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For further information, see CMDT Part 8-13: Epistaxis

Key Features

Essentials of Diagnosis

  • Bleeding from a unilateral anterior nasal cavity along the septum is most common

  • Most cases can be successfully treated by direct pressure on the bleeding site for 15 minutes

  • When this is unsuccessful, topical sympathomimetics or various nasal tamponade methods are usually effective

  • Posterior, bilateral, or large-volume epistaxis should be triaged immediately to a specialist in a critical care setting

General Considerations

  • Anterior nasal cavity bleeding originates from Kiesselbach plexus, a vascular plexus on the anterior nasal septum

  • Posterior nasal cavity bleeding

    • Originates from the posterior half of the inferior turbinate or the top of the nasal cavity

    • More commonly associated with atherosclerotic disease and hypertension

    • Only 5% of nasal bleeding originates in the posterior nasal cavity

  • Predisposing factors

    • Nasal trauma (eg, nose picking, forceful nose blowing, foreign body)

    • Nasal mucosa drying from low humidity or supplemental nasal oxygen

    • Allergic or viral rhinitis

    • Deviation of the nasal septum

    • Inhaled corticosteroids

    • Inhaled cocaine use

    • Excessive alcohol intake

    • Anticoagulation or antiplatelet medications (eg, aspirin, clopidogrel)

    • Atherosclerotic disease

    • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

  • Poorly controlled hypertension is associated with epistaxis

Clinical Findings

Symptoms and Signs

  • Bleeding from nostril or nasopharynx

  • Posterior bleeding may present with hemoptysis or hematemesis

Differential Diagnosis

  • Thrombocytopenia

  • Immune thrombocytopenia

  • Thrombotic thrombocytopenic purpura

  • Hemophilia

  • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu syndrome)

  • Polycythemia vera

  • Leukemia

  • Granulomatosis with polyangiitis

  • Nasal tumor


  • Laboratory assessment of bleeding parameters (platelet count, coagulation studies) may be indicated, especially in recurrent cases


  • Most cases of anterior epistaxis may be successfully treated by direct pressure on the bleeding site


  • Short-acting topical nasal decongestants (eg, phenylephrine, 0.125–1% solution, one or two sprays, or oxymetazoline), which act as vasoconstrictors, may help

  • If a posterior pack is required for > 5 days, administer antistaphylococcal antibiotics to limit possibility of toxic shock syndrome

    • Cephalexin, 500 mg orally four times daily

    • Clindamycin, 150 mg orally four times daily


  • Ligation of the nasal arterial supply (internal maxillary artery and ethmoid arteries) is indicated when direct pressure and nasal packing fail

  • Endoscopic sphenopalatine artery ligation

    • Most common approach

    • Has reported efficacy of 73–100%

    • However, bleeds caused by ethmoid arterial supply may be missed

  • Endovascular epistaxis control

    • Highly effective (75–92%)

    • Can address all potential sources of bleeding

    • However, risk of stroke is 1.1–1.5%

    • Therefore, may be reserved for cases in which surgery failed

Therapeutic Procedures

Anterior nasal bleeding

  • Compress the nasal alae firmly for 15 min

  • Venous pressure is reduced in the ...

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