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Nose bleeds account for most of the emergency ENT work load. Mostly they are minor, arising from Little’s area of the nasal septum. Conservative management with local pressure, ice packs and silver nitrate cautery is usually all that is required. In some cases the bleeding is more severe and may arise further back the septum. If pressure and ice packs are insufficient and the bleeding vessel is too far back to cauterize, then packing of the nasal cavity is necessary. These patients should be adequately resuscitated with intravenous rehydration and a full blood count should be obtained.

Different nasal packs may be used including merocel nasal tampons and BIPP (bismuth iodoform parriffin paste).
Patients who have nasal packs inserted should be admitted to hospital for observation.
This is necessary as:
- Bleeding may recur despite packing.
- Patients with nasal packs have altered pulmonary reflexes and may require oxygen.
- There is also a theoretical risk of displacement and inhalation of the pack.

Although this will control most anterior epistaxes, those patients with a severe posterior nasal haemorrhage will need a posterior pack. The simplest posterior pack is an inflatable balloon catheter which is passed into the postnasal space, inflated and secured under tension to occlude the choanae. An anterior BIPP or merocel pack is then inserted. Patients who have a posterior pack are at risk of developing acute otitis media and should be given prophylactic antibiotics.

The packs are normally left for 24 hours before removal. Very rarely does epistaxes require further treatment. Sometimes packing of the nose is difficult because of a deviated nasal septum. Surgery in the form of an SMR corrects the deformity and allows adequate packing. The operation also induces fibrosis of the septal mucosa which stops the haemorrhage. Should all this fail then examination under anaesthesia, with facilities for suction and diathermy, is performed and the bleeding point identified and diathermised. It is extremely unusual for arterial ligation or angiography with embolization to be necessary.

The aetiology of epistaxis is not fully understood but as it occurs in the elderly with a history of hypertension, it has been proposed that the nasal blood vessels are more fragile and susceptible to injury.