Epistaxis (Nosebleed): Causes, Symptoms, Diagnosis, Prevention, and Treatment
What is Epistaxis?
Epistaxis is the medical term for nosebleed. It is one of the most common ENT emergencies worldwide, affecting people of all ages. While most nosebleeds are benign and stop within minutes, recurrent or heavy epistaxis can occasionally signal serious underlying disease.
Nosebleeds are classified in two main ways:
1.Anterior epistaxis (90–95% of cases)
– Originates from Kiesselbach’s plexus (Little’s area) on the anterior nasal septum
– Usually mild and self-limiting
2.Posterior epistaxis(5–10% of cases)
– Arises from branches of the sphenopalatine artery or other deeper vessels
– More severe, often requires medical intervention
Common Synonyms
– Nosebleed
– Nasal hemorrhage
– Rhinorrhagia
– Epistaxis anterior/posterior
– Bleeding from the nose
Epidemiology (2025 Data)
– Lifetime incidence: ~60% of the global population
– Only 6–10% seek medical care
– Bimodal age distribution: children 2–10 years and adults >50 years
– Slight male predominance after puberty
Causes of Epistaxis
Local Causes (Most Common)
1. Trauma
– Nose picking (most common in children)
– Blunt trauma or facial injury
– Foreign body insertion
– Vigorous nose blowing
2. Dryness and Crusting
– Low humidity (winter, air-conditioned rooms, high altitudes)
– Prolonged oxygen therapy
– Chronic nasal spray overuse (rhinitis medicamentosa)
3. Inflammatory & Infectious
– Viral upper respiratory infections
– Allergic rhinitis
– Sinusitis
– Nasal septal deviation or perforations
4. Tumors (Rare but Serious)
– Juvenile nasopharyngeal angiofibroma (adolescents)
– Inverted papilloma
– Squamous cell carcinoma or esthesioneuroblastoma
Systemic Causes
1. Hypertension – controversial direct cause, but worsens bleeding
2. Coagulopathies
– Thrombocytopenia (ITP, leukemia, dengue)
– Hemophilia, von Willebrand disease
– Liver cirrhosis, chronic kidney disease
3. Medications & Substances
– Anticoagulants (warfarin, DOACs – apixaban, rivaroxaban)
– Antiplatelet drugs (aspirin, clopidogrel)
– NSAIDs
– Intranasal cocaine or methamphetamine
4. Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome)
– Classic triad: recurrent epistaxis, mucocutaneous telangiectasias, family history
5. Others
– Alcohol excess
– Vitamin C or K deficiency (rare)
– Pregnancy (increased vascularity)
Signs and Symptoms
Mild Anterior Epistaxis
– Bright red blood dripping from one nostril
– Blood in throat if swallowed (hematemesis mimic)
Severe/Posterior Epistaxis
– Blood flowing down both nostrils and throat even when sitting upright
– Hematemesis (vomiting blood)
– Hemodynamic instability (tachycardia, hypotension)
– Dysphagia or respiratory distress (rare)
Red Flag Signs – Seek Immediate Care
– Bleeding >20–30 minutes despite first aid
– Recurrent episodes (>3–4 per month)
– Associated bruising, petechiae, or gum bleeding
– Syncope or near-syncope
– Hemoglobin drop or need for transfusion
Diagnosis
History Taking (Key Questions)
– Unilateral or bilateral?
– Duration and frequency?
– Trigger (trauma, picking, medications)?
– Associated symptoms (headache, visual changes, easy bruising)?
– Current medications (especially anticoagulants)?
– Family history of bleeding disorders or HHT?
