Special Senses & Otolaryngology

Epistaxis: anterior and posterior management

Clinical Overview and When to Suspect Epistaxis

— Anterior (90%): bleeding from Kiesselbach's plexus on the anterior nasal septum (Little's area), confluence of branches from the anterior ethmoidal, sphenopalatine, greater palatine, and superior labial arteries

— Posterior (10%): bleeding from the sphenopalatine artery branches in the posterior nasal cavity (Woodruff's plexus), more brisk, often bilateral, blood seen draining down the posterior pharynx

— Failure of anterior packing to control bleeding

— Hemorrhage from both nares

— Persistent posterior pharyngeal blood drainage with anterior packing in place

— Hemodynamic instability or hemoptysis/hematemesis from swallowed blood

— Local: digital trauma (nose-picking), dry air/winter, intranasal steroids, cocaine, septal deviation, neoplasm (squamous cell, juvenile nasopharyngeal angiofibroma in adolescent males)

— Systemic: hypertension (correlation, not direct cause), anticoagulants/antiplatelets, liver disease, uremia, hereditary hemorrhagic telangiectasia (HHT/Osler-Weber-Rendu), von Willebrand disease, leukemia

Epistaxis = bleeding from the nasal cavity; one of the most common ENT emergencies, with a bimodal age distribution (children 2–10, adults >50)

Anatomic classification drives management:

When to suspect posterior epistaxis:

Common precipitants:

Step 3 management: Anticoagulation use is the single most important modifier — always ask about warfarin, DOACs, dual antiplatelets, NSAIDs, and herbal supplements (ginkgo, garlic, fish oil) before deciding on disposition

Board pearl: Recurrent unilateral epistaxis in an adolescent male = juvenile nasopharyngeal angiofibroma until proven otherwise — do not biopsy in clinic (catastrophic bleeding); obtain contrast imaging and ENT referral

Epistaxis is usually self-limited, but 5–10% require medical intervention, and posterior bleeds carry mortality up to 3–6% in elderly anticoagulated patients

Presentation Patterns and Key History

— Unilateral bleeding from one naris, often after nose-blowing, sneezing, or trauma

— Patient leaning forward, blood visible at the nasal vestibule

— Self-limited or stops with simple pressure

— Bleeding from both nares OR brisk unilateral bleed not controlled by anterior measures

— Blood dripping down the oropharynx with patient swallowing/spitting blood

— Hematemesis or coffee-ground emesis from swallowed blood (mimics UGIB)

— Older patient on anticoagulation, often hypertensive on arrival

— Duration and estimated volume — soaked tissues vs. cups of blood

— Laterality and whether bilateral

— Trauma, foreign body (especially pediatrics), recent surgery

— Prior episodes and prior interventions (cautery, packing, embolization)

— Atrial fibrillation, mechanical valve, recent DVT/PE → anticoagulation

— Coronary stents → DAPT

— Cirrhosis, ESRD on dialysis (uremic platelet dysfunction)

— Hematologic disorders, HHT, recurrent mucocutaneous bleeds

— Hypertension, especially uncontrolled

— Warfarin (check INR), apixaban/rivaroxaban/dabigatran, aspirin, clopidogrel/ticagrelor

— Intranasal steroids, oxymetazoline overuse

— Cocaine, methamphetamine (septal perforation)

— NSAIDs, SSRIs (mild platelet effect), supplements

Classic anterior presentation:

Classic posterior presentation:

Critical history elements (HPI):

Past medical history red flags:

Medications to elicit:

Family history: HHT (autosomal dominant — recurrent epistaxis + telangiectasias + AVMs in lung/brain/liver + family history = Curaçao criteria)

Key distinction: Hematemesis from swallowed posterior epistaxis vs. true UGIB — clarify whether the patient saw nasal bleeding first and whether the emesis is bright red (recent swallowing) vs. coffee-ground; nasal exam clarifies

Step 3 management: Always document last anticoagulant dose, indication, and time-since-last-dose — drives reversal decisions and disposition

Physical Exam Findings and Hemodynamic Assessment

— Vital signs: tachycardia, hypotension, orthostatics

— Airway compromise from posterior bleed or aspiration in obtunded patients

— Establish two large-bore IVs if bleeding is brisk or patient is on anticoagulation

— Headlamp or head mirror, nasal speculum, Frazier suction, bayonet forceps

— Topical anesthetic + vasoconstrictor (lidocaine 4% + oxymetazoline, or lidocaine + epinephrine)

— PPE: gown, face shield, gloves — high splash risk

— Have patient blow nose to clear clots

— Apply topical vasoconstrictor on cotton pledgets for 10–15 minutes

— Reexamine after vasoconstriction — often reveals the bleeding source

— Discrete bleeding point or oozing on the anterior septum (Kiesselbach's)

— Bleeding stops with pinching the cartilaginous portion of the nose (NOT the bony bridge)

