Epistaxis is the medical term for a nosebleed, which is a common presenting concern in the emergency room. The most common site of bleeding is the Kiesselbach plexus, where the vessels supplying the nasal mucosa anastomose, resulting in bleeding from the nostrils (anterior epistaxis). Posterior epistaxis is less common and may not be clinically apparent because blood may flow down the throat. The most common causes of epistaxis include nose picking, a foreign body in the nasal cavity, and a dry nose. Usually, bleeding is self-limited, but severe epistaxis may occur in patients with posterior bleeding sites, systemic conditions such as hypertension or bleeding disorders, and/or following traumatic injury. Hereditary hemorrhagic telangiectasia, which is an autosomal dominant vasculopathy characterized by telangiectasia on the skin and mucosa, may cause recurrent epistaxis. Immediate measures to control epistaxis include elevating the patient's head and tilting it forward and pinching the nose. For continued bleeding from an anterior site, local hemostatic measures (i.e., vasoconstrictors and nasal cautery) are used. If hemostasis cannot be achieved with these measures, the nasal cavity must be packed and the patient referred to an ENT surgeon.
In most cases, the exact cause of epistaxis remains unknown (idiopathic epistaxis). While a single episode of epistaxis usually does not require any investigation, recurrent epistaxis must be investigated for an underlying cause (e.g., a bleeding disorder).
Local causes 
- Nasal irritation
- Vascular malformations
- Inflammatory/granulomatous disorders
- Craniofacial trauma
Nasal septal defects
- Deviated nasal septum
- Septal spurs
- Septal perforation
- Tumors of the nasopharynx and/or paranasal sinuses
Systemic causes 
|Classification of epistaxis |
|Criteria||Anterior epistaxis||Posterior epistaxis|
|Clinical features|| |
|Relative frequency|| || |
|Peak incidence || || |
|Most common site of bleeding|
Posterior epistaxis may be a sign of life-threatening hemorrhages.
Immediate management 
- Use to avoid exposure to body fluids.
Stabilize patients using the ABCDE approach, including:
- in patients with
- Keep the patient's head elevated and tilted forward.
- Control bleeding by applying uninterrupted, bilateral pressure.
- Perform to identify the source of bleeding.
Management of ongoing bleeding 
- For anterior epistaxis with the bleeding site identified, consider:
- If bleeding persists or the bleeding site cannot be identified, place nasal packing.
- For refractory or recurrent bleeding, consider arterial embolization or endoscopic ligation of the bleeding vessel, i.e.:
Consult otolaryngology for refractory or recurrent bleeding despite nasal cautery and packing. 
- Topical anesthesia (e.g., 2% lidocaine) and analgesia as needed 
- Consider prophylactic antibiotics for patients who require packing. 
- Consider posterior and/or severe epistaxis.  after specialist consultation for patients with
- Consider discharge after observation if hemostasis is successful.
- Counsel patients on preventative measures and .
- Arrange follow-up and ensure packing removal within 48–72 hours if discharging with nonresorbable packing.
- Posterior epistaxis
- ABCDE approach
- Bilateral pressure for 15–20 minutes
- Bleeding site identified: topical vasoconstrictors and/or cautery
- Persistent bleeding or unclear bleeding site:
- Nasal packing unsuccessful: ENT consult
- Analgesia and local anesthesia as needed
- Anterior epistaxis: Discharge if hemostasis is successful.
- Posterior epistaxis: Admit for monitoring.
- Definition: a hereditary, systemic vasculopathy characterized by telangiectasia on the skin and mucosa, particularly in the area of the face (nose, lips, tongue)
- Pattern of inheritance: : autosomal dominant
- Pathophysiology: mutations in genes which code for TGF-β receptors (e.g., endoglin or ALK-1) → structural defects in the vessel wall → postcapillary venous pooling → formation of small and large arteriovenous shunts
- Clinical features 
- Diagnosis