This is commonest in the very young and the very old. It may present routinely as a recurrent problem, or in the acute situation when the patient cannot control the bleeding. The latter cases usually result in trivial haemorrhage by clinical standards, but may create a disproportionate amount of alarm. Occasionally, a prolonged nosebleed can cause significant hypovolaemia, especially in the elderly.

Published: 2nd August 2022 | Updated: 15th August 2022

Differential diagnosis

Common Diagnoses

  • Spontaneous (from Little’s Area; May be Aggravated by Nose-Picking and Sneezing)
  • Nasal Infection and Ulceration
  • Drugs (e.g. Anticoagulants)
  • Allergic Rhinitis (and Atrophic Rhinitis)
  • Hypertension (often with Atherosclerosis)

Occasional Diagnoses

  • Nasal Sprays (e.g. Corticosteroids)
  • Septal Granulomas and Perforations
  • Severe Liver Disease
  • Tumours of Nose and/or Sinuses
  • Abnormal Anatomy: Septal Deviation
  • Trauma: Nasal Fracture

Rare Diagnoses

  • Leukaemia
  • Thrombocytopenia
  • Coagulopathy: Haemophilia, Christmas and Von Willebrand’s Diseases
  • Vitamin Deficiencies: C and K
  • Hereditary Haemorrhagic Telangiectasia

Ready reckoner

Key distinguishing features of the most common diagnoses

Generalised BruisingNoNoNoYesNo
Discharge or CrustingNoNoYesNoNo
Nasal CongestionNoNoPossibleNoYes
Soreness/Pain in NosePossibleNoYesNoNo

Possible investigations

Likely: None (INR if on warfarin).

Possible: FBC, clotting studies.

Small Print: LFT, sinus X-ray, CT scan.

  • FBC: To check for thrombocytopenia or other signs of blood dyscrasia.
  • LFT: Severe (e.g. alcoholic) liver disease causes clotting problems.
  • Raised INR may reflect severe liver disease or warfarin overdose.
  • Further clotting studies: If disorders such as haemophilia or von Willebrand’s disease are suspected.
  • Sinus X-ray/CT scanning (usually secondary care): If tumour a possibility.

Top Tips

  • Emergency calls for children with acute epistaxis can usually be dealt with by clear, calm and authoritative advice on the telephone. First-aid measures should also be advised in the elderly, but hospital referral may prove necessary, as the bleeding can be considerable and more difficult to stop.
  • When children are presented in the surgery, establish any parental concerns. The main problem is often a fear of a blood disorder such as leukaemia rather than the inconvenience of the symptom itself.
  • In young or middle-aged adults with recurrent bleeding and ulceration, consider cocaine abuse.
  • Adults with recurrent epistaxis may well expect their blood pressure to be taken; either go ahead and take it, or, if the cause is obviously not hypertension, explain why there is no need.

Red Flags

  • Severe nosebleed unresponsive to standard first-aid measures is best dealt with in hospital – especially in the elderly. Refer urgently to ENT or A&E.
  • If recurrent nosebleeds with purpuric bruising, check FBC and coagulation screen urgently.
  • Beware of recent onset of persistent unilateral bloodstained discharge and obstruction in the middle-aged and elderly. Carcinoma of the nose, nasopharynx or sinus is possible.
  • Patients on warfarin should have an urgent INR and review of their dosage requirements.
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Website disclaimer

Pulse Reference is based on the best-selling book Symptom Sorter.

The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.

This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.