— No identifiable anterior source despite good visualization

— Blood streaming down posterior pharyngeal wall on oral exam

— Persistent bleeding after well-placed anterior pack

— Bilateral bleeding

— Telangiectasias on lips/tongue/fingers → HHT

— Petechiae, ecchymoses → thrombocytopenia or coagulopathy

— Hepatomegaly, jaundice, spider angiomas → cirrhotic coagulopathy

— Lymphadenopathy, pallor → hematologic malignancy

Initial priority = ABCs and hemodynamics:

Position the patient: upright, leaning forward (not back — prevents aspiration and accurate assessment of volume swallowed)

Equipment for exam:

Sequence:

Anterior bleed signs:

Posterior bleed signs:

Systemic exam clues:

Board pearl: Pinch the soft cartilaginous nose (not the nasal bridge) firmly for 15 continuous minutes — most anterior bleeds stop with this maneuver alone; premature release is the #1 reason for "failure"

CCS pearl: Order CBC, type & screen, PT/INR, PTT early in any patient on anticoagulation or with hemodynamic changes — don't wait for packing failure

Diagnostic Workup — Initial Labs and Imaging

— Anticoagulant or antiplatelet use

— Suspected coagulopathy (cirrhosis, ESRD, hematologic disease)

— Heavy or prolonged bleeding requiring packing

— Hemodynamic instability

— Recurrent epistaxis without clear local cause

— CBC: hemoglobin/hematocrit (may underestimate acute loss), platelet count

— PT/INR, aPTT: essential if on warfarin or unexplained bleeding

— Type and screen if transfusion may be needed or posterior bleed suspected

— BMP: renal function (uremic platelet dysfunction; also dosing for reversal agents)

— LFTs if cirrhosis suspected

— Fibrinogen if DIC or massive transfusion considered

— Routine PT/PTT are unreliable for DOACs

— Anti-Xa level (calibrated for apixaban/rivaroxaban) — limited availability

— Dilute thrombin time or ecarin clotting time for dabigatran

— In practice: rely on time since last dose and renal function

— Trauma with suspected facial fracture → CT face/maxillofacial

— Recurrent unilateral epistaxis with suspected mass → CT or MRI with contrast

— Adolescent male with recurrent unilateral bleed → CT with contrast for juvenile nasopharyngeal angiofibroma (do NOT biopsy)

— Pre-embolization planning → CT angiography

Most epistaxis is a clinical diagnosis — labs are selective, not routine

Indications for laboratory workup:

Initial labs:

DOAC-specific testing:

Imaging — generally NOT needed acutely for routine epistaxis

Imaging indications:

ECG: in elderly patients with significant blood loss, tachycardia, chest pain, or known CAD — assess demand ischemia

Board pearl: Hemoglobin in acute hemorrhage lags real blood loss by hours; don't be falsely reassured by a normal initial Hgb in a brisk posterior bleed

Step 3 management: In a warfarin patient with INR >3 and active epistaxis, do not wait for bleeding to fail conservative measures — start reversal planning while applying initial hemostatic measures

Diagnostic Workup — Advanced and Confirmatory Studies

— Performed by ENT (or trained EM in some centers) with flexible or rigid endoscope

— Allows direct visualization of posterior bleeding sites including sphenopalatine artery branches and Woodruff's plexus

— Enables targeted electrocautery or chemical cautery under direct vision

— Should be considered before blind posterior packing when ENT is available

— Indicated when planning endovascular embolization

— Identifies vascular anomalies, tumors, traumatic pseudoaneurysm

— Evaluates aberrant internal carotid contributions (important to avoid catastrophic embolization complications)

— Both diagnostic and therapeutic for refractory posterior epistaxis

— Maps internal maxillary artery distribution and identifies bleeding source

— von Willebrand panel (VWF antigen, ristocetin cofactor, factor VIII) — most common inherited bleeding disorder

— Platelet function testing (PFA-100) if platelet dysfunction suspected

— Peripheral smear if thrombocytopenia or hematologic malignancy suspected

— Genetic testing for HHT (ENG, ACVRL1 mutations) — confirms diagnosis when Curaçao criteria suggest

— Pulmonary AVMs: contrast echocardiography (bubble study), then CT chest if positive

— Cerebral AVMs: MRI brain

— Hepatic AVMs: abdominal Doppler US if symptomatic

Nasal endoscopy is the definitive diagnostic and often therapeutic tool when source unclear or bleeding persists:

CT angiography (CTA):

Conventional angiography:

Workup for underlying systemic cause (in recurrent/severe cases):

HHT screening when diagnosed:

Key distinction: Workup of a first uncomplicated anterior bleed in a healthy adolescent or adult does not require imaging or extensive labs — vs. recurrent unilateral, family history, or severe presentations which mandate further evaluation

Board pearl: In confirmed/suspected HHT, screen for pulmonary AVMs — they cause paradoxical embolic stroke and brain abscess, and are treatable with embolization

Step 3 management: Refer recurrent epistaxis without identifiable local cause to hematology for bleeding disorder workup before assuming it is idiopathic

Risk Stratification and First-Line Management Logic

— Step 1: ABCs, IV access, hemodynamic stabilization, suction

— Step 2: Have patient blow nose to evacuate clots

— Step 3: Direct pressure — pinch cartilaginous nose firmly for 15 continuous minutes, leaning forward

