Epistaxis and ENT emergencies

• Epistaxis is common: about 60% of people have one nosebleed in their lifetime, and 80 to 90% come from the anterior nose, usually the Kiesselbach plexus on the anterior septum.^[1] In the United States about 1 in 200 emergency department attendances is for epistaxis, and incidence rises after the sixth decade.^[1]
• Emergency care is simple and works for most: pinch the soft part of the nose firmly for 10 to 15 minutes while leaning forward, then add a topical vasoconstrictor with local anaesthetic if needed.^[1]
• If a bleeding point can be seen, it can often be closed with chemical or electrical cautery. If it cannot, the usual next step is an anterior nasal pack.^[1]
• Topical tranexamic acid may reduce early re‑bleeding in anterior epistaxis compared with a matched vehicle, but its effect on the need for further packing is uncertain.^[1]
• The other emergencies on this page are a nasal or an ear foreign body, sudden sensorineural hearing loss, and the airway threats of quinsy and epiglottitis. All are time‑critical: a dead battery in a nose burns within minutes, sudden hearing loss treated within days has a better chance of recovery, and quinsy or epiglottitis can obstruct the airway.
• Management here follows the AAO‑HNS Clinical Practice Guideline on Nosebleed (2020) and its executive summary, the British Rhinological Society (INTEGRATE) consensus on the hospital management of epistaxis (2017), and the AAO‑HNS Clinical Practice Guideline on Sudden Hearing Loss (update, 2019).^[2][3][4]

By the end of this page you should be able to:

1. Take a safe history and examination in a patient with nosebleed, and know when bleeding is posterior.
2. Apply the stepwise management of epistaxis: emergency care, then cautery, then packing, then specialist options.
3. Recognise when bleeding is not from a simple anterior source, and when to involve an ENT specialist on the day.
4. Manage nasal and aural foreign bodies, including the special danger of a button battery.
5. Diagnose sudden sensorineural hearing loss, start the right early investigations and treatment, and arrange follow‑up.
6. Recognise quinsy and epiglottitis as airway emergencies, cross‑checked with MedGrasp pages on retropharyngeal and peritonsillar abscess and on croup, epiglottitis and bacterial tracheitis.
7. Adapt this care to settings with limited equipment and refer at the right time.

Epistaxis itself is a symptom, not a diagnosis. A complete topic treats it as a presentation, and this page does the same for the related emergencies: foreign body, sudden sensorineural hearing loss, and deep neck and supraglottic infection.

• Anterior (most common). Accessible to direct pressure and local treatment; usually one sided.^[1]
• Posterior. Often heavier, may flow into the throat, and may not stop with anterior measures; more common in older people.
• Local or systemic cause. Trauma, dryness, infection, anticoagulant or antiplatelet drugs, blood pressure, and bleeding disorders can all precipitate it; ask about them.

• Lifetime prevalence is about 60%, and only a minority need medical care; hospital admission is uncommon but accounts for a disproportionate share of cost.^[1]
• 80 to 90% of episodes arise from the anterior nasal cavity.^[1]
• 1 in 200 ED attendances in the United States is for epistaxis, with a steep rise in incidence after the sixth decade.^[1]
• Sudden sensorineural hearing loss affects 5 to 27 per 100,000 people each year, roughly 66,000 new cases per year in the United States.^[4][5]
• Epiglottitis became rare in children after Haemophilus influenzae type b (Hib) vaccination: current annual Hib infection rate in preschool children is 0.22 per 100,000, versus more than 20 per 100,000 before vaccination.^[6]

Most nosebleeds start from a small anterior vessel that dries, crusts and bleeds, often after nose picking, trauma, infection or a change in humidity. Bleeding disorders and anticoagulant or antiplatelet drugs do not usually cause epistaxis on their own but make it harder to stop. In the bleed that does not stop, ask about hypertension, anticoagulation, aspirin, clopidogrel, liver disease and previous epistaxis. Posterior bleeds are more likely in older patients with hardened arteries.

The Kiesselbach plexus is a rich network of small vessels on a thin septal lining with little soft tissue behind it. When it bleeds, the blood comes forward; when a posterior vessel bleeds, blood runs backward into the pharynx and is swallowed or spat. That difference drives the whole assessment: a patient sitting forward and spitting blood from the front is manageable; a patient swallowing blood may be bleeding posteriorly and deteriorating quietly. Drying and crusting damage the mucosa and start the cycle, which is why moisturising sprays help prevention.

• Ask when the bleeding started, which side, how much blood, and whether it was swallowed or spat. The amount swallowed is easily underestimated.
• Ask about previous episodes, hypertension, drugs (especially anticoagulants and antiplatelets), liver or bleeding disorders, recent surgery or trauma, and whether there is a family history.
• Ask whether the bleeding is tied to a cold, allergy or nose picking, and whether it is worse in dry air.

• Look before touching: observe the patient quietly. If they are unstable, treat first and examine later.
• Check pulse, blood pressure and oxygen saturation; do not rely on the amount of blood seen.
• Sit the patient forward, have a kidney dish ready, and shine a good light into the nose with a speculum.
• Find the point: its position (anterior or posterior), which side, diffuse ooze or a discrete vessel, and blood flowing behind the septum or into the postnasal space.
• Note septal deviation, crusting, ulcers, masses, foreign bodies and telangiectasia (which suggest hereditary haemorrhagic telangiectasia).
• Use suction gently after the patient has blown the nose; do not agitate them.

Bleeding from the nose is usually straightforward; the important distinction is local disease from a systemic bleeding tendency, and an anterior bleed from a posterior one.

