Epistaxis (anteriorMANAGEMENT

ENT AND MAXILLOFACIAL PRESENTATIONS · 12 SECTIONS

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372 items

☷ Legend

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Cardiovascular Presentations66▾

Respiratory Presentations47▾

Neurological Presentations77▾

Gastrointestinal Presentations63▾

Genitourinary and Reproductive Presentations44▾

Infectious Disease Presentations146▾

Trauma Presentations88▾

Toxicologic Presentations67▾

Psychiatric Presentations25▾

Musculoskeletal and Rheumatologic Presentations89▾

Dermatology Presentations21▾

Environmental and Exposure Presentations26▾

Hematologic and Oncologic Presentations30▾

Pediatric-Specific Presentations13▾

Endocrine and Metabolic Presentations42▾

ENT and Maxillofacial Presentations21▾

Acute laryngitis Acute pharyngitis Bezold's Abscess Cerumen impaction Epistaxis (anterior)Epistaxis (Posterior)Labyrinthitis Ludwig's Angina Malignant Otitis Externa Marcus Gunn Pupil Mastoiditis Meniere's Disease Nasal Bone Fracture Nasal foreign body Nasal Septal Hematoma Otitis externa Otitis Media Sinusitis Sudden Sensorineural Hearing Loss Tympanic membrane perforation Vestibular Neuronitis

Ophthalmologic Presentations15▾

Obstetric Presentations17▾

Systemic and Miscellaneous Presentations15▾

01Approach to the Critical Patient/attcp28

Triage and immediate threats

›Initial priorities

›Airway risk from active posterior bleeding

›If inability to clear blood or altered mental status, airway management escalation

›Hemorrhagic shock risk

›If hypotension or syncope, resuscitation bay escalation

›Uncontrolled bleeding despite first aid

›If continuous brisk bleeding after 10 to 15 minutes compression, advanced hemostasis pathway

›High risk features

›Suspected posterior source

›Anticoagulant or antiplatelet therapy

›Known bleeding disorder

›Hereditary hemorrhagic telangiectasia

›Facial trauma

Monitoring and access

›Monitoring setup

›Continuous pulse oximetry

›Oxygen if hypoxemia or significant ongoing blood loss

›Cardiac monitoring for significant bleeding or posterior packing

›Dysrhythmia risk with posterior packs and hypoxia

›Two large bore IV access if moderate to severe bleeding

›Type and screen if transfusion plausible

Hemostatic positioning and first measures

›First measures

›Upright posture with slight forward lean

›Oropharyngeal suction readiness

›Direct compression of soft anterior nose

›Continuous compression without frequent release

›High success rates reported with proper compression

›Topical vasoconstrictor adjunct

›Oxymetazoline or phenylephrine with compression per guideline first line options

