#172: Getting Nosy About Nosebleeds: A Primer on Epistaxis

March 25, 2026 | By Sam Masur

Audio

Stop the bleed and master the mucosal nuances of pediatric epistaxis in this high-yield session! We are joined by Pediatric Otolaryngologist Dr. Jennifer Lavin to deconstruct everything from the superficial vessels of Kiesselbach’s plexus to the rare, high-stakes diagnosis of Juvenile Nasopharyngeal Angiofibroma. Discover how to avoid incorrectly applied pressure, how to effectively utilize oxymetazoline, and exactly when to pivot to absorbable packing. This episode delivers the durable reference tools you need to handle any nosebleed with total clinical confidence.

Epistaxis Pearls

• Pinch the “Fleshy” Nares: The most common mistake in home management is applying pressure to the nasal bridge. Instruct caregivers to apply continuous, firm pressure to the lower, fleshy part of the nose (the nostrils) for at least 5 minutes without interruption to effectively compress Kiesselbach’s plexus.
• Nasal spray technique is everything: Remember what you’re aiming for! When using nasal oxymetazoline, spray with the right hand to the right nostril and towards the left ear, targeting the septum; and vice versa! When using nasal steroids, spray with the right hand into the left nostril, toward the left ear, targeting the conchae.
• JNA Red Flag: In adolescent males, recurrent epistaxis paired with progressive, unilateral nasal obstruction is a major red flag for Juvenile Nasopharyngeal Angiofibroma (JNA), and requires prompt ENT referral. 

Epistaxis Notes 

Anatomy, Etiology & Terminology

Epistaxis is divided by source of bleeding: anterior and posterior. Over 90% of pediatric nosebleeds are anterior, originating from a superficial collection of blood vessels known as Kiesselbach’s plexus, located on the anterior cartilaginous septum.

Posterior bleeds are rare, and arise from arterial sources in the posterior nasopharynx, such as the sphenopalatine or internal maxillary arteries. 

Common triggers for epistaxis includes digital instrumentation (nose picking), mucosal dryness, upper respiratory infections, and allergic rhinitis, leading to anterior epistaxis. Rare causes include neoplasm (Juvenile nasopharyngeal Angiofibroma), coagulopathy, and vascular disorders (Hereditary Hemorrhagic Telangiectasias). Seasonality in epistaxis is typically driven by changes in ambient humidity and nasal mucosal dryness.

According to Dr. Lavin, epistaxis can be labeled as recurrent, when it occurs more than twice per month and causes dysfunction in a child’s normal development. 

Acute Outpatient Management

Proper Technique: Apply firm, continuous pressure to the lower fleshy part of the nose (the nostrils) for a minimum of 5 to 30 minutes without releasing to “check” if it has stopped. Success with this technique is highly suggestive of an anterior bleed. Recommend against parents using tissue paper to pack the nares. If the bleeding persists after 30 minutes of high-quality pressure, or if there is life-threatening blood loss, patients should present to the ED. (AAFP Epistaxis)

Positioning: The patient should lean forward while pressure is applied. Leaning the head back allows for blood to drain to the oropharynx and may cause ingestion or aspiration of blood. 

Vasoconstrictors, such as Oxymetazoline 0.05% (Afrin) nasal sprays are used in tandem with compression as a first-line intervention, per guideline based expert opinion. Oxymetazoline remains off-label for this indication. Dosing: 1 spray per nostril, twice daily, up to 6 times; aim spray towards site of bleeding (i.e. the septum). This is different from the technique that should be used with steroid nasal sprays. For active bleeding, an oxymetazoline-soaked cotton ball can also be inserted into the nares before applying external pressure. Avoid using the medication more than 3 days in a row, per week.  

ED and Specialist Interventions

Pressure and Oxymetazoline: In Dr. Lavin’s experience, many bleeds stop once effective pressure is applied, and intranasal vasoconstrictors applied or re-applied in the emergency room. Barring hemodynamic instability or other red-flag signs, this remains the first step in emergency management. 

