Can a patient with a nose bleed (epistaxis) and potential history of respiratory illnesses or bleeding disorders undergo COVID-19 testing?

COVID-19 Testing in Patients with Active Epistaxis

Yes, COVID-19 testing can be performed in patients with nosebleeds, but an oropharyngeal swab or alternative sampling method should be used instead of the standard nasopharyngeal swab to avoid worsening bleeding or causing complications. 1, 2

Recommended Testing Approach

Primary Recommendation: Use Alternative Sampling Sites

• Perform oropharyngeal swab testing rather than nasopharyngeal swab in patients with active epistaxis or recent nosebleeds 1
• Consider mid-turbinate sampling, nasal swab (avoiding deep insertion), or saliva testing as safer alternatives that avoid trauma to bleeding sites 2
• RT-PCR remains the gold standard for COVID-19 diagnosis regardless of sampling site, though sensitivity varies by specimen type (throat swabs: 32% vs nasal swabs: 63%) 3

Risk Assessment Before Testing

Document these specific bleeding risk factors before choosing a sampling method: 4, 2

• Current use of anticoagulants (warfarin, DOACs) or antiplatelet agents (aspirin, clopidogrel)
• Personal or family history of bleeding disorders (including hereditary hemorrhagic telangiectasia)
• Recent nasal trauma or prior nasal/sinus surgery
• Chronic kidney or liver disease
• Use of nasal cannula oxygen or CPAP (both increase epistaxis risk)
• Intranasal drug use

Clinical Context and Complications

Why Nasopharyngeal Swabs Are Problematic

• Nasopharyngeal swabbing causes epistaxis in approximately 5-10% of cases in general populations 2
• In high-risk patients (anticoagulated, bleeding disorders, active epistaxis), nasopharyngeal swabs can cause massive hemorrhage requiring nasal packing, blood transfusions, intubation, or even tracheostomy 2, 5
• One documented case required mechanical ventilation and tracheostomy after nasopharyngeal swab-induced epistaxis in an anticoagulated patient 2
• Complications include nasal septal abscess formation, particularly in elderly patients or those with hemoglobinopathies 6

Special Population: Hereditary Hemorrhagic Telangiectasia (HHT)

For HHT patients with recurrent epistaxis, oropharyngeal swab is strongly preferred despite lower sensitivity because: 1

• Risk of massive epistaxis requiring hospitalization, nasal packing, and blood transfusions outweighs the benefit of marginally higher nasopharyngeal swab sensitivity
• These patients have nasal mucosal telangiectases that bleed profusely with minimal trauma
• History of anemia and repeated hospitalizations for epistaxis makes nasopharyngeal sampling unacceptably risky

Testing Protocol for Active Epistaxis

Step 1: Control Active Bleeding First

• Do not attempt any nasal sampling while epistaxis is active 4
• Apply direct pressure by pinching the soft part of the nose for 10-15 minutes 4
• Consider topical vasoconstrictors if bleeding continues 4
• If bleeding is controlled and testing is urgent, proceed to Step 2

Step 2: Choose Appropriate Sampling Method

Preferred options in order: 1, 2

1. Oropharyngeal swab (safest, avoids nasal cavity entirely)
2. Saliva testing (non-invasive, CDC-approved alternative)
3. Anterior nasal swab (shallow insertion only, avoiding deep nasopharynx)
4. Lower respiratory tract specimen if patient is intubated (highest sensitivity at 93%) 3

Step 3: Timing Considerations

• A single negative test should not rule out COVID-19 in patients with strongly suggestive symptoms 4
• Repeat testing after 48-72 hours if initial test is negative but clinical suspicion remains high 4
• Viral shedding in the nasopharynx increases over time during the incubation period (mean 5.2 days), so delayed testing may improve detection 4

Common Pitfalls to Avoid

• Never perform nasopharyngeal swab in anticoagulated patients without considering bleeding risk - one case required 9 days hospitalization and coronary angiography postponement after routine COVID testing 5
• Do not assume low pretest probability eliminates need for risk assessment - inadvertent complications occur even in low-risk COVID scenarios 2
• Avoid nasopharyngeal swabs in nursing home populations on chronic anticoagulation (high CHADVASc scores) where bleeding risk is elevated 2
• Do not repeat testing beyond 9 days of illness as positive results likely represent dead virus particles 2

Prevention Strategies for Hospitalized COVID Patients

For patients with COVID-19 receiving supplementary oxygen (nasal cannula or CPAP) who are at risk for epistaxis: 7

• Apply nasal lubricant regularly to prevent crust formation
• Use humidification with oxygen delivery
• Administer prophylactic nasal saline to maintain mucosal moisture
• Monitor closely as both oxygen delivery methods and prophylactic anticoagulation (standard in COVID patients) increase epistaxis risk 7