Epistaxis (Nosebleed)

Table of Contents

1. Overview
2. Epidemiology
3. Anatomy of Nasal Vasculature
4. Etiology and Risk Factors
5. Clinical Assessment
6. Diagnosis
7. Treatment
8. Hereditary Hemorrhagic Telangiectasia (HHT)
9. Complications
10. Prevention
11. Key Research Papers
12. Featured Videos

1. Overview

Epistaxis — the medical term for a nosebleed — is one of the most common otolaryngologic emergencies, accounting for approximately 1 in 200 emergency department visits in the United States each year. Despite its alarming appearance, the vast majority of nosebleeds are benign, self-limiting events that can be managed at home. Only a minority require medical intervention, and a small but important subset represent a marker of underlying systemic disease or life-threatening hemorrhage.

Epistaxis is classified by its anatomical origin:

• Anterior epistaxis accounts for approximately 90-95% of all nosebleeds and originates from Kiesselbach's plexus (also called Little's area) on the anteroinferior nasal septum. These bleeds are typically mild, visible on anterior rhinoscopy, and amenable to simple first aid or office-based cautery.
• Posterior epistaxis accounts for approximately 5-10% of nosebleeds and arises from branches of the sphenopalatine artery in the posterior nasal cavity. These bleeds are more severe, more common in elderly patients, and frequently require specialist intervention including nasal packing, balloon tamponade, or arterial ligation/embolization.

Understanding the nasal blood supply, the distinction between anterior and posterior sources, and the range of available treatments — from simple pinching to interventional radiology — allows clinicians and patients to appropriately triage and manage what is one of medicine's oldest-described conditions. Hippocrates described nasal packing for epistaxis in the 5th century BCE, and the fundamental principles he established remain in use today.

Back to Table of Contents

2. Epidemiology

Epistaxis is extremely common across all age groups. In the United States, approximately 60% of the population will experience at least one nosebleed in their lifetime, and roughly 6% will seek medical care for epistaxis at some point. The annual emergency department visit rate for epistaxis is estimated at 1.7 visits per 1,000 population, translating to approximately 450,000 emergency visits per year in the US.

Epistaxis follows a bimodal age distribution:

• Children under 10 years: primarily anterior bleeds, most commonly due to nose picking, dry air, and upper respiratory infections; typically benign and self-limiting.
• Adults over 50 years: higher incidence of posterior epistaxis; greater association with hypertension, anticoagulant use, atherosclerosis, and hereditary hemorrhagic telangiectasia. Nasal mucosal atrophy with age reduces protective moisture and elasticity.

There is a modest male predominance (approximately 1.5:1 male-to-female ratio) for epistaxis overall. A seasonal pattern is well recognized, with higher incidence in winter months when cold, dry ambient air reduces nasal mucosal humidity and promotes mucosal desiccation and cracking. Geographic areas with low humidity also have higher incidence.

Epistaxis requiring hospitalization is associated with increased morbidity in elderly patients. Studies report in-hospital mortality rates of approximately 0.5-1% in admitted patients, almost exclusively related to underlying comorbidities (cardiovascular disease, coagulopathy) rather than blood loss alone. Posterior epistaxis has a higher rate of rebleeding (25-50%) compared to anterior epistaxis after initial treatment.

Back to Table of Contents

3. Anatomy of Nasal Vasculature

Kiesselbach's Plexus (Little's Area)

Kiesselbach's plexus, also called Little's area, is the most important vascular landmark in epistaxis. It is a dense anastomotic network of blood vessels located on the anteroinferior nasal septum, approximately 1 cm posterior to the columella. It was named after German otolaryngologist Wilhelm Kiesselbach, who described the anastomosis in 1884.

Kiesselbach's plexus is a convergence of four named arteries, each from a different vascular territory:

• Anterior ethmoidal artery — a branch of the ophthalmic artery (internal carotid system); enters the nasal cavity through the cribriform plate and supplies the anterior superior septum and lateral wall.
• Posterior ethmoidal artery — also a branch of the ophthalmic artery; smaller than the anterior ethmoidal; supplies the posterior superior septum.
• Sphenopalatine artery — the terminal branch of the maxillary artery (external carotid system); the dominant blood supply to the nasal cavity; its septal branch anastomoses on the anterior septum.
• Superior labial branch of the facial artery — external carotid system; ascends through the nasal floor to the anterior septum.

