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

Epistaxis (also called a nosebleed) refers to bleeding from the blood vessels of the nose. Epistaxis is common, especially in emergency medicine and ear, nose, and throat (ENT) conditions. Epistaxis more commonly occurs in children aged 2-10 years and in adults aged 50-80 years.

Epistaxis is classified into two types, according to the site of origin: anterior and posterior epistaxis. Anterior epistaxis, the most common type, refers to a nosebleed that originates from the anterior part of the nose. Most of the time, the bleeding involves one nostril and originates from the Kiesselbach plexus—a vascular network found on the nasal septum— where vessels are easily traumatized. Posterior epistaxis refers to bleeding from the posterior or superior nasal cavity. It most often originates from the Woodruff plexus; a vascular network found in the lateral wall of the nasal cavity. Posterior epistaxis usually involves both nostrils, and the blood may also flow backward and be swallowed or coughed up (hemoptysis). Often, posterior epistaxis is recognized when anterior epistaxis management fails, or when bleeding is noticed in the posterior pharynx or throat. Because the source of posterior bleeding is often difficult to see on physical examination, a nasal endoscopy is often performed to locate its source.

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

Local causes include trauma from nose-picking or a foreign body in the nose, anatomic irregularities such as a deviated septum, facial trauma, frequent or improper use of topical nasal sprays, inflammatory reactions, and, rarely, intranasal tumors. Smoking and intranasal drug use, such as cocaine, can also cause frequent nosebleeds due to irritation of the nasal mucosa and may lead to further nasal damage.

Systemic conditions that increase the risk of epistaxis include high blood pressure (hypertension), especially when severe or uncontrolled, which can increase the number, severity, and duration of nosebleeds. Posterior epistaxis is more common in people with hypertension. Other contributing systemic conditions include vascular malformations, cardiovascular diseases, and bleeding disorders like von Willebrand disease and hemophilia A and B. Additionally, chronic alcohol use can disrupt normal blood clotting and dilate superficial blood vessels, making them more prone to rupture.

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. Environmental factors can trigger allergies, increasing the risk of epistaxis due to mucosal inflammation, frequent nose blowing, and use of medications that dry the nasal mucosa, such as decongestants and antihistamines.

Some medications can predispose individuals to epistaxis. Blood thinners, which include anticoagulants (e.g., warfarin) and antiplatelet agents, interfere with blood clotting and increase bleeding risk. In addition, NSAIDs, such as aspirin and ibuprofen, and some supplements that can prolong bleeding (such as ginseng and vitamin E), may increase the risk of epistaxis.

Management of epistaxis depends on the severity of the bleeding and the individual’s underlying medical conditions. Anterior epistaxis is usually the easiest to manage, whereas posterior epistaxis often requires medical attention, since it is more difficult to control and may compromise the airway or cause blood aspiration.

Most often, management of epistaxis can be performed at home or by a primary care physician with simple first-aid measures. The first step in management is applying direct pressure by pinching the soft part of the nose for 15 to 20 minutes. Sitting upright and leaning the head slightly forward can help prevent blood from reaching the throat.

If bleeding persists, topical sprays containing vasoconstrictive medications or local anesthetics may be used. If epistaxis is severe, prolonged, causes difficulty breathing, results in vomiting from swallowed blood, follows significant trauma, or occurs in a child younger than 2 years; urgent medical evaluation is warranted.

Medical management may include topical vasoconstrictive nasal sprays, such as epinephrine or oxymetazoline, often combined with local anesthetics. If this is ineffective, anterior, or posterior, nasal packing or cauterization may be required. Nasal packing involves inserting gauze or a nasal tampon into the nasal cavity to absorb blood and apply pressure. Infectious complications are uncommon and typically localized; however, rare systemic infections such as toxic shock syndrome, can occur and require immediate removal of the packing, nasal cultures, and antibiotic therapy.

Cauterization may be used for recurrent or persistent anterior epistaxis. Chemical cauterization with silver nitrate is typically attempted before electrocautery and should be performed on only one side of the nasal septum to reduce risk of perforation.

If epistaxis persists despite packing or cauterization, surgical options, such as anteriorl ligation or embolization, may be considered.

Preventative measures include avoiding nose picking, keeping fingernails short, gentle nose blowing—especially during winter and allergy season – appropriate use of intranasal medications, wearing protective headgear during high-risk activities, and avoiding smoking and excessive alcohol use.

Epistaxis (also called a nosebleed) refers to bleeding from the blood vessels of the nose. Anterior epistaxis, the most common type, originates from the anterior nasal cavity, usually the Kiesselbach plexus; posterior epistaxis originates from the posterior or superior nasal cavity, usually the Woodruff plexus. Epistaxis generally occurs due to a rupture of blood vessels in the nasal mucosa and may be triggered by local or systemic causes, environmental factors, or medications.

Most cases can be managed at home by pinching the nose for 15 to 20 minutes or using topical sprays. Severe, prolonged epistaxis; bleeding associated with respiratory distress or trauma; or epistaxis in children younger than 2 years warrants medical evaluation. Home-based treatments include vasoconstrictive nasal sprays, nasal packing, cauterization, and surgery.