Management of Epistaxis

  • Kasım DurmuşEmail author
  • Emine Elif Altuntaş
  • Mario Milkov


Epistaxis is a common phenomenon in the emergency departments. Each year, nearly 5–10% of the public experience an active nasal bleeding. Among acute otorhinolaryngologic emergency disorders, epistaxis is the most common one and affects persons of all ages and both sexes. Its incidence is higher in males when compared to females. Most episodes are uncomplicated while 6% require medical attention. Epistaxis has a bimodal distribution with the frequency of occurrence peaking twice at the ages of 2–10 and 50–80. About 30% of children up to 5 years old have had at least one epistaxis. Its incidence is very low in babies and decreases after puberty. In autumn and winter, the incidence of epistaxis increases due to upper respiratory tract infections, overheating of closed areas, and lack of moisture. Epistaxis, which can be a severe or even fatal condition, refers to bleeding of nasal mucosa and is associated with significant morbidity and occasional mortality. Based on the primary bleeding site, epistaxis is defined as anterior or posterior. Typically, the origin of bleeding is the Kiesselbach’s plexus which is an anatomic network of vessels on the anterior portion of the nasal septum. Blood vessels within the nasal mucosa are superficial and therefore unprotected. In this chapter, management of epistaxis is discussed in all aspects.


Epistaxis Management Emergency Frequency Nasal 


  1. 1.
    Pope LE, Hobbs CG. Epistaxis: an update on current management. Postgrad Med J. 2005;81(955):309–14.PubMedPubMedCentralGoogle Scholar
  2. 2.
    Zahed R, Moharamzadeh P, Alizadeharasi S, Ghasemi A, Saeedi M. A new and rapid method for epistaxis treatment using injectable form of tranexamic acid topically: a randomized controlled trial. Am J Emerg Med. 2013;31(9):1389–92. Epub 2013 Jul 30CrossRefPubMedGoogle Scholar
  3. 3.
    Duncan IC, Fourie PA, le Grange CE, van der Walt HA. Endovascular treatment of intractable epistaxis—results of a 4-year local audit. S Afr Med J. 2004;94(5):373–37.PubMedGoogle Scholar
  4. 4.
    Bertrand B, Eloy P, Rombaux P, Lamarque C, Watelet JB, Collet S. Guidelines to the management of epistaxis. B-ENT. 2005;Suppl 1:27–41. quiz 42-3PubMedGoogle Scholar
  5. 5.
    Gifford TO, Orlandi RR. Epistaxis. Otolaryngol Clin N Am. 2008;41(3):525–36.Google Scholar
  6. 6.
    Pallin DJ, Chng YM, McKay MP, et al. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46:77–81.PubMedGoogle Scholar
  7. 7.
    Sowerby LJ, DeSerres JJ, Rudmik L, Wright ED. Role of season, temperature and humidity on the incidence of epistaxis in Alberta, Canada. J Otolaryngol Head Neck Surg. 2014;43:10. Scholar
  8. 8.
    Eccles R. An explanation for the seasonality of acute upper respiratory tract viral infections. Acta Otolaryngol. 2002;122(2):183–91. Scholar
  9. 9.
    Rundgren M, Engstrom M. A thromboelastometric evaluation of the effects of hypothermia on the coagulation system. Anesth Analg. 2008;107(5):1465–8. Scholar
  10. 10.
    Kodiya AM, Labaran AS, Musa E, Mohammed GM, Ahmad BM. Epistaxis in Kaduna, Nigeria: a review of 101 cases. Afr Health Sci. 2012;12(4):479–82.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Abdelkader M, Leong SC, White PS. Endoscopic control of the sphenopalatine artery for epistaxis: long-term results. J Laryngol Otol. 2007;121(8):759–62.PubMedGoogle Scholar
  12. 12.
    Faistauer M, Faistauer A, Grossi RS, Roithmann R. Clinical outcome of patients with epistaxis treated with nasal packing after hospital discharge. Braz J Otorhinolaryngol. 2009;75(6):857–65.PubMedGoogle Scholar
  13. 13.
