AKT · ENT/Nose & sinuses

Epistaxis

Bleeding from the nasal mucosa (Little's area / posterior)

Overview

Nosebleed. Most bleeds are ANTERIOR from Little's area (Kiesselbach plexus) and stop with first aid; posterior bleeds are heavier and higher-risk. Management runs first aid → cautery → packing → ENT, with attention to anticoagulation and haemodynamics.

Recognise

Anterior: visible bleeding point on the anterior septum, usually controllable with pressure
Posterior: profuse bleeding, bleeding into the throat, harder to control, more common in older/hypertensive/anticoagulated patients
Precipitants: nose-picking, trauma, dry air, URTI, anticoagulants/antiplatelets, hypertension, (rarely) HHT or clotting disorder

Red flags

Haemodynamic compromise, posterior bleed not controlled by packing, anticoagulated/bleeding disorder → resuscitate + urgent ENT

Differentials & how to tell them apart

Anterior vs posterior bleeda visible anterior septal point that stops with pressure vs profuse bleeding into the throat needing packing

Hereditary haemorrhagic telangiectasiarecurrent bleeds + mucocutaneous telangiectasia + family history

Sinonasal tumourunilateral recurrent bleeding ± obstruction — ENT

Coagulopathy/anticoagulant effectbleeding elsewhere, drug history, abnormal clotting

Investigations

Usually clinical. FBC/clotting/group-and-save if heavy or anticoagulated; review anticoagulant/antiplatelet drugs and BP.

Management

First aid (lean forward + pinch 10–15 min) → cautery → packing → ENT

1First aid: sit forward, pinch the soft (cartilaginous) part of the nose continuously for 10–15 minutes, breathe through the mouth. If a bleeding point is then visible, cauterise (silver nitrate) and apply Naseptin.Gate: Pinch the SOFT cartilaginous part (not the bony bridge) and lean FORWARD (not back, which sends blood to the airway/stomach) — getting the first aid right stops most anterior bleeds without escalation
2Failed first aid/cautery → nasal packing (anterior ± posterior) and admit; correct/withhold anticoagulation as appropriate; persistent/posterior bleeding → ENT (further packing, ligation/embolisation).

First aid: lean forward, pinch the soft part of the nose 10–15 min — controls most anterior bleeds

Nasal cautery (silver nitrate) — if a bleeding point is seen after the bleeding settles

Topical antiseptic (Naseptin) cream — after cautery to reduce crusting/recurrence

Nasal packing — if first aid/cautery fail; admit

Key points

Lean forward + pinch the soft part = correct first aid. Most are anterior (Little's area). Posterior bleeds in anticoagulated older patients are the dangerous ones. Recurrent unilateral bleeding → exclude a tumour.

Monitor & prognosis

Haemodynamics, recurrence, anticoagulation; Hb if heavy.

Most are minor and self-limiting; posterior bleeds need ENT.

Source: NICE CKS Epistaxis