Epistaxis

What Is It, Types, Causes, Prevention, Treatment, and More

Author: Lahav Constantini

Editors: Antonella Melani, MD, Ian Mannarino, MD, MBA

Illustrator: Aileen Lin


What is epistaxis?

How do you pronounce epistaxis?

Epistaxis (eh·puh·stak·suhs) comes from the Greek word “epistazein” which means "bleed from the nose" and is a combination of the two words: “epi” meaning "upon, in addition" and “stazein” meaning "to drip".

What does epistaxis mean?

Epistaxis (also called a nosebleed) refers to a minor bleeding from the blood vessels of the nose. Epistaxis is a commonly-found complaint, especially in fields of emergency medicine related to the treatment of ear, nose, and throat (ENT) conditions. Epistaxis more commonly occurs in children (ages 2–10) and older adults (ages 50–80). There are two types of epistaxis depending on their origin: anterior and posterior epistaxis. 

What is anterior epistaxis?

Anterior epistaxis refers to a nosebleed that originates from the anterior (frontal) part of the nose. Most of the time, cases of anterior epistaxis originate from the Kiesselbach plexus, which is a vascular network found on the nasal septum, as these arteries can be easily traumatized. Anterior epistaxis is the most common type of nosebleed, and usually involves one nostril.

What is posterior epistaxis?

Posterior epistaxis refers to bleeding from the posterior or superior nasal cavity. Most often, it originates from the Woodruff plexus, which is a vascular network found in the lateral wall of the nasal cavity. Posterior epistaxis usually involves both nostrils. For these types of nosebleeds, the blood may also flow backwards and uncomfortably get swallowed or coughed up (hemoptysis).

Often, diagnosis of posterior epistaxis occurs after failing to manage an anterior epistaxis, or noticing bleeding into the posterior pharynx or throat. It is often harder for healthcare professionals to visualize the source of a posterior bleeding in a physical examination; thus, a nasal endoscopy is often performed by a clinician to help identify the origin of the bleed.

What causes epistaxis?



Epistaxis generally occurs due to a rupture of blood vessels in the nasal mucosa. This rupture can be triggered by local or systemic causes, environmental factors, or medications. 

Local causes

Local causes of epistaxis can include local trauma caused by nose-picking, a foreign body in the nose, anatomic irregularities such as a deviated septum, facial trauma, incorrect or excessive use of topical nasal sprays, inflammatory reactions, and rarely intranasal tumors. Smoking and snorting illicit drugs such as cocaine can also cause frequent nosebleeds due to irritation of the nasal mucosa, and can lead to further nasal damage in come cases.

Systemic causes

Some systemic conditions that increase the risk of epistaxis include high blood pressure (hypertension), vascular malformations, cardiovascular diseases, and bleeding disorders like von Willebrand disease and hemophilia A and B. Additionally, heavy alcohol use can also increase the risk for epistaxis, since it disrupts normal blood clotting activity and dilates superficial blood vessels, which increases the risk of a rupture. 

Environmental factors

Common environmental causes of epistaxis include changes in temperature or humidity, as nose vessels are more prone to rupture in cold weather and dry environments. Additionally, environmental factors can trigger allergies. Allergies can increase the risk of epistaxis for multiple reasons. Not only can the allergic inflammatory reaction itself increase the risk, but excessive nose blowing and the use of allergy medications that dry the nasal mucosa—for instance, decongestants and antihistamines—can further compound the risk of developing a nose bleed.

Medications

Some medications can predispose individuals to epistaxis. This is especially true for blood thinners, which interfere with blood clotting. Anticoagulants such as warfarin, platelet aggregation inhibitors, NSAIDs (aspirin and ibuprofen), as well as homeopathic medications that prolong bleeding (like ginseng and Vitamin E), can all increase the risk of epistaxis.

How do you treat epistaxis?


Management of epistaxis depends on the severity of the bleeding and the individual’s accompanying medical conditions. Treating minor nosebleeds can often be managed at home with simple first aid measures. If needed, the course of treatment can progress to visiting a physician or the emergency room. In more serious or recurrent cases, surgical intervention may be required. Anterior epistaxis is usually the easiest to manage. Posterior epistaxis is more likely to require medical attention, since it is more difficult to control and may compromise the airways or cause aspiration.

How to treat epistaxis at home

Most often, management of epistaxis can be performed at home or by a primary care physician. The first step to stop a nosebleed is to apply direct pressure by pinching the tip of the nose using two fingers for 15 to 20 minutes. You can help prevent blood from reaching the throat by sitting up straight, slightly leaning forward and tilting your head a little forward. These measures are usually enough to stop a nosebleed, but if bleeding persists, topical sprays containing vasoconstrictive medications or local anesthetics can help too. 

If the nosebleed is severe, extended, causes difficulty breathing, makes you vomit due to swallowing a large amount of blood, was caused by a serious traumatic injury, or if a child under two years of age has a nosebleed, go to the nearest emergency room and seek for attention from medical professionals. 

How is epistaxis managed in the hospital setting?