    Meric TA, Korkut AY, Kahya V, Gedikli O. Prospective, randomized, controlled clinical trial of Ankaferd Blood Stopper in patients with acute anterior epistaxis. Eur Arch Otorhinolaryngol. 2010;267(9):1377–81.Google Scholar
  14. 14.
    Nikolaou G, Holzmann D, Soyka MB. Discomfort and costs in epistaxis treatment. Eur Arch Otorhinolaryngol. 2013;270(8):2239–44. Epub 2013 Jan 5CrossRefPubMedGoogle Scholar
  15. 15.
    Young TK, Hall R. The occasional management of epistaxis. Can J Rural Med. 2010;15(2):70–4.PubMedGoogle Scholar
  16. 16.
    Watkinson J. Epistaxis. In: Kerr AG, editor. Scott-Brown’s Otolaryngology, Rhinology, vol. 4. Oxford: Butterworth-Heinemann; 1997. p. 1–19.Google Scholar
  17. 17.
    Joice P, Ross P, Robertson G, White P. The effect of hand dominance on recurrent idiopathic paediatric epistaxis. Clin Otolaryngol. 2008;33(6):570–4. Scholar
  18. 18.
    Sandoval C, Dong S, Visintainer P, Ozkaynak MF, Jayabose S. Clinical and laboratory features of 178 children with recurrent epistaxis. J Pediatr Hematol Oncol. 2002;24:47–9.PubMedGoogle Scholar
  19. 19.
    Syed I, Sunkaraneni VS. Evidence-based management of epistaxis in hereditary haemorrhagic telangiectasia. J Laryngol Otol. 2015;129(5):410–5. Epub 2015 Mar 4.CrossRefPubMedGoogle Scholar
  20. 20.
    Sarhan NA, Algamal AM. Relationship between epistaxis and hypertension: A cause and effect or coincidence? J Saudi Heart Assoc. 2015;27(2):79–84. Scholar
  21. 21.
    Shiny Sherlie V, Varghese A. ENT changes of pregnancy and its management. Indian J Otolaryngol Head Neck Surg. 2014;66(Suppl 1):6–9. Scholar
  22. 22.
    Parajuli R. Evaluation of Etiology and Treatment Methods for Epistaxis: A Review at a Tertiary Care Hospital in Central Nepal. Int J Otolaryngol. 2015;2015:283854. Epub 2015 Aug 9CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Hussain G, Iqbal M, Shah SA, Said M, Sanaullah KSA, Iqbal M, Zaman J. Evaluation of aetiology and efficacy of management protocol of epistaxis. J Ayub Med Coll Abbottabad. 2006;18(4):63–6.PubMedGoogle Scholar
  24. 24.
    Tanner R, Harney MS. The initial management of epistaxis. Ir Med J. 2015;108(4):123–4.PubMedGoogle Scholar
  25. 25.
    Ecevit MC, Erdağ TK, Uçar S, Demiryoğuran NS, Ikiz AO, Karcıoğlu O, Sütay S. Epistaxis management: is medical intervention required for inactive epistaxis? Kulak Burun Bogaz Ihtis Derg. 2014;24(4):211–6. Scholar
  26. 26.
    Sparacino LL. Epistaxis management: what’s new and what’s noteworthy. Lippincotts Prim Care Pract. 2000;4(5):498–507.PubMedGoogle Scholar
  27. 27.
    Zhang J, Qiu R, Wei C. Long-term efficacy of Nd:YAG laser photocoagulation vs. liquid paraffin plus antiseptic cream in the treatment of recurrent epistaxis. Eur Arch Otorhinolaryngol. 2015;272(12):3721–5.PubMedGoogle Scholar
  28. 28.
    SCL L, Roe RJ, Karkanevatous A. No frills management of epistaxis. Emerg Med J. 2005;22:470–2.Google Scholar
  29. 29.
    Alter H. Approach to the adult with epistaxis. Accessed 29 Dec 2008.
  30. 30.
    Toner JG, Walby AP. Comparison of electro and chemical cautery in the treatment of anterior epistaxis. J Laryngol Otol. 1990;104(8):617–8.PubMedGoogle Scholar
  31. 31.
