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For greater detail see: Nose Bleed Management and Epistaxis Control

Return to: Otolaryngology Medical Student Clerkship Objectives and Exam Topics (University of Iowa)

See also: Nosebleed - Epistaxis: Anterior Ethmoid Artery Ligation (External - Open Approach)

Nosebleed - Epistaxis: Sphenopalatine Artery (SPA) Ligation - Endoscopic


  • Epistaxis, or nosebleeds: common problem that most people have dealt with at some point in their life
  • Though most people don't seek medical attention, severe epistaxis can have complications
  • More common in winter months
  • Caused by trauma or irritation
    • Children- digital trauma or other foreign object insertion 
    • Mucosal dryness
    • Chronic intranasal drug use (cocaine, steroids)
    • Neoplasm
    • Anticoagulation (warfarin therapy)
    • Nasal cannula

By TonyTheTiger (Own work) [CC BY-SA 3.0 ( or GFDL (], via Wikimedia Commons


  • Anterior bleeds (90%)
  • Posterior bleeds (10%)
    • Woodruff's plexus:
      • Confluence of vessels posterior to the middle turbinate 
      • Formed from contributions of the:
        • Sphenopalatine (from maxillary artery)
        • Ascending pharyngeal (from external carotid)
        • Internal maxillary veins


  • Severity of bleed
    • Ensure airway is secured and breathing is adequate
    • Evaluate hemodynamics if a large volume of blood loss is suspected
  • Underlying causes 
    • Local
    • Systemic
      • Chronic disease conditions
        • Hypertension
        • Cancer
        • Hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome) 
      • Medications
      • Coagulopathy
  • Anterior vs Posterior bleed
    • Important for management
    • Treatment with a vasoconstrictive and anesthetic agent can aid in visualization
    • Nasal endoscope can be helpful
  • Posterior bleed in an adolescent male
    • Consider nasopharyngeal angiofibroma
    • Otolaryngology consult is required for possible surgical intervention


  • Anterior bleeds
    • Direct pressure for 10-15 minutes will often resolve mild cases
    • Sit patient forward so blood does not drain into nasopharynx 
      • Ingested blood can cause nausea and vomiting
      • Ingestion of blood prevents accurate estimation of blood loss as it cannot be visualized 
    • Topical vascoconstriction- pledgets soaked with oxymetazoline may be used
    • Cautery- silver nitrate sticks
    • Nasal packing
      • 3-5 days 
      • Types
        • Nasal tampons (eg. Rhino Rocket) 
        • Gauze
        • Balloon catheters
      • Some hospitalize if bilateral packing is used due to concern for airway obstruction 
      • Prophylactic antibiotics can be considered due to concern for development of toxic shock syndrome (TSS) 
  • Posterior bleeds
    • More difficult to manage 
    • Hospitalization is recommended for most posterior bleeds as they are more difficult to control 
    • Nasal packing
      • Balloon catheter
      • Cotton packing
      • Consider antibiotics
  • Surgical Management
    • Arterial ligation
    • Endoscopic cautery
    • Angiographic embolization by Interventional Radiology 
    • Tumor removal if present (eg. angiofibroma) 


American Academy of Otolaryngology–Head and Neck Surgery Foundation. (2011). Primary Care Otolaryngology, Third Edition. Retrieved from: 

Alter, H. Approach to the adult with epistaxis. In: UpToDate, Grayzel, J. (Ed), UpToDate, Waltham, MA. (Accessed on June 10, 2015.)