Red flag symptoms: Epistaxis

Recurrent bleeds may warrant further investigation by ENT, says Dr Anna Cumisky.

A nasal speculum examination (Photo: DR P. MARAZZI/SCIENCE PHOTO LIBRARY)
A nasal speculum examination (Photo: DR P. MARAZZI/SCIENCE PHOTO LIBRARY)
Red flag symptoms
  • Recurrent bleeds
  • Persistent bleeds
  • Brisk bilateral bleed
  • Purulent bleeds
  • Signs of shock

The cause of epistaxis is often benign but there are features to be aware of that may indicate serious pathology. The most common local cause is internal or external trauma. The use of anticoagulant medication, hypertension and increased venous pressure associated with cardiac failure are potential exacerbating factors. Similarly, patients receiving oxygen via nasal cannulae or with an altered nasal mucosa, for example from excessive topical steroid or cocaine use, are at increased risk of epistaxis.

Anterior bleeds

About 90% of epistaxis reflects an anterior bleed. The presenting feature is usually unilateral epistaxis, although both nostrils may be involved if bleeding is particularly brisk.

In the majority of cases, primary care management will be appropriate, with little other action required.

Once controlled, examination using a nasal speculum commonly highlights the origin of the bleed but may also reveal nasal polyps, signs of inflammation or other lesions.

An initial assessment of haemodynamic stability is important.

If the bleeding cannot be controlled, emergency secondary care admission is required.

Posterior bleeds

Posterior bleeds are more rare and often more difficult to stop. They may result from pathology involving the vasculature of the nasal cavity or nasopharynx, or nasopharyngeal tumours, or can occur postoperatively. Signs suggestive of a posterior bleed include brisk bilateral bleeding at the outset, blood clearly visible in the oropharynx or epistaxis persisting. All posterior bleeds need secondary care assessment.

Other causes

In recurrent cases with no clear trigger or with obvious unilateral obstruction, referral to ENT is prudent. Purulent bleeds may indicate foreign body entrapment.


It is common for BP to be raised as a response to an acute epistaxis but it is unusual for a newly hypertensive patient to present this way. In patients who are known to have hypertension it would be prudent to monitor BP periodically after a nosebleed to ensure their treatment is optimal.

Dr Cumisky is a GP in Bath, Somerset

Possible causes
Localised trauma
Nasopharyngeal tumour


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