Changes

October 2024 — reviewed. A literature search was conducted in September 2024 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. A recommendation was added to consider tranexamic acid for people presenting after a major haemorrhage supported by a UK guideline and expert opinion in a review article. A section was added to highlight potential differential diagnoses. There have been minor structural changes to the topic updating the basis for recommendation sections in line with the updated literature.

Update

Goals

To support primary healthcare professionals to:

• Offer appropriate first aid advice to people with epistaxis.
• Manage acute epistaxis that has not stopped after adequate pressure has been applied to the soft lower part of the nose.
• Appropriately admit or refer people with acute epistaxis to secondary care for management.
• Appropriately refer people with recurrent epistaxis to secondary care for management.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Epistaxis is bleeding from the nose.
  • This includes bleeding from the nostril, nasal cavity, or nasopharynx and may be classified as either anterior or posterior.
  • In most cases (80–95%), epistaxis originates from Little's area on the anterior nasal septum, which contains the Kiesselbach plexus of vessels.
  • Less commonly, epistaxis originates from branches of the sphenopalatine artery in the posterior nasal cavity.
    • Posterior nosebleeds usually occur in older people, are more profuse, result in bleeding from both nostrils, and the bleeding site cannot be identified on examination.

[Seikaly, 2021; BMJ Best Practice, 2023; Gottlieb, 2023]

What causes it?

• Blood vessels inside the nose are superficial and easily damaged, particularly in Little's area, where numerous arteries anastomose to form Kiesselbach’s plexus under the thin overlying nasal mucosa. Most epistaxis is self-limiting and harmless, and the cause of damage to the blood vessels is not identified.
• Local causes of damage to the blood vessels may include:
  • Trauma — injury from nose-picking, nasal fractures, septal ulcers or perforations, foreign body, or blunt trauma (such as falls in children).
  • Inflammation — infection (for example, chronic sinusitis), allergic rhinosinusitis, or nasal polyps.
  • Topical drugs — for example, cocaine, decongestants, or corticosteroids.
  • Vascular causes — for example, hereditary haemorrhagic telangiectasia or granulomatosis with polyangiitis (previously known as Wegener's granulomatosis).
  • Post-operative bleeding — for example, following ear, nose, and throat surgery; maxillofacial surgery; or ophthalmic surgery.
  • Tumours — benign (such as angiofibroma — a rare nasopharyngeal tumour largely affecting adolescent males) or malignant (such as squamous cell carcinoma — more likely in older people) 
  • Nasal oxygen therapy — causes drying of the nasal mucosa and possible direct mucosal trauma via prongs of cannulae.
• More general causes of damage may include:
  • Atherosclerosis.
  • Increased venous pressure from mitral stenosis.
  • Haematological conditions affecting clotting — such as thrombocytopenia, platelet dysfunction, Von Willebrand disease, leukaemia, and haemophilia.
  • Environmental factors — temperature, humidity, altitude, exposure to irritants such as dust, certain chemicals, and cigarette smoke.
  • Systemic drugs — including anticoagulants and antiplatelet drugs (for example, aspirin and clopidogrel).
  • Excessive alcohol consumption.
• Hypertension is common in people who present with epistaxis; however, there is insufficient evidence to establish a causal relationship:
  • The reported prevalence of hypertension in people with epistaxis is up to 64%.
  • A meta-analysis of ten studies concluded that people with hypertension had a statistically-significant up to 50% increased risk of epistaxis compared to people without hypertension.
  • However, the authors concluded that the presence of high arterial blood pressure during acute epistaxis cannot prove causation, partly because of the potential confounding effects of stress caused by the bleeding episode [Min, 2017].

[Kucik, 2005]  [Schlosser, 2009; Kasperek, 2013; McGarry, 2013; Patel, 2013; Tunkel, 2020; Yan, 2021; BMJ Best Practice, 2023]

How common is it?

