1. DEFINITION

Epistaxis refers to bleeding from the nose or nasal cavity, arising from mucosal, vascular, cartilaginous, or post-traumatic disruption.
It is one of the most common ENT emergencies, accounting for a major portion of nasal presentations in OPD and emergency settings.
Most bleeds are simple anterior bleeds, but some are posterior, severe, recurrent, or require packing and surgical ligation.

2. APPLIED ANATOMY RELEVANT TO EPISTAXIS

Understanding anatomy is mandatory because 90% of bleeds arise from identifiable vascular plexuses.

2.1 Blood Supply of Nose

A. External Carotid System

Sphenopalatine artery
- Terminal branch of maxillary artery
- Main supplier of posterior nasal cavity
- Key source in posterior epistaxis
Greater palatine artery
- Supplies inferior meatus and floor of nose
Superior labial artery (branch of facial artery)
- Supplies anterior septum and vestibule
- Major contributor to anterior bleeds

B. Internal Carotid System

Anterior ethmoidal artery
Posterior ethmoidal artery
- Both from ophthalmic artery
- Bleeds due to trauma or skull base fractures

2.2 Venous Drainage

Dense venous plexus under thin mucosa
Drains into:
- Facial vein
- Pterygoid plexus
- Cavernous sinus (rare but explains cavernous sinus thrombosis risk)

2.3 Kiesselbach’s Plexus (Little’s Area)

Critical in children and young adults.

Formed by:

Anterior ethmoidal artery
Sphenopalatine artery branch
Superior labial artery
Greater palatine artery

Features

Thin mucosa
Highly vascular
Exposed to dryness and trauma
Responsible for 80–90% of epistaxis cases

2.4 Woodruff’s Plexus

Located in posterior nasal cavity (posterior end of inferior turbinate).

Features

Venous plexus
Source of posterior bleeds in older adults
High-flow bleeds → can be life-threatening
Difficult to visualize directly

2.5 Septal Deviation & Crusting

Deviated septum leads to airflow turbulence
Causes mucosal dryness → cracks → bleeding
Spurs especially contribute to recurrent epistaxis

3. CLASSIFICATION OF EPISTAXIS

3.1 Based on Location

A. Anterior Epistaxis

Originates from Kiesselbach’s plexus
Bright red bleeding
Usually mild to moderate
Easy to control
Seen in children & young adults

B. Posterior Epistaxis

Origin: Woodruff’s plexus or sphenopalatine branches
Profuse bleeding
Blood flows into throat
Occurs in elderly (hypertension, arteriosclerosis)
Requires packing, endoscopic cautery, or arterial ligation

3.2 Based on Severity

Mild
Moderate
Severe (hemodynamic compromise)
Recurrent
Intractable (requires surgical intervention)

3.3 Based on Duration

Acute
Episodic/Recurrent
Chronic (rare, usually underlying tumor or granulomatous disease)

4. PATHOGENESIS OF EPISTAXIS

Epistaxis occurs due to breakdown of mucosa + vessel wall disruption, triggered by:

A. Mucosal dryness → cracking → capillary rupture

Seen in:

Hot climate
Winter dryness
Indoor heating
Atrophic rhinitis

B. Local trauma

Finger picking (most common cause in children)
Nose blowing
Rubbing due to allergies

C. Vessel fragility

Hypertension
Atherosclerosis
Aging vessels

D. Septal deformities

Deviated septum increases airflow turbulence → focal dryness → rupture

E. Infection & Inflammation

Rhinitis
Sinusitis
Vestibulitis

F. Neoplastic erosion

Juvenile nasopharyngeal angiofibroma (JNA) in adolescent males
Nasal carcinomas
Hemangiomas

G. Coagulopathy

Platelet disorders
Liver disease
Anticoagulant use

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

5. CAUSES OF EPISTAXIS (DETAILED)

5.1 LOCAL CAUSES

A. Trauma

Digital trauma (“nose picking”)
Blunt trauma
Post-surgical trauma (septoplasty, rhinoplasty)
Foreign body insertion

B. Inflammatory

Acute rhinitis
Allergic rhinitis (constant rubbing)
Chronic sinusitis
Granulomatous diseases (e.g., Wegener’s granulomatosis)

C. Septal Abnormalities

Deviated nasal septum
- Sharply angled lamina leads to mucosal cracking
Septal perforation
- Turbulent airflow → whistling + bleeding
Septal spurs
- Frequent cause of unilateral bleeding

D. Neoplastic

JNA → severe recurrent epistaxis in adolescent boys
Angiomas
Inverted papilloma
Malignancies eroding mucosa

E. Environmental Factors

Hot dry climate
Low humidity
High altitude
Working in dusty environments
Smoke exposure

These factors thin mucosa and destabilize capillaries.

