What are the possible causes and treatment options for a 1-day episode of epistaxis (nose bleed) accompanied by left ear pain in a patient with unknown age, gender, and past medical history?

Epistaxis with Unilateral Ear Pain: Evaluation and Management

Most Likely Diagnosis and Immediate Action

This presentation of unilateral epistaxis with ipsilateral ear pain suggests either referred pain from the nasal bleeding itself or, more concerning, a localized process such as rhinosinusitis, nasal trauma, or rarely a unilateral mass lesion that requires targeted examination. 1

Initial Management of the Epistaxis

Apply firm, continuous pressure to the soft lower third of the nose for 10-15 minutes without interruption, with the patient sitting upright and head tilted slightly forward to prevent blood aspiration. 2, 3, 4

• The patient should breathe through their mouth and spit out blood rather than swallowing it 3, 4
• Compression alone resolves the vast majority of anterior epistaxis cases 3, 4
• Do not check if bleeding has stopped during the compression period—this is a common error that prevents adequate hemostasis 3

If Bleeding Persists After 10-15 Minutes

• Clear the nasal cavity of blood clots by suction or gentle nose blowing 4
• Apply topical vasoconstrictor (oxymetazoline or phenylephrine) spray—2 sprays directly into the bleeding nostril 3, 4
• Resume firm compression for another 5-10 minutes after vasoconstrictor application 4
• This approach stops bleeding in 65-75% of emergency department cases 3, 5

Critical Diagnostic Evaluation for Unilateral Presentation

The combination of unilateral epistaxis and ipsilateral ear pain requires anterior rhinoscopy after clot removal to identify the bleeding site and rule out concerning pathology. 1, 4

Key Red Flags to Assess

• Nasal obstruction, facial pain, or visual changes accompanying unilateral epistaxis may indicate a mass lesion and require urgent ENT referral 1
• Local trauma history, including digital manipulation or nasal foreign bodies 1
• Localized infection such as rhinosinusitis affecting one side of the nasal cavity 1
• Intranasal drug use (topical medication overuse or illicit drugs) 1
• Previous nasal or sinus surgery 1

Ear Pain Etiology

The left ear pain is most likely:

• Referred pain from the nasal bleeding site via shared sensory innervation 6
• Associated acute rhinosinusitis causing Eustachian tube dysfunction 1
• Less commonly, a sign of more extensive pathology requiring imaging

When to Seek Emergency Care

Transfer to the emergency department if: 3

• Bleeding does not stop after 15 minutes of continuous pressure with vasoconstrictors 3
• Signs of hemodynamic instability (tachycardia, hypotension, dizziness, pallor) 3, 1
• Bleeding duration exceeds 30 minutes over a 24-hour period 3

Advanced Treatment if Initial Measures Fail

Nasal Cauterization

• Perform after anesthetizing the area with topical lidocaine or tetracaine 1, 4
• Restrict cautery only to the active bleeding site in the affected nostril 1
• Avoid bilateral septal cautery to prevent septal perforation 1, 4

Nasal Packing

• Use resorbable packing materials (Nasopore, Surgicel, Floseal) as first choice, especially if the patient has any bleeding risk factors 3, 4
• Non-resorbable materials may be used in patients without bleeding disorders 4

Prevention of Recurrence

Apply petroleum jelly or other moisturizing agents to the nasal mucosa once bleeding stops. 3, 4

• Use saline nasal sprays regularly to maintain mucosal moisture 3, 4
• Consider humidifier use, especially in dry environments 3
• Avoid nose picking, vigorous nose blowing, and nasal manipulation for 7-10 days 4

Follow-Up and Specialist Referral

Arrange follow-up within 30 days to assess outcome and evaluate for underlying conditions if treatments are ineffective or bleeding recurs. 4

Indications for ENT Referral

• Recurrent bleeding despite appropriate treatment 4
• Inability to identify bleeding source on anterior rhinoscopy 4
• Persistent unilateral symptoms with ear pain suggesting possible mass lesion or chronic rhinosinusitis 1
• Need for nasal endoscopy to examine posterior nasal cavity and nasopharynx 1, 4

Common Pitfalls to Avoid

• Insufficient compression time—must maintain pressure for full 10-15 minutes without checking 3
• Neglecting to address nasal mucosal dryness, leading to recurrent episodes 3
• Missing red flag symptoms (unilateral obstruction, facial pain, visual changes) that suggest mass lesion 1
• Failing to perform adequate anterior rhinoscopy after clot removal 1, 4