02History/hx38

Focused bleeding history

›Bleeding characterization

›Anterior dripping versus posterior blood in throat

›Posterior symptoms with gagging, hemoptysis, hematemesis

›Duration and frequency

›Recurrent episodes within days

›Laterality

›Unilateral recurrent bleeding concern for local lesion

›Trigger

›Nose picking

›URI and forceful blowing

›Dry air

›Facial trauma

Medication and comorbidity risks

›Hemorrhage risk factors

›Anticoagulants

›Warfarin

›DOAC

›Antiplatelets

›Aspirin

›P2Y12 inhibitor

›NSAID use

›Recent high dose exposure

›Bleeding disorders

›Von Willebrand disease

›Hemophilia

›Liver disease

›Uremia

›Vascular disorders

›Hereditary hemorrhagic telangiectasia

Red flags and alternative sources

›Red flags

›Syncope or presyncope

›Chest pain or dyspnea

›Severe headache with hypertension

›Melena or hematemesis

›Alternative source concern

›Hemoptysis

›Hematemesis

›Oropharyngeal bleeding

›Recent nasal surgery

03Physical Exam/exam23

Rapid assessment

›Physiologic status

›Vital signs trend

›Orthostasis indicators

›Perfusion

›Capillary refill delay

›Cool extremities

›Mental status

›Confusion with hypoperfusion concern

Nose and oropharynx exam

›Focused ENT exam

›External nose deformity

›Nasal fracture concern

›Anterior rhinoscopy with speculum and headlamp

›Kiesselbach area visible bleeding point

›Posterior pharynx blood pooling

›Posterior source concern

›Septal hematoma

›Trauma associated urgent drainage pathway

›Mucosal lesion

›Mass or ulceration concern

PITFALLS

›Common pitfalls

›Posterior bleed misclassified as anterior due to anterior spillover

›Incomplete visualization without suction and vasoconstriction

›Apparent control with continued posterior trickle into pharynx

04Differential Diagnosis/ddx27

Life threatening and urgent causes

›High acuity differentials

›Posterior epistaxis from sphenopalatine system

›Brisk bleeding and hemodynamic impact

›Nasal or nasopharyngeal tumor

›Recurrent unilateral bleeding

›Severe coagulopathy

›Anticoagulant excess

›Thrombocytopenia

›Facial trauma with arterial injury

›Midface fracture

›Hereditary hemorrhagic telangiectasia

›Recurrent mucosal bleeding

Common mimics and contributors

›Mimics and contributors

›Rhinitis and mucosal irritation

›Allergic rhinitis

›URI

›Septal perforation

›Chronic topical decongestant use

›Cocaine exposure

›Hypertension association

›Persistent bleeding with severe hypertension

›Foreign body

›Pediatric unilateral malodorous discharge

›Coding anchors

›ICD-10 R04.0 epistaxis

›ICD-10 I78.0 hereditary hemorrhagic telangiectasia

›SNOMED CT 249366005 epistaxis

05Laboratory Tests/lt20

Hemorrhage and coagulopathy evaluation

›Baseline labs when indicated

›Complete blood count for significant bleeding or recurrent episodes

›Hemoglobin trend for occult blood loss

›Platelet count for thrombocytopenia

›INR for warfarin or liver disease

›Supratherapeutic INR as bleeding driver

›aPTT for heparin effect or intrinsic pathway disorder

›Prolongation as reversal trigger context

›Creatinine for DOAC pharmacokinetics and uremia bleeding

›Reduced clearance in renal impairment

Transfusion planning

›Blood bank testing when moderate to severe bleeding

›Type and screen

›Crossmatch if ongoing brisk bleeding or instability

›Fibrinogen if massive bleeding pattern or DIC concern

›Low fibrinogen as component therapy trigger

Point of care testing

›Point of care considerations

›Glucose if altered mental status

›Hypoglycemia mimic

›Venous blood gas if shock concern

›Lactate as hypoperfusion marker

06Diagnostic Tests/dt33

Scoring Systems

›Risk and severity tools

›Shock index heart rate divided by systolic blood pressure

›Elevated values supporting hemorrhage concern

›Epistaxis Severity Score for hereditary hemorrhagic telangiectasia

›Range 0 to 10

›Six factor questionnaire based score

MRI

›MRI indications

›Suspected tumor with persistent unilateral symptoms

›Soft tissue characterization advantage

›Vascular malformation evaluation when stable

›Pre procedural planning for specialized care

›Contraindications screening

›Ferromagnetic implant concern

›Unstable patient unsuitability

›CT indications

›Significant facial trauma

›Fracture assessment

›Recurrent unilateral bleeding with mass suspicion

›Sinonasal lesion mapping

›Persistent posterior bleeding with unclear source

›Anatomic planning for endoscopic ligation or embolization

›CT considerations

›Radiation exposure

›Pediatric minimization strategies

›Contrast considerations

›Renal function context

Ultrasound

›Ultrasound applications

›POCUS for volume status in shock concern

›IVC size and collapsibility as adjunct

›Cardiac POCUS for alternative instability causes