Chemical Cautery: Silver nitrate sticks can be used to cauterize a specifically identified bleeding vessel. These are caustic and should be used in moderation. Dr. Lavin notes that because of the difficulty with exam, cautery tends to be less useful. When it is used: avoid applying chemical cautery to both sides of the septum at the same time or perform “blanket” cautery over a wide area, as this increases the risk of septal perforation. 

Absorbable Packing: If bleeding is refractory, use absorbable materials like Surgicel, Nasopore, or Gelfoam, which have hemostatic properties or help to apply direct pressure to the nasal mucosa. These are preferred in children because they do not require painful removal and minimize mucosal trauma.  ENT should be consulted to guide decisions on packing placement, according to Dr. Lavin, although regional practice variations exist. 

Nonabsorbable Packing: Dr. Lavin notes that removable packing is uncomfortable and much less tolerable in the pediatric population. There are two main devices used for nonabsorbable packing, the “Merocel” Nasal Packing Angiocatheter is a rigid catheter placed in the nares parallel to the nasal floor, and expands when in contact with the nasal mucosa, to provide pressure to the site of bleeding. The other commonly used device is the “RhinoRocket”, which is an inflatable packing device, made of gauze surrounding an inflatable balloon, that can be insufflated after similarly inserting it into the nasal canal. Packing with gauze or similar material may also be performed manually. Packing is typically applied to the affected nares but sometimes bilateral application is required to achieve hemostasis. Avoid sedation as it may hinder a child’s ability to protect their airway. Nonabsorbable packing stays in for 3-5 days and is removed in ENT clinic on follow-up. Antibiotics are administered when nonabsorbable packing is administered, based on expert opinion, empirically covering GAS, such as with cephalexin. 

Tranexamic Acid (TXA): The use of TXA for epistaxis is not evidence-based but can be used, either as a solution on a small applicator into the nares, or via a nebulizer through a face mask to avoid the trauma of nasal insertion. 

ENT Consult: At Dr. Lavin’s institution, ENT is consulted early on in the course of a complicated bleed, to help guide the decision to place packing. Flexible nasopharyngoscopy has limited use in active or treated bleeds. Serious bleeds are either treated in the ED or triaged to the OR for rigid nasopharyngoscopy in a more controlled environment.

Diagnostic Evaluation

Dr. Lavin suggests that laboratory work is not routinely indicated. Especially for a simple, first-time, or occasional anterior nosebleed that resolves with pressure, even if it persists after 30 minutes. Consider a lab workup for a bleeding disorder and/or anemia if the patient has recurrent bleeding, refractory bleeding, or stigmata of secondary epistaxis (bruising, petechiae, anemia, etc.), or prior to outpatient referral (see below). 

Physical exam should focus on visualizing the anterior septum and examining the oronasopharynx. Exams are often limited, and may only reveal bright red blood, or fail to identify a source of a bleed after it has resolved, and occasionally may reveal a clot at the site of a recent bleed. When a bleed is identified, its location can assist with management decisions. Posterior bleeds and Juvenile Nasopharyngeal Angiofibromas (JNAs) cannot be visualized without dedicated rigid or flexible nasopharyngoscopy. The general exam should also focus on identifying stigmata of secondary causes of epistaxis. This may include oropharyngeal telangiectasias suggesting Hereditary Hemorrhagic Telangiectasia (HHT), or easy bruising or bleeding that may suggest leukemia or coagulopathy.

Prevention and Long-term Care

Mucosal Moisturization: Prevention is centered on keeping the septum moist. Dr. Lavin suggests applying nasal saline spray or gel twice daily to the anterior septum. Any emollient is acceptable, although Dr. Lavin prefers the nasal saline gels; She notes that some ENT physicians will also use mupirocin off-label to improve nasal saline moisturization. 

