ENT

Epistaxis

Nasal bleeding is usually anterior and responds to correct pressure, but heavy, posterior or recurrent bleeding needs structured assessment, packing and ENT escalation.

In a nutshell

Most epistaxis is anterior from Little's area and stops with correct uninterrupted pressure. Sit up, lean forward and pinch the soft nose; if bleeding persists, localise the source for cautery, pack when necessary and escalate posterior or refractory bleeding to ENT.

Classic presentation

Anterior nasal bleeding after minor trauma or dryness that usually settles with firm continuous pressure over the soft part of the nose while sitting upright and leaning forward.

Key points

Little's area on the anterior septum is the commonest bleeding site and is accessible to compression and cautery.
First aid: sit up, lean forward and pinch the soft lower nose continuously; do not tilt the head back or release pressure early.
A visible anterior point can be cauterised; if the point is not visible or cautery fails, pack and involve ENT.
Posterior bleeding is suggested by heavy flow into the throat, bilateral bleeding, no anterior point or failure of compression; it is a hospital problem.
Do not independently stop anticoagulant or antiplatelet treatment; review the indication and haemostasis plan with the responsible team.
Recurrent unilateral bleeding, obstruction, anaemia or a mass needs ENT investigation for structural disease.
Airway compromise, shock, severe ongoing blood loss or inability to control bleeding requires emergency resuscitation and escalation.

First-line investigation

ABCDE assessment followed by anterior rhinoscopy and oropharyngeal examination to identify an anterior versus posterior source; order blood tests when severity, recurrence or coagulopathy warrants them.

Management

Resuscitate and apply first aid

Use ABCDE for severe bleeding; otherwise sit upright, lean forwards and apply firm uninterrupted pressure to the soft nose.^2,4

Localise the source

Use anterior rhinoscopy and examine the oropharynx; assess posterior drainage, antithrombotics and coagulopathy risk.^2,3

Cauterise or pack

Cauterise one visible anterior point; pack when the point is not visible or bleeding persists, with appropriate monitoring and ENT review.^1,2,3

Control posterior or refractory bleeding

Persistent or posterior haemorrhage needs hospital ENT assessment for endoscopic cautery, arterial ligation or embolisation, with transfusion/reversal decisions as indicated.^2,3

Prevent recurrence

Address dryness and crusting, consider topical antiseptic treatment under NICE CKS/local formulary advice, and review contributing medicines without unilateral cessation of antithrombotic therapy.^1,4

Safety-net and investigate recurrence

Give aftercare and emergency return advice; refer recurrent unilateral bleeding, anaemia, obstruction, a mass or uncertain diagnosis to ENT.^1,4

Exam traps

Pinch the soft part of the nose, not the bony bridge.
Head tilt backwards increases swallowed blood and aspiration risk; lean forwards.
Do not cauterise both sides of the septum at the same sitting because of perforation risk.
A posterior bleed is not simply a larger anterior bleed: it often needs admission, specialist packing or intervention.
Do not stop anticoagulation or antiplatelets without a clinician-directed plan.

Illustrations

Little's area vascular anatomyDiagram of Kiesselbach's plexus on the anterior nasal septum showing the confluence of vessels that makes it the commonest bleeding site.PassFinals · original

Anterior nasal packingDiagram showing placement of an anterior nasal pack within the nasal cavity to tamponade a diffuse or posterior bleeding source.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.