›Pericardial effusion exclusion in unexplained hypotension

›Soft tissue ultrasound for septal collection when uncertain

›Adjunct to direct visualization

07Disposition/dispo25

Level of care decisions

›Disposition framework

›Discharge eligibility

›Bleeding controlled with compression or minor anterior measures

›Hemodynamic stability

›No concerning unilateral mass findings

›Reliable follow up and return precautions

›Observation indications

›Rebleeding risk after packing removal plan

›Significant comorbidities or anticoagulation

›Admission indications

›Posterior packing in place

›Ongoing transfusion requirement

›Recurrent bleeding despite appropriate anterior packing

›Need for operative or interventional radiology control

Consultation and transfer

›Specialty involvement

›Otolaryngology consultation triggers

›Posterior epistaxis suspicion

›Failure of anterior measures and anterior packing

›Need for endoscopic cautery or arterial ligation

›Interventional radiology consultation triggers

›Persistent bleeding despite packing

›Candidate for embolization per guideline discussion

›Transfer considerations

›No local ENT coverage with posterior pack

›Need for endoscopic ligation or embolization capability

08Treatment/t98

Stepwise anterior epistaxis pathway

›Noninvasive measures

›Compression protocol

›Continuous pinch of soft anterior nose for 10 to 15 minutes

›Repeat cycle with topical vasoconstrictor if needed

›Topical vasoconstrictors

›Oxymetazoline 0.05 percent intranasal

›2 sprays to affected nostril then compression

›Repeat once after 10 minutes if persistent bleeding

›Phenylephrine 0.25 to 1 percent intranasal

›1 to 2 sprays then compression

›Avoid in severe uncontrolled hypertension when possible

›Visualization and directed therapy

›Anterior suction and illumination

›Clot removal enabling source identification

›Chemical cautery for visible anterior point

›Silver nitrate applicator

›Single site application after relative hemostasis

›Avoid bilateral septal cautery in same visit

›Topical hemostatic materials

›Absorbable packing options

›Oxidized cellulose

›Gelatin sponge

›Thrombin based agents

Anterior nasal packing

›Packing selection

›Nonabsorbable anterior pack

›Compressed sponge tampon

›Saline expansion per product instructions

›Balloon anterior device

›Inflation with air or saline per device limits

›Analgesia and anxiolysis

›Intranasal lidocaine adjunct when feasible

›Systemic analgesia for discomfort

›Packing management

›Reassessment after placement

›Oropharynx check for continued posterior flow

›Antibiotic considerations

›Limited evidence for routine prophylaxis

›Consider antibiotics for prolonged nonabsorbable packing and high risk sinusitis or immunocompromise

›Removal timing plan

›Typical anterior pack removal within 24 to 72 hours with follow up

Posterior epistaxis pathway

›Posterior bleed recognition

›Persistent bleeding with bilateral nares and posterior pharynx blood

›Failure of anterior packing control

›Higher severity typical pattern

›Posterior packing techniques

›Balloon catheter posterior pack

›Double balloon devices commonly used

›Admit with monitoring due to complication risk

›Foley catheter posterior pack when appropriate expertise

›Balloon seated in nasopharynx with anterior traction

›Combined anterior pack for stabilization per technique descriptions

›Posterior pack precautions

›Continuous pulse oximetry

›Hypoxia risk

›Telemetry

›Dysrhythmia risk

›Airway readiness

›Aspiration risk from continued bleeding or sedation

Definitive escalation therapies

›Endoscopic management

›Endoscopic cautery when bleeding point identified

›Potential to avoid prolonged packing in selected posterior cases

›Endoscopic sphenopalatine artery ligation

›Common definitive surgical option for posterior epistaxis

›Embolization

›Interventional radiology embolization for refractory severe epistaxis

›Guideline includes embolization among complex management options

Anticoagulation and antiplatelet associated bleeding

›Medication related bleeding framework

›Shared decision making with prescribing team when feasible

›Thrombotic risk versus bleeding control

›Warfarin reversal for life threatening bleeding

›Four factor PCC dosing per institutional protocol

›Concurrent vitamin K IV per institutional protocol

›INR reassessment after PCC effect

›Dabigatran reversal for life threatening bleeding

›Idarucizumab per institutional protocol

›Factor Xa inhibitor reversal for life threatening bleeding

›Andexanet alfa when available per institutional protocol

›Four factor PCC as alternative per institutional protocol

›Antiplatelet effect mitigation

›Platelet transfusion consideration only for life threatening bleeding and active antiplatelet effect with specialist input