5.2 SYSTEMIC CAUSES

A. Hypertension

Most common systemic cause in adults
High pressure → rupture of posterior vessels
Posterior epistaxis has strong association

B. Bleeding Disorders

Thrombocytopenia
Hemophilia
Von Willebrand disease
DIC

C. Liver Disease

Reduced clotting factor synthesis

D. Renal Disease

Uremic platelet dysfunction

E. Medications

Aspirin
NSAIDs
Anticoagulants (warfarin, DOACs)
Antiplatelet drugs (clopidogrel)

F. Alcoholism

Causes mucosal dryness
Impairs clotting mechanisms

5.3 AGE-RELATED CAUSES

Children

Digital trauma
Allergic rhinitis
Foreign bodies
Bleeding disorders

Young Adults

Trauma
Deviated septum
Infections

Elderly

Hypertension
Posterior bleeds
Atherosclerotic vessels
Atrophic rhinitis

5.4 SPECIAL CLINICAL SITUATIONS

A. Pregnancy

High estrogen → mucosal edema & vascularity → recurrent epistaxis

B. Influenzal Rhinitis (“Epistaxis in Flu”)

Viral destruction of mucosa → capillary fragility

C. Cocaine Abuse

Causes septal perforation → recurrent bleeding

6. CLINICAL FEATURES OF EPISTAXIS

Presentation varies depending on location, severity, and patient age.

6.1 Symptoms

A. Visible Bleeding

Blood coming from nostril (anterior bleed)
Blood trickling posteriorly into throat (posterior bleed)
Unilateral or bilateral

B. Sensation of Warm Fluid

Patients often report a warm sensation in the nose or throat before obvious bleeding begins.

C. Swallowing of Blood

Leads to:

Nausea
Vomiting (often blood-stained)
Metallic taste

D. Nasal Obstruction

Due to clots or swelling.

E. Weakness or Lightheadedness

If bleeding is severe or prolonged.

F. Coughing Blood

Retrograde trickling into the oropharynx and larynx.

6.2 Signs

A. Anterior Epistaxis Signs

Blood seen in Little’s area on inspection
Source usually visible
Mild to moderate bleeding
More common in children and young adults

B. Posterior Epistaxis Signs

Blood seen flowing down throat
No obvious anterior bleeding point
Profuse bleeding
Elderly patients, hypertensives
Hemodynamic instability possible

C. Examination Findings

Crusting or dryness
Septal deviation
Spur touching lateral wall → trauma point
Mucosal inflammation
Presence of foreign body
Tramline scars from repeated picking

6.3 Associated Symptoms Suggesting Underlying Cause

Bruising → platelet disorder
Gum bleeding → coagulopathy
Recurrent episodes → vascular malformation or septal abnormality
Unilateral foul smell in child → foreign body
Headache + epistaxis → hypertension or sinusitis
Epistaxis + nasal obstruction in adolescent boy → nasopharyngeal angiofibroma

7. EXAMINATION

ENT examination is essential to localize the bleeding point.

7.1 General Examination

Pulse (tachycardia if blood loss)
Blood pressure (rule out hypertensive crisis)
Pallor
Respiratory effort
Signs of shock (rare in epistaxis but important)

7.2 Local Nasal Examination

A. Anterior Rhinoscopy

Using Thudichum’s nasal speculum + headlight.

Look for:

Fresh or clotted blood
Little’s area bleeding point
Crusts
Spur erosion
Inflamed mucosa
Foreign body
Perforation edges

B. Posterior Rhinoscopy

Often difficult; blood obscures view.

