• Blood supply of nose
    • The nasal blood supply comes from both internal and external carotid artery systems
      • External carotid
        • facial artery
          • superior labial artery, supplies the septum and nasal alae.
        • internal maxillary artery (IMA).
          • Sphenopalatine
            • the septum and middle and inferior turbinate area
          • pharyngeal
            • inferior aspect of the lateral nasal wall,
          • greater palatine
            • anterior aspect of the septum.
      • Internal carotid artery
        • ophthalmic artery
          • septum and lateral nasal walls
        • anterior ethmoid artery
        • posterior ethmoid artery
    • Of note, 2 anastomotic areas within the nose often provide a source of epistaxis.
      • Woodruff area
        • located on the inferior aspect of the lateral nasal wall,posterior to the inferior turbinate.
        • It is formed from the anastomoses of the
          • Sphenopalatine arteries.
          • Pharyngeal arteries.
        • The posterior location makes it a common source for severe, nontraumatic bleeds.
      • Kiesselbach plexus(MCQ)
        • source of the majority of nose bleeds
        • form a plexus of vessels in the anteroinferior nasal septum.
        • an anastomosis with branches from both the internal and external carotid artery systems.
        • Anterior ethmoidal artery (from the ophthalmic artery)
        • Sphenopalatine artery (terminal branch of the maxillary artery)
        • Greater palatine artery (from the maxillary artery)
        • Septal branch of the superior labial artery (from the facial artery).
    • Causes of epistaxis
      • Most common site of epistaxis in children — Kisselbach ‘s plexus (littles area)(MCQ)
      • Most common cause of epistaxis in elderly – hypertension (MCQ)
      • Most common cause of epistaxis in a 15 yr old female-Hematopoetic disorder  (MCQ)
      • Most common cause of epistaxis in children — Habitual nose pricking (Trauma) (MCQ)
  • Sites of epistaxis
    • Little’s area.
      • In 90% cases of epistaxis, bleeding occurs from this site.(MCQ)
    • Above the level of middle turbinate.
      • Bleeding is often from the anterior and posterior ethmoidal vessels (internal carotid system).
    • Below the level of middle turbinate.
      • bleeding is from the branches of sphenopalatine artery.
    • Diffuse.
      • Both from septum and lateral nasal wall.
      • This is often seen in general systemic disorders and blood dyscrasias.

Classification of epistaxis


  • Management
    • First Aid
      • Most of the time, bleeding occurs from the Little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 minutes. This compresses the vessels of the Little’s area.
      • Trotter’s method
      • patient is made to sit, leaning a little forward over a basin to spit any blood, and breathe quietly from the mouth.
      • Cold compresses should be applied to the nose to cause reflex vasoconstriction.
    • Cauterisation
      • This is useful in anterior epistaxis when bleeding point has been located.
      • The area is first anaesthetised and the bleeding point cauterised with a bead of silver nitrate or coagulated with electrocautery.
    • Anterior Nasal Packing
    • Posterior Nasal Packing
  • Endoscopic Cautery
  • Posterior bleeding point can sometimes be better located with an endoscope.
  • Elevation of Mucoperichondrial Flap and SMR Operation
    • In case of persistent or recurrent bleeds from the septum, just elevation of mucoperichondrial flap and then repositioning it back helps to cause fibrosis and constrict blood vessels.
    • SMR operation is done for septal spur which is sometimes the cause of epistaxis.
  • Ligation of Vessels
    • External carotid.
    • Maxillary artery.
      • done in uncontrollable posterior epistaxis.
      • Approach is via Caldwell-Luc operation.
    • Endoscopic ligation of the maxillary artery can also be done through nose.
  • Ethmoidal arteries.
    • In anterosuperior bleeding above the middle turbinate, not controlled by packing, anterior and posterior ethmoidal arteries which supply this area, can be ligated.(MCQ)

ENT Basics: Epistaxis
We hope you enjoy our humorous guide to understanding and managing Epistaxis!

The video covers the basic anatomy, aetiology and management of acute epistaxis for the use of junior doctors, trainees, medical students and A&E Staff in particular.

Any feedback will help us improve future videos and is much appreciated! Feedback to [email protected]

Our next video will be on Foreign Bodies.

Please note that gloves, aprons and – if needed – a visor should be worn when managaing Epistaxis, though for the purposes of the video (and because we were dealing with Ketchup) we have not worn such protection!

This video is for trained professionals and is a basic guide, we accept no liability for any injuries caused by any cavalier use of ENT equipment!
Management of epistaxis
Basic guide on how to manage epistaxis. Actors: Karan Kapoor and Tom Ashfield, Filming: Anil Joshi, Editing: Tom Ashfield.
Endoscopic Control of Epistaxis
Demonstrates cauterization of bleeding mucosa and sphenopalatine artery ligation for epistaxis (nosebleeds).
Epistaxis – Nosebleeds
emergency physician, talks about nosebleeds
A scene from the classic Tv show cardiac arrest showing how serious expistaxis (nosebleeds) can be.
Epistaxis Training Video
A video-based training aid for the treatment of Epistaxis (Nose Bleeds) which covers, in detail, various treatments of the condition.

The purpose of the video is to teach/recap junior ENT (Ears, Nose and Throat) doctors just starting out in their ENT posts via a quick, informative and visual way when senior doctors or consultants are not immediately available.

Footage was taken on site at the Queen Alexandra Hospital in Cosham, Portsmouth as well as in the CCi Television Studios at the University of Portsmouth.
Large Epistaxis
Large Epistaxis