Approach to nosebleed
- Approach to a complaint
Almost all nosebleeds are anterior, from Kiesselbach's area, and stop with pressure; posterior and recurrent bleeds need more work-up.
What it is
Epistaxis is one of the most common ENT emergencies. Most bleeds are anterior and arise from Kiesselbach's plexus (Little's area) on the anterior septum, where branches of several arteries meet; they stop with pressure and cautery. Posterior bleeds are less common, heavier and more frequent in older, hypertensive and anticoagulated patients. The approach starts with the patient's stability, goes on to find the bleeding point and ends by looking for the cause: local, drug-related, systemic or a tumour, such as juvenile angiofibroma in an adolescent boy.
Key questions in the history
- Which side did it start on? Is blood running down the throat?
- How heavy, and for how long? Previous episodes?
- Anticoagulants or antiplatelet drugs?
- Bruising, bleeding gums or a family history of bleeding?
- Hypertension, liver disease or recent trauma?
- One-sided nasal blockage, foul discharge or facial pain?
Causes and classification
- Anterior (most): Kiesselbach's plexus on the anterior septum.
- Posterior (less common, more severe): branches of the sphenopalatine artery at the back of the nasal cavity.
- Local causes: nose picking, dry air, rhinitis, foreign body, nasal fracture, septal perforation and tumours.
- Systemic causes: anticoagulants and antiplatelet drugs, coagulopathy, thrombocytopenia, liver disease and hereditary haemorrhagic telangiectasia.
- By age: child (nose picking, foreign body), adolescent boy (angiofibroma), older adult (posterior bleeding, drugs).
Step-by-step approach
- Assess the airway and haemodynamic state; if unstable, resuscitate first.
- Sit the patient leaning forward and pinch the soft part of the nose without letting go for 10 to 15 minutes.
- Remove clots and apply a topical vasoconstrictor, with or without local anaesthetic.
- Use anterior rhinoscopy to find the bleeding point on the anterior septum.
- If you see it, cauterise it with silver nitrate on one side of the septum only.
- If it persists, place an anterior pack; if it still runs down the throat, suspect a posterior source.
- Order a blood count and clotting tests if the bleed is heavy or recurrent or the patient is anticoagulated.
Differential diagnosis of nosebleed
| Cause | Who | Key clue |
|---|---|---|
| Nose picking and dry mucosa | Children, dry climate | Mild anterior bleed, crusts on the septum |
| Anticoagulant or antiplatelet drugs | Older adults | Prolonged or posterior bleeding |
| Nasal foreign body | Young children | One-sided foul, bloody discharge |
| Juvenile nasopharyngeal angiofibroma | Adolescent boys | One-sided blockage and a nasopharyngeal mass |
| Hereditary haemorrhagic telangiectasia | Any age, family history | Recurrent nosebleeds and telangiectasias |
| Sinonasal tumour | Adults | One-sided bleeding, blockage, pain or eye symptoms |
Red flags
- Haemodynamic instability or bleeding that does not stop with pressure and anterior packing.
- Blood running into the throat from both sides: possible posterior source.
- An adolescent boy with one-sided nasal blockage and recurrent nosebleeds.
- An adult with recurrent one-sided nosebleeds, blockage, facial pain or eye symptoms: rule out a tumour.
- Mucocutaneous telangiectasias and a family history of nosebleeds.
- Bleeding elsewhere or bruising: coagulopathy.
Next step / Initial management
- First line: continuous pressure, a topical vasoconstrictor, cautery of a visible point and, if that fails, anterior packing.
- Afterwards: keep the mucosa moist with an ointment or petroleum jelly and avoid picking.
- Anticoagulated patients: check the INR and discuss the anticoagulant with the prescriber.
- Urgent same-day ENT referral: posterior bleeding, bleeding despite packing or instability.
- Priority referral: one-sided bleeding with blockage or a mass (angiofibroma, tumour); routine referral if recurrent or hereditary haemorrhagic telangiectasia is suspected.
Test yourself
Think of the answer, then tap the question to see it.
A 7-year-old has a mild left anterior nosebleed that stops with pressure. Where does it most often come from?
Kiesselbach's plexus (Little's area) on the anterior septum, where branches of several arteries meet.
A 15-year-old boy has progressive right nasal blockage and recurrent nosebleeds. What do you suspect and what must you not do?
Juvenile nasopharyngeal angiofibroma. Do not biopsy it in clinic because of the risk of severe bleeding; order imaging and refer to ENT.
An anticoagulated 75-year-old bleeds into the throat from both sides despite a good anterior pack. What do you suspect?
Posterior epistaxis from the sphenopalatine territory: urgent ENT referral for posterior packing or endoscopic treatment.
What is the first manoeuvre for an anterior nosebleed?
Sit the patient leaning forward and pinch the soft part of the nose continuously for 10 to 15 minutes.
Connections
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Epistaxis (StatPearls Publishing (NCBI Bookshelf), 2022); Hereditary Hemorrhagic Telangiectasia (HHT) (StatPearls Publishing (NCBI Bookshelf), 2026); Nasal Foreign Body (StatPearls Publishing (NCBI Bookshelf), 2023).
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Representative model, for educational purposes only.