— Step 4: If continues, apply topical vasoconstrictor (oxymetazoline) on cotton pledget + topical anesthetic (lidocaine 4%) for 10–15 minutes

— Step 5: Inspect with nasal speculum and headlamp; identify bleeding point

— Step 6: Silver nitrate cautery if discrete anterior bleeding point is visualized after hemostasis (do NOT cauterize both sides of septum simultaneously → septal perforation risk)

— Step 7: Anterior nasal packing if bleeding persists despite above (Merocel/Rapid Rhino balloon catheter or ribbon gauze with petrolatum)

— Step 8: If anterior pack fails, blood still draining posteriorly, or bilateral → posterior pack + ENT consult + admit

— Step 9: Refractory posterior bleeding → endoscopic sphenopalatine artery ligation or endovascular embolization

— Treat severe HTN (SBP >180 or DBP >110) after initial hemostatic measures

— Use short-acting agents (labetalol, nicardipine); avoid aggressive lowering

— Balance bleeding severity vs. thrombotic risk (mechanical valve, recent stent)

— Anterior pack only, stable patient, no comorbidities → discharge with ENT follow-up in 48–72 hours

— Posterior pack → admit, often to monitored bed/ICU (risk of nasopulmonary reflex, hypoxia, dysrhythmia)

— Significant blood loss, ongoing anticoagulation → admit

Stepwise algorithm for acute epistaxis:

Hypertension management:

Anticoagulant reversal decisions (see chunk 7):

Disposition logic:

Board pearl: Posterior packing requires admission — historically associated with the "nasopulmonary reflex" causing bradycardia/hypoxia, plus continuous monitoring for re-bleeding and airway compromise

CCS pearl: Order BP control, hold anticoagulants, give appropriate reversal agent, type and screen, ENT consult, and admit to telemetry/ICU — all early in the encounter, not sequentially

Pharmacotherapy — Hemostatic Agents and Anticoagulant Reversal

— Oxymetazoline 0.05% — 2–3 sprays or on cotton pledget; alpha-1 agonist

— Phenylephrine 0.25–1% — alternative

— Cocaine 4% (topical) — combines vasoconstriction + anesthesia; rarely used today

— Caution in uncontrolled HTN, CAD, MAOI use

— Lidocaine 4% spray or pledget

— Often combined with vasoconstrictor: lidocaine + oxymetazoline soaked pledgets for 10–15 minutes

— Tranexamic acid (TXA) 500 mg soaked on gauze applied intranasally — increasing evidence for benefit

— Floseal, Surgicel, gelfoam — absorbable hemostatic matrices

— Silver nitrate sticks for chemical cautery of discrete anterior bleeding points

— IV TXA may be considered in significant or refractory bleeding, especially with antiplatelet use

— Warfarin:

— Severe bleed: 4-factor PCC (Kcentra) + IV vitamin K 5–10 mg

— FFP if PCC unavailable

— Dabigatran: Idarucizumab (Praxbind) 5 g IV

— Apixaban/Rivaroxaban: Andexanet alfa (expensive, limited availability) or 4-factor PCC 50 units/kg

— Heparin: protamine sulfate

— Antiplatelets: platelet transfusion only for life-threatening bleeding; DDAVP for uremic platelet dysfunction

— Minor anterior bleed, controlled with packing: hold anticoagulant 24–48 hours, no reversal

— Major or posterior bleed with hemodynamic compromise: reverse

— Mechanical mitral valve, recent PE, recent coronary stent → consult cardiology before full reversal

Topical vasoconstrictors (first-line adjunct):

Topical anesthetics:

Topical hemostatics:

Systemic TXA:

Anticoagulant reversal (when bleeding severe):

Hold vs. reverse decision:

Step 3 management: Resume anticoagulation as soon as hemostasis is durable (typically 24–72 hours post-packing removal) — thrombotic risk often exceeds re-bleeding risk in high-risk patients

Board pearl: Andexanet alfa has a short half-life and rebound anti-Xa activity; coordinate timing with hemostatic intervention

Procedures — Packing, Cautery, Ligation, and Embolization

— Apply for 5–10 seconds to bleeding point AFTER hemostasis achieved

— Never cauterize both sides of septum at the same visit → septal perforation

— Avoid in bleeding diathesis or large bleeds (ineffective)

— Merocel sponge: insert dry, then hydrate with saline; expands to tamponade

— Rapid Rhino: carboxymethylcellulose-coated balloon, soak in water first, inflate with air; less mucosal trauma

— Petrolatum/bismuth ribbon gauze: layered packing for experienced operators

— Leave 24–72 hours; provide prophylactic antibiotics to cover S. aureus (cephalexin, augmentin) — concerns for toxic shock syndrome historically (evidence weak but practice persists)

— Foley catheter (12–14 Fr): pass into nasopharynx, inflate balloon with 7–10 mL saline, pull anteriorly to seat against posterior choana, secure with umbilical clamp (protect ala with padding)

— Epistat or double-balloon devices: dedicated posterior packs

— Classic gauze posterior pack (rarely used now)

— Admit all patients with posterior packs — monitor for hypoxia, dysrhythmia, pressure necrosis