The convergence of internal and external carotid arterial territories at a single, thin, poorly supported mucosal site explains why Kiesselbach's plexus is so vulnerable. The mucosa overlying it is thin, tightly adherent to the underlying cartilage, and subjected to the drying effects of inspired air and the mechanical trauma of digital manipulation. Small vessels in this region can rupture with minimal provocation, producing the characteristic anterior nosebleed that stops with sustained pressure.

Posterior Nasal Vasculature

Posterior epistaxis arises primarily from the sphenopalatine artery and its branches as they traverse the posterior nasal cavity and lateral nasal wall. The sphenopalatine artery enters the nasal cavity through the sphenopalatine foramen, located at the posterior end of the middle turbinate, and divides into the lateral nasal artery (supplying the lateral wall and turbinates) and the posterior septal artery (supplying the posterior septum).

The Woodruff's plexus (or naso-nasopharyngeal plexus) is a venous plexus on the posterior lateral nasal wall beneath the posterior end of the inferior turbinate — a less common but recognized site of posterior epistaxis, particularly in the elderly. The posterior nasal cavity's vasculature is inaccessible to anterior rhinoscopy, explaining why posterior bleeds are difficult to localize and control with simple pressure.

Back to Table of Contents

4. Etiology and Risk Factors

Local (Nasal) Causes

• Mucosal desiccation — the most common cause overall; dry ambient air (heated indoor air in winter, arid climates, high altitude) reduces mucosal humidity, causing cracking and spontaneous bleeding of superficial septal vessels.
• Digital trauma (nose picking) — the most common cause in children; repeated mechanical disruption of Kiesselbach's plexus mucosa; often cyclic (picking causes crusting, which provokes more picking).
• Nasal steroid sprays — inhaled corticosteroids (fluticasone, budesonide, mometasone) can cause mucosal atrophy and bleeding, particularly when sprayed directly at the septum rather than toward the lateral wall; a known side effect in 5-10% of users.
• Cocaine insufflation — cocaine causes intense vasoconstriction followed by ischemic mucosal damage, ulceration, and septal perforation with repeated use; also promotes local thrombocytopenia and nasal congestion rebound.
• Foreign bodies — particularly in young children; unilateral foul-smelling bloody discharge raises suspicion for a retained nasal foreign body.
• Nasal polyps and tumors — benign polyps can bleed; juvenile nasopharyngeal angiofibroma (a highly vascular benign tumor in adolescent males) classically presents with severe recurrent epistaxis.
• Deviated nasal septum — turbulent airflow over a deviated septum increases mucosal drying and trauma at the point of deviation.
• Rhinitis and sinusitis — mucosal inflammation, congestion, and excessive nasal blowing increase vessel fragility.
• Nasal oxygen therapy — supplemental oxygen via nasal cannula causes significant mucosal desiccation; humidification reduces epistaxis risk in patients on long-term oxygen.

Systemic Causes

• Hypertension — strongly associated with epistaxis, particularly posterior bleeds; however, the relationship is complex (see Clinical Assessment section); elevated blood pressure in the epistaxis setting is often reactive rather than causal.
• Anticoagulant therapy — warfarin (vitamin K antagonist), heparin/LMWH (parenteral anticoagulants), and direct oral anticoagulants (DOACs: rivaroxaban, apixaban, dabigatran, edoxaban) all impair clot formation and prolong bleeding time; epistaxis is the most common bleeding complication with warfarin (occurring in up to 15% of patients per year).
• Antiplatelet drugs — aspirin (irreversibly inhibits cyclooxygenase-1, impairing thromboxane A2-mediated platelet aggregation), clopidogrel (P2Y12 inhibitor), ticagrelor, and dual antiplatelet therapy significantly increase epistaxis duration and severity.
• Nonsteroidal anti-inflammatory drugs (NSAIDs) — reversibly inhibit platelet function; shorter duration of effect than aspirin.
• Von Willebrand disease — the most common inherited bleeding disorder (1% of the general population); Type 1 (partial quantitative deficiency) is the mildest and most common form; recurrent spontaneous epistaxis is the most frequent presenting symptom, particularly in childhood.
• Hemophilia A and B — X-linked deficiency of factor VIII or IX; epistaxis is a common manifestation in moderate-to-severe disease.
• Thrombocytopenia — platelet counts below 50,000/µL significantly increase bleeding risk; causes include immune thrombocytopenic purpura (ITP), drug-induced thrombocytopenia, hematologic malignancies, and chemotherapy.
• Hereditary hemorrhagic telangiectasia (HHT) — autosomal dominant disorder causing mucocutaneous telangiectasias; recurrent, severe epistaxis is the hallmark symptom (see dedicated section).
• Liver disease — hepatic cirrhosis reduces production of clotting factors (I, II, V, VII, IX, X, XI) and causes thrombocytopenia from portal hypertension and hypersplenism.
• Renal failure — uremic platelet dysfunction impairs primary hemostasis.
• Leukemia and lymphoma — thrombocytopenia, coagulopathy, and mucosal infiltration.

