What is the appropriate workup for epistaxis?

Workup for Nosebleed (Epistaxis)

The workup for epistaxis should focus on a targeted history documenting risk factors and severity assessment, followed by direct visualization to locate the bleeding source, with laboratory testing reserved only for patients with specific risk factors rather than routine use. 1

Initial Assessment and History

Begin by assessing acuity and severity to determine if timely intervention is needed 1. Your history must document specific factors that affect bleeding severity and recurrence:

Critical Risk Factors to Document 1

• Personal or family history of bleeding disorders
• Anticoagulant or antiplatelet medication use (including aspirin, warfarin, DOACs, clopidogrel)
• Intranasal drug use (cocaine, nasal sprays)
• Prior nasal or sinus surgery
• Nasal or facial trauma
• Nasal cannula oxygen or CPAP use
• Chronic kidney or liver disease
• Current medical conditions including hypertension

Bleeding Characteristics to Elicit

• Onset, duration, and frequency of nosebleeds
• Laterality (unilateral vs bilateral)
• Anterior vs posterior bleeding (blood dripping forward vs down throat)
• Other sites of bleeding or bruising
• Previous episodes and treatments attempted

Important caveat: While hypertension is commonly associated with epistaxis, the evidence does not support routinely lowering blood pressure acutely in patients with nosebleeds, as this may cause end-organ ischemia 1. Monitor blood pressure but avoid aggressive reduction unless there is hypertensive emergency.

Physical Examination

Direct visualization is essential to locate the bleeding source and guide treatment 2. Use:

• Nasal speculum and good light source (headlamp preferred)
• Examine for anterior bleeding points (most common, >90% of cases arise from anterior circulation) 2
• Assess for active bleeding vs resolved bleeding with visible vessel
• Look for signs of trauma, masses, or anatomical abnormalities

Laboratory Testing - Selective, Not Routine

Do not order routine coagulation studies on all epistaxis patients. Laboratory workup should be selective and targeted based on your history:

Order Coagulation Studies Only When: 3

• Patient is on anticoagulant medication
• Personal or family history of bleeding disorders
• Evidence of bleeding from multiple sites
• Recurrent epistaxis without obvious local cause

The evidence shows coagulation screening is useful specifically in patients on anticoagulant medication but not as routine testing 3. Unnecessary diagnostic procedures can delay first-line treatment 1.

Imaging

Imaging is not part of routine epistaxis workup. Consider imaging only for:

• Suspected tumor or mass
• Significant facial trauma
• Recurrent unilateral epistaxis requiring further investigation
• Failed conservative management requiring surgical planning

Risk Stratification

Patients at higher risk for complications or recurrence include those with 3:

• Sustained ambulatory hypertension
• Anticoagulant therapy
• Posterior bleeding source
• Elderly patients
• Patients with renal failure

These factors should guide your decision about disposition (outpatient vs admission) and intensity of follow-up.

Common Pitfalls to Avoid

1. Don't delay treatment while obtaining extensive workup - control bleeding first, investigate later 1
2. Don't routinely check coagulation studies - they're only useful in specific populations 3
3. Don't aggressively lower blood pressure unless hypertensive emergency exists 1
4. Don't assume all epistaxis needs ENT referral - most anterior bleeds can be managed in primary care 2, 4

When to Consider ENT Referral

Refer to ENT for 4:

• Active bleeding with no visible bleeding point (often fails initial management within 48 hours)
• Posterior epistaxis
• Recurrent severe epistaxis despite appropriate treatment
• Need for nasal endoscopy to identify bleeding source 1