Epistaxis Management Protocols
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Direct answer
Nine of ten nose bleeds arise from Little's area on the anterior septum, where Kiesselbach's plexus — the confluence of the anterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries — sits within reach of a fingertip and a cautery stick. Management climbs a fixed ladder: first aid by sitting the patient forward and pinching the soft cartilaginous nose for ten minutes, then cautery of a visible anterior point, then anterior packing, then posterior packing with a balloon or post-nasal pack, and finally, for refractory bleeding, endoscopic sphenopalatine artery ligation or clipping (the artery of epistaxis), anterior ethmoidal artery ligation for high bleeds, or, in selected centres, embolisation. Every step is preceded by the same two questions: is the patient haemodynamically stable, and is there a correctable systemic cause — anticoagulants, antiplatelets, hypertension, or a bleeding disorder?
What you must remember
- Little's area (Kiesselbach's plexus) on the anteroinferior septum causes about 90 per cent of bleeds; Woodruff's plexus, a venous plexus behind the inferior turbinate at the nasopharyngeal end, is the source of posterior bleeds in the elderly and hypertensive.
- The sphenopalatine artery — the "artery of epistaxis" — enters the nose through the sphenopalatine foramen just posterior to the middle turbinate and supplies most of the nasal cavity; it is the target of endoscopic ligation.
- First aid done correctly stops many bleeds: patient sitting forward (not lying back, which swallows blood), pinch the alar cartilage firmly for a full 10 minutes, ice and mouth breathing, and spit blood out rather than swallow it.
- Cauterise only a visible bleeding point — with silver nitrate or electrocautery — and avoid opposing septal surfaces (risk of septal perforation); bilateral cautery of the septum is a recognised cause of perforation.
- Anterior packing options: merocel sponge, ribbon gauze with antiseptic paste, or an inflatable anterior balloon; packs stay roughly 24–48 hours with antibiotic cover, and posterior packs (Foley catheter, Bellocq pack, dedicated balloons) demand admission with airway monitoring.
- Refractory or recurrent severe epistaxis: endoscopic sphenopalatine artery ligation or clipping (first-line surgical), anterior ethmoidal artery ligation for superior/superior-septal bleeding, and selective embolisation of the internal maxillary artery where surgery is unfit — each with its risks (stroke, tissue necrosis for embolisation).
- Systemic screen in every severe case: blood pressure, full blood count, coagulation profile, platelet function if on antiplatelets; ask about nasal sprays, intranasal drug use and family history (Osler-Weber-Rendu hereditary haemorrhagic telangiectasia).
- Specific paediatric-adolescent rule: recurrent significant epistaxis in an adolescent boy is juvenile angiofibroma until imaging excludes it — never biopsy such a posterior nasal mass.
Walking the protocol, rung by rung
A 58-year-old hypertensive man on aspirin arrives with active right-sided bleeding. Rung zero: assess — vitals, IV access, bloods, resuscitate if needed; sit him forward and have him pinch the cartilaginous nose for ten uninterrupted minutes while you prepare. Rung one: after the pinch, suction and inspect the anterior septum under a headlight with a nasal speculum. A visible vessel on Little's area gets silver nitrate or bipolar cautery in a ring around, then on, the point, followed by a topical antiseptic ointment and 24 hours of precautions — no nose blowing, no hot drinks, no straining.
Rung two: if the point is invisible or bleeding continues, insert a merocel pack soaked in antibiotic ointment along the floor of the nose, hydrate it, and admit or observe. Rung three: if both nares flood and blood runs down the pharynx, suspect a posterior source — place a Foley catheter with the balloon inflated in the nasopharynx or a dedicated posterior balloon plus an anterior pack; these patients are admitted with oxygen saturation and airway watch, packs for 24–48 hours, and prophylactic antibiotics per local policy. Control the blood pressure in parallel and review the aspirin with the physician.
Rung four: bleeding that recurs on pack removal, or needs repeated admission, goes to theatre. Endoscopic sphenopalatine artery ligation — elevating a flap behind the posterior middle turbinate, clipping or diathermising the artery as it exits the foramen, often with multiple branches — controls the great majority of severe posterior bleeds. High anterior bleeds from the ethmoidal territory get anterior ethmoidal artery ligation via a medial orbitofrontal approach. Embolisation is reserved for the unfit or bleeding-disorder patient. Alongside the ladder, chase the cause: a teleangiectasia-spotted tongue and lips in a patient with a family history of bleeds flags hereditary haemorrhagic telangiectasia — a lifetime diagnosis with laser ablation and systemic options, not a one-time packing problem.
How the exam frames it
Question writers test the anatomy first — name the four arteries of Kiesselbach's plexus, name the artery of epistaxis, name the site of posterior bleeds. Then the sequence: first-line manoeuvre (pinch the ala for ten minutes), then cautery, then anterior pack, then posterior pack, then surgery — and the specific vessel ligated for refractory posterior bleeding (sphenopalatine). The traps: septal perforation after bilateral cautery; the child with recurrent bleeds and a nasal mass (do not biopsy — angiofibroma); and the coagulopathic patient where the answer is correction plus gentle packing, not repeated cautery. A viva favourite connects HHT — autosomal dominant, telangiectases of lips, tongue, fingers — with recurrent familial epistaxis.
Frequently asked questions
What is Kiesselbach's plexus and which arteries form it?
A vascular anastomosis on the anteroinferior nasal septum (Little's area) formed by the anterior ethmoidal, sphenopalatine, greater palatine and superior labial arteries — the source of about 90 per cent of epistaxis.
What is the correct first-aid for epistaxis?
Sit the patient leaning forward, pinch the soft cartilaginous part of the nose continuously for about 10 minutes, apply ice, and instruct spitting rather than swallowing blood.
How is refractory posterior epistaxis managed surgically?
Endoscopic sphenopalatine artery ligation or clipping is first line; anterior ethmoidal artery ligation addresses high anterior bleeding, and selective arterial embolisation is an alternative in unfit patients.
Why should both sides of the septum not be cauterised?
Opposing chemical or electrical injury devascularises the intervening cartilage and predisposes to septal perforation.
Which systemic conditions must be excluded in severe epistaxis?
Hypertension, anticoagulant or antiplatelet therapy, coagulopathies and thrombocytopenia, and hereditary haemorrhagic telangiectasia; adolescents with recurrent bleeds need imaging to exclude juvenile angiofibroma.