What is the appropriate evaluation and management of unilateral epistaxis, including initial control, assessment for systemic causes, and indications for referral?

Management of Unilateral Epistaxis

Unilateral epistaxis requires nasal endoscopy to exclude serious pathology—including nasal foreign bodies in children, juvenile nasopharyngeal angiofibroma in adolescent males, and nasal malignancies in adults—because these conditions present with unilateral bleeding and can cause life-threatening complications if diagnosis is delayed. 1

Immediate Control Measures

First-Line Intervention

• Seat the patient with head tilted slightly forward to prevent blood from entering the airway or stomach 2
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without checking for cessation; premature release is the most common cause of treatment failure 2, 3
• Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it 2

Adjunctive Pharmacologic Therapy

• If compression alone fails, apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril and resume firm compression for another 5–10 minutes 2
• Vasoconstrictors stop bleeding in 65–75% of emergency department cases 2
• Obtain baseline blood pressure before using vasoconstrictors because approximately one-third of epistaxis patients have undiagnosed hypertension, and vasoconstrictors carry increased cardiac risk in this population 2

Critical Diagnostic Evaluation for Unilateral Bleeding

Why Unilateral Epistaxis Demands Endoscopy

The unilateral nature of bleeding is a red flag that mandates endoscopic examination to exclude structural pathology. 1

Specific Pathologies by Age Group

Children:

• Nasal foreign bodies present with unilateral epistaxis, rhinorrhea, and foul smell in 7% of cases 1
• Disk batteries can cause tissue necrosis and septal perforation in as little as 3 hours 1
• Nasal endoscopy allows rapid identification of foreign bodies not visible on anterior rhinoscopy 1

Adolescent Males:

• Juvenile nasopharyngeal angiofibroma presents with unilateral, unprovoked, profuse epistaxis in 60–76% of cases 1
• Examination of the posterior nasal cavity and nasopharynx is mandatory in adolescent males with these symptoms 1

Adults:

• Nasal malignancies present with unilateral nasal obstruction (66.7%) and epistaxis (55%) 1
• These tumors may not be visible on anterior rhinoscopy alone 1
• Life-threatening bleeding has been associated with delayed diagnosis 1

Endoscopic Examination Protocol

After achieving initial hemostasis:

• Remove blood clots by suction or gentle nose blowing 2, 3
• Perform anterior rhinoscopy first to examine the nasal septum 2, 3
• Proceed to nasal endoscopy when anterior rhinoscopy fails to identify the source, bleeding is difficult to control, or unilateral presentation raises concern for pathology 1
• Nasal endoscopy localizes the bleeding site in 87–93% of cases 1

Definitive Treatment After Source Identification

Cautery (When Focal Bleeding Point Identified)

• Anesthetize the site with topical lidocaine before cautery 2
• Limit cautery strictly to the active bleeding point to minimize mucosal injury 2
• Avoid bilateral simultaneous septal cautery because it markedly increases the risk of septal perforation 2
• Silver nitrate cauterization has an 80% success rate with the lowest recurrence rate (14.5% vs 35.1% for chemical cauterization) 2, 4

Nasal Packing (If Cautery Fails or Bleeding Persists)

Indications for packing: 2, 3

• Bleeding continues after 15–30 minutes of proper compression with vasoconstrictors
• Life-threatening hemorrhage
• Posterior bleeding source suspected

Material selection: 2, 3

• Use only resorbable/absorbable materials (Nasopore, Surgicel, Floseal) in patients on anticoagulants or antiplatelet agents to avoid trauma during removal
• Non-resorbable packing may be used in patients without bleeding risk factors

Assessment for Systemic Causes

Critical History Elements

• Document duration of bleeding; episodes >30 minutes over 24 hours indicate severe epistaxis 2, 3
• Record all anticoagulant and antiplatelet medications including NSAIDs and aspirin 2
• Screen for personal or family history of bleeding disorders: easy bruising, prolonged bleeding from minor cuts, family history of bleeding disorders 2
• Document prior hospitalizations or blood transfusions for epistaxis 3

Laboratory Testing

• Complete blood count (CBC) is mandatory to assess for anemia and quantify blood loss severity 3
• Obtain PT/INR and aPTT in all patients on anticoagulation or with clinically relevant bleeding 3
• Coagulation studies with hematology referral are indicated when there is positive family history of bleeding disorders, severe or bilateral recurrent episodes, or associated bruising/petechiae 5

Indications for Specialist Referral

Immediate Otolaryngology Referral Required

• Recurrent bleeding despite appropriate treatment with packing or cautery 1, 2, 5
• Unilateral epistaxis with suspected foreign body or mass 5
• Adolescent males with unilateral, unprovoked, profuse epistaxis to rule out juvenile nasopharyngeal angiofibroma 5
• Persistent bleeding despite appropriate nasal packing 2, 3
• Recurrent bilateral nosebleeds to evaluate for hereditary hemorrhagic telangiectasia 2, 5

Advanced Interventions for Refractory Cases

• Evaluate candidacy for surgical arterial ligation or endovascular embolization when bleeding is not controlled by packing or cautery 2, 3
• Endoscopic sphenopalatine artery ligation has a 97% success rate vs 62% for conventional packing 2
• Endovascular embolization has an 80% success rate with recurrence rates <10% vs 50% for nasal packing 2

Post-Treatment Care and Prevention

Mucosal Moisturization

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily after hemostasis to prevent recurrence 2, 5
• Use saline nasal sprays frequently throughout the day to maintain mucosal moisture 2, 5
• Recommend humidifier use in dry environments 2

Patient Education on Warning Signs

• Return immediately if bleeding persists after 15 minutes of continuous proper compression 2
• Seek care for active bleeding despite packing, hemodynamic instability, fever >101°F, vision changes, or facial swelling 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7–10 days after treatment 5

Common Pitfalls to Avoid

• Do not check for bleeding cessation during the initial 10–15 minutes of compression; this is the most common cause of treatment failure 2, 3
• Do not perform bilateral simultaneous septal cautery due to high risk of septal perforation 2
• Do not use non-resorbable packing in patients on anticoagulants or antiplatelet agents 2, 3
• Do not dismiss unilateral epistaxis as benign without endoscopic evaluation, especially in children (foreign body), adolescent males (angiofibroma), or adults (malignancy) 1
• Do not discontinue anticoagulants or antiplatelet agents before attempting local measures unless bleeding is life-threatening 2