What is the general treatment approach to epistaxis (nosebleed)?

Updated: May 08, 2020
  • Author: Quoc A Nguyen, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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In most patients with epistaxis, the bleeding responds to cauterization, nasal packing, or both. For those who have recurrent or severe bleeding for which medical therapy has failed, various surgical options are available. After surgery or embolization, patients should be closely observed for any complications or signs of rebleeding.

Medical approaches to the treatment of epistaxis may include the following:

  • Adequate pain control in patients with nasal packing, especially in those with posterior packing (However, the need of adequate pain control has to be balanced with the concern over hypoventilation in the patient with posterior pack.)
  • Oral and topical antibiotics to prevent rhinosinusitis and possibly toxic shock syndrome
  • Avoidance of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs)
  • Medications to control underlying medical problems (eg, hypertension, vitamin K deficiency) in consultation with other specialists

Arterial ligation

The choice of the specific vessel or vessels to be ligated depends on the location of the epistaxis. In general, the closer the ligation is to the bleeding site, the more effective the procedure tends to be. Ligation of the external carotid artery (ECA) can be performed with the patient under local or general anesthesia. Internal maxillary artery ligation has a higher success rate than ECA ligation because of the more distal site of intervention.

If bleeding occurs high in the nasal vault, consider ligation of the anterior ethmoidal artery, the posterior ethmoidal artery, or both. These arteries are approached through an external ethmoidectomy incision.


Bleeding from the ECA system may be controlled with embolization, either as a primary modality in poor surgical candidates or as a second-line treatment in those for whom surgery has failed.

Also see Anterior Epistaxis Nasal Pack, Posterior Epistaxis Nasal Pack, and Surgery for Pediatric Epistaxis.

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