Applied Evidence

Epistaxis: A guide to assessment and management

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Is your patient’s nosebleed a self-limiting occurrence, or a sign of something more worrisome? And which treatments are best in which situations?


› Use topical vasoconstrictor and local anesthetic agents as a first line therapy for epistaxis. Consider the additional use of topical tranexamic acid. A

› Perform chemical cautery with silver nitrate in cases of anterior epistaxis. This approach is cheap, easy to perform, and silver nitrate is readily available. A

› Consider endoscopic sphenopalatine artery ligation in the acute management of posterior epistaxis. It is superior to posterior nasal packing and embolization when it comes to pain, cost-effectiveness, risk, and overall control of bleeding. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series



Epistaxis is a common presenting complaint in family medicine. Successful treatment requires knowledge of nasal anatomy, possible causes, and a step-wise approach.

Epistaxis predominantly affects children between the ages of 2 and 10 years and older adults between the ages of 45 and 65.1-4 Many presentations are spontaneous and self-limiting; often all that is required is proper first aid. It is important, however, to recognize the signs and symptoms that are suggestive of more worrisome conditions.

Management of epistaxis requires good preparation, appropriate equipment, and adequate assistance. If any of these are lacking, prompt nasal packing followed by referral to an emergency department or ear, nose, and throat (ENT) service is recommended.

Anatomy of the nasal cavity

The nasal cavity has a rich and highly varied blood supply arising from the internal and external carotid arteries with multiple anastomoses and a crossover between the left and right arterial systems.2,4,5 The internal maxillary artery (IMAX) supplies 80% of the nasal vault.2 The sphenopalatine artery (SPA) supplies most of the nasal septum and the turbinates, while the greater palatine artery (GPA) supplies the floor of the nasal septum.3,5 The ethmoidal arteries course through the cribriform plate to supply the roof of the nasal cavity. The ethmoidal arteries communicates with branches of the SPA posteriorly and several branches anteriorly (FIGURE 1).

Anatomy of the nasal cavity

Kiesselbach’s plexus is a highly vascularized region of cartilaginous nasal septum anteroinferiorly that is also known as Little’s area. It is supplied by the SPA, GPA, superior labial artery, and ethmoidal arteries.5 Woodruff’s plexus is the richly vascularized posterior aspect of the nasal cavity primarily supplied by the SPA.3,5

Is the bleed anterior or posterior; primary or secondary?

Epistaxis is classified as anterior or posterior based on the arterial supply and the location of the bleed in relation to the piriform aperture.2,3 Anterior epistaxis occurs in >90% of patients and arises in Little’s area.6 Posterior epistaxis arises from Woodruff’s plexus in the posterior nasal septum or lateral nasal wall. It occurs in 5% to 10% of patients, is usually arterial in origin, and leads to a greater risk of airway compromise, aspiration, and difficulty in controlling the hemorrhage.2,6

Epistaxis can be classified further as primary or secondary hemorrhage. Primary epistaxis is idiopathic, spontaneous bleeds without any precipitants.2 Blood vessels within the nasal mucosa run superficially and are relatively unprotected. Damage to this mucosa and to vessel walls can result in bleeding.4 Spontaneous rupture of vessels may occur occasionally, during, say the Valsalva maneuver or when straining to lift heavy objects.4 Secondary epistaxis occurs when there is a clear and definite cause (eg trauma, anticoagulant use, or surgery).

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