Clues:

Blood in nasopharynx
No identifiable anterior source
Visible clot hanging posteriorly

C. Endoscopic Examination

If available, a 0° or 30° nasal endoscope is ideal for:

Posterior bleed localization
Visualizing sphenopalatine area
Identifying tumors
Foreign bodies
Septal perforation

7.3 Throat Examination

Look for trickling blood
Clots in oropharynx
Important to distinguish posterior bleed

7.4 Blood Pressure Monitoring

Elderly hypertensive patients commonly present with posterior bleeds.

8. INVESTIGATIONS

Most cases require no investigations unless bleeding is severe, recurrent, or systemic disease is suspected.

8.1 Basic Tests

Complete Blood Count (CBC) → anemia, platelet count
PT, APTT, INR → coagulopathies
Bleeding time → platelet function
Renal and liver function tests → systemic causes

8.2 Imaging (Rarely Required)

A. X-ray PNS

Not useful for epistaxis itself, but may show:

Sinusitis
Deviated septum

B. CT Scan

Used when:

Suspecting tumor
Facial trauma
Posterior epistaxis requiring surgical planning

C. Angiography

Rare, but used for:

Arteriovenous malformations
Refractory bleeding for embolization

8.3 Endoscopy

Most useful investigation for ENT surgeons.

Findings:

Bleeding point in posterior septum
Torn sphenopalatine artery branches
Granulomas
Neoplasms (e.g., JNA)

9. MANAGEMENT OF EPISTAXIS (ENT-PURE STEPWISE APPROACH)

Management must be systematic to prevent panic, aspiration, or unnecessary intervention.

9.1 Step 1 — Initial Measures

A. Patient Positioning

Sit upright
Head slightly tilted forward
Prevents swallowing blood
Avoids aspiration

B. Clear the Nose

Ask patient to blow gently
Remove superficial clots

C. Apply Pressure

Pinch the soft part of the nose (alae) for 10–15 minutes continuously.

D. Ice Pack

Placed on nasal bridge → causes vasoconstriction.

These alone stop up to 90% of anterior bleeds.

9.2 Step 2 — Local Measures

After clearing field:

A. Suction

To visualize bleeding point.

B. Topical Vasoconstrictors

Xylometazoline
Oxymetazoline
Adrenaline-soaked pledgets (1:10000)

Shrink mucosa → exposes bleeding point.

9.3 Step 3 — Chemical Cautery (For Anterior Bleeds)

Indications

Visible bleeding point in Little’s area
Non-pulsatile, localized bleeding

Method

Silver nitrate stick
Roll gently over bleeding point until grey eschar forms

Precautions

Never cauterize both sides of septum at the same time
→ risk of septal perforation
Local anesthesia should be applied before procedure

9.4 Step 4 — Electrical Cautery (If Chemical Fails)

Electrocautery Advantages

Useful for larger or deeper vessels
Controlled depth of cauterization

Risks

Mucosal burns
Septal perforation
Damage to surrounding tissues

9.5 Step 5 — Anterior Nasal Packing

If cautery fails or bleeding point not visualized.

Types of Packing

Merocel sponge (common)
Ribbon gauze with bismuth iodoform paraffin paste
Commercial nasal tampons

Mechanism

Tamponade effect
Local pressure
Promotes clot formation

Duration

24 to 48 hours
Antibiotics to prevent toxic shock syndrome

9.6 Step 6 — Posterior Nasal Packing

Required when:

Bleeding persists despite anterior packing
Blood seen trickling into throat

Methods

Foley catheter balloon
Commercial posterior pack
Gauze posterior pack (very painful, rarely used today)

Risks

Hypoxia
Aspiration
Bradycardia (vagal stimulation)
Infection

Posterior packing usually requires hospital admission.

9.7 Step 7 — Surgical Management (For Refractory Epistaxis)

A. Endoscopic Sphenopalatine Artery Ligation (ESPAL)

Gold standard today
High success (>90%)
Targets main arterial supply

B. Anterior Ethmoidal Artery Ligation

Indicated for persistent anterior ethmoidal bleed (rare).

C. External Carotid Artery Ligation

Last resort.

D. Embolization

Performed by interventional radiology for non-surgical candidates.

9.8 Additional Measures

A. Treat Underlying Cause

Control hypertension
Stop NSAIDs/anticoagulants (if safe)
Treat infection/allergies
Repair septal spur
Surgery for tumors

B. Hydration & Humidification

Critical for preventing recurrence.