    Siddiq S, Grainger J. Fifteen-minute consultation: investigation and management of childhood epistaxis. Arch Dis Child Educ Pract Ed. 2015;100(1):2–5. Scholar
  32. 32.
    Thaha MA, Nilssen EL, Holland S, Love G, White PS. Routine coagulation screening in the management of emergency admission for epistaxis is it necessary? J Laryngol Otol. 2000;114(1):38–40.PubMedGoogle Scholar
  33. 33.
    Awan MS, Iqbal M, Imam SZ. Epistaxis: when are coagulation studies justified? Emerg Med J. 2008;25(3):156–7.PubMedGoogle Scholar
  34. 34.
    Dizdar O, Onal IK, Ozakin E, Karakiliç E, Karadag O, Kalyoncu U, Cookun F, Buyukasik Y. Research for bleeding tendency in patients presenting with significant epistaxis. Blood Coagul Fibrinolysis. 2007;18(1):41–3.PubMedGoogle Scholar
  35. 35.
    Shakeel M, Trinidade A, Iddamalgoda T, Supriya M, Ah-See KW. Routine clotting screen has no role in the management of epistaxis: reiterating the point. Eur Arch Otorhinolaryngol. 2010;267(10):1641–4. Epub 2010 Apr 9.CrossRefPubMedGoogle Scholar
  36. 36.
    Ozmen S, Ozmen OA. Is local ointment or cauterization more effective in childhood recurrent epistaxis. Int J Pediatr Otorhinolaryngol. 2012;76(6):783–6. Epub 2012 Mar 10.CrossRefPubMedGoogle Scholar
  37. 37.
    Hanif J, Tasca RA, Frosh A, Ghufoor K, Stirling R. Silver nitrate: histological effects of cautery on epithelial surfaces with varying contact times. Clin Otolaryngol Allied Sci. 2003;28(4):368–70.PubMedGoogle Scholar
  38. 38.
    Murthy P, Laing MR. An unusual, severe adverse reaction to silver nitrate cautery for epistaxis in an immunocompromised patient. Rhinology. 1996;34(3):186–7.PubMedGoogle Scholar
  39. 39.
    McClurg SW, Carrau R. Endoscopic management of posterior epistaxis: a review. Acta Otorhinolaryngol Ital. 2014;34(1):1–8.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Thornton MA, Mahesh BN, Lang J. Posterior epistaxis: identification of common bleeding sites. Laryngoscope. 2005;115:588–90.PubMedGoogle Scholar
  41. 41.
    Pinto JA, Cintra PP, Sônego TB, Leal Cde F, Artico MS. Soares Jdos S. Severe complication of posterior nasal packing: Case Report. Int Arch Otorhinolaryngol. 2012;16(4):527–9. Scholar
  42. 42.
    Paul J, Kanotra SP, Kanotra S. Endoscopic management of posterior epistaxis. Indian J Otolaryngol Head Neck Surg. 2011;63(2):141–4. Scholar
  43. 43.
    Koudounarakis E, Chatzakis N, Papadakis I, Panagiotaki I, Velegrakis G. Nasal packing aspiration in a patient with Alzheimer’s disease: a rare complication. Int J Gen Med. 2012;5:643–5. Scholar
  44. 44.
    Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope. 1987;97(12):1392–6.PubMedGoogle Scholar
  45. 45.
    Hashmi SM, Gopaul SR, Prinsley PR, Sansom JR. Swallowed nasal pack: a rare but serious complication of the management of epistaxis. J Laryngol Otol. 2004;118(5):372–3.PubMedGoogle Scholar
  46. 46.
    Civelek B, Kargi AE, Sensöz O, Erdogan B. Rare complication of nasal packing: alar region necrosis. Otolaryngol Head Neck Surg. 2000;123(5):656–7.PubMedGoogle Scholar
  47. 47.
    Sheen TS, Ko JY, Hsu YH. Pyogenic granuloma – an uncommon complication of nasal packing. Am J Rhinol. 1997;11(3):225–7.PubMedGoogle Scholar
  48. 48.
