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This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
Key points
- Anterior (90%): Little's area (Kiesselbach's plexus) — usually minor, self-limiting
- Posterior (10%): sphenopalatine artery — heavier, elderly/anticoagulated
- First aid: sit upright, lean FORWARD, pinch SOFT part of nose 10–20 min
- If continues: silver nitrate cautery (visible point) or nasal packing (Rapid Rhino/BIPP)
- Posterior: posterior packing, may need sphenopalatine artery ligation or embolisation
- Check: medications (anticoagulants), BP, FBC, clotting
Overview
Epistaxis is nasal bleeding, classified as anterior (Kiesselbach's plexus where four arteries anastomose) or posterior (sphenopalatine artery branches). Anterior accounts for ~90% and is usually self-limiting. Causes include nose-picking, dry air, trauma, anticoagulants, hypertension, and coagulopathies.
Epidemiology
60% of people experience at least one episode. Bimodal: children (2–10, anterior, minor) and older adults (>50, posterior, anticoagulants). Risk factors: digital trauma, anticoagulants, bleeding disorders, HHT.
Clinical Features
Symptoms
Unilateral or bilateral nasal bleeding
Blood draining posteriorly
Dizziness, tachycardia — significant blood loss
Recurrent unilateral epistaxis + nasal obstruction — suspect neoplasm
Signs
Visible bleeding point on anterior septum
No anterior source, blood running posteriorly — posterior bleed
Haemodynamic compromise — severe bleed
Investigations
First-line
Anterior rhinoscopyIdentify bleeding point after topical vasoconstrictor
ObservationsBP, pulse, SpO₂
Second-line
FBC, coagulation, INRIf significant or on anticoagulants
Group and saveIf severe
Specialist
Nasal endoscopyFor posterior source
Management
ENT UK Epistaxis Guidelines and NICE CKS1
First aid
- Sit upright, lean FORWARD
- Pinch SOFT part of nose 10–20 min continuously
- Breathe through mouth, spit blood
2
Anterior epistaxis if first aid fails
- Co-phenylcaine spray
- Silver nitrate cautery to visible point — ONE side only (bilateral = septal perforation risk)
- If fails: anterior nasal packing (Rapid Rhino/BIPP) for 24–48 h
- Oral co-amoxiclav while pack in situ
3
Posterior epistaxis
- Posterior packing (Rapid Rhino posterior balloon / Foley catheter)
- Admit — monitor SpO₂
- Surgical: sphenopalatine artery ligation or embolisation
4
Prevention
- Review anticoagulants (haematology input)
- Naseptin cream (chlorhexidine + neomycin) BD 2 weeks
- Humidification, avoid nose-picking
Complications
- Hypovolaemic shock
- Aspiration
- Septal perforation: From bilateral cautery
- Toxic shock syndrome: Rare with packing
UKMLA Exam Tips
- 1Little's area: anastomosis of anterior ethmoidal, sphenopalatine, superior labial, greater palatine
- 2First aid: lean FORWARD, pinch SOFT part, 10–20 min — commonly tested
- 3Never cauterise BOTH sides — septal perforation risk
- 4Posterior bleed in elderly + anticoagulated + hypertensive = common exam scenario
- 5Recurrent unilateral epistaxis + obstruction = exclude malignancy
- 6HHT (Osler-Weber-Rendu): autosomal dominant, recurrent epistaxis + telangiectasia + AVMs
- 7Naseptin cream BD 2 weeks prevents recurrence
practicetest your knowledge on EpistaxisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — ENT and beyond.
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Epistaxis: guidance by region
Recommendations, thresholds and pathways can differ. Open the page written for the jurisdiction you need.