• Epistaxis is common:
  • It is estimated that up to 60% of the population will experience an episode of epistaxis, but only 6% will seek medical attention, and hospitalization is rare (0.16%) [Tunkel, 2020].
• The incidence of epistaxis changes with age:
  • Epistaxis is common in children of 2 years of age and older. Spontaneous epistaxis in children younger than 2 years of age is rare and may be associated with injury or an underlying coagulopathy [Patel, 2014; Siddiq, 2015].
  • Peaks in incidence occur in children younger than 10 years of age, and in adults 70 to 79 years of age [Tunkel, 2020].
• Posterior epistaxis accounts for approximately 5 to 10% of epistaxis episodes, is more common in older people than younger people and is often more difficult to manage [Tunkel, 2020].
• Recurrent epistaxis is estimated to occur in around 9% of affected children, but becomes less common in people aged 15 years of age and older [McGarry, 2013; Yan, 2021].

What is the prognosis?

• Most episodes of epistaxis are self-limiting and do not require medical treatment.
• Mortality from epistaxis is rare and is usually associated with complications such as hypovolaemia (secondary to severe bleeding) or toxic shock syndrome (from prolonged nasal packing), and in people with comorbidities such as coronary artery disease, severe hypertension, a clotting disorder, or significant anaemia.

[Kucik, 2005; Schlosser, 2009; BMJ Best Practice, 2023]

What are the complications?

• Rare complications of nasal bleeding include [Kucik, 2005; Kasperek, 2013; BMJ Best Practice, 2023]:
  • Hypovolaemia.
  • Anaemia.
  • Aspiration from dislodgement or malpositioning (especially with posterior epistaxis).
  • Death.
• Recalcitrant epistaxis — profuse and persistent bleeding which responds poorly to standard management approaches, including pressure and nasal packing. Most likely to occur due to an underlying coagulopathy or in those with abnormal blood vessels, such as hereditary haemorrhagic telangiectasia [BMJ Best Practice, 2023] .
• Recurrent epistaxis — many people experience recurrent minor bleeding episodes, and this appears to be most common in children [Tunkel, 2020; BMJ Best Practice, 2023].
  • People who use anticoagulant or antiplatelet medications are at increased risk of experiencing recurrent epistaxis [Seikaly, 2021].
  • Frequent episodes of epistaxis and abundant bleeding have been associated with decreased psychosocial quality of life measures [Tunkel, 2020].
• Potential complications of nasal packing treatment may include [Tunkel, 2020; Seikaly, 2021; BMJ Best Practice, 2023]:
  • Sinusitis.
  • Septal haematoma or abscess (due to traumatic packing).
  • Pressure necrosis (secondary to excessively tight packing).
  • Toxic shock syndrome (from prolonged packing).
  • Apnoeic episodes or hypoxia (associated with bilateral anterior or posterior nasal packs).
• A possible complication of nasal cautery treatment is septal perforation due to a direct effect of the silver nitrate stick— this is a risk particularly if cautery is attempted at the same location on both sides of the septum and should therefore be avoided [Kasperek, 2013; BMJ Best Practice, 2023].

How should I assess a person with acute epistaxis?

