Epistaxis
A board-focused walkthrough of epistaxis: anterior (Kiesselbach's plexus/Little's area) versus posterior (sphenopalatine artery) bleeds, the stepwise next-best-step management ladder, and classic vignettes including the anticoagulated elder and the adolescent male with JNA.
Overview: it's all about anterior vs posterior
Epistaxis (nosebleed) is usually benign, but it is a board favorite because management is a stepwise next-best-step ladder and because the exam wants you to separate anterior from posterior bleeds. About 90% are anterior, arising from Kiesselbach's plexus in Little's area on the anterior nasal septum — an anastomosis fed by both the internal carotid (anterior ethmoidal artery) and external carotid (sphenopalatine, greater palatine, superior labial) systems. These are typically self-limited and provoked by digital trauma (nose-picking), dry/cold air, and mucosal irritation.
Posterior bleeds (~10%) arise from the sphenopalatine artery (a branch of the maxillary artery) and are more dangerous: they favor older, often hypertensive or anticoagulated patients, bleed briskly into the oropharynx, and threaten the airway. Always begin with ABCs — but most questions really test where the bleed is and what you do next.
- Anterior (~90%): Kiesselbach's plexus / Little's area on anterior septum; usually unilateral, visible, self-limited
- Posterior (~10%): sphenopalatine artery; bleeds into the throat / both nares; older, HTN, anticoagulated; airway risk
- Risk factors: nose-picking, dry air, septal deviation, cocaine/intranasal drugs, NSAIDs/aspirin, warfarin/DOACs, alcohol, coagulopathy (thrombocytopenia, vWD, hemophilia)
- HHT (Osler–Weber–Rendu): recurrent epistaxis + mucocutaneous telangiectasias + AVMs + autosomal dominant family history
- Adolescent male + recurrent unilateral epistaxis + nasal obstruction → juvenile nasopharyngeal angiofibroma; do NOT biopsy (highly vascular) — image with contrast CT/MRI
- Child, unilateral bleed + foul-smelling discharge → suspect nasal foreign body
- Persistent unilateral epistaxis in an adult → rule out neoplasm
Anterior vs posterior epistaxis
| Feature | Anterior | Posterior |
|---|---|---|
| Frequency | ~90% | ~10% |
| Source vessel | Kiesselbach's plexus (Little's area) | Sphenopalatine artery |
| Typical patient | Children, young adults | Older, HTN / anticoagulated |
| Bleeding pattern | One nostril, visible | Both nostrils / down the throat |
| Airway / aspiration risk | Low | High |
| First-line control | Pressure → cautery → anterior packing | Posterior packing / balloon + admit |
| Refractory therapy | Repeat packing | SPA ligation or embolization |
- 1. First step — direct pressure: patient leans forward (prevents aspiration/swallowing blood) and pinches the soft cartilaginous part of the nose firmly for 10–15 min; add a topical vasoconstrictor (oxymetazoline)
- 2. Anterior source seen, still bleeding: chemical cautery with silver nitrate (or electrocautery). Do NOT cauterize both sides of the septum → risk of septal perforation
- 3. Cautery fails / source not visualized: anterior nasal packing (nasal tampon, balloon, or ribbon gauze)
- 4. Posterior bleed: posterior packing / balloon catheter and admit + monitor (airway, hypoxia, bradycardia)
- 5. Refractory: endoscopic sphenopalatine artery ligation or arterial embolization
- Throughout: correct coagulopathy, address anticoagulation, and control BP. Consider prophylactic antibiotics with prolonged packing (toxic shock syndrome concern)
Vignette: A 68-year-old man on warfarin for atrial fibrillation has brisk bleeding from both nostrils with blood trickling down his throat. BP is 190/100. Anterior rhinoscopy shows no anterior source, and firm anterior pressure for 15 minutes fails to stop the bleeding.
Diagnosis: Posterior epistaxis (sphenopalatine artery) — favored by age, hypertension, and anticoagulation.
Next best step: Place a posterior pack / balloon catheter and admit for monitoring (airway and cardiopulmonary risk). Concurrently control blood pressure, check INR, and hold/reverse anticoagulation as indicated. If bleeding persists → sphenopalatine artery ligation or embolization.
Vignette: A 15-year-old boy has months of recurrent, unilateral epistaxis with progressive nasal obstruction. Exam reveals a reddish-blue mass in the posterior nasal cavity.
Diagnosis: Juvenile nasopharyngeal angiofibroma (JNA) — a benign but locally aggressive, highly vascular tumor of adolescent males.
Next best step: Obtain contrast-enhanced CT or MRI (may show anterior bowing of the posterior maxillary wall — Holman–Miller sign). Do NOT biopsy in clinic — risk of massive hemorrhage. Definitive treatment is surgical resection, often after preoperative embolization.
"LEGS" — the arteries anastomosing at Kiesselbach's plexus (Little's area) behind most anterior nosebleeds:
- L — septal branch of the superior Labial artery (from the facial artery)
- E — anterior Ethmoidal artery (from ophthalmic → internal carotid)
- G — Greater palatine artery (from the maxillary artery)
- S — Sphenopalatine artery (from the maxillary artery)
Hook: because the anterior ethmoidal feeds this plexus from the internal carotid system while the others come from the external carotid, this one small area draws on both carotid circulations — part of why brisk bleeds here can be stubborn to control.
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