Back to Table of Contents

5. Clinical Assessment

Initial Assessment and Triage

Most epistaxis presenting to medical attention is not life-threatening, but a rapid initial assessment is essential to identify the minority of patients requiring urgent intervention. Key triage questions include:

• Is the patient hemodynamically stable? (Heart rate, blood pressure, orthostatic changes)
• Is bleeding bilateral or unilateral? Is blood appearing in the oropharynx (suggesting posterior bleed)?
• What is the volume of blood loss and duration of bleeding?
• Is the patient on anticoagulants, antiplatelets, or other medications affecting hemostasis?
• Is there a history of a bleeding disorder, liver disease, or malignancy?
• Is there trauma, including nasal fracture?

Anterior vs. Posterior Epistaxis: Distinguishing Features

Correct localization of the bleeding site guides treatment selection. The key distinguishing features are:

• Blood flows forward through the nares, controllable with pinching
• Bleeding visible on anterior rhinoscopy at or near Kiesselbach's plexus
• Typically occurs in younger patients, with clear precipitating factors (dry air, nose picking)
• Usually self-limiting or responds to 10-15 minutes of continuous pressure
• Rarely causes significant hemodynamic compromise

• Blood flows predominantly backward into the pharynx; patient spits or swallows blood; blood visible in the oropharynx on examination
• No discrete bleeding point visible on anterior rhinoscopy
• More common in patients over 50 years, with hypertension, atherosclerosis, or anticoagulant use
• Does not respond to external nasal pressure
• Can be profuse enough to cause hemodynamic instability; more often requires hospitalization
• Associated with higher rebleeding rates (25-50%) after initial treatment

Hypertension and Epistaxis

Hypertension is strongly associated with epistaxis, particularly posterior bleeds, but the precise causal relationship remains debated. Studies consistently show that patients presenting with epistaxis have higher blood pressure readings than controls, but this is often a stress response to pain, anxiety, and blood loss rather than a primary cause. Elevated sympathetic tone during an acute bleed raises blood pressure via catecholamine release. In most patients, blood pressure normalizes once the bleeding is controlled and anxiety resolves, without any antihypertensive medication.

The clinical implication is that the raised blood pressure seen during a nosebleed is often a reaction to the bleeding and stress, and it frequently settles once the bleeding is controlled and the patient has calmed. Treating reactive hypertension aggressively with antihypertensive drugs can precipitate hypotension once the stress stimulus resolves. That said, chronic, uncontrolled hypertension does appear to increase the severity of epistaxis once it begins, likely by impairing vasoconstriction at the bleeding site.

Back to Table of Contents

6. Diagnosis

History and Physical Examination

Diagnosis of epistaxis is clinical. The history covers the bleeding site (anterior vs. posterior), severity, duration, frequency of episodes, precipitating factors, medication use, family history of bleeding disorders, and associated symptoms (recurrent epistaxis + telangiectasias + family history = consider HHT).

Examination tools:

• Nasal speculum and headlight or otoscope: the essential first step; allows visualization of Kiesselbach's plexus and the anterior nasal septum and turbinates after gentle suctioning of clot with a Frazier suction tip.
• Rigid or flexible nasal endoscope: provides superior visualization of the entire nasal cavity, including posterior sites; preferred in recurrent or posterior epistaxis; performed in the ENT office or operating room.
• Nasopharyngoscopy: evaluates the nasopharynx and posterior choanae for posterior bleeding sources.

Laboratory Studies

Routine laboratory workup is not required for uncomplicated anterior epistaxis but is appropriate in the following situations:

• Complete blood count (CBC): assess for thrombocytopenia (platelet count), anemia from blood loss, and underlying hematologic malignancy.
• Prothrombin time (PT/INR): essential in patients on warfarin or with suspected coagulopathy; guides reversal decisions.
• Partial thromboplastin time (aPTT): elevated in hemophilia A/B, heparin therapy, lupus anticoagulant.
• Type and screen/crossmatch: for severe hemorrhage with hemodynamic compromise.
• Von Willebrand factor antigen and activity (ristocetin cofactor assay): consider in recurrent childhood epistaxis or strong family history of bleeding; can be ordered by primary care or hematology.
• Renal and liver function tests: if uremic or hepatic coagulopathy suspected.

