Red flag symptoms
- Haemorrhagic shock
Bleeding not stopped by direct pressure
Recurrent unilateral epistaxis
Nasal obstruction, rhinorrhoea, facial pain, facial numbness or diplopia
Signs suggestive of a bleeding disorder
Epistaxis prevalence is increased in children under the age of 10 years and in adults aged over 35 years.
- Trauma - nose picking, facial injury, postoperative
- Foreign body
- Inflammation/infection - allergic rhinosinusitis, nasal polyps
- Neoplasia - squamous cell carcinoma
- Drugs - topical decongestants, anticoagulants, antiplatelets, cocaine
- Haematological - coagulopathies, acquired coagulopathies caused by liver or renal disease, thrombocytopenia, platelet dysfunction in von Willebrand disease
Most nasal bleeding is idiopathic; trauma to the nasal mucosa may damage superficial blood vessels.
Rarely, recurrent unilateral epistaxis may be suggestive of an underlying malignancy. Local damage of blood vessels may be caused by squamous cell carcinoma. Malignancy of the sinonasal tract may present with nasal obstruction, rhinorrhoea, epistaxis, headaches and facial pain.
There should be a high index of suspicion if there is unilateral facial swelling, diplopia, unilateral proptosis or cranial neuropathies.
The nose has a blood supply arising from the internal and external carotid arteries. Epistaxis may be classified as anterior or posterior.
The ethmoidal arteries, which arise from the internal carotid artery, supply the area above the middle turbinate.
The sphenopalatine artery, which arises from the external carotid artery, supplies most of the nasal septum and turbinates on the lateral wall.
Most nasal bleeding is anterior and often arises from Kiesselbach's plexus on the lower part of the anterior septum (Little's area). Approximately 10% of nosebleeds are posterior bleeds, which are more common in older patients.
It is important to establish whether the nosebleed started on one or both sides and how long it lasted. If the bleeding has stopped, it is helpful to ask how the patient tried to stop it.
Establishing previous epistaxis is useful, as well as its frequency and severity. There may have been a trigger, such as sneezing, or nose blowing or picking preceding the episode.
Associated factors include symptoms of URTI, nasal obstruction or facial pain. It may be relevant to ask about excessive bleeding with minor trauma, easy bruising and haemoptysis.
The medical history may reveal a background of bleeding disorders or other conditions which can result in platelet dysfunction or coagulation. The latter includes malignancy, cirrhosis and pregnancy. A detailed drug history should be taken.
Physical examination should include assessing vital signs, as resuscitation may be required.
There could be signs to indicate the presence of a bleeding disorder, such as petechiae or purpura. If there is unexplained bruising, bleeding and/or petechiae an urgent blood test should be arranged to exclude leukaemia, other features such as fever and a history of infection may be present.
Telangiectasia may be visible in the mouth. The head and neck should be examined and it may be relevant to carry out cranial nerve examination. Nasal endoscopy could be warranted, depending on the clinical presentation.
If there is active bleeding, this needs to be stopped in the first instance; resuscitation may be necessary. Most anterior nosebleeds are self-limiting and do not require intervention.
Pinching the anterior part of the nose for 15 minutes can stop bleeding by providing tamponade for the anterior septal blood vessels. Ideally, this should be performed with the patient sitting upright.
Examination usually reveals an anterior bleeding site. Anaesthetic and vasoconstrictor topical sprays can be used, for example, oxymetazoline spray. A cotton pledget impregnated with a vasoconstrictor and a topical anaesthetic may be inserted into the nose.
In the acute setting, it is important to identify a bleeding point, so that chemical or electrocautery can be carried out. Chemical cautery is performed using a silver nitrate stick, which is applied to the bleeding point for five seconds with firm pressure. Normal saline may be used to neutralise staining.
Only one side of the nasal septum should be treated, due to the risk of septal perforation. If this is unsuccessful, anterior packing, compressive balloons, posterior packing or embolisation may be required.
In the primary care setting, nasal tampons can be used. It is worth excluding high BP as a possible contributing factor, although the relationship between the two is controversial.
If there are symptoms or signs of a bleeding disorder, blood tests, such as FBC and coagulation screen, may be required.
- Dr Kochhar is a GP in Bexhill, East Sussex. This article was first published in 2016 and updated in December 2020
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