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Epistaxis (nosebleed)
Most nosebleeds are anterior, from Kiesselbach area on the septum, and stop with sustained pressure, focal cautery or packing; posterior bleeding from branches of the sphenopalatine artery is harder, requires posterior packing or admission, and on failure endoscopic sphenopalatine artery ligation or embolisation.
Why it matters in the exam
The exam tests the order: first haemodynamic stability and the airway, then firm, continuous pinching of the soft lower nose for at least 5 minutes, sitting with the head forward, and then finding the bleeding point. Kiesselbach area (Little area) is where branches of the anterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries meet. Posterior bleeding is typical of older patients with hypertension, anticoagulants or vascular disease, and is seen as blood running into the pharynx even while the front of the nose is pressed.
Chemical cautery (silver nitrate) is applied only to an identified point, and not to both sides of the septum at the same time because of the risk of perforation. In a patient on anticoagulants or with a bleeding disorder, resorbable packing is preferred. The AAO-HNS guideline advises against routinely stopping anticoagulants unless the bleeding is life-threatening. After posterior packing the patient is admitted for monitoring because of the risk of hypoxia and arrhythmias. In recurrent or refractory bleeding, endoscopic sphenopalatine artery ligation (SPA ligation) is highly effective; embolisation of the internal maxillary artery is an alternative, with a rare risk of stroke.
An adolescent boy with recurrent one-sided bleeding and nasal obstruction — think of juvenile nasopharyngeal angiofibroma and do not biopsy. Recurrent bleeds with telangiectasias on the lips and fingers and a first-degree relative — hereditary haemorrhagic telangiectasia (HHT); under the Curaçao criteria, 3 of 4 criteria make a definite diagnosis. An anterior bleed that stops easily from a visible point differs from a posterior bleed whose source cannot be seen on anterior examination.
Key points
- Most bleeds are anterior, from Kiesselbach area.
- Sustained pressure 5 minutes or more, head forward.
- Posterior: posterior packing and admission.
- Refractory: sphenopalatine artery ligation or embolisation.
- Adolescent boy: JNA; telangiectasias: HHT.
Summary table
| Type | Source and clue | Treatment |
|---|---|---|
| Anterior | Kiesselbach area, children and young adults, visible on examination | Pressure 5 minutes or more, focal cautery, anterior packing |
| Posterior | Sphenopalatine artery branches, older patient, blood running into the pharynx | Posterior packing or balloon, admission and monitoring |
| Refractory or recurrent | Packing has failed | Endoscopic sphenopalatine artery ligation or embolisation |
| Anticoagulants | Prolonged bleeding | Resorbable packing; do not stop the drug routinely |
| HHT | Telangiectasias, family history | Topical care, laser, bevacizumab in severe cases |
| Adolescent boy with obstruction | Recurrent one-sided bleeding | Imaging for suspected JNA, no biopsy |
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Sources
- AAO-HNS Clinical Practice Guideline: Nosebleed (Epistaxis), 2020 — Initial management, packing and surgical options
- Curaçao criteria for hereditary haemorrhagic telangiectasia, 2000, reaffirmed 2020 international guideline — Diagnosis of HHT
- Scott-Brown's Otorhinolaryngology Head and Neck Surgery, 8th edition (2018) — Epistaxis
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.