• Follow local guidelines for the use of personal protective equipment, such as wearing a non–water-permeable gown, protective eyewear, gloves, and a face mask.
• Be aware that complications are most likely if bleeding is severe and/or the person is older, unwell, or frail. Use clinical judgement to determine if it is necessary to assess the person's airway, breathing, pulse, and blood pressure. Also, be aware of potential symptoms of haemodynamic compromise, including lightheadedness, tachycardia, syncope, and pallor.
• If the person exhibits signs and symptoms of compromise, arrange immediate transfer to Accident and Emergency. Use first aid measures while awaiting hospital transfer.
• If the person is not haemodynamically compromised, ask:
  • When the bleeding started, and from which nostril.
  • How much blood has been lost. This is difficult to estimate, but establish whether the bleeding is light or heavy. If bleeding is heavy, ask the person how many cups (each equates to approximately 250 mL) they think they have lost. Significant blood loss may necessitate admission to hospital.
  • Whether a temporary pack (such as cotton wool) has been used before seeking medical help. These are not always easily visible, and formal nasal packing can push foreign bodies further into the nose.
  • About any previous episodes of epistaxis and how they were treated.
• Examine both nasal passages (ideally with adequate lighting and a nasal speculum).
  • Where clinically appropriate, ask the person to gently blow the nose to clear old blood and large clots.
  • Look for a bleeding point. It will look like a small red dot (less than 1 mm) and may not be actively bleeding (note: active bleeding may prevent accurate assessment).
• Suspect a posterior bleed if bleeding is profuse, from both nostrils, the bleeding site cannot be identified on speculum examination, and/or if bleeding first started down the throat (however, be aware that if bleeding commenced while the person was supine, blood is likely to have drained to the throat regardless of bleeding site).
• Consider a differential diagnosis, particularly where atypical features are present.
• Determine if there may be an underlying cause, particularly in children younger than 2 years of age as epistaxis is unusual in this age group. Ask about/consider:
  • A history of surgery or recent trauma (consider the possibility of non-accidental injury).
    • Be aware that epistaxis in children under the age of two years has been associated with intentional or non-intentional asphyxia. Features associated with asphyxiation for those with epistaxis include pallor, cyanosis, respiratory difficulty, altered heart rate, reduced consciousness, and a possible history of Apparent Life-Threatening Events (ALTE). However, some children presenting with epistaxis due to asphyxia have no other overt symptoms. For further information, see the CKS topic on Child maltreatment - recognition and management.
  • Symptoms suggestive of a tumour including nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy (for example, facial numbness or double vision). Be aware that nasal, sinus, and nasopharyngeal cancers are most common in people older than 50 years of age, in those with occupational exposure to wood dust or chemicals, and (for nasopharyngeal cancer) in people of South Chinese or North African family origin.
  • Other nasal symptoms that may be suggestive of allergic rhinitis or bacterial rhinosinusitis, nasal polyps, or nasal foreign body. For further information, see the CKS topics on Sinusitis and Allergic rhinitis.
  • Current medications (for example, aspirin, warfarin, or nasally-administered drugs).
    • If the person is taking warfarin, check the INR (international normalized ratio) or admit to hospital if bleeding is difficult to control.
  • Conditions predisposing to bleeding (such as haemophilia or leukaemia). For further information, please see the CKS topic on Haematological cancers - recognition and referral.
  • Symptoms or family history of bleeding disorders (such as hereditary haemorrhagic telangiectasia — suggested by red or purple spots on the fingertip pads, lips, lining of the nose, gut and occasionally the ears and face).
  • Environmental factors (such as cold, dry weather, low humidity).
• Laboratory investigations are not usually required unless an underlying cause is suspected:
  • A full blood count should be considered if bleeding has been heavy or recurrent, or anaemia is suspected.
  • Coagulation studies should be requested only if a clotting disorder is suspected or an INR is required.
  • The elderly are at higher risk of complications associated with bleeding, use clinical judgment to determine if laboratory investigations may be appropriate for older people with epistaxis.

What else could it be?

• Nosebleeds may occasionally drain posteriorly resulting in atypical presentations that mimic features of:
  • Haemoptysis — likely to present with additional respiratory signs and symptoms, such as cough, dyspnoea, wheeze, or abnormal breath sounds on chest auscultation.
  • Haematemesis — likely to present with additional gastrointestinal signs and symptoms, such as abdominal pain, melaena, or history of peptic ulcer disease.

Scenario: Acute epistaxis

From age 1 month onwards.

Scenario: Recurrent epistaxis

From age 1 month onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of epistaxis.

Search dates

July 2019 - September 2024

Key search terms

The terms listed below are the core search terms that were used for EBSCOhost MEDLINE (searched 26th July 2019). These were combined with filters to identify guidelines, systematic reviews and primary care relevant literature in EBSCOhost MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S7    S1 OR S2 OR S3 OR S4 OR S5 OR S6 
S6    AB nosebleed* OR TI nosebleed* 
S5    AB ( (nasal* n2 haemorrhag*) or (nasal* n2 hemorrhag*) ) OR TI ( (nasal* n2 haemorrhag*) or (nasal* n2 hemorrhag*) ) 
S4    AB nasal* n2 bleed* OR TI nasal* n2 bleed* 
S3    AB nose* n2 bleed* OR TI nose* n2 bleed* 
S2    AB epistaxis OR TI epistaxis 
S1    (MH "Epistaxis") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
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• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
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• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
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Evidence exclusion criteria

Our policy

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Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
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  • Current interventions
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  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

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Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

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Competing interests declared for this topic:

None.