EpistaxisBMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e1097 (Published 23 February 2012) Cite this as: BMJ 2012;344:e1097
- Omar Mulla, specialty registrar1,
- Simon Prowse, specialist registrar1,
- Tim Sanders, academic general practitioner2,
- Paul Nix, consultant ear, nose, and throat surgeon1
- 1Ear, Nose, and Throat Department, Leeds General Infirmary, Leeds LS1 3EX, UK
- 2The Shap Medical Practice, Penrith CA10 3LW, UK
- Correspondence to: O Mulla
- Accepted 7 December 2011
A 52 year old man presents with recurrent epistaxis. It usually settles after 10 minutes.
What you should cover
Initial onset, frequency, duration, and triggers (such as weather)
How are the nose bleeds controlled?
Distinguish between anterior (blood running out of the nose, usually one nostril) and posterior (blood running into the throat or from both nostrils) bleeds
Trauma, including nose picking
Previous nasal surgery
Medical history, specifically checking for hypertension and clotting disorders in the patient or their family
Medication—check for aspirin, clopidogrel, warfarin, and any potential drug interactions that might have precipitated bleeding. If appropriate, test blood clotting. Also inquire about any homeopathic medicines
Assess for symptoms and signs of anaemia if bleeding has been heavy or prolonged. If appropriate, carry out a full blood count
Facial pain or deep otalgia with epistaxis may be the first sign of a nasopharyngeal tumour
In young male patients consider juvenile nasopharyngeal angiofibroma and ask about nasal obstruction, headache, rhinorrhea, and anosmia. These are rare benign tumours that tend to bleed. They occur in the nasopharynx of prepubertal and adolescent males
Ninety five per cent of nose bleeds arise from Little’s area, a region of the anteroinferior nasal septum. This area is extremely vascular, as terminal branches of the internal and external carotid arteries anastamose here.
What you should do
Whether the patient is bleeding or not, assess their cardiovascular state—pulse, blood pressure, and capillary refill. If the patient is actively bleeding, seat them and ask them to lean forward (to minimise the swallowing of blood) and apply pressure on to the soft cartilaginous part of the nose for 10 minutes. If bleeding does not stop, refer them to an ear, nose, and throat department and sent them to hospital. The urgency and mode of transfer will depend on the clinical condition of the patient, but do not underestimate the amount of blood that can be lost during epistaxis. Patients should not drive themselves to hospital because they may be not covered by their motor insurance in this situation.
If the patient has stopped bleeding, use an otoscope or a torch and nasal speculum to look at the anterior nose and septum for evidence of a bleeding vessel, which will often appear as a red dot on pale mucosa. If a vessel is seen, chemical cautery may be attempted using a topical local anaesthetic such as lidocaine or co-phenylocaine (5% lignocaine with 0.5% phenylephrine) to help vasoconstriction, if bleeding is active, and a silver nitrate stick. If no facility for cautery is available refer to ear, nose, and throat; most departments have rapid access casualty clinics designed for this purpose.
If the patient’s history suggests anterior epistaxis and no vessel is seen, it is reasonable to discharge with a two week course of 0.1% chlorhexidine, 0.5% neomycin cream or petroleum jelly—these help with drying of the nasal mucosa and can prevent further bleeding. Advise patients to return if bleeding persists.
Simple pressure will not stop epistaxis from posteriorly placed vessels, so recurrent or heavy bleeds that appear posterior in origin need endoscopic assessment in an ear, nose, and throat clinic to help identify a bleeding point.
Always give patients advice about how to stop further bleeding:
(1) Pinch the soft part of the nose and lean forward
(2) Avoid hot foods and drinks (preventing vasodilatation)
(3) Place ice packs on the nose (to promote vasoconstriction).
If epistaxis is refractory or if you suspect any problem other than a simple bleed—for example, a septal perforation or tumour—seek an opinion from an ear, nose, and throat clinician.
Causes of epistaxis
Drugs: aspirin, clopidogrel, warfarin
Rhinitis: viral, allergic
Neoplastic: tumours of the nose, sinuses, and nasopharynx
Hereditary: Osler-Weber-Rendu disease, haemophilia, von Willebrand disease
Kucik CJ, Clenney T. Management of epistaxis. Am Fam Physician 2005;71:305-11
Murthy P, Nilssen EL, Rao S, McClymont LG. A randomised clinical trial of antiseptic nasal carrier cream and silver nitrate cautery in the treatment of recurrent anterior epistaxis. Clin Otolaryngol Allied Sci 1999;24:228-31
Cite this as: BMJ 2012;344:e1097
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Not commissioned; externally peer reviewed.