Epistaxis and Its Causes
On this page
Direct answer
Epistaxis, or bleeding from the nose, arises most often from Little's area on the anteroinferior nasal septum, where Kiesselbach's plexus of vessels anastomoses; posterior bleeds from Woodruff's plexus near the spenopalatine foramen are less common but more dangerous. Management follows a graded ladder — resuscitation and first-aid compression, cautery of the visible anterior point, anterior then posterior packing, and endoscopic or open arterial ligation for refractory bleeding, alongside treatment of the underlying cause.
What you must remember
- Anterior bleeds: the vast majority arise from Little's area, formed by anastomosis of the anterior ethmoidal, sphenopalatine, greater palatine and septal branches of the superior labial arteries; visible on speculum examination and easily cauterised.
- Posterior bleeds: Woodruff's venous plexus below the posterior end of the middle turbinate; suspected when both nostrils and the pharynx show blood, and in elderly hypertensive patients.
- Local causes: trauma and nose picking, foreign body (children), deviated septum, dry rhinitis, granulomatous disease and tumours such as angiofibroma in adolescent boys or carcinomas in adults.
- Systemic causes: hypertension, anticoagulant and antiplatelet therapy, coagulation disorders, leukaemia and thrombocytopenia, liver disease, and hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease), which is autosomal dominant.
- First line: sit the patient up leaning forward, pinch the alae against the septum continuously for about ten minutes, apply ice and encourage mouth breathing, while checking pulse, blood pressure and blood counts.
- Definitive steps: chemical cautery with silver nitrate or electrocautery for visible points; anterior packing with ribbon gauze or merocel; posterior balloon or pack for posterior bleeds under monitoring; then endoscopic sphenopalatine artery ligation, anterior ethmoidal artery ligation, or embolisation if bleeding continues.
- Do not forget: control blood pressure, correct coagulopathy and reverse anticoagulation where possible, and remove the pack with lubrication and re-examine the nose for the source.
Common confusion
Students remember the name Little's area but cannot list its contributing arteries — a standard viva question. Also distinguish the child with recurrent mild anterior bleeds and nose picking from the adult with unilateral blood-stained discharge and obstruction, in whom a tumour must be excluded by endoscopy and imaging; and remember that a posterior pack is not a bigger anterior pack but a distinct, monitored intervention.
Exam-focused takeaway
For theory, answer with the classification of causes, the arterial anastomosis of Little's area, and the stepwise management ladder, adding the systemic work-up. In viva, expect the four arteries of Kiesselbach's plexus, the danger of posterior bleeds, and what to do when packing fails. In the casualty posting, practise the calm sequence — position, pressure, examination, cautery, pack — because epistaxis is one emergency where a medical student can genuinely take charge of the first steps.
Frequently asked questions
What is the commonest site of epistaxis?
Little's area on the anteroinferior part of the nasal septum, over Kiesselbach's plexus, responsible for most anterior bleeds.
Which arteries form Kiesselbach's plexus?
The anterior ethmoidal and sphenopalatine, greater palatine and septal branch of the superior labial artery, anastomosing on the septum.
How is a posterior bleed recognised?
Bleeding from both nostrils with blood trickling into the pharynx, often in an older hypertensive patient, with the source invisible on anterior speculum examination.
What is done when cautery and packing fail?
Endoscopic sphenopalatine artery cautery or ligation, anterior ethmoidal artery ligation for high bleeds, or selective arterial embolisation in suitable centres.
What is hereditary haemorrhagic telangiectasia?
An autosomal dominant disorder with telangiectatic vessels of the nasal mucosa and elsewhere, causing recurrent bleeds; also called Osler-Weber-Rendu disease.
Why is blood pressure control important in epistaxis?
Uncontrolled hypertension both precipitates and perpetuates bleeding, and epistaxis may be the first clue to it; control stabilises the patient alongside local measures.