About This Page
This is a clinician-written, evidence-based guide aligned to the MCC Examination Objectives. It is structured by clinical presentation — the way the MCCQE tests and the way patients actually present. Management reflects current Canadian guidelines (CMA, CFPC, CPS). Always cross-reference with institutional protocols and clinical judgment.
The Bottom Line
- Most epistaxis is anterior from Kiesselbach plexus and responds to firm continuous nasal compression
- Immediate priorities are airway, breathing, circulation, haemodynamic status, anticoagulant/antiplatelet use, and bleeding severity
- Posterior epistaxis is suggested by brisk bilateral bleeding, blood in the posterior pharynx, older age, hypertension, or failure of anterior measures
- First-line management: sit forward, pinch soft alae continuously, topical vasoconstrictor/anaesthetic, identify bleeding point, cautery or packing if needed
- Recurrent unilateral bleeding, nasal obstruction, facial pain, or mass requires ENT assessment for tumour or structural lesion
Approach to the Presentation
Epistaxis is common and often benign, but the MCCQE1 framing is resuscitation plus localization. First determine whether the patient is unstable, aspirating blood, anticoagulated, thrombocytopenic, or bleeding posteriorly. Ask about trauma, nose picking, dryness, intranasal drug use, recent surgery, anticoagulants/antiplatelets, liver disease, renal disease, family history of bleeding, and recurrent mucocutaneous bleeding. Examine the nose after clearing clots, inspect the posterior pharynx, check vital signs, and look for telangiectasias, bruising, petechiae, septal perforation, or mass. Most cases resolve with correct compression; failure usually reflects poor technique, persistent anticoagulant effect, posterior source, or missed local pathology.
Differential Diagnosis
| diagnosis | likelihood | key features | distinguishing test |
|---|---|---|---|
| Posterior Epistaxis | must-not-miss | Brisk bleeding into throat, bilateral nasal bleeding, older patient, hypertension, anticoagulation, failure of anterior pressure/cautery | Persistent posterior pharyngeal bleeding despite anterior control; ENT endoscopy |
| Haemodynamic Instability / Major Blood Loss | must-not-miss | Syncope, hypotension, tachycardia, pallor, ongoing large-volume bleeding, anaemia symptoms | Vitals, CBC, type and screen/crossmatch, coagulation studies |
| Coagulopathy or Medication-Related Bleeding | must-not-miss | Warfarin/DOAC/antiplatelet use, liver disease, renal failure, thrombocytopenia, easy bruising, bleeding elsewhere | CBC/platelets, INR, aPTT if indicated, renal/liver function; medication review |
| Nasal / Nasopharyngeal Tumour | must-not-miss | Recurrent unilateral epistaxis, unilateral obstruction, facial pain, cranial neuropathy, neck mass, weight loss | Urgent ENT nasoendoscopy ± CT/MRI and biopsy |
| Anterior Septal Epistaxis | common | Bleeding from one nostril, visible anterior septal point, triggered by nose picking, dryness, URTI, allergic rhinitis, intranasal steroids | Anterior rhinoscopy after clot evacuation |
| Traumatic Epistaxis | common | Nasal injury, facial trauma, septal haematoma, deformity, clear rhinorrhea if skull base injury | Clinical exam; CT facial bones/head if significant trauma or CSF leak concern |
| Mucosal Dryness / Rhinitis | common | Dry winter air, crusting, irritation, recurrent minor anterior bleeds, intranasal steroid misdirection | Clinical; inspect septum for crusting/fissures |
| Hereditary Haemorrhagic Telangiectasia | less common | Recurrent spontaneous epistaxis, mucocutaneous telangiectasias, family history, iron deficiency anaemia, AVMs | Curacao criteria; CBC/ferritin; screen for pulmonary/cerebral/hepatic AVMs when suspected |
| Septal Perforation / Intranasal Drug Use | less common | Crusting, whistling, recurrent epistaxis, cocaine or vasoconstrictor misuse, prior surgery, autoimmune disease | Anterior rhinoscopy; consider vasculitis work-up if systemic features |
| Juvenile Nasopharyngeal Angiofibroma | rare | Adolescent male with recurrent profuse epistaxis and unilateral nasal obstruction | ENT referral; contrast imaging. Avoid biopsy outside specialist setting due to bleeding risk |
Red Flags & Key History
Symptoms
Large-volume bleeding, syncope, chest pain, dyspnea, or presyncope — possible significant blood loss
Blood flowing into the throat despite pinching the nose — posterior epistaxis
Anticoagulant/antiplatelet use, liver disease, renal failure, chemotherapy, or known bleeding disorder
Recurrent unilateral epistaxis with obstruction, facial pain, cranial symptoms, or neck mass — tumour concern
Facial trauma, septal swelling, deformity, or clear rhinorrhea — trauma complication
Frequent minor anterior bleeds during winter or with nasal steroid use — mucosal dryness/trauma
