Nose Bleeds (Epistaxis)

Epistaxis — the medical term for nosebleed — is one of the most commonly encountered ENT emergencies and a frequent reason for ENT outpatient assessment. Approximately 60% of the population will experience at least one significant nosebleed in their lifetime, and about 10% will require medical attention for it. Most nosebleeds arise from the anterior nasal septum — a highly vascularised region just inside the nostril — and can be effectively treated with a brief clinic procedure. A smaller proportion originate from deeper or posterior locations and may require endoscopic assessment and treatment under anaesthesia.

The Nasal Blood Supply

The nose has an exceptionally rich blood supply, derived from both the external and internal carotid artery systems. This dual supply explains why nasal bleeding can be both profuse and difficult to control.

Kiesselbach’s Plexus (Little’s Area)

The most important anatomical region for understanding nosebleeds. Little’s area is an anastomotic plexus of vessels on the anteroinferior nasal septum, approximately 1–2cm inside the nostril, where branches of five arteries converge:

• The anterior ethmoidal artery (from the ophthalmic artery — internal carotid system)
• The superior labial branch of the facial artery (external carotid system)
• The greater palatine artery (from the maxillary artery — external carotid system)
• The posterior septal branch of the sphenopalatine artery (external carotid system)
• The nasopalatine artery

The vessels of Kiesselbach’s plexus lie immediately beneath a thin mucosa with no intervening fat or connective tissue cushion, making this the most vulnerable site for nosebleeds. Approximately 80–90% of all nosebleeds originate here — hence the term “anterior epistaxis”. They are easily visible on anterior rhinoscopy, relatively straightforward to cauterise, and rarely life-threatening.

Woodruff’s Plexus

Located on the posterior lateral nasal wall, in the region of the inferior meatus, near the posterior end of the inferior turbinate. Woodruff’s plexus is the primary source of posterior epistaxis — a less common but potentially severe form of nosebleed that is more common in older adults, often associated with hypertension or anticoagulant use, and can be difficult to control with simple pressure. Posterior nosebleeds typically present as blood running down the throat rather than from the anterior nostril, and may require endoscopic assessment and cauterisation or packing under anaesthesia.

Sphenopalatine Artery

The sphenopalatine artery — the terminal branch of the maxillary artery, entering the nasal cavity through the sphenopalatine foramen — is the dominant blood supply to the nasal mucosa. Branches supply the lateral nasal wall, the posterior septum, and the sinus mucosa. Sphenopalatine artery ligation or embolisation is the definitive treatment for severe recurrent posterior epistaxis not controlled by other means.

Causes

Local Causes

• Digital trauma (nose-picking): The most common cause of epistaxis, particularly in children. Repeated finger trauma to the fragile mucosa of Little’s area ruptures vessels and prevents healing. The cycle of picking, minor bleeding, and scab formation perpetuates the problem.
• Dry nasal mucosa: Low humidity — from heated or air-conditioned environments, high altitude, or prolonged mouth breathing — desiccates the nasal mucosa, causing crusting and fragility. The mucosal blood vessels lose the protection of an intact overlying mucosal layer and bleed with minimal provocation.
• Incorrectly used nasal sprays: Directing nasal steroid sprays toward the nasal septum rather than toward the outer nasal wall (turbinate) repeatedly traumatises the septal mucosa and is a common cause of recurrent anterior epistaxis. Correct technique — directing the nozzle toward the outside of the nose, not the septum — prevents this.
• Nasal septal deviation: Areas of septal deflection create turbulent airflow and localised mucosal drying, making the convex surface of a spur prone to crusting and bleeding.
• Allergic rhinitis and nasal polyps: Inflamed, hyperaemic nasal mucosa bleeds more readily.
• Nasal trauma: Blunt nasal trauma, fractures, or foreign bodies cause direct mucosal laceration.
• Post-surgical: Bleeding from FESS or septoplasty is expected in the first week and usually settles with irrigation.