10. COMPLICATIONS OF EPISTAXIS & ITS TREATMENT

A. From Disease

Blood loss anemia
Aspiration pneumonia
Airway obstruction (rare with posterior bleeds)
Syncope

B. From Treatment

1. Cautery

Septal perforation
Mucosal necrosis

2. Packing

Toxic shock syndrome
Alar necrosis
Sinusitis
Hypoxia
Pain

3. Posterior Packing

Arrhythmia (vagal stimulation)
Otitis media due to Eustachian tube blockage

4. Surgery

Injury to surrounding structures
Recurrence

11. PREVENTION OF EPISTAXIS

Preventive strategies focus on protecting the fragile nasal mucosa and reducing systemic risk factors.

11.1 Local Preventive Measures

A. Moisturization of Nasal Mucosa

Saline sprays
Humidified air
Water-based gels (avoid petroleum in children)
Steam inhalation

B. Avoid Nose Picking

Most common cause in children.
Parent education is essential.

C. Control of Infections

Treat allergic & infective rhinitis
Reduce sneezing & itching
Prevent continuous mucosal trauma

D. Avoid Nasal Trauma

Gentle blowing
Protective gear in contact sports

E. Avoid Irritants

Smoke
Dust
Chemicals
Perfumes

11.2 Systemic Preventive Measures

A. Control Hypertension

BP monitoring
Antihypertensive therapy
Avoid sudden surges (stress, exertion)

B. Review Medications

Avoid unnecessary:

Aspirin
NSAIDs
Anticoagulants
Antiplatelet drugs

C. Treat Coagulopathies

Replacement therapy for hemophilia
Vitamin K supplementation
Platelet transfusions when indicated

11.3 Post-Treatment Advice to Prevent Recurrence

Avoid hot drinks for 24 hours
Avoid straining or bending forward
No nose blowing for 48–72 hours
Avoid picking crusts
Apply lubricant at night
Maintain hydration

These instructions significantly reduce recurrence risk.

12. PROGNOSIS

Anterior Epistaxis

Excellent prognosis
Easily controlled
Rare complications
Recurrence possible if dryness or trauma persists

Posterior Epistaxis

Worse prognosis
Common in elderly
High risk of aspiration & hemodynamic compromise
Often requires hospitalization
May need surgical intervention

Recurrent Epistaxis

Usually due to:
- Hypertension
- Atrophic rhinitis
- Septal abnormality
- Medication effects
- Systemic disease

Treatment of underlying cause improves long-term outcomes.

13. HIGH-YIELD ENT-VIVA POINTS

These give guaranteed marks in ward exams, vivas, and OSCEs.

1. Most common site of anterior epistaxis:

Little’s area (Kiesselbach’s plexus).

2. Most common site of posterior epistaxis:

Woodruff’s plexus.

3. Most important step in managing epistaxis:

Pinching the nose for 10–15 minutes.

4. Never cauterize both sides of septum simultaneously:

→ Causes septal perforation.

5. Posterior epistaxis is common in:

Elderly, hypertensive patients.

6. Best test for localizing posterior bleed:

Nasal endoscopy.

7. Gold standard for refractory epistaxis:

Endoscopic sphenopalatine artery ligation (ESPAL).

8. Toxic shock syndrome risk is associated with:

Nasal packing, especially ribbon gauze.

9. Always check BP in an adult with epistaxis:

Hypertension contributes to bleeding severity.

10. If a child has unilateral, foul-smelling bleed:

Think foreign body.

11. JNA suspicion rises with:

Recurrent epistaxis + nasal obstruction in adolescent male.

12. A bleeding point that stops with vasoconstrictor is usually:

Anterior.

14. CLINICAL SCENARIOS (OSCE-STYLE)

Scenario 1

A 12-year-old boy presents with recurrent anterior epistaxis. Examination shows crusting at Little’s area.

Diagnosis: Digital trauma
Management: Local cautery + moisturization + counseling

Scenario 2

70-year-old hypertensive male presents with profuse bleeding into throat.

Diagnosis: Posterior epistaxis
Management: Posterior nasal packing + BP control + ESPAL if persistent

Scenario 3

A patient on warfarin arrives with constant nasal bleeding.

Diagnosis: Drug-induced epistaxis
Management: Reverse coagulopathy + pack if needed

Scenario 4

15-year-old male with recurrent epistaxis and unilateral nasal obstruction.