Imaging

Imaging is rarely needed for acute epistaxis but is indicated in specific scenarios:

• Computed tomography (CT) of the paranasal sinuses: for suspected nasal tumor, polyp, foreign body, or nasal fracture.
• Computed tomography angiography or conventional angiography: for interventional radiology planning (embolization) in refractory posterior epistaxis; delineates the sphenopalatine artery anatomy.
• Magnetic resonance imaging (MRI): superior soft tissue contrast for evaluating vascular malformations (AVMs in HHT) or sinonasal tumors.

Back to Table of Contents

7. Treatment

First Aid: Home Management

Most anterior nosebleeds can be managed effectively at home with proper technique. The points that matter most:

1. Sitting upright and leaning slightly forward — not backward; backward positioning allows blood to flow into the nasopharynx and oropharynx, causing swallowing of blood (which provokes nausea and vomiting), aspiration risk, and obscuring assessment of bleeding volume.
2. Pinching the soft, fleshy lower portion of the nose (the part that moves) — not the bony bridge; the bony nasal pyramid contains no soft tissue that can be compressed against a bleeding vessel; only the soft cartilaginous alar portion, when compressed against the nasal septum, can tamponade Kiesselbach's plexus.
3. Continuous pressure, commonly held for 10-15 minutes without releasing to check (the 2020 American Academy of Otolaryngology–Head and Neck Surgery guideline states firm sustained compression to the lower third of the nose for 5 minutes or longer) — releasing to check every few minutes is the most common reason home management fails; each pressure release allows the clot to re-examine and dislodge before it matures.
4. Breathing through the mouth during compression.
5. Topical decongestant spray: oxymetazoline 0.05% nasal spray applied to a cotton pledget and inserted into the bleeding nostril provides vasoconstriction that can slow or stop anterior bleeding; can also be sprayed directly into the nostril before applying pressure.
6. Ice pack to the nasal bridge: optional adjunct; evidence is limited but harmless; may provide mild vasoconstriction and patient comfort.
7. Signs that a nosebleed needs medical care: bleeding that does not stop after two 10-15 minute pressure cycles, a nosebleed in someone taking blood thinners (anticoagulants), or signs of heavy blood loss (dizziness, rapid heartbeat, pallor).

Office-Based: Chemical Cautery

Silver nitrate chemical cautery is the most commonly performed office procedure for anterior epistaxis. A silver nitrate stick (typically 75% silver nitrate with 25% potassium nitrate) is applied for 5-10 seconds to a visible, discrete bleeding point or prominent vessel at Kiesselbach's plexus after the mucosa has been anesthetized with topical lidocaine and decongested with oxymetazoline.

Key technical points:

• Cauterize a small circumferential area around the bleeding point, not just the vessel itself, to coagulate collateral supply.
• Never cauterize both sides of the septum at the same session: bilateral simultaneous cautery risks ischemic necrosis of the avascular septal cartilage and septal perforation, a difficult-to-repair complication.
• Success rate for anterior epistaxis with a discrete identifiable bleeding point: approximately 75-90%.
• Not appropriate when the bleeding point cannot be visualized, when bleeding is too brisk for safe cauterization, or when bleeding arises posteriorly.

Electrocautery

Electrocautery (monopolar or bipolar) is used under endoscopic visualization for larger, more persistent bleeding vessels or for posterior epistaxis. Bipolar electrocautery is preferred near the septum to minimize lateral thermal spread and reduce perforation risk. Electrocautery under endoscopic guidance allows precise treatment of the sphenopalatine artery and its branches for posterior epistaxis.

Nasal Packing

Nasal packing is indicated when epistaxis cannot be controlled with pressure, topical vasoconstrictors, or cautery, or when the bleeding site cannot be identified.

• Expandable nasal tampon (polyvinyl acetate foam sponge): the most widely used modern anterior packing; inserted dry into the nasal cavity along the floor; expands to 3-5 times its original size upon absorbing blood and secretions, creating tamponade; easy to insert; generally left in place 2-3 days; rehydrated with saline for atraumatic removal.
• Inflatable balloon pack (carboxymethylcellulose-coated balloon): an inflatable device with a hydrocolloid coating that promotes platelet aggregation; available in anterior-only and anterior-posterior configurations; comfortable removal.
• Petroleum jelly gauze: the traditional anterior pack; 0.5-inch petrolatum-impregnated ribbon gauze layered in the nasal cavity using bayonet forceps in a sequential fashion from floor to roof; effective but technically demanding and uncomfortable.
• Compressed-sponge nasal tampons: expandable compressed sponge; similar to the polyvinyl acetate foam tampon; inserted easily by non-specialists.

