with recurrent epistaxis?
Ask the person about:
Which side the bleeding occurs.
How much blood is lost during an episode. This is difficult to estimate, but establish whether the
bleeding is light or heavy. If bleeding is heavy, ask the person how many cups (each equates to
approximately 250 mL) they think they have lost.
How previous episodes of epistaxis have been treated. Mild episodes usually stop with first aid
measures. The need for cautery or packing indicates a more severe bleed.
Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
Look for a bleeding point. Bleeding points which have stopped look like a small red dot (less than
1 mm).
Check for a nasal tumour.

Determine if there is an underlying cause, particularly in children younger than 2 years of age as
epistaxis is unusual in this group.
Laboratory investigations are not usually required unless an underlying cause is suspected.
A full blood count should be considered if bleeding has been heavy or recurrent, or anaemia is
suspected.
Coagulation studies should be requested only if a clotting diathesis is suspected or an INR
(international normalized ratio) is required to determine if warfarin treatment needs adjusting.

Identifying an underlying cause

How should I identify an underlying cause for recurrent epistaxis?
Determine whether an underlying cause is likely, by asking about:
Symptoms suggestive of a tumour (benign or malignant) including nasal obstruction,
rhinorrhoea, facial pain, or evidence of cranial neuropathy (for example facial numbness or double
vision).
Current medications (for example aspirin and warfarin, nasally-administered drugs).
If the person is taking warfarin, check the INR (international normalized ratio).
Conditions predisposing to bleeding (such as haemophilia or leukaemia).
Family history of bleeding disorders.
Environmental factors (such as humidity and allergens).
Have a low threshold for referral in children younger than 2 years of age (underlying cause likely

Management
How should I manage recurrent epistaxis?
If the person is not at high risk of having a serious cause of epistaxis, discuss treatment options for
recurrent epistaxis.
Topical treatment with antiseptic cream to reduce crusting and vestibulitis. This may be
particularly useful in children, as it is easier to tolerate than nasal cautery.

Prescribe Naseptin cream first-line. It should be applied to the nostrils four times daily for
10 days (if compliance is a problem, experts suggest it can be used twice daily for up to
2 weeks). Do not prescribe Naseptin for people known to be allergic to peanuts as it contains
arachis oil (peanut oil).
If the person is allergic to peanuts or neomycin, consider prescribing mupirocin nasal ointment.
Apply to the nostrils two to three times a day for 57 days.
Nasal cautery is similarly effective to Naseptin antiseptic cream, but may be more uncomfortable.
Consider it for use in primary care only if:
The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal
speculum) are available.
The bleeding point can be identified.
It can be tolerated (for example adults and older children, but not younger children).
If epistaxis does not improve with antiseptic cream or nasal cautery, consider referral.

Referral
When should I refer a person with recurrent epistaxis?
Refer the person to an ear, nose, and throat specialist if:
Epistaxis episodes do not settle with the treatments available in primary care further
investigation and treatment in secondary care may be required.
The person has recurrent episodes and is at high risk of having a serious underlying cause.
Clinical judgement is required, for example consider referral for:
Males 1220 years of age angiofibroma is possible (but rare).
Middle-aged people of chinese origin due to the high incidence of nasopharyngeal cancer.
People older than 50 years of age as nasal, sinus, and nasopharyngeal cancers are more
common (although they usually present with associated symptoms).
People with any symptoms suggestive of cancer such as nasal obstruction, facial pain,
hearing loss, eye symptoms (proptosis or double vision), or palpable neck glands.
People with a family history of hereditary haemorrhagic telangiectasia and suggestive features
upon examination telangiectasia on the lips, mucous membranes, and fingers.

People with occupational exposure to wood dust or chemicals

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