    Wiorowski M, Schultz P, Perrot JB, Gentine A, Debry C. Indications and results of cauterization by endoscopic approach of the sphenopalatine artery in severe posterior epistaxis. Auris Nasus Larynx. 2004;31(2):131–3.PubMedGoogle Scholar
  49. 49.
    Wurman LH, Sack JG, Flannery JV, Paulson TO. Selective endoscopic electrocautery for posterior epistaxis. Laryngoscope. 1988;98:1348–9. Scholar
  50. 50.
    Aslan G. Assessment of utilization and efficiency of rhinocell sinus packs with thread in management of posterior nasal bleeding. ENT Forume. 2013;12(1):1–5.Google Scholar
  51. 51.
    Aslan G, Şapçı T, Candan S. Anterior septal burun kanamalarında elektrokoterizasyon mu kimyasal koterizasyon mu? KBB Forum. 2011;10(4)Google Scholar
  52. 52.
    Midilli R, Orhan M, Saylam CY, Akyildiz S, Gode S, Karci B. Anatomic variations of sphenopalatine artery and minimally invasive surgical cauterization procedure. Am J Rhinol Allergy. 2009;23(6):e38–41. Epub 2009 Sep 21.PubMedGoogle Scholar
  53. 53.
    Holzmann D, Kaufmann T, Pedrini P, Valavanis A. Posterior epistaxis: endonasal exposure and occlusion of the branches of the sphenopalatine artery. Eur Arch Otorhinolaryngol. 2003;260(8):425–8.PubMedGoogle Scholar
  54. 54.
    Agreda B, Urpegui A, Alfonso J, Valles H. Ligadura de la artéria esfenopalatina em la epistaxis posterior. Estudio retrospectivo de 50 pacientes. Acta Otorrinolaringol Esp. 2011;62(3):194–8.PubMedGoogle Scholar
  55. 55.
    Araújo Filho BC, Pinheiro-Neto CD, Ramos HF, Voegels RL, Sennes LU. Endoscopic ligation of the anterior ethmoidal artery: a cadaver dis- section study. Braz J Otorhinolaryngol. 2011;77(1):33–8.PubMedGoogle Scholar
  56. 56.
    Saraceni Neto P, Nunes LM, Gregório LC, Santos Rde P, Kosugi EM. Surgical treatment of severe epistaxis: an eleven-year experience. Braz J Otorhinolaryngol. 2013;79(1):59–64. English, Portuguese.PubMedGoogle Scholar
  57. 57.
    Jindal G, Gemmete J, Gandhi D. Interventional neuroradiology applications in otolaryngology, head and neck surgery. Otolaryngol Clin N Am. 2012;45(6):1423–49.Google Scholar
  58. 58.
    Cullen MM, Tami TA. Comparison of internal maxillary artery ligation versus embolization for refractory posterior epistaxis. Otolaryngol Head Neck Surg. 1998;118(5):636–42.PubMedGoogle Scholar
  59. 59.
    Villwock JA, Jones K. Recent trends in epistaxis management in the United States: 2008-2010. JAMA Otolaryngol Head Neck Surg. 2013;139(12):1279–84. Scholar
  60. 60.
    Soyka MB, Nikolaou G, Rufibach K, Holzmann D. On the effectiveness of treatment options in epistaxis: an analysis of 678 interventions. Rhinology. 2011;49(4):474–8.PubMedGoogle Scholar
  61. 61.
    Hyde FT. Ligation of the external carotid artery for the control of idiopathic nasal hemorrhage. Laryngoscope. 1925;35(12):899–902.Google Scholar
  62. 62.
    Cooke ET. An evaluation and clinical study of severe epistaxis treated by arterial ligation. J Laryngol Otol. 1985;99(8):745–9.PubMedGoogle Scholar
  63. 63.
    Srinivasan V, Sherman IW, O’Sullivan G. Surgical management of intractable epistaxis: audit of results. J Laryngol Otol. 2000;114(9):697–700.PubMedGoogle Scholar
  64. 64.
    Chandler JR, Serrins AJ. Transantral ligation of the internal maxillary artery for epistaxis. Laryngoscope. 1965;75:1151–9.PubMedGoogle Scholar
  65. 65.