Anterior packs are typically left in place for 48-72 hours. Antibiotics (amoxicillin-clavulanate or trimethoprim-sulfamethoxazole) have traditionally been given during this period out of concern for toxic shock syndrome from Staphylococcus aureus, which colonizes anterior packs. A 2020 meta-analysis of 383 patients with anterior packing found clinically significant infection in 0.8% overall, a number needed to treat of 571 to prevent one infection, and concluded that prophylactic antibiotics for anterior nasal packing may not be necessary; practice varies.

Balloon tamponade is the mainstay of initial hospital management for posterior epistaxis. Double-balloon devices have a posterior balloon that is inflated in the posterior choana/nasopharynx to occlude the posterior nasal cavity, and an anterior balloon that is inflated in the anterior nasal passage to complete the tamponade. Technique:

1. Insert the catheter through the bleeding nostril along the nasal floor until the tip is visible in the oropharynx.
2. Inflate the posterior balloon (typically 4-8 mL of saline); gently retract the catheter until resistance is felt at the posterior choana.
3. Inflate the anterior balloon (typically 15-30 mL of saline) to fill the nasal cavity.
4. Apply gentle traction and secure the catheter externally with an umbilical clamp or foam block to prevent the balloon from slipping posteriorly and causing airway obstruction.

Control rates with balloon tamponade for posterior epistaxis: approximately 75-85%. Patients with posterior packs or balloons are usually admitted for monitoring due to risk of hypoxia (nasopulmonary reflex), airway obstruction, sinusitis, and pressure necrosis. Supplemental oxygen is typically provided.

Surgical and Interventional Options

For epistaxis refractory to packing/balloon tamponade, or when repeated rebleeding occurs after pack removal, definitive vascular control is required:

• Endoscopic sphenopalatine artery ligation (ESPAL): the current surgical gold standard for refractory posterior epistaxis; performed under general anesthesia; the sphenopalatine artery is identified at the sphenopalatine foramen under nasal endoscopy and clipped or cauterized; success rate approximately 90-98%; faster recovery than older approaches.
• Endoscopic anterior ethmoidal artery ligation: for refractory anterior-superior epistaxis from the ethmoidal arteries; performed via the orbit or transnasally.
• Interventional radiology embolization: selective catheter angiography with embolization of the internal maxillary artery or sphenopalatine artery using microcoils or polyvinyl alcohol particles; success rate approximately 80-90%; preferred in patients who are poor surgical candidates; risk of facial nerve injury, trismus, or cerebral embolization is low but present.
• Transantral (Caldwell-Luc) maxillary artery ligation: largely superseded by endoscopic approaches; rarely performed today.

Pharmacologic Adjuncts

• Tranexamic acid: an antifibrinolytic agent that inhibits plasmin-mediated clot dissolution; available topically (applied to nasal pledgets) and systemically (intravenous (IV) or oral); particularly useful in HHT-related epistaxis and in patients on anticoagulants; topical tranexamic acid has been shown in randomized trials to be as effective as anterior nasal packing for spontaneous anterior epistaxis.
• Oxymetazoline: topical alpha-1 agonist decongestant; causes nasal mucosal vasoconstriction; first-line adjunct for anterior epistaxis; use beyond 3 days leads to rebound congestion.
• Thrombin-soaked absorbable gelatin sponge: absorbable hemostatic packing placed under endoscopic visualization; dissolves within weeks; avoids the discomfort of pack removal.
• Nasal saline and emollients: regular saline irrigation and application of petroleum jelly or antibiotic ointment (bacitracin, mupirocin) to the anterior septum reduces drying and recurrence.
• Anticoagulant reversal: reversal agents used in life-threatening epistaxis: vitamin K, fresh frozen plasma, prothrombin complex concentrate (PCC), or idarucizumab (dabigatran reversal)/andexanet alfa (factor Xa inhibitor reversal) as appropriate; anticoagulant/antiplatelet therapy is not routinely stopped for minor epistaxis because stopping it raises the risk of clots.

Back to Table of Contents

8. Hereditary Hemorrhagic Telangiectasia (HHT)

Hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu syndrome, is an autosomal dominant vascular dysplasia characterized by mucocutaneous telangiectasias and visceral arteriovenous malformations (AVMs). It is one of the most common inherited vascular disorders, with a prevalence of approximately 1 in 5,000, though underdiagnosis is common.