— First-line surgical management of refractory posterior epistaxis

— Performed by ENT; high success rate (>95%); lower morbidity than embolization

— Performed by interventional radiology

— Targets internal maxillary artery branches

— Reserved for failed ligation, surgical contraindications, or massive bleeding

— Risks: stroke, facial pain, skin necrosis, ophthalmoplegia (avoid internal carotid territory)

Silver nitrate cautery (anterior, discrete source):

Anterior nasal packing:

Posterior nasal packing:

Endoscopic sphenopalatine artery ligation (ESPAL):

Endovascular embolization:

External carotid artery ligation: rarely performed today

CCS pearl: For refractory posterior epistaxis — ENT consult, transfer to OR for endoscopic sphenopalatine artery ligation; if unavailable or unstable, IR consult for embolization

Board pearl: Patients with posterior packs need continuous pulse oximetry and cardiac monitoring; supplemental O2 is reasonable

Special Populations — Elderly and Renal/Hepatic Impairment

— Higher anticoagulation prevalence (afib, valves, VTE)

— Atherosclerotic, friable vessels less responsive to vasoconstrictors

— Higher incidence of posterior bleeds (sphenopalatine territory)

— Hypertension often poorly controlled

— Reduced physiologic reserve → faster decompensation with blood loss

— Lower threshold for admission even with anterior packing if frail, on AC, or living alone

— Cautious BP lowering (avoid cerebral hypoperfusion)

— Cardiac monitoring with posterior packs (high rate of demand ischemia, AFib triggers)

— Avoid cocaine-containing topicals (CV risk)

— Use lower doses of sedatives if needed for packing

— Uremic platelet dysfunction (GFR <30, especially dialysis-dependent)

— Treat with DDAVP 0.3 mcg/kg IV/SC, cryoprecipitate, or conjugated estrogens

— Consider dialysis if uremia severe

— Apixaban is the preferred DOAC in CKD; dabigatran is contraindicated in severe renal impairment (renally cleared, accumulates)

— Adjust reversal agent dosing per renal function

— Decreased clotting factor synthesis (II, VII, IX, X), thrombocytopenia (hypersplenism), platelet dysfunction

— Check INR and platelets; consider FFP or 4-factor PCC + vitamin K

— Avoid NSAIDs entirely

— Cirrhotic patients are often rebalanced — hemostatic resuscitation should be guided by active bleeding, not just abnormal labs

Elderly patients carry disproportionate epistaxis morbidity:

Management modifications in elderly:

Renal impairment:

Hepatic impairment:

Polypharmacy: review for redundant antiplatelets, supplements (ginkgo, fish oil, garlic, vitamin E)

Step 3 management: In an elderly patient on apixaban with controlled anterior epistaxis — hold apixaban 24–48 hours, do NOT routinely reverse; resume after hemostasis confirmed and ENT follow-up arranged

Board pearl: DDAVP is the go-to for uremic bleeding — works by releasing endogenous vWF and factor VIII from endothelium

Special Populations — Pregnancy, Pediatrics, and HHT

— Almost always anterior from Kiesselbach's plexus

— Triggers: digital trauma, dry air, allergic rhinitis, foreign body (suspect with unilateral foul-smelling discharge)

— Treatment: pressure, humidification, saline spray, petroleum jelly to vestibule, treat underlying allergic rhinitis

— Avoid silver nitrate cautery in young children when possible; if needed, very limited application

— Recurrent pediatric epistaxis → consider von Willebrand disease (most common inherited bleeding disorder; ask about easy bruising, menorrhagia in adolescents, family history)

— Recurrent unilateral epistaxis in adolescent male → juvenile nasopharyngeal angiofibroma — imaging, ENT, do NOT biopsy

— Increased epistaxis frequency due to estrogen-driven mucosal vascularity and edema (rhinitis of pregnancy)

— Usually self-limited, anterior

— Treatment: humidification, saline, gentle pressure

— Avoid oxymetazoline overuse; safe for short-term use but rebound congestion concerns

— Avoid cocaine topicals

— Silver nitrate and packing safe

— Severe bleeding: TXA considered safe in pregnancy

— Autosomal dominant; Curaçao criteria: spontaneous recurrent epistaxis, mucocutaneous telangiectasias, visceral AVMs, first-degree relative — 3 of 4 = definite

— Epistaxis is the most common presentation (90%+)

— Management: humidification, nasal moisturizers, ablative therapy (laser, sclerotherapy, bevacizumab intranasal/IV), septodermoplasty, Young's procedure (nasal closure for severe cases)

— Systemic anti-angiogenics (bevacizumab) for severe/refractory bleeding

— Screen for pulmonary, cerebral, hepatic AVMs

Pediatric epistaxis:

Pregnancy:

Hereditary Hemorrhagic Telangiectasia (HHT):

Board pearl: Pediatric recurrent epistaxis + heavy menses + family history = von Willebrand disease — order vWF antigen, ristocetin cofactor, factor VIII

Step 3 management: Counsel HHT patients to avoid NSAIDs and aspirin; iron deficiency anemia is common — supplement and monitor

