Epistaxis — Anatomy, Assessment, and the Management Ladder

Epistaxis (nosebleed) is one of the commonest ENT emergencies. Roughly 60% of people get one at some point, though fewer than 10% ever need medical attention. The incidence is bimodal, peaking in children under 10 and again in adults over 50. Most bleeds are trivial and anterior; a minority are posterior, torrential, and genuinely dangerous. Because management hinges on one early question — anterior or posterior? — the anatomy is where any account of epistaxis has to begin.

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Anterior vs posterior

• Anterior epistaxis — bleeding from the anteroinferior nasal septum, specifically Kiesselbach’s plexus (Little’s area). Accounts for about 80% of all cases, and the source is usually visible on anterior rhinoscopy.
• Posterior epistaxis — bleeding from the posterior lateral nasal wall, often the posterior septal branch of the sphenopalatine artery. Typically more severe, more common in older adults, and more likely to need invasive control.

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Vascular anatomy

Kiesselbach’s plexus (Little’s area) is an anastomosis on the anterior septum formed by the terminal branches of five arteries:

• Sphenopalatine artery
• Greater palatine artery
• Superior labial artery (from the facial artery)
• Anterior ethmoidal artery
• Posterior ethmoidal artery

The first three derive ultimately from the external carotid system and the two ethmoidals from the internal carotid (via the ophthalmic artery) — which is why the anterior septum, sitting at this watershed, bleeds so readily. Posteriorly, the sphenopalatine artery (the terminal branch of the internal maxillary artery) enters through the posterior lateral nasal wall, and Woodruff’s plexus is the recognised site for posterior bleeds.

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Causes

Local

• Digital trauma (nose-picking) — the single most common cause at any age.
• Mucosal dryness; maxillofacial trauma (fractures, septal deviation); inflammation/infection (including nasal polyps).
• Tumours — inverting papilloma, juvenile nasopharyngeal angiofibroma (JNA) (the classic unilateral epistaxis in an adolescent male), squamous cell carcinoma, melanoma.
• Excessive intranasal corticosteroid use, especially if the spray is directed at the septum.

Systemic

• Medications — aspirin, NSAIDs, warfarin, and direct oral anticoagulants (e.g. rivaroxaban).
• Coagulopathies — von Willebrand disease, haemophilia, and leukaemia (via thrombocytopenia).
• Hereditary haemorrhagic telangiectasia (HHT) — an autosomal dominant condition with mucosal arteriovenous malformations; recurrent, difficult epistaxis is its hallmark. Refractory HHT epistaxis is one setting where anti-angiogenic therapy (submucosal bevacizumab, often combined with laser) has been used to reduce bleeding frequency and transfusion need.
• Hypertension — not established as an independent cause of epistaxis, but it makes an active bleed harder to control.

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Assessment and resuscitation

• History and examination directed at the side, duration, and likely source; a full blood count for active or recurrent bleeds to gauge loss.
• Haemodynamics and airway first — severe haemorrhage risks aspiration and hypovolaemia; follow acute-care (ABC) protocols before focusing on the nose.
• Anterior vs posterior — if anterior rhinoscopy shows blood tracking posterior and superior to the inferior turbinate with no visible anterior source, suspect a posterior bleed.
• Platelets matter — a count below 20,000/mm³ markedly increases the difficulty of controlling haemorrhage.

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The management ladder

Work up the ladder only as far as you need to.

1. First aid — sit forward, and apply firm direct pressure to both nares (the soft cartilaginous part) for 15–20 minutes.
2. Topical vasoconstrictor — oxymetazoline or phenylephrine to shrink the mucosa and slow the bleed.
3. Cautery — topical silver-nitrate cautery for a localised, visible anterior bleeding point. Avoid aggressive bilateral septal cautery — it risks septal perforation.
4. Anterior nasal packing — expandable sponge packs, inflatable packs, or ribbon gauze coated in petroleum jelly. If bleeding persists, pack the other side too, to buttress the septum and raise the pressure.
5. Posterior packing — purpose-made anterior–posterior packs, or the classic Foley-catheter technique: pass a 12–14 Fr catheter, inflate the balloon with ~10 mL saline, and draw it anteriorly until it seats in the posterior choana. Posterior packing controls up to about 70% of posterior bleeds.
6. Surgical / radiological control — if packing fails: endoscopic electrocautery (usually the next step), arterial ligation (sphenopalatine or anterior ethmoidal artery), or embolisation of selected external-carotid branches for the unstable patient or one unfit for general anaesthesia.

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Red flags and complications

• Posterior-bleed danger signs — severe or persistent haemorrhage, failure of anterior measures, and the risk of hypoxia and cardiac arrhythmia; these patients warrant admission and oxygen monitoring.
• Packing complications — mucosal/skin/cartilage ulceration and necrosis (nasal tip, septum, nasopharynx); toxic shock syndrome (hence prophylactic antibiotics while packs are in situ); septal perforation, sinusitis, and synechiae (adhesions).
• Timeframe — nasal packs are usually removed after 48–72 hours.

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Frequently Asked Questions

Where do most nosebleeds come from? About 80% are anterior, from Kiesselbach’s plexus (Little’s area) on the anteroinferior septum — an anastomosis of five arteries that sits at the junction of the internal and external carotid supplies, which is why it bleeds so easily. Posterior bleeds, usually from the sphenopalatine artery, are fewer but more severe.

How do I know if it’s a posterior bleed? Suspect it when there is no visible anterior source, blood is seen tracking high and posterior to the inferior turbinate, the bleeding is heavy or bilateral, or the patient is older — and when anterior first aid and packing fail to control it. Posterior bleeds often need a posterior pack or arterial control.

Does high blood pressure cause nosebleeds? Hypertension is not established as an independent cause of epistaxis, but it does make an active bleed harder to stop. Don’t attribute a nosebleed to blood pressure alone or miss another cause.

How long do nasal packs stay in, and why the antibiotics? Packs are usually removed after 48–72 hours. Prophylactic antibiotics are given while packs are in place because of the risk of toxic shock syndrome from retained nasal packing.

When should recurrent or unusual nosebleeds be investigated further? Recurrent, unilateral, or unusually heavy epistaxis — particularly in an adolescent male (juvenile nasopharyngeal angiofibroma), with a family history of recurrent bleeds (HHT), or in a patient on anticoagulants or with a bleeding tendency — deserves fuller assessment rather than repeated simple treatment.