Physical Examination
1. Vital signs (rule out shock)
2. Anterior rhinoscopy – locate bleeding point
3. Look for telangiectasias, ulcers, perforations, tumors
4. Oral cavity – blood in posterior pharynx suggests posterior bleed
Investigations (Selected Cases)
– CBC with platelet count
– PT/INR, aPTT (if on anticoagulants)
– Liver and renal function tests
– Nasal endoscopy (in recurrent cases)
– CT sinuses or angiography (suspected tumor or vascular anomaly)
– Genetic testing (if HHT suspected)
First Aid & Home Treatment (2025 Guidelines)
Step-by-Step Self-Management
1. Stay calm – anxiety worsens bleeding
2. Sit upright and lean slightly forward
3. Pinch soft part of nose continuously for 10–15 minutes (do NOT release early)
4. Avoid swallowing blood – spit into a bowl
5. Apply ice pack to bridge of nose
6. Use oxymetazoline or phenylephrine nasal spray (if available)
What NOT to do
– Tilt head back
– Stuff tissue or cotton inside nose
– Lie flat
Medical Treatment
Office-Based Procedures
1. Chemical cautery – Silver nitrate sticks (most common)
2. Electrocautery – Bipolar preferred (less septal perforation risk)
3.Topical hemostatic agents – Tranexamic acid-soaked pledgets, Surgicel, Floseal
Hospital Management (Persistent Bleeding)
1. Anterior nasal packing
– Non-absorbable (Merocel, Rapid Rhino)
– Absorbable (Nasopore, Surgiflo)
2. Posterior packing– Foley catheter or commercial balloon devices
3. Surgical ligation or embolization
– Endoscopic sphenopalatine artery ligation (ESPAL) – gold standard
– Anterior ethmoidal artery ligation (if needed)
– Interventional radiology – embolization (high success but risk of stroke)
Newer Therapies (2025)
– Topical tranexamic acid (TXA) – 500 mg/5 mL soaked pledgets
– Bevacizumab (Avastin) intranasal injection or spray for HHT
– Pafolacianine-guided surgery for angiofibromas
Prevention of Recurrent Epistaxis
Daily Preventive Measures
1. Maintain nasal humidity
– Saline spray or gel (4–6 times/day)
– Petroleum jelly (Vaseline) thin layer twice daily
– Room humidifier (40–60% humidity)
2. Avoid nose picking and forceful blowing
3. Treat allergies aggressively
4. Use protective gear in contact sports
5. Review and optimize anticoagulant therapy with physician
For HHT Patients
– Regular laser ablation or sclerotherapy
– Low-dose bevacizumab or oral pazopanib (clinical trials 2025)
– Iron supplementation or IV iron infusions
When to See a Doctor Urgently
– Bleeding not controlled after 20–30 minutes of correct pressure
– Heavy bleeding with clots and dizziness
– Recurrent nosebleeds (>once/week)
– Bleeding with easy bruising elsewhere
– Child <2 years with nosebleed
Frequently Asked Questions (FAQs)
Q1. Are nosebleeds a sign of high blood pressure?
A. Hypertension alone rarely causes epistaxis, but it makes bleeding harder to stop. Poorly controlled BP is a risk factor for severity.
Q2. Can stress cause nosebleeds?
A. Indirectly yes – stress raises blood pressure and may lead to nose picking or forceful blowing.
Q3. Why do children get more nosebleeds?
A. Prominent Kiesselbach’s plexus, frequent colds, nose picking, and dry air.
Q4. Is cauterization painful?
A. Mild discomfort only; local anesthetic spray is used. Most patients tolerate it well.
Q5. Can I fly with recent epistaxis?
A. Avoid flying for 48–72 hours after significant bleed due to low cabin humidity and pressure changes.
Q6. Are there any foods that prevent nosebleeds?
A. No strong evidence, but adequate vitamin C and hydration help maintain healthy mucosa.
Q7. When is nosebleed a sign of cancer?
A. Unilateral persistent bleeding + nasal obstruction, facial pain, or cranial nerve deficits in adults >40 years warrants urgent ENT referral.
Conclusion
Epistaxis remains a common condition that is usually benign but can occasionally be life-threatening. Proper first-aid technique stops 90–95% of bleeds at home. Recurrent or posterior epistaxis requires specialist evaluation. With modern endoscopic techniques and hemostatic agents, even severe cases are managed effectively with minimal morbidity in 2025.
Key Takeaway: Never ignore recurrent nosebleeds. Early intervention prevents complications and improves quality of life.