Complications and Adverse Outcomes

— Hypovolemic shock — uncommon but more frequent with posterior bleeds and anticoagulation

— Acute anemia requiring transfusion

— Aspiration of blood → pneumonitis, pneumonia, hypoxia

— Hematemesis from swallowed blood, may trigger unnecessary UGIB workup

— Septal hematoma (after trauma or packing) → must drain to prevent septal abscess and saddle-nose deformity

— Septal perforation from bilateral simultaneous cautery or pressure necrosis

— Synechiae (adhesions) from prolonged packing

— Sinusitis, otitis media (eustachian tube obstruction) with packing

— Pressure necrosis of ala from improperly secured posterior pack/Foley

— Vasovagal/bradycardic reflex during nasal manipulation

— Hypoxia, hypoventilation

— Bradycardia, dysrhythmias

— Sleep apnea exacerbation

— Demand cardiac ischemia in CAD patients

— Toxic shock syndrome (TSS) — historically associated with packing; rare but reportable; mandates prophylactic antibiotics in most practices (cephalexin, amoxicillin-clavulanate)

— Sinusitis, bacteremia

— Stroke (inadvertent ICA territory embolization)

— Facial pain, trismus, mucosal/skin necrosis

— Ophthalmoplegia, blindness (rare)

— Chronic anemia, iron deficiency (especially HHT)

— Recurrent epistaxis, anxiety, reduced quality of life

— Psychological impact in pediatric patients

Hemorrhagic complications:

Procedure-related complications:

Posterior packing-specific risks ("nasopulmonary reflex"):

Infectious complications:

Embolization complications:

Long-term:

Board pearl: Septal hematoma = boggy, fluctuant septal swelling after trauma — emergent incision and drainage to prevent cartilage necrosis (septum is avascular and depends on perichondrium)

Step 3 management: Any patient with prolonged anterior or posterior packing should receive prophylactic antibiotics (anti-staphylococcal) and have packing removed within 72 hours to minimize TSS and necrosis risk

When to Escalate Care — ICU, Consult, and Inpatient Triage

— Anterior bleeding not controlled with cautery and packing

— Suspected or confirmed posterior bleed

— Recurrent epistaxis despite outpatient management

— Suspicion of nasal mass, neoplasm, or foreign body

— Trauma with possible septal hematoma

— HHT patients with severe bleeding

— Posterior nasal pack (mandatory admission)

— Hemodynamic instability or significant blood loss requiring transfusion

— Anticoagulated patient requiring reversal

— Severe comorbidities (CAD, CHF, COPD) with significant bleeding

— Failure of outpatient management

— Inability to manage at home, frailty, lack of follow-up access

— Posterior packs — telemetry minimum; ICU if elderly, OSA, CAD, or hypoxia

— Active or recently controlled massive bleeding

— Ongoing transfusion requirement

— Significant anticoagulation reversal

— Airway concerns

— Failed surgical ligation

— Surgical contraindication

— Massive uncontrolled bleeding

— HHT with refractory bleeding

— Suspected bleeding disorder (vWD, hemophilia, platelet dysfunction)

— Recurrent unexplained epistaxis

— Anticoagulation management in complex patients (mechanical valves, recent VTE)

— Anticoagulation reversal in mechanical valve, recent stent

— Demand ischemia from blood loss

Indications for ENT consult:

Admission criteria:

ICU/monitored bed criteria:

Interventional radiology consult:

Hematology consult:

Cardiology consult:

CCS pearl: Patient with posterior pack — admit to telemetry/ICU, continuous pulse oximetry, supplemental O2 as needed, ENT consult for definitive management (endoscopic ligation in next OR window), hold AC, BP control, IV fluids/transfusion as needed

Step 3 management: Do not discharge a patient with a posterior pack — this is a tested decision point; even hemodynamically stable patients require monitored admission

Key Differentials — Same-Category (Otolaryngologic) Causes

— Anterior septal bleed (Kiesselbach's) — most common, easily visualized, responds to pressure

— Posterior bleed (sphenopalatine/Woodruff's) — brisk, bilateral, posterior drainage

— Septal perforation — chronic crusting and intermittent bleeding; causes: trauma, cocaine, surgery, GPA (Wegener's), syphilis

— Septal deviation — turbulent airflow → mucosal drying and bleeding

— Allergic rhinitis — clear rhinorrhea, sneezing, congestion, pale boggy mucosa; treat underlying

— Viral URI — vasodilation, friable mucosa

— Acute bacterial sinusitis — purulent rhinorrhea, facial pain

— Granulomatosis with polyangiitis (GPA) — chronic sinusitis, crusting, septal perforation, saddle-nose; check c-ANCA/PR3

— Juvenile nasopharyngeal angiofibroma — adolescent male, unilateral recurrent epistaxis, nasal obstruction; vascular, do NOT biopsy

— Squamous cell carcinoma — chronic smoker, unilateral mass, recurrent bleeding

— Inverted papilloma — unilateral nasal mass, malignant potential

— Nasopharyngeal carcinoma — Asian/Mediterranean ancestry, EBV-associated, cervical lymphadenopathy

— Esthesioneuroblastoma — rare, anosmia, epistaxis

— Nasal bone fracture — periorbital ecchymosis, crepitus, deformity

— Septal hematoma — examine after any nasal trauma

— CSF rhinorrhea with basilar skull fracture — clear fluid with halo sign or beta-2 transferrin positive

— Post-septoplasty, sinus surgery, nasogastric/nasotracheal tube placement

— Intranasal steroid sprays (direct septal trauma — direct nozzle laterally)

— Pediatric, unilateral foul-smelling purulent rhinorrhea

Local mucosal causes of epistaxis to distinguish:

Inflammatory/infectious:

Neoplastic:

Traumatic:

Iatrogenic:

Foreign body:

Key distinction: Adolescent male + recurrent unilateral epistaxis + nasal obstruction = JNA, not idiopathic — contrast imaging mandatory, biopsy contraindicated due to massive hemorrhage risk

Key Differentials — Other-Category (Systemic) Causes

— von Willebrand disease — most common inherited bleeding disorder; mucocutaneous bleeding, menorrhagia, family history; vWF antigen, ristocetin cofactor, factor VIII

— Hemophilia A/B — X-linked; deep tissue bleeding more typical, but mucosal bleeding possible

— Immune thrombocytopenia (ITP) — petechiae, isolated thrombocytopenia

— Leukemia — pancytopenia, fatigue, infections, bleeding

— Disseminated intravascular coagulation (DIC) — sepsis, malignancy, OB emergencies; ↑PT/PTT, ↓fibrinogen, ↑D-dimer, ↓platelets

— Platelet dysfunction — uremia, medications, Glanzmann's, Bernard-Soulier

— Hereditary hemorrhagic telangiectasia (HHT) — Curaçao criteria

— Ehlers-Danlos (vascular type, type IV) — fragile vessels, easy bruising

— Warfarin, DOACs, heparin — primary culprits

— Aspirin, clopidogrel, ticagrelor

— NSAIDs — both gastric and mucosal bleeding

— SSRIs — mild platelet effect, additive with other agents

— Cocaine, methamphetamine — vasoconstriction → necrosis → bleeding; septal perforation

— Topical steroids with poor technique

— Herbal: ginkgo, garlic, ginseng, fish oil, vitamin E

— Low humidity (winter heating, high altitude, supplemental O2)

— Occupational chemical exposure

— Hemoptysis from lower airway

— Hematemesis from UGIB

— Post-tonsillectomy bleed presenting as oral/posterior blood

Hematologic disorders:

Vascular/structural:

Pharmacologic causes:

Hepatic disease: cirrhosis-related coagulopathy and thrombocytopenia

Renal disease: uremic platelet dysfunction (treat with DDAVP, dialysis)

Hypertensive crisis: severe HTN may be associated but rarely sole cause; treat both

Environmental:

Mimics of epistaxis (blood appearing to come from nose):

Board pearl: Recurrent epistaxis + telangiectasias on lips/tongue/fingers + family history of bleeding/strokes/lung AVMs = HHT — initiate Curaçao criteria assessment and AVM screening

Secondary Prevention, Discharge Medications, and Long-Term Plan

— Avoid nose-blowing for at least 12 hours

— Sneeze with mouth open

— Avoid heavy lifting, straining, bending for 24–48 hours

— Avoid hot beverages, spicy foods, alcohol initially (vasodilation)

— No smoking, no nasal picking

— Humidified air, saline nasal spray, petroleum jelly or bacitracin ointment to vestibule 2–3× daily for 1–2 weeks

— Cephalexin 500 mg QID or amoxicillin-clavulanate — covers S. aureus

— Continue until packing removed (typically 48–72 hours)

— Theoretical TSS prevention; evidence modest

— Anterior packs: 24–72 hours, in ENT clinic or by trained provider

— Soak with saline before removal to ease extraction

— Hold for 24–48 hours after hemostasis in most cases

— Resume when hemostasis durable — typically within 72 hours

— Coordinate with cardiology/hematology for high-risk patients (mechanical valves, recent VTE, recent stent)

— For DAPT after recent PCI: avoid stopping if at all possible; consult cardiology

— Blood pressure control — long-term target <130/80

— Treat allergic rhinitis (intranasal steroids — teach proper technique, direct nozzle laterally away from septum)

— Smoking cessation, cocaine cessation

— Environmental: humidifier in winter, especially with home O2

— Ferrous sulfate 325 mg daily; IV iron if oral intolerant or severe deficiency

— vWD: desmopressin prophylaxis for known triggers

— HHT: bevacizumab considerations, AVM management

Discharge instructions after anterior packing/cautery:

Antibiotic prophylaxis while packing in place:

Pack removal:

Anticoagulation management:

Risk factor modification:

Iron supplementation for chronic/recurrent bleeders (HHT especially):

Bleeding disorder management:

Step 3 management: Always document anticoagulation hold and restart plan at discharge — failure to bridge or restart appropriately is a major source of post-discharge thrombotic events and malpractice risk

Board pearl: Teach proper intranasal steroid spray technique — angled away from the nasal septum — prevents the most common iatrogenic epistaxis cause

Follow-Up, Monitoring Parameters, and Counseling

— Anterior packing → 48–72 hours for pack removal and nasal exam

— Cautery only → 1–2 weeks to assess healing

— Posterior packing/surgical intervention → admission with inpatient ENT care, then outpatient follow-up 1–2 weeks

— Recurrent epistaxis without clear etiology → ENT evaluation with nasal endoscopy

— Within 1–2 weeks for medication reconciliation (AC restart), BP optimization, anemia recheck

— CBC at 1–2 weeks if significant blood loss occurred

— Recurrent epistaxis without local cause

— Family history of bleeding disorder

— Personal history of mucocutaneous bleeding, easy bruising, menorrhagia

— HHT diagnosis or suspicion

— Patient/family education on recognizing re-bleeding

— Counsel on return precautions: bleeding lasting >20 min despite pressure, lightheadedness, syncope, large clots, hematemesis, melena

— First-aid technique: sit upright, lean forward, pinch soft part of nose firmly for 15 minutes continuously, breathe through mouth

— Saline spray 2–4× daily

— Petrolatum or mupirocin/bacitracin ointment to anterior septum nightly (HHT and recurrent bleeders)

— Avoid digital trauma; trim children's nails

— Maintain home humidity (40–50%)

— Address nose-picking habit

— Treat underlying allergic rhinitis

— Reassurance — usually benign and self-limited

— Annual screening for new symptoms

— Periodic re-evaluation of pulmonary/cerebral/hepatic AVMs

— Iron status monitoring (CBC, ferritin)

ENT follow-up:

Primary care follow-up:

Hematology referral:

Monitoring parameters at home:

Counseling and self-management (key for prevention):

Pediatric counseling:

HHT longitudinal care:

CCS pearl: Order outpatient CBC and ferritin in 2 weeks for any patient who lost significant blood; iron deficiency anemia often emerges after the acute event

Step 3 management: Schedule ENT follow-up before discharge — patients with packs cannot remove their own packing safely; lack of follow-up = repeat ED visit

Ethical, Legal, and Patient Safety Considerations

— Posterior packing, cautery, and embolization require explanation of risks: pain, septal perforation, infection, hypoxia (posterior packs), stroke (embolization)

— Document discussion of alternatives and risks

— Capacity assessment in intoxicated, hypoxic, or hypovolemic patients — proceed with emergency exception if life-threatening

— Document the risk-benefit analysis: severity of bleed, indication for AC, thrombotic risk

— Discuss with the patient (or surrogate) whenever feasible

— In mechanical mitral valves and recent stents, reversal carries significant thrombotic risk — multidisciplinary input documented

— High-risk transition: ED discharge of anticoagulated patient with packed nose

— Closed-loop communication: ED → ENT → primary care

— Written instructions on pack removal date, anticoagulation restart, return precautions

— Confirm patient can read instructions; provide translation services as needed

— Pack tracking: document number and type of packs placed; failure to remove packing has caused toxic shock syndrome and death

— Some institutions use checklists or wristbands for indwelling nasal packs

— Verify removal at follow-up; if missed appointment, contact the patient

— Recurrent epistaxis in a child should prompt evaluation for abuse if accompanied by other suspicious findings (bruising patterns, inconsistent histories)

— Foreign body epistaxis — explore non-accidental causes when context suggests

— Suspected child or elder abuse with associated injuries

— Cocaine use as cause of severe epistaxis — does not require reporting in adults but document and offer counseling/treatment for substance use

— Ensure access to humidifiers, ointments, follow-up — barriers disproportionately affect low-income patients with recurrent epistaxis

Informed consent issues:

Anticoagulation reversal decisions:

Transitions of care:

Patient safety:

Pediatric considerations:

Mandatory reporting:

Health equity:

Step 3 management: Always document pack placement and removal plan in the chart and on after-visit summary — undocumented/forgotten packing is a sentinel patient-safety event with regulatory implications

Board pearl: A patient discharged with an indwelling nasal pack who does not follow up requires active outreach — this is a tested transitions-of-care safety scenario

High-Yield Associations and Rapid-Fire Clinical Facts

Anterior bleed = Kiesselbach's plexus (Little's area) = 90% of cases

Posterior bleed = sphenopalatine artery (Woodruff's plexus) = 10%, but disproportionate morbidity

Pinch the soft cartilaginous nose, not the bony bridge — for 15 minutes continuously

Lean forward, not back — prevents aspiration and accurate volume assessment

Adolescent male + recurrent unilateral epistaxis = juvenile nasopharyngeal angiofibroma — do NOT biopsy

Recurrent epistaxis + telangiectasias + AVMs + family history = HHT (Osler-Weber-Rendu) — Curaçao criteria

HHT AVMs: screen pulmonary (bubble echo), cerebral (MRI), hepatic (US)

Recurrent pediatric epistaxis + menorrhagia in teen + family history = von Willebrand disease

Cocaine → septal perforation, recurrent epistaxis

GPA (Wegener's) → saddle nose, septal perforation, c-ANCA/PR3

Septal hematoma after trauma → emergent I&D to prevent cartilage necrosis and saddle deformity

Never cauterize both sides of the septum simultaneously → perforation

Posterior pack → admit (telemetry/ICU) → endoscopic sphenopalatine artery ligation or embolization for refractory cases

Idarucizumab = dabigatran reversal; andexanet alfa = apixaban/rivaroxaban reversal; PCC = universal option

DDAVP = uremic platelet dysfunction

Topical TXA has emerging evidence for reducing rebleed

Antibiotic prophylaxis with packing → cover S. aureus → prevent TSS

Intranasal steroid spray technique = nozzle aimed away from septum (laterally)

Acute Hgb in active bleeding lags real loss — don't be falsely reassured

Hypertension during acute epistaxis is often reactive — treat the bleed first, then BP

Most epistaxis is self-limited — only 5–10% require medical intervention

Embolization targets internal maxillary artery branches; avoid internal carotid territory

Board pearl: Memorize the algorithm: pressure → vasoconstrictor → cautery → anterior pack → posterior pack + admit → endoscopic ligation → embolization

Board Question Stem Patterns

— Young adult, anterior bleeding, BP normal, no anticoagulation → direct pressure for 15 min on the cartilaginous portion → likely answer choice

— Distractor: leaning the head back, pinching the bony bridge

— Persistent bleeding despite pressure and vasoconstrictor → silver nitrate cautery if discrete source, otherwise anterior packing

— Elderly anticoagulated patient, blood from both nares, persistent oropharyngeal blood despite anterior pack → posterior packing + admit + ENT consult

— Warfarin patient with INR 4.5, hypotensive, brisk posterior bleed → 4-factor PCC + IV vitamin K

— Dabigatran patient with massive epistaxis → idarucizumab

— Apixaban patient → andexanet alfa or 4-factor PCC

— Adolescent male with recurrent unilateral epistaxis, nasal obstruction → CT with contrast for JNA — do NOT biopsy

— Young child with unilateral foul-smelling discharge → foreign body

— Recurrent pediatric epistaxis + menorrhagia + family history → vWD workup

— Recurrent epistaxis, telangiectasias on lips/tongue, sibling with epistaxis → HHT → screen for pulmonary AVMs with bubble echo

— Post-trauma, boggy septal swelling → incision and drainage

— Anterior pack placed → antibiotic prophylaxis + ENT follow-up in 48–72 hours

— Don't forget to hold anticoagulation and arrange restart

— Posterior pack fails → endoscopic sphenopalatine artery ligation (first surgical option) or embolization if unstable/surgical contraindication

— ESRD on HD, mucosal bleeding → DDAVP

Stem 1 — Anterior epistaxis basics:

Stem 2 — Failed anterior management:

Stem 3 — Posterior bleed identification:

Stem 4 — Anticoagulant reversal:

Stem 5 — Pediatric patient:

Stem 6 — HHT:

Stem 7 — Septal hematoma:

Stem 8 — Discharge planning:

Stem 9 — Refractory bleed:

Stem 10 — Uremic patient:

Step 3 management: Stems often hinge on disposition — recognizing that posterior pack = admit is high-yield

Board pearl: When asked "next best step," follow the algorithm strictly: pressure → vasoconstrictor → cautery → anterior pack → posterior pack/admit → procedural intervention

One-Line Recap

Epistaxis management follows a stepwise algorithm — pressure and vasoconstriction first, anterior cautery or packing next, and posterior packing with admission plus ENT-guided ligation or embolization for refractory bleeds — while always identifying and addressing anticoagulation, hypertension, and underlying bleeding diatheses.

Anatomy drives management: anterior (90%, Kiesselbach's plexus) responds to pressure/cautery/anterior pack; posterior (10%, sphenopalatine artery) requires posterior pack and admission with consideration of endoscopic sphenopalatine artery ligation or endovascular embolization

The algorithm: 15 minutes of pressure on the cartilaginous nose while leaning forward → topical oxymetazoline + lidocaine pledget → silver nitrate cautery of discrete source → Merocel or Rapid Rhino anterior pack → posterior pack (Foley balloon) + ENT consult + admit → ESPAL or embolization

Anticoagulation is the dominant modifier: hold all AC, reverse only for severe/life-threatening bleeds (4-factor PCC + vitamin K for warfarin, idarucizumab for dabigatran, andexanet alfa or PCC for Xa inhibitors, DDAVP for uremia/vWD), and plan timely restart to balance thrombotic risk

High-yield associations: adolescent male + recurrent unilateral bleed = JNA (image, don't biopsy); recurrent epistaxis + telangiectasias + family history = HHT (screen AVMs); post-trauma boggy septum = septal hematoma (drain emergently); never cauterize bilateral septum (perforation); posterior packs mandate admission with telemetry and antibiotic prophylaxis to prevent TSS

Step 3 disposition pearls: anterior pack → discharge with ENT follow-up in 48–72 hours and antibiotic prophylaxis; posterior pack → admit to monitored bed; always document anticoagulation hold/restart plan and arrange closed-loop ENT follow-up to prevent retained packing and re-bleeding