Environmental Control: Use a cool-mist humidifier in the bedroom during winter months or in dry climates. In patients who require chronic nasal cannula, the use of humidified air or humidified-mask or face-tent can reduce the drying effect of the nasal cannula. Patients with limited access to humidified ambient air are at higher risk for epistaxis.

Steroid Spray Technique: Intranasal corticosteroids (INCs) use may increase the risk of epistaxis, especially when applied to the nasal septum, thinning the mucosa above Kiesselbach’s plexus. Use the “cross-body” technique to minimize steroid application to the septum and to target the middle and inferior turbinates: use the right hand to spray into the left nostril, aiming the nozzle toward the ear (away from the septum). In Dr. Lavin’s experience, the application of nasal saline gel to the septum prior to INCS may also help to reduce this adverse effect. 

ENT Referral: Dr. Lavin suggests referral after the first complicated episode of epistaxis, recurrent epistaxis, patients with red flags or concern for JNA or HHT, when there is suspicion for posterior bleeding, or for secondary medical issues driven by epistaxis (anemia). Before referring, Dr. Lavin suggests basic labs including a CBC, coags, and a platelet function assay. 

Posterior Epistaxis

Posterior Epistaxis is characterized by brisk, sometimes bilateral bleeding from larger arterial sources in the more posterior nasopharynx, such as the internal maxillary or sphenopalatine arteries. Risk factors include vascular lesions, neoplasias (Juvenile Nasopharyngeal Angiofibromas, etc), a history of nasopharyngeal radiation, or other processes that impact the structural integrity of these arteries. It is often difficult to identify posterior bleeds. Signs may include bright red blood in the posterior nasopharynx, and failure of the above management. There may be more blood from the oropharynx than the nasopharynx, and posterior bleeds tend to be more brisk and can be bilateral. It is similarly difficult to differentiate between GI bleeds with hematemesis and pulmonary bleeds with hemoptysis, especially in the distressed child. A multidisciplinary approach is often required to identify a source of bleeding. 

After compression and vasoconstrictive nasal sprays have been exhausted, packing is the single most important first intervention for posterior nose bleeds, followed by IR-guided embolization or endoscopy with surgical ligation. 

Juvenile Nasopharyneal Angiofibroma

Juvenile Nasopharyngeal Angiofibroma (JNA): This is a rare, highly vascular, benign but invasive tumor occurring almost exclusively in adolescent males; due to their location they have potential for significant clinical complications and should be managed aggressively. Red flags include recurrent refractory epistaxis associated with unilateral nasal obstruction and cheek swelling. When suspected, Dr. Lavin suggests early ENT consult and CT scan of the sinuses.

Links

Rounds To Runways 

Saline Nasal Gel (example only, not sponsored or affiliated in any way)

Example epistaxis clip (example only, not sponsored or affiliated in any way)

Goal

Listeners will be familiar with a high-yield framework for managing pediatric epistaxis, from basic compression to pharmacologic and advanced interventions, as well as identify rare, high-stakes red flags and when ENT referral should be sought.

Learning Objectives

After listening to this episode, listeners will be able to:

• Identify Kiesselbach’s plexus as the primary anatomical source for over 90% of pediatric epistaxis cases.
• Demonstrate the correct technique for nasal compression, specifically pinching the fleshy nostrils for at least five continuous minutes while leaning the patient forward.
• Differentiate between anterior and posterior epistaxis based on the patient’s response to pressure and the presence of blood in the posterior pharynx.
• Implement a step-wise management protocol for refractory bleeding, utilizing topical vasoconstrictors, nebulized TXA, or absorbable nasal packing.
• Recognize high-stakes red flags, such as the presentation of Juvenile Nasopharyngeal Angiofibroma (JNA) in adolescent males with recurrent bleeding and progressive nasal obstruction.

Disclosures

Dr. Jennifer Lavin reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Srikureja N, Lavin J, Berk J, Chiu C, Masur S. “#172: Getting Nosy About Nosebleeds: A Primer on Epistaxis ”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ March 25, 2026.