Systemic Causes

• Anticoagulant and antiplatelet medications: Warfarin, apixaban (Eliquis), rivaroxaban (Xarelto), dabigatran (Pradaxa), aspirin, clopidogrel, and other blood-thinning medications impair haemostasis and convert otherwise minor bleeds into significant or life-threatening events. These must always be disclosed at consultation and are a key factor in management planning.
• Hypertension: Elevated blood pressure is associated with more severe and more difficult-to-control epistaxis, particularly from posterior sources. Hypertension does not cause epistaxis directly — it is not the initiating event — but once bleeding has begun, high pressure makes haemostasis more difficult. Blood pressure should be controlled aggressively in patients with recurrent epistaxis.
• NSAIDs: Non-steroidal anti-inflammatory drugs (ibuprofen, naproxen, diclofenac) impair platelet function and increase mucosal bleeding tendency. Should be avoided by patients with recurrent epistaxis.
• Hereditary haemorrhagic telangiectasia (HHT — Osler-Weber-Rendu disease): An autosomal dominant condition characterised by abnormal blood vessel formation throughout the body. Recurrent epistaxis is the dominant symptom in 90% of affected patients, typically beginning in adolescence and worsening progressively throughout life. HHT telangiectasias in the nasal mucosa are visible on endoscopy as small red spots. Associated with AVMs (arteriovenous malformations) in the lungs, liver, and brain. Any patient with recurrent nosebleeds from early adulthood, a family history of similar problems, or multiple small red spots on the lips, tongue, or face should be assessed for HHT.
• Coagulation disorders: Von Willebrand disease (the most common inherited coagulopathy), haemophilia, thrombocytopenia (low platelet count), and liver disease impairing coagulation factor synthesis can all cause recurrent or difficult-to-control epistaxis.
• Nasal tumours: Benign tumours (juvenile angiofibroma — typically in adolescent males, inverted papilloma) and malignant tumours of the nasal cavity or sinuses can present with unilateral epistaxis. Any patient with persistent unilateral epistaxis, unilateral nasal obstruction, or epistaxis in the absence of a simple local cause should have endoscopic assessment to exclude a nasal mass.

First Aid — The Correct Technique

ENT Assessment

Assessment begins with a thorough history — frequency, duration, laterality, precipitating factors, medications, family history, and any associated symptoms (unilateral nasal obstruction, facial swelling). Anterior rhinoscopy identifies obvious anterior septal vessels. Nasal endoscopy with a rigid telescope allows full assessment of the nasal cavity, identification of the bleeding source, visualisation of polyps or masses, and examination of the posterior nose and nasopharynx where posterior sources are suspected.

Investigations as indicated include:

• Full blood count: To identify thrombocytopenia
• Coagulation screen (PT/APTT/INR): For suspected coagulation disorder or patients on warfarin
• Von Willebrand factor assay: Where HVW disease is suspected (recurrent epistaxis, family history, or abnormal platelet function tests)
• CT sinuses/nasal cavity: Where a nasal mass, sinus disease, or posterior bleeding source is suspected

Treatment

Chemical Cauterisation (In-Clinic)

The standard first-line treatment for recurrent anterior epistaxis from Little’s area. After applying a topical anaesthetic and decongestant spray, silver nitrate on a cotton-tipped applicator is applied directly to the visible bleeding vessel or vascular area. The chemical precipitates protein, sealing the vessel. The procedure causes minimal discomfort and takes only a few minutes. Only one side of the nose should be cauterised at a time — bilateral simultaneous cauterisation risks septal perforation from bilateral mucosal necrosis. The opposite side can be treated after six weeks if needed.

Electrocautery (Bipolar)

For larger vessels or bleeding that does not respond to silver nitrate, bipolar diathermy under local anaesthetic (in adults) or under general anaesthetic can precisely cauterise the vessel with electrical energy.

Nasal Packing

Where bleeding cannot be controlled by cauterisation — typically for severe or posterior epistaxis — nasal packing provides tamponade. Options range from dissolvable haemostatic dressings (Surgiflo, Nasopore) and inflatable nasal balloons, through to formal anterior and posterior gauze packing. Traditional gauze packing is uncomfortable and requires removal under anaesthesia or sedation. Modern dissolvable dressings have largely replaced gauze for most anterior bleeds. Posterior packing — where bleeding is from behind the posterior choanae — requires admission to hospital and often anaesthesia for placement.

Endoscopic Sphenopalatine Artery Ligation (ESPAL)

For recurrent severe posterior epistaxis not controlled by packing and cauterisation, endoscopic ligation or diathermy of the sphenopalatine artery at the sphenopalatine foramen is highly effective (success rate approximately 90%) and is now the preferred surgical approach over external approaches or arterial embolisation in most centres. Performed under general anaesthesia through the nose without external incisions.

Arterial Embolisation

Endovascular embolisation — a radiological procedure in which microspheres or coils are delivered through a catheter into the internal maxillary artery to reduce blood flow to the nasal mucosa — is effective for severe or recalcitrant posterior epistaxis. It is particularly useful when surgery is contraindicated. Carries a small risk of stroke from inadvertent embolisation of intracranial vessels.

Preventive Measures

• Apply a small amount of petroleum jelly (Vaseline) to the nasal septum with a cotton bud daily — lubricating dry mucosa and covering fragile vessels
• Regular saline nasal spray to maintain mucosal hydration
• Increase ambient humidity with a humidifier in dry or air-conditioned environments
• Avoid NSAIDs and stop nose-picking
• Review nasal spray technique — spray toward the outer wall, not the septum

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Dr Jason Roth (MED0001185485) — Specialist Otolaryngologist & Head and Neck Surgeon.