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Bleeding (epistaxis)

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

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Epistaxis is one of the commonest presentations at the accident and emergency (A&E) department and is the most common ENT emergency (1). Most cases of nose bleeds are minor or self limiting but rarely can be a life threatening emergency due to massive bleeding (1,2).

An estimated 60 % of the general population has had at least one episode of epistaxis throughout their life time (2).

  • out of these only 6% sought medical assistance for it
  • 1.6 in 10,000 required hospitalisation (3)
  • a bimodal distribution is seen in the poulation
    • the incidence peaks at ages less than 10 years and above 50
    • in the young, the blood comes from Little's area, a highly vascular area at the anterior border of the nasal septum. With age the site of bleeding moves posteriorly (2)
  • rare in children under the age of 2 years and if present is often associated with injury or serious illness (4)
  • seasonal variation can also be seen with an increase during the winter months (4)
  • occurs frequently in males than in females (2)

Epistaxis may be due to local causes or general causes.

Epistaxis is usually classified into two types:

  • anterior bleeding
  • posterior bleeding (2)

Epistaxis summary (5)

  • epistaxis is common
    • an estimated lifetime prevalence in the United States of 60%
    • approximately 6% of persons who have nosebleeds seek medical attention.
  • management of epistaxis is straightforward in most cases but can be challenging in patients with cardiovascular disease, impaired coagulation, or platelet dysfunction.
  • epistaxis is appropriately controlled in a systematic and escalating fashion
    • initial management
      • patients in the medical setting are advised to apply digital compression to the lower third of the nose for 15 to 20 minutes, which is followed by anterior rhinoscopy
  • anterior bleeding can usually be controlled with topical vasoconstrictors, tranexamic acid, cautery, or anterior nasal packing
    • intranasal tranexamic acid
      • study evidence found addition of intranasal tranexamic acid to controlled topical therapy of phenylephrine and lidocaine was linked to a lower rate of need for anterior nasal packing, stay in A+E for >2hrs, and rebleeding in 24hrs (6)
  • continued epistaxis despite these measures requires more aggressive treatment, with the involvement of specialists in otolaryngology and head and neck surgery and, generally, hospital admission


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