Adjunct pharmacologic hemostasis

›Tranexamic acid topical

›Evidence mixed across trials

›Faster cessation and reduced rebleeding reported in some RCTs

›No benefit reported in large pragmatic ED trial summary

›Practical topical approach

›TXA 500 mg in 5 mL on pledget to bleeding nostril

›Leave in place 10 to 15 minutes then reassess

›Avoid if known hypersensitivity

Evidence levels and guideline alignment

›Guideline supported first line steps

›Compression and topical vasoconstrictors

›Recommended as first line options in AAO-HNSF guideline

›Nasal packing and cautery as escalation

›Included in AAO-HNSF guideline management steps

›Evidence grading placeholders for local mapping

›ACEP Level B for topical TXA as adjunct

›Evidence heterogeneity and local protocol dependent

›Class IIa recommendation for posterior epistaxis definitive control with endoscopic arterial ligation when available

›Guideline includes ligation among complex options

09Special Populations/sp25

Pregnancy

›Pregnancy considerations

›Increased nasal mucosal vascularity and congestion

›Higher baseline epistaxis propensity

›Medication safety

›Prefer topical local therapies over systemic agents when possible

›Avoid excessive systemic vasoconstrictor exposure

›Severe bleeding escalation

›Obstetric consultation when hemodynamic instability or significant anemia

Geriatric

›Older adult considerations

›Higher anticoagulant and antiplatelet prevalence

›Lower threshold for labs and observation

›Posterior bleeds more common relative to younger patients in practice patterns

›Lower threshold for ENT involvement

›Pack related complications

›Hypoxia and delirium risk with sedation and obstruction

Pediatrics

›Pediatric considerations

›Most episodes anterior and benign

›Digital trauma and mucosal dryness common

›Foreign body suspicion

›Unilateral malodor and discharge

›Bleeding disorder screening

›Recurrent severe episodes

›Family history

›Sedation caution

›Airway protection priority in active bleeding

10Background/b24

Epidemiology

›Epidemiologic facts

›Common lifetime occurrence

›Most patients managed conservatively

›Anterior predominance

›Approximately 90 percent anterior reported in clinical summaries

›Posterior epistaxis less common and more severe

›More likely to require packing and admission

Pathophysiology

›Bleeding anatomy

›Kiesselbach plexus anterior septum source

›Common anterior site accessible to cautery

›Sphenopalatine artery branches posterior source

›Higher flow and more difficult visualization

›Mucosal dryness and inflammation

›Barrier disruption and friability

Therapeutic Considerations

›Treatment principles

›Stepwise escalation

›Compression and vasoconstrictor

›Visualization and cautery

›Packing

›Definitive ligation or embolization for refractory cases

›Posterior packing risk profile

›Hypoxia and dysrhythmias and pressure necrosis concerns

›Topical TXA uncertainty

›Conflicting RCT outcomes

11Patient Discharge Instructions/pdi21

Copy discharge instructions

›Discharge instructions

›If bleeding restarts, pinch soft part of nose continuously for 10 to 15 minutes while leaning forward

›If not controlled after two cycles, return to ED

›Avoid nose blowing for 24 to 48 hours

›Sneeze with mouth open

›Avoid heavy lifting and strenuous exercise for 48 hours

›Avoid hot showers and alcohol for 24 hours

›Saline spray or gel several times daily for moisture

›Humidifier at night if dry environment

›Thin layer of petroleum based ointment to anterior septum nightly for 3 to 5 days if dryness

›Avoid deep insertion

›Return immediately for red flags

›Bleeding that will not stop with pressure

›Large clots or heavy continuous flow

›Fainting or severe weakness

›Shortness of breath or chest pain

›Vomiting blood or black stools

›If packing in place

›Do not remove at home unless specifically instructed

›Follow up for removal within 24 to 72 hours per plan

›Return for fever, worsening pain, foul discharge, or recurrent bleeding

12References/r10

Clinical guidelines and society documents

›Guideline sources

›AAO-HNSF Clinical Practice Guideline Nosebleed Epistaxis 2020

›AAFP Epistaxis Outpatient Management 2018

Evidence based studies and reviews

›Evidence sources

›Zahed et al topical tranexamic acid versus anterior nasal packing RCT

›Hosseinialhashemi et al intranasal topical TXA randomized trial 2022

›Large ED topical TXA trial summary no benefit reported

›StatPearls Posterior Epistaxis Nasal Pack complications and monitoring

›Literature review posterior epistaxis management and balloon pack timing

›Hoag et al Epistaxis Severity Score for HHT validated tool

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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