    Metson R, Lane R. Internal maxillary artery ligation for epistaxis: an analysis of failures. Laryngoscope. 1988;98(7):760–4.PubMedGoogle Scholar
  66. 66.
    Traboulsi H, Alam E, Hadi U. Changing Trends in the Management of Epistaxis. Int J Otolaryngol. 2015;2015:263987. Scholar
  67. 67.
    Kamani T, Shaw S, Ali A, Manjaly G, Jeffree M. Sphenopalatine-sphenopalatine anastomosis: a unique cause of intractable epistaxis, safely treated with microcatheter embolization: a case report. J Med Case Rep. 2007;1:article 125. Scholar
  68. 68.
    Prades J. Abord endonasal de la fossa pterygo-maxillaire. In: LXIII Congress France. Compte Rendus dês Séance. pp. 290–296.Google Scholar
  69. 69.
    Voegels RL, Thomé DC, Iturralde PPA, Butugan O. Endoscopic ligature of the sphenopalatine artery for severe posterior epistaxis. Otolaryngol Head Neck Surg. 2001;124(4):464–7. Scholar
  70. 70.
    Pádua FGM, Voegels RL. Severe posterior epistaxis-endoscopic surgical anatomy. Laryngoscope. 2008;118(1):156–61. Scholar
  71. 71.
    Pothier DD, MacKeith S, Youngs R. Sphenopalatine artery ligation: technical note. J Laryngol Otol. 2005;119(10):810–2. Scholar
  72. 72.
    Rudmik L, Smith TL. Management of intractable spontaneous epistaxis. Am J Rhinol Allergy. 2012;26(1):55–60. Scholar
  73. 73.
    Rockey JG, Anand R. A critical audit of the surgical management of intractable epistaxis using sphenopalatine artery ligation/diathermy. Rhinology. 2002;40:147–9.PubMedGoogle Scholar
  74. 74.
    Budrovich R, Saetti R. Microscopic and endoscopic ligature of the sphenopalatine artery. Laryngoscope. 1992;102:1391–4.PubMedGoogle Scholar
  75. 75.
    Simmen DB, Raghavan U, Briner HR, Manestar M, Groscurth P, Jones NS. The anatomy of the sphenopalatine artery for the endoscopic sinus surgeon. Am J Rhinol. 2006;20(5):502–5. Scholar
  76. 76.
    Nouraei SA, Maani T, Hajioff D, et al. Outcome of endoscopic sphenopalatine artery occlusion for intractable epistaxis: A 10-year experience. Laryngoscope. 2007;117:1452–6.PubMedGoogle Scholar
  77. 77.
    Spafford P, Durham JS. Epistaxis: efficacy of arterial ligation and long-term outcome. J Otolaryngol. 1992;21:252–6.PubMedGoogle Scholar
  78. 78.
    Weddell G, MacBeth RG, Sharp HS, Calvert CA. The surgical treatment of severe epistaxis in relation to the ethmoidal arteries. Br J Surg. 1946;33(132):387–92. Scholar
  79. 79.
    Isaacson G, Monge JM. Arterial ligation for pediatric epistaxis: developmental anatomy. Am J Rhinol. 2003;17(2):75–81.PubMedGoogle Scholar
  80. 80.
    Woolford TJ, Jones NS. Endoscopic ligation of anterior ethmoidal artery in treatment of epistaxis. J Laryngol Otol. 2000;114:858–60.PubMedGoogle Scholar
  81. 81.
    Brouzas D, Charakidas A, Androulakis M, Moschos M. Traumatic optic neuropathy after posterior ethmoidal artery ligation for epistaxis. Otolaryngol Head Neck Surg. 2002;126(4):323–5.PubMedGoogle Scholar
  82. 82.
    Yeh S, Yen MT, Foroozan R. Orbital apex syndrome after ethmoidal artery ligation for recurrent epistaxis. Ophthal Plast Reconstr Surg. 2004;20(5):392–4.PubMedGoogle Scholar
  83. 83.