Genetics

• HHT Type 1: mutations in the ENG gene (chromosome 9q34), which encodes endoglin, a co-receptor for TGF-β on vascular endothelial cells; associated with higher rates of pulmonary and cerebral AVMs.
• HHT Type 2: mutations in ACVRL1 (chromosome 12q13), encoding activin receptor-like kinase 1 (ALK1), a TGF-β family receptor; associated with higher rates of hepatic AVMs.
• HHT Type 3: linked to a region of chromosome 5; the gene has not been identified (SMAD4 was excluded in the family studied). SMAD4 mutations instead cause a separate combined syndrome of juvenile polyposis and HHT.
• All types disrupt the TGF-β/BMP signaling pathway, leading to defective angiogenesis and formation of fragile, ectatic vessels without proper capillary beds, creating direct AV connections prone to hemorrhage.

Diagnosis: Curaçao Criteria

HHT is diagnosed clinically using the Curaçao criteria (published 2000). A definite diagnosis requires three or more of the following four criteria; two criteria is "suspected"; one or none is "unlikely":

1. Spontaneous, recurrent epistaxis
2. Mucocutaneous telangiectasias at characteristic sites (lips, oral cavity, fingers, nose)
3. Visceral AVMs (pulmonary, hepatic, cerebral, gastrointestinal, spinal)
4. First-degree relative with HHT meeting the above criteria

Epistaxis in HHT

Recurrent, spontaneous epistaxis is the most common and often earliest symptom of HHT, present in approximately 90-95% of affected individuals. Epistaxis typically begins in childhood or adolescence (median age of onset: 12 years) and increases in frequency and severity with age, often becoming debilitating in adult life. Unlike idiopathic epistaxis, HHT epistaxis arises from multiple telangiectatic lesions on the nasal septum and turbinates that cannot be permanently cauterized without destroying normal mucosa. Cautery provides temporary relief but causes scarring that promotes further telangiectasia formation.

Treatment of HHT-Associated Epistaxis

• Topical treatments: saline moisturization, topical estrogenic creams, and sesame oil drops help maintain mucosal integrity.
• Tranexamic acid (oral or topical): antifibrinolytic; reduces bleeding duration and severity; commonly prescribed for HHT patients with frequent epistaxis.
• Bevacizumab (anti-VEGF): a recombinant humanized monoclonal antibody targeting vascular endothelial growth factor; used both intranasal (topically or submucosal injection) and systemically (intravenous infusion); the evidence of benefit for refractory HHT bleeding comes from intravenous use; two 2016 randomized trials of bevacizumab nasal spray found no benefit — one found no significant reduction in nosebleed frequency or need for transfusion compared with saline, and the other found no significant difference in nosebleed duration and was stopped for futility.
• Thalidomide and lenalidomide: anti-angiogenic agents; used in severe refractory cases; significant side effect profiles limit routine use.
• Laser photocoagulation: Nd:YAG or KTP laser under endoscopic guidance; effective for treating discrete visible lesions but needs repeating.
• Young's procedure (nasal closure): surgical closure of the nasal passages; highly effective for severe, refractory HHT epistaxis; eliminates airflow-induced desiccation; patients breathe entirely through the mouth; reserved for the most severe, treatment-refractory cases.
• Visceral AVM screening: the 2011 international HHT guidelines recommend screening all HHT patients for pulmonary AVMs (contrast echocardiography or computed tomography angiography), hepatic AVMs (Doppler ultrasound), and cerebral AVMs (magnetic resonance imaging) regardless of epistaxis severity, as visceral AVMs carry risks of stroke, brain abscess, pulmonary hemorrhage, and high-output cardiac failure.

Back to Table of Contents

9. Complications

From the Bleeding Itself

• Anemia: significant blood loss can cause iron deficiency anemia, particularly in patients with chronic or recurrent epistaxis (e.g., HHT); transfusion is rarely required except in severe posterior bleeds or medically compromised patients.
• Hemodynamic compromise: life-threatening hemorrhagic shock from epistaxis is rare but well-described in posterior bleeds, particularly in elderly anticoagulated patients; requires airway protection, volume resuscitation, and emergent ENT consultation.
• Aspiration: posterior blood flow into the airway poses aspiration risk, especially in patients who are unconscious, heavily sedated, or prone; maintaining upright positioning and forward lean is critical.
• Nausea and hematemesis: swallowed blood irritates the gastric mucosa and triggers vomiting; this is distressing but not dangerous and resolves when bleeding stops.