In uncomplicated anterior epistaxis, no test is needed; investigate when the pattern is unusual, heavy or recurrent.

• Bedside. Pulse, blood pressure, oxygen saturation, temperature if unwell, and a careful nasal examination after suction.
• Laboratory. A full blood count and coagulation tests when bleeding is heavy, recurrent or unexplained; check the INR if on warfarin. Routine laboratory testing is not advised for sudden sensorineural hearing loss, but the nosebleed patient with a bleeding tendency needs it.^[4]
• Imaging. Not usually required for epistaxis. A lateral neck film or other imaging is for airway emergencies and foreign bodies (see below). Postoperative or bleeding after sinus surgery is a separate, specialist problem.
• Nasal endoscopy. Worthwhile in recurrent, one‑sided or heavy bleeds, and for masses.

There is no formal score for epistaxis. Points that change management:

• Source visible and anterior. Cautery is possible and first‑line.
• No visible source or diffuse ooze. Local pressure and packing are needed, and the patient should be reassessed after removal.
• Posterior source suspected. Treat as an emergency and involve ENT on the day.
• The bleed does not stop with 10 to 15 minutes of correct pressure. Move to the next step rather than repeating the same failed measure.^[1]

1. Airway and circulation first. Any patient in shock, with airway compromise or with heavy ongoing bleeding needs immediate resuscitation and senior help.
2. Position. Sit the patient forward; do not have them lying back swallowing blood.
3. Emergency care. Pinch the soft, cartilaginous part of the nose firmly between thumb and forefinger for 10 to 15 minutes. The patient can add a cold pack to the bridge of the nose and a vasoconstrictor spray to the bleeding side if available.^[1]
4. Bleeding fighters in shock. If the patient is haemodynamically unstable, control the airway, give oxygen, get intravenous access, check the blood group and cross‑match, and call for senior and specialist help early. Reverse specific agents where indicated.

Cautery, where a point can be seen, is the first definitive treatment after failed emergency care. Use it after topical anaesthesia and vasoconstriction; limit cautery on both sides of the septum to avoid septal perforation.

Nasal packing remains standard practice when cautery fails or no source is visible. Absorbable matrices and powders have been introduced to achieve haemostasis without a tampon that has to be removed. Non‑resorbable packing can hurt during insertion and removal and can cause mucosal injury, infection, pressure necrosis and rarely toxic shock; it can also prolong the emergency department stay and lead to admission. In pooled trials:

• Floseal (a gelatin‑thrombin matrix) had a higher physician‑rated effectiveness score than conventional nasal packing (9.9 ± 0.4 versus 7.7 ± 3.6) and failure‑related crossover in 3% rather than 23% of patients.^[1]
• Bleeding arrest within 10 minutes occurred in 71.0% of patients given topical tranexamic acid on a pledget, versus 31.2% given anterior nasal packing.^[1]
• Bleeding cessation at 15 minutes occurred in 91.1% with atomised tranexamic acid plus external compression and in 93.3% with Merocel packing.^[1]
• Packing type made little difference to immediate haemostasis in comparative trials (Singer Rapid Rhino versus Rhino Rocket 90% in both, Moumoulidis Merocel 81% versus Rapid Rhino 76%, Murray Floseal 77% versus traditional packing 85%).^[1]

These numbers come from small, often open‑label trials, so choose the method you and your unit can use well, and prefer resorbable materials when pain and removal logistics matter.

Topical tranexamic acid has been studied as a drug treatment for acute anterior epistaxis, given as a 500 mg in 5 mL pledget or by atomised spray with external compression. Pooled results from three trials found re‑bleeding within 24 hours fell compared with a matched vehicle (risk ratio 0.39, 95% confidence interval 0.17 to 0.89), an absolute reduction of 19.1 percentage points, a number needed to treat of 5. The effect on the need for further packing was less certain (risk ratio 0.59, 95% confidence interval 0.22 to 1.59). In single trials, atomised tranexamic acid at 500 mg and 1000 mg gave bleeding cessation at 5 minutes in 52.0% and 64.7% of patients versus 29.4% with saline. The largest neutral trial (NoPAC, 496 patients) found no benefit when a different, smaller dose and a later treatment point were used, so do not present tranexamic acid as a proven replacement for packing. Follow local formulary guidance and the safety guidance at the end of the trials.^[1]

Nasal foreign bodies are mainly a problem of children aged 1 to 5 years, who insert objects attracted by their colour and shine. Button batteries are the dangerous subset.

• Remove early. A button battery can cause a septal perforation even after an hour. In a large series 162 of 176 button batteries (92.05%) were identified within 24 hours, epistaxis occurred in 164 cases (93.18%), and 12 cases (6.81%) needed removal under general anaesthesia.^[8]
• Calm, cooperate, visualise. Calm the child, enlist the parents, use good light, suction secretions, then attempt removal with a suitable hook or forceps.
• Button batteries look different on X‑ray. On radiographs they show a step‑off between anode and cathode on the anteroposterior view and a double ring or halo on the lateral view.^[8]
• Do not delay imaging to wait for a clinic. When a battery is suspected, one failed attempt is not a reason to wait; attempt removal promptly and arrange surgery under general anaesthesia with nasal endoscopy if outpatient removal fails.- Hooks and curettes. An L-shaped hook, Rosen needle, or ring/wax curette passes beyond a smooth or round object and draws it out; the Rosen needle tip is ideal for beads with a hole in the centre. A refashioned hypodermic needle can substitute in a non-specialist setting. Ring curettes are less traumatic than L-shaped hooks.^[7]