    Basak S, Karaman CZ, Akdilli A, Mutlu C, Odabasi O, Erpek G. Evaluation of some important anatomical variations and dangerous areas of the paranasal sinuses by CT for safer endonasal surgery. Rhinology. 1998;36(4):162–7.PubMedPubMedCentralGoogle Scholar
  84. 84.
    Pletcher SD, Metson R. Endoscopic ligation of the anterior ethmoid artery. Laryngoscope. 2007;117:378–81.PubMedGoogle Scholar
  85. 85.
    Sokoloff J, Wickbom I, McDonald, et al. Therapeutic percutaneous embolisation in intractable epistaxis. Radiology. 1974;111:285–7.PubMedGoogle Scholar
  86. 86.
    Yilmaz M, Mamanov M, Yener M, Aydin F, Kizilkilic O, Eren A. Acute ischemia of the parotid gland and auricle following embolization for epistaxis. Laryngoscope. 2013;123(2):366–8.PubMedGoogle Scholar
  87. 87.
    Moreau S, De Rugy MG, Babin E, Courtheoux P, Valdazo A. Supraselective embolization in intractable epistaxis: review of 45 cases. Laryngoscope. 1998;108(6):887–8.PubMedGoogle Scholar
  88. 88.
    Reyre A, Michel J, Santini L, Dessi P, Vidal V, Bartoli JM, Moulin G, Epistaxis VA. The role of arterial embolization. Diagn Interv Imaging. 2015;96(7–8):757–73. Epub 2015 Jul 17CrossRefPubMedGoogle Scholar
  89. 89.
    Krajina A, Chrobok V. Radiological diagnosis and management of epistaxis. Cardiovasc Intervent Radiol. 2014;37(1):26–36.PubMedGoogle Scholar
  90. 90.
    Gottumukkala R, Kadkhodayan Y, Moran CHJ, Cross DWT III, Derdeyn CP. Impact of vessel choice on outcomes of polyvinyl alcohol embolisation for intractable idiopathic epistaxis. J Vasc Interv Radiol. 2013;24:234–9. Scholar
  91. 91.
    Melia L, McGarry GW. Epistaxis: update on management. Curr Opin Otolaryngol Head Neck Surg. 2011;19:30–5. Scholar
  92. 92.
    Walker FDL, Rutter C, McGarry GW. The use of anticoagulants in epistaxis patients. Rhinology. 2008;46:346.Google Scholar
  93. 93.
    Rudmik L, Leung R. Cost-effectiveness analysis of endoscopic sphenopalatine artery ligation vs arterial embolization for intractable epistaxis. JAMA Otolaryngol Head Neck Surg. 2014;140(9):802–8. Scholar
  94. 94.
    Christensen NP, Smith DS, Barnwell SL, Wax MK. Arterial embolization in the management of posterior epistaxis. Otolaryngol Head Neck Surg. 2005;133(5):748–53.PubMedGoogle Scholar
  95. 95.
    Strach K, Schröck A, Wilhelm K, et al. Endovascular treatment of epistaxis: indications, management, and outcome. Cardiovasc Interv Radiol. 2011;34:1190–8. Scholar
  96. 96.
    Duncan IC, Spiro FI, van Staden D. Acute ischemic sialadenitis following facial artery embolization. Cardiovasc Interv Radiol. 2004;27(3):300–2. Scholar
  97. 97.
    Barlow DW, Deleyiannis WB, Pinczower EF. Effectiveness of surgical management of epistaxis at a tertiary care center. Laryngoscope. 1997;107(1):21–4.PubMedGoogle Scholar
  98. 98.
    Cohen JE, Moscovici S, Gomori JM, et al. Selective endovascular embolization for refractory idiopathic epistaxis is a safe and effective therapeutic option: technique, complications, and outcomes. J Clin Neurosci. 2012;19:687–90.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Kasım Durmuş
    • 1
    Email author
  • Emine Elif Altuntaş
    • 1
  • Mario Milkov
    • 2
  1. 1.Medical Faculty, Department of OtorhinolaryngologyCumhuriyet UniversitySivasTurkey
  2. 2.Medical Faculty, Department of OtorhinolaryngologyVarna UniversityVarnaBulgaria

Personalised recommendations