From Treatment

• Nasal packing complications: pain, pressure necrosis (alar, columellar, palate), sinusitis, otitis media (eustachian tube obstruction), toxic shock syndrome (rare), septal perforation, and vasovagal syncope during insertion.
• Balloon tamponade complications: hypoxia from the nasopulmonary reflex (bradycardia and hypoxia triggered by nasal pressure), airway obstruction if the balloon migrates posteriorly, pressure necrosis, and sinusitis.
• Silver nitrate cautery complications: septal perforation (bilateral simultaneous cautery), mucosal scarring with adhesion formation, and skin/clothing burns from contact with the chemical.
• Embolization complications: facial nerve palsy, trismus, facial skin necrosis, and cerebral ischemia from non-target embolization.

Back to Table of Contents

10. Prevention

Environmental and Behavioral Modifications

• Humidified indoor air: a cool-mist humidifier in the bedroom, particularly in winter months, is commonly used to keep indoor relative humidity at 40-50%.
• Nasal saline irrigation: twice-daily saline rinses (neti pot or squeeze bottle with isotonic or hypertonic saline) maintain mucosal moisture, flush crusts, and reduce infection-related inflammation.
• Topical petroleum jelly: applying a small amount of plain petroleum jelly to the inside of each nostril with a fingertip or cotton swab daily keeps the anterior septum moist and pliable; a safe, effective, well-studied preventive measure.
• Less nose picking: nose picking is the most common cause in children; trimming fingernails reduces mucosal trauma.
• Nasal spray technique: for people using intranasal corticosteroids, spray directed toward the outer (lateral) wall of the nose (toward the ear on the same side) rather than at the septum reduces steroid-induced mucosal atrophy and bleeding.
• Stay hydrated: adequate systemic hydration maintains mucosal moisture; relevant in hot or dry climates.

Medical Optimization

• Anticoagulation control: for people taking warfarin, an international normalized ratio (INR) above the therapeutic range raises the risk and severity of bleeding. The 2020 nosebleed guideline states that, unless bleeding is life-threatening, first-line treatments (compression, packing, cautery) come before transfusion, reversal of anticoagulation, or stopping anticoagulant or antiplatelet medicines.
• Treat underlying rhinitis or sinusitis: reduce mucosal inflammation and the associated nasal blowing that disrupts fragile vessels.
• Vitamin C supplementation: vitamin C is required for collagen synthesis, which maintains capillary wall integrity; adequate vitamin C intake (≥75-90 mg/day) supports vascular health.
• Vitamin K status: vitamin K-dependent coagulation factors (II, VII, IX, X) are essential for clot formation; adequate dietary vitamin K (green leafy vegetables) supports normal hemostasis, particularly in patients on anticoagulants.
• Iron supplementation: for patients with HHT or chronic recurrent epistaxis, iron replacement therapy addresses iron deficiency anemia from chronic blood loss.
• Correct vitamin D deficiency in benign paroxysmal positional vertigo (BPPV)-prone patients: while primarily relevant to vestibular health, vitamin D deficiency is associated with increased nasal mucosal fragility and may have indirect relevance to epistaxis in some populations.

Post-Procedure Precautions

After treatment of an acute nosebleed, the usual precautions for 7-10 days are to stay away from: blowing the nose forcefully, heavy lifting or straining (Valsalva), aspirin and nonsteroidal anti-inflammatory drugs, hot beverages and spicy foods (which cause vasodilation), high-altitude travel, and vigorous exercise. These precautions reduce risk of dislodging the forming clot.

Back to Table of Contents

Key Research Papers

The following studies represent landmark and contemporary research in epistaxis management, pathophysiology, and hereditary hemorrhagic telangiectasia.