Family history of recurrent epistaxis or telangiectasias — possible HHT
Signs
Hypotension, tachycardia, pallor, ongoing brisk bleeding — resuscitation priority
Posterior pharyngeal blood after anterior control — posterior source
Septal haematoma after trauma — urgent drainage to prevent cartilage necrosis
Visible anterior septal bleeding point — amenable to cautery
Petechiae, purpura, bruising, mucosal bleeding elsewhere — systemic haemostasis disorder
Mucocutaneous telangiectasias on lips, tongue, nose, or fingers — HHT clue
Approach to Investigation
First-line
No routine labs for minor anterior epistaxisIf bleeding is brief, anterior, and patient is well, investigations are usually unnecessary
CBCIf recurrent, prolonged, heavy, symptomatic, anticoagulated, or concern for anaemia/thrombocytopenia
Coagulation testingINR for warfarin; aPTT/INR if liver disease, unexplained bleeding, or systemic coagulopathy. DOAC effect requires medication timing/renal function assessment rather than routine INR interpretation
Type and screen/crossmatchFor haemodynamic instability, major bleeding, or anticipated transfusion/procedure
Second-line
Nasal endoscopyFor recurrent, posterior, unilateral, or unexplained epistaxis; identifies posterior bleeding point, tumour, septal perforation, or vascular lesion
CT/MRI sinonasal regionIf tumour, juvenile nasopharyngeal angiofibroma, facial trauma, invasive infection, or structural lesion suspected
HHT assessmentCBC/ferritin and targeted screening for AVMs if clinical criteria suggest hereditary haemorrhagic telangiectasia
Specialist
ENT cautery, posterior packing, endoscopic ligation, or embolizationFor failed anterior measures, posterior bleeding, recurrent severe epistaxis, or unstable patients
Haematology consultationFor major bleeding with complex anticoagulation reversal, thrombocytopenia, inherited bleeding disorder, or unexplained coagulopathy
Management Principles
CSO-HNS epistaxis teaching + CMAJ anterior epistaxis guidance + general Canadian emergency practice1
Immediate control for most patients
- Sit patient upright and leaning forward; suction/clear clots if available
- Apply firm continuous pressure to the soft alae for 10-15 minutes without checking repeatedly
- Use topical vasoconstrictor such as oxymetazoline when appropriate; topical anaesthetic may help examination and cautery
2
If bleeding point is visible
- Cauterize with silver nitrate on one side of septum only; avoid bilateral opposing cautery to reduce septal perforation risk
- If diffuse or not controlled, use absorbable or non-absorbable anterior packing according to local protocol
- Provide clear return instructions and packing follow-up/removal plan
3
Posterior or severe epistaxis
- ABC assessment, IV access, CBC/coagulation studies, type and screen/crossmatch
- Urgent ENT involvement for posterior packing, endoscopic sphenopalatine artery ligation, or interventional radiology embolization
- Reverse or hold anticoagulation only when bleeding severity justifies it; balance thrombotic risk and involve appropriate specialists
4
Prevention and follow-up
- Humidification, saline spray/gel, petroleum-free nasal emollient if appropriate, avoid nose picking and forceful blowing
- Correct intranasal steroid technique: aim away from septum
- Investigate recurrent unilateral epistaxis, persistent obstruction, or systemic bleeding features rather than repeatedly packing
Complications & Pitfalls
- Poor compression technique: Patients often pinch the nasal bones rather than the soft alae; this fails to compress the anterior septum.
- Posterior bleed missed: Ongoing blood in the throat despite anterior measures should trigger ENT involvement.
- Septal haematoma missed after trauma: This requires urgent drainage to prevent septal necrosis and saddle nose deformity.
- Over-reversal of anticoagulation: Reversal decisions must balance bleeding severity and thromboembolic risk.
- Unilateral recurrent epistaxis: Do not assume dryness; consider tumour or vascular lesion.
MCCQE1 Exam Tips
- 1First step in uncomplicated epistaxis: sit forward and apply firm continuous pressure to the soft part of the nose
- 2Do not tilt the head back — it increases swallowed blood and aspiration risk
- 3Posterior epistaxis is an older, brisk, difficult-to-control bleed with blood in the throat; call ENT
- 4Silver nitrate is for a visible anterior bleeding point, not blind cautery
- 5Septal haematoma after nasal trauma is a must-not-miss diagnosis requiring urgent drainage
- 6Recurrent unilateral epistaxis with obstruction or neck mass is cancer until proven otherwise
- 7For minor anterior epistaxis in a stable patient, routine CBC/coagulation tests are usually unnecessary
practicetest your knowledge on epistaxisApply what you've learnt with MCCQE1-style questions from the iatroX Q-Bank — ent & ophthalmologic and beyond.
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