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Epistaxis (Nosebleeds)

NICE CKS Epistaxis. Last revised Oct 2024.

Background

Epistaxis can be classifed into 2 main groups:
 
Classification Implicated vessel Description
Anterior epistaxis Kiesselbach plexus (Little's area of the anterior nasal septum) 80-95% cases
Posterior epistaxis Branches of the sphenopalatine artery in the posterior nasal cavity Usually in older people
 

Local causes of damage to blood vessels:
  • Trauma (e.g. nose picking, nasal fractures, septal perforation)
  • Nasal oxygen therapy 
  • Inflammation (e.g. chronic sinusitis, nasal polyps, allergic rhinosinusitis)
  • Topical drugs (e.g. cocaine, decongestants, corticosteroids)
  • Vascular causes (e.g. HHTHereditary haemorrhagic telangiectasia, GPAGranulomatosis with polyangiitis)
  • Post-operative bleeding
  • Tumours (e.g. angiofibroma, squamous cell carcinoma)

General causes of vessel damage (non-specific):
  • Atherosclerosis
  • Clotting disorder (e.g. vWDVon Willebrand disease, haemophilia, leukaemia, thrombocytopaenia)
  • Anti-thrombotic drugs (antiplatelet and anticoagulants)
  • Excessive alcohol consumption
  • Environmental factors (temperature, humidity, altitude, exposure to irritants)

Guidelines

Clinical diagnosis. Laboratory investigations are not usually required unless an underlying cause is suspected.
  • Examine both nasal passages
  • Ideally with a nasal speculum and adequate lighting


Features suggestive of a posterior bleed:
  • Bleeding is profuse
  • Bleeding from both nostrils
  • Bleeding site cannot be identified on speculum examination
  • Bleeding first started down the throat 

If the patient is hameodynamically unstable:
  • Imediate transfer to A&E
  • Consider tranexamic acid 1g PO while awaiting hospital transfer to major haemorrhage

If posterior epistaxis is suspected → admit to hospital

Haemodynamically stable management:
 

  • Sit up + tilt forward (avoid lying down, unless feeling faint)
  • Pinch the soft cartilaginous part of the nose firmly for 10-15 min without releasing the pressure
  • Keep the mouth open and breath through the mouth

  • If bleeding point is identifiable → silver nitrate nasal cautery (avoid in younger children), if ineffective → nasal packing
  • If bleeding point is not identifiable →  nasal packing + admit to hospital

If nasal cautery and nasal packing is not available in primary care → admit to hospital.
 

Potential complications of nasal cautery:

  • Septal perforation
  • Therefore should be avoided performing on both sides of the septum

Potential complications of nasal packing:
  • Sinusitis
  • Septal haematoma / abscess
  • Pressure necrosis
  • Toxic shock syndrome

Optiosn include:
  • Endoscopic assessment and electrocautery
  • Formal packing 
  • Radiological arterial embolisation
  • Surgical intervention (e.g. diathermy, septal surgery, arterial ligation, laser treatment)
 

If the bleeding stops with first aid measures:
  • Consider Naseptin® (chlorhexidine and neomycin) cream - QDS for 10 days
  • If allergic to neomycin / peanus / 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 the person to hospital for observation

Advise the person on first aid measures to control bleeding during an acute episode
  • Sit up + tilt forward (avoid lying down, unless feeling faint)
  • Pinch the soft cartilaginous part of the nose firmly for 10-15 min without releasing the pressure
  • Keep the mouth open and breath through the mouth

Determine if there is an underlying cause for epistaxis:
  • Consider FBC
  • If < 2 y/o → consider referral to a paediatrician as underlying cause is likely
 

  • 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

References

Author: Stella Panou 
Reviewer:
Last edited: 07/05/2025