1. Pallin DJ, Chng YM, McKay MP, Emond JA, Pelletier AJ, Camargo CA Jr, 2005 — Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81. — PubMed PMID: 15988431
2. Abrich V, Brozek A, Boyle TR, Chyou PH, Yale SH, 2014 — Risk factors for recurrent spontaneous epistaxis. Mayo Clin Proc. 2014;89(12):1636-43. — PubMed PMID: 25458126
3. Pope LE, Hobbs CG, 2005 — Epistaxis: an update on current management. — Search PubMed
4. Shargorodsky J, Bleier BS, Holbrook EH, et al., 2013 — Outcomes analysis in epistaxis management: development of a therapeutic algorithm. — Search PubMed
5. Saunders WH, 1960 — Hereditary hemorrhagic telangiectasia. Control of nosebleeds by septal dermoplasty. JAMA. 1960;174:1972-4. — PubMed PMID: 13746809
6. Richer SL, Geisthoff UW, Livada N, Ward PD, Johnson L, Mainka A, Henderson KJ, Maune S, White RI Jr, Ross DA, 2012 — The Young's procedure for severe epistaxis from hereditary hemorrhagic telangiectasia. Am J Rhinol Allergy. 2012;26(5):401-4. — PubMed PMID: 23168156
7. Faughnan ME, Palda VA, Garcia-Tsao G, et al., 2011 — International guidelines for the diagnosis and management of hereditary haemorrhagic telangiectasia. — Search PubMed
8. Dupuis-Girod S, Ginon I, Saurin JC, et al., 2012 — Bevacizumab in patients with hereditary hemorrhagic telangiectasia and severe hepatic vascular malformations and high cardiac output. — Search PubMed
9. Pashen D, Stevens M, 2002 — Management of epistaxis in general practice. Aust Fam Physician. 2002;31(8):717-21. — PubMed PMID: 12189661
10. Kucik CJ, Clenney T, 2005 — Management of epistaxis. — Search PubMed
11. Soyka MB, Rufibach K, Huber A, Holzmann D, 2010 — Is severe epistaxis associated with acetylsalicylic acid intake? Laryngoscope. 2010;120(1):200-7. — PubMed PMID: 19877246
12. Cole SG, Begbie ME, Wallace GM, Shovlin CL, 2005 — A new locus for hereditary haemorrhagic telangiectasia (HHT3) maps to chromosome 5. J Med Genet. 2005;42(7):577-82. — PubMed PMID: 15994879
13. Gallione CJ, Repetto GM, Legius E, et al., 2004 — A combined syndrome of juvenile polyposis and hereditary haemorrhagic telangiectasia associated with mutations in MADH4 (SMAD4). Lancet. 2004;363(9412):852-9. — PubMed PMID: 15031030
14. Whitehead KJ, Sautter NB, McWilliams JP, et al., 2016 — Effect of Topical Intranasal Therapy on Epistaxis Frequency in Patients With Hereditary Hemorrhagic Telangiectasia: A Randomized Clinical Trial. JAMA. 2016;316(9):943-51. — PubMed PMID: 27599329
15. Dupuis-Girod S, Ambrun A, Decullier E, et al., 2016 — Effect of Bevacizumab Nasal Spray on Epistaxis Duration in Hereditary Hemorrhagic Telangectasia: A Randomized Clinical Trial. JAMA. 2016;316(9):934-42. — PubMed PMID: 27599328
16. Tran QK, Rehan MA, Haase DJ, Matta A, Pourmand A, 2020 — Prophylactic antibiotics for anterior nasal packing in emergency department: A systematic review and meta-analysis of clinically-significant infections. Am J Emerg Med. 2020;38(5):983-989. — PubMed PMID: 31839514
17. Tunkel DE, Anne S, Payne SC, et al., 2020 — Clinical Practice Guideline: Nosebleed (Epistaxis) Executive Summary. Otolaryngol Head Neck Surg. 2020;162(1):8-25. — PubMed PMID: 31910122
18. Shovlin CL, Guttmacher AE, Buscarini E, et al., 2000 — Diagnostic criteria for hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Am J Med Genet. 2000;91(1):66-7. — PubMed PMID: 10751092

PubMed Topic Searches

1. PubMed: Epistaxis management and treatment
2. PubMed: Anterior epistaxis cautery and packing
3. PubMed: Posterior epistaxis sphenopalatine artery
4. PubMed: Hereditary hemorrhagic telangiectasia epistaxis
5. PubMed: HHT bevacizumab anti-VEGF treatment
6. PubMed: Tranexamic acid nosebleed antifibrinolytic
7. PubMed: Kiesselbach plexus nasal vasculature anatomy
8. PubMed: Epistaxis and hypertension blood pressure
9. PubMed: Endoscopic sphenopalatine artery ligation
10. PubMed: Von Willebrand disease epistaxis bleeding

Back to Table of Contents

Connections

• ENT
• Sinusitis
• Tonsillitis
• Hypertension
• Stroke
• Vitamin K
• Vitamin C
• Scurvy: Nosebleeds & Capillary Fragility — when a nosebleed is a vitamin C sign, and when it is not
• Natural Nosebleed Relief — the pinch technique, humidification, and what actually prevents epistaxis
• Iron
• Vertigo & Ménière's Disease
• Lab Tests
• Von Willebrand Disease

Featured Videos