Epistaxis

What is Epistaxis?

Epistaxis involves hemorrhage from the nasal cavity, most frequently originating from the anterior septal arterial network. It is a common clinical event affecting approximately 60% of individuals during their lifetime. Most episodes are anterior and self-limited, but posterior epistaxis can be more severe and may require urgent intervention.

What causes Epistaxis?

Mechanical trauma often disrupts the fragile mucosa of the anterior septum and causes the majority of episodes. Factors that predispose individuals to bleeding include chronic rhinitis, mucosal inflammation, and dry air. An anterior nosebleed usually involves the Kiesselbach’s plexus. In contrast, a posterior nosebleed originates from the sphenopalatine artery branches along the posterolateral wall.

A posterior nosebleed causes blood to drain into the oropharynx. Posterior epistaxis is more common in older adults and in those with anticoagulant use, coagulopathy, or vascular fragility. Systemic hypertension and platelet dysfunction may be associated with more severe or prolonged bleeding and impaired hemostasis. Severe epistaxis may also result from hypervascular tumors or hereditary hemorrhagic telangiectasia.

What are the signs and symptoms of Epistaxis?

Epistaxis typically presents with visible bleeding from one or both nostrils. The symptoms of epistaxis vary significantly depending on the anatomical source of the hemorrhage. External flow through the nares typically indicates an anterior origin. Conversely, a posterior nosebleed forces blood into the oropharynx, which may cause nausea, coughing, or swallowing difficulties.

Large-volume blood loss triggers systemic signs such as tachycardia, hypotension, and pallor. Severe bleeding episodes sometimes provoke aspiration concerns, especially in individuals with impaired airway protection.

How is Epistaxis diagnosed?

Initial evaluation focuses on airway patency and hemodynamic stability. Clinicians prioritize identifying the bleeding source through anterior rhinoscopy after removing clots with gentle suction. The application of topical vasoconstrictors often helps clear the field for better visualization. Nasal endoscopy may be needed when the bleeding source is not identified on initial examination.

Laboratory testing is not routinely required for self-limited epistaxis, but complete blood count and coagulation studies may be indicated in severe, persistent, recurrent, or anticoagulant-associated bleeding.

How is Epistaxis treated?

Individuals should lean forward and apply firm pressure by pinching the soft part of the nose against the septum for 10 to 15 minutes. Topical vasoconstrictors or chemical cautery can control visible anterior bleeding sites. If these measures fail, clinicians may use anterior nasal packing or absorbable hemostatic agents to provide tamponade.

A posterior nosebleed often necessitates the use of balloon catheters or specialized posterior packs. Posterior epistaxis often requires otolaryngology involvement. Management should include correction of coagulopathy when present and treatment of contributing underlying factors. Prevention of recurrent epistaxis includes humidification and use of saline spray or gel to reduce mucosal dryness.

What are the most important facts to know about Epistaxis?

• Epistaxis is bleeding from the nasal mucosa; most people experience at least one episode during their lifetime.
• Most cases are anterior and arise from local mucosal trauma or irritation, whereas a posterior nosebleed is less common and often more severe.
• Anterior epistaxis usually causes bleeding from the nostril, whereas posterior epistaxis may cause blood to drain into the oropharynx.
• Evaluation begins with assessment of airway and hemodynamic stability, followed by localization of the bleeding source with anterior rhinoscopy and, when needed, nasal endoscopy.
• Management transitions from simple digital pressure and cautery to nasal packing or arterial embolization for refractory cases.