You should contact your general practitioner or go to a medical center for special cases. For instance, if you have recurrent episodes, or if the bleeding doesn’t stop—especially if you have a bleeding disorder or you are taking blood thinners. Simple medications used for treatment include topical vasoconstrictive nasal sprays (such as epinephrine, oxymetazoline, local anesthetics). If this doesn’t work—or if you have posterior epistaxis—posterior or anterior nasal packing is used. Nasal packing involves inserting a  gauze-like material or nasal tampon into the nasal cavity to absorb blood and provide pressure to the affected area. Infectious complications arising from nasal packing are uncommon and usually local. Rhinosinusitis can develop, but usually spontaneously heals after packing removal or a short course of antibiotics. Other bacterial systemic infections like toxic shock syndrome can occur. Toxic shock syndrome is treated by immediate removal of the nasal packing and any infected or necrotic tissue, as well as antibiotic therapy following a nasal culture. 

Recurrent or persistent anterior epistaxis may need cauterization. Chemical cauterization using a silver nitrate swab should be tried before more advanced electrocautery is used. In any case, this is done only on one side of the nasal septum in order to avoid perforation.

How do you prevent epistaxis?

There are a few tips you can use to prevent nosebleeds. First, avoid nose-picking as much as possible, and try to keep your fingernails short. Try to not blow your nose too often, and only gently when you do, especially in winter time and during allergy seasons. If you’re taking cold or allergy medications, make sure you follow the instructions that come with the package. Next, if you are taking part in any activities that can endanger the nose and head, make sure to wear proper protective headgear. Lastly, avoid excessive alcohol drinking and smoking.

Related links

High Yield: Nasal, oral, and pharyngeal diseases
Clinical Reasoning: Pediatric ear, nose, and throat conditions
Clinical Reasoning: Bleeding disorders

Resources for research and reference

Beck, R., Sorge, M., Schneider, A., & Dietz, A. (2018). Current Approaches to Epistaxis Treatment in Primary and Secondary Care in Deutsches Arzteblatt International, 115(1–2):12–22. doi: 10.3238/arztebl.2018.0012 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5778404/

Bickley, L. S., Szilagyi, P. G., & Hoffman, R. M. (2016). Bates' Guide to Physical Examination and History Taking (13 edition). Philadelphia, Pennsylvania: Wolters Kluwer.

Fatakia, A., Winters, R., & Amedee, R. G. (2010). Epistaxis: A Common Problem in The Ochsner Journal, 10(3): 176–178. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096213/

Kucik, C. J. & Clenney, T. (2005). Management of Epistaxis in American Family Physician, 71(2): 305–311. Retrieved July 21, 2020, from https://www.aafp.org/afp/2005/0115/p305.pdf

Lautieri, A. Why Does Cocaine Cause Nosebleeds, Weight Loss, & Bloodshot Eyes? Sunrise House. Retrieved July, 21, 2020, from https://sunrisehouse.com/cause-effect/cocaine-use/

Livesey, J. R., Watson, M. G., Kelly, P. J., & Kesteven, P. J. (1995). Do patients with epistaxis have drug-induced platelet dysfunction? In Clinical Otolaryngology & Allied Sciences, 20(5): 407–10. doi: 10.1111/j.1365-2273.1995.tb00071.x https://pubmed.ncbi.nlm.nih.gov/8582070/

Marton, K. I. (1994). Alcohol consumption and nosebleeds in NEJM. Retrieved July 21, 2020, from https://www.jwatch.org/jw199410070000007/1994/10/07/alcohol-consumption-and-nosebleeds

Min, H. J., Kang, H., Choi, G. J., & Kim, K. S. (2017). Association between Hypertension and Epistaxis: Systematic Review and Meta-Analysis in Otolaryngol Neck Surg, 157(6): 921–927. doi: 10.1177/0194599817721445 https://pubmed.ncbi.nlm.nih.gov/28742425/

Nasal Packing. (2010). ScienceDirect. Retrieved July 21, 2020, from https://www.sciencedirect.com/topics/medicine-and-dentistry/nasal-packing

Nose Bleed Management and Epistaxis Control. (2019). Iowa Head and Neck Protocols. Retrieved July 21, 2020, from https://medicine.uiowa.edu/iowaprotocols/nose-bleed-management-and-epistaxis-control

Nosebleed. (n.d.). NHSInform. Retrieved July 21, 2020, from https://www.nhsinform.scot/illnesses-and-conditions/ears-nose-and-throat/nosebleed

Nosebleed (Epistaxis). (n.d.). Harvard Health Publishing. Retrieved July 21, 2020, from https://www.health.harvard.edu/a_to_z/nosebleed-epistaxis-a-to-z

Pediatric Nosebleed Cauterization and Aftercare. (2019). Retrieved July 21, 2020, from https://www.youtube.com/watch?v=yBbm2SYUu-0

Sarhan, N. A. & Algamal, A. M. (2015). Relationship between epistaxis and hypertension: A cause and effect or coincidence? In Journal of the Saudi Heart Association, 27(2): 79–84. Doi: 10.1016/j.jsha.2014.09.002 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4392352/

Silva, M., Hosman, A. E., Devlin, H. L., & Shovlin, C. L. (2013). Lifestyle and dietary influences on nosebleed severity in hereditary hemorrhagic telangiectasia in Laryngoscope, 123(5): 1092–9. Retrieved July 31, 2020, from https://pubmed.ncbi.nlm.nih.gov/23404156/ 

Tabassom, A. & Cho, J. J. (2020). Epistaxis (Nose Bleed). Treasure Island, FL: StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK435997/

Tunkel, D. E., et al. (2020). Clinical Practice Guideline: Nosebleed (Epistaxis) in Otolaryngol Neck Surg, 162(1 suppl.):S1–S38. doi:10.1177/0194599819890327 https://pubmed.ncbi.nlm.nih.gov/31910111/