Diagnosis: Juvenile nasopharyngeal angiofibroma
Management: CT scan + surgical excision

Scenario 5

Patient presents with epistaxis after blowing nose vigorously.

Diagnosis: Anterior epistaxis
Management: Compression → vasoconstrictor → cautery

Scenario 6

A child has epistaxis with petechiae on skin.

Diagnosis: Thrombocytopenia
Management: CBC + hematology consult

Scenario 7

A diabetic patient with sinusitis develops epistaxis.

Diagnosis: Infective epistaxis due to mucosal inflammation
Management: Treat infection + local measures

Scenario 8

Bleeding does not stop after anterior packing.

Diagnosis: Posterior bleed
Management: Posterior packing → consider ligation

Scenario 9

A patient complains of recurrent epistaxis after septal surgery.

Diagnosis: Septal perforation
Management: Moisturization + repair if large

Scenario 10

A trauma case with nasal bone fracture and epistaxis.

Diagnosis: Traumatic epistaxis
Management: Evaluate fracture + control bleeding + reduction

15. MCQs (20 EXAM-STYLE QUESTIONS)

1. The most common site of anterior epistaxis is:

A. Woodruff’s plexus
B. Posterior ethmoidal artery
C. Little’s area
D. Sphenopalatine artery
Correct Answer: C

2. The most common site of posterior epistaxis is:

A. Little’s area
B. Woodruff’s plexus
C. Superior labial artery
D. Anterior ethmoidal artery
Correct Answer: B

3. A child with recurrent unilateral epistaxis likely has:

A. Foreign body
B. Hypertension
C. Atherosclerosis
D. JNA
Correct Answer: A

4. Posterior bleeds are usually:

A. Mild
B. Self-limiting
C. Profuse and dangerous
D. Only in children
Correct Answer: C

5. Best first step in epistaxis management:

A. Cautery
B. Packing
C. Tilt head back
D. Compression of nostrils
Correct Answer: D

6. Never cauterize both sides because:

A. Causes bleeding
B. Increases pain
C. Causes septal perforation
D. Prevents clotting
Correct Answer: C

7. Most common age for Little’s area bleeds:

A. Elderly
B. Middle-aged
C. Children
D. Neonates
Correct Answer: C

8. Most important artery in posterior bleeds:

A. Superior labial
B. Anterior ethmoidal
C. Sphenopalatine
D. Angular
Correct Answer: C

9. The first-line investigation in recurrent epistaxis is:

A. CT scan
B. MRI
C. Endoscopy
D. X-ray
Correct Answer: C

10. Unilateral recurrent epistaxis in teenage boy suggests:

A. Polyps
B. Rhinitis
C. JNA
D. Atrophic rhinitis
Correct Answer: C

11. After anterior packing, antibiotics are given to prevent:

A. Pneumonia
B. Asthma
C. Toxic shock syndrome
D. Hypertension
Correct Answer: C

12. Posterior packing complications include:

A. Ear wax
B. Vagal arrhythmia
C. Hair loss
D. Hearing loss
Correct Answer: B

13. Best surgical treatment for refractory epistaxis:

A. Tonsillectomy
B. ESPAL
C. Rhinoplasty
D. Septoplasty
Correct Answer: B

14. Woodruff’s plexus is predominantly:

A. Arterial
B. Venous
C. Neural
D. Lymphatic
Correct Answer: B

15. Hypertension causes epistaxis mainly by:

A. Mucosal dryness
B. Vessel fragility
C. Trauma
D. Tumor
Correct Answer: B

16. Foreign body-induced epistaxis is most common in:

A. Elderly
B. Adults
C. Children
D. Newborns
Correct Answer: C

17. Silver nitrate cautery appears as:

A. Black crust
B. Grey-white eschar
C. Red patch
D. Blue discoloration
Correct Answer: B

18. Posterior pack must be avoided in:

A. Healthy adults
B. Children
C. Elderly
D. Pregnant women
Correct Answer: B

19. Major risk factor for posterior epistaxis:

A. Digital trauma
B. Allergies
C. Hypertension
D. Rhinitis
Correct Answer: C

20. Bilateral nasal cautery causes:

A. Septal perforation
B. Saddle nose
C. CSF leak
D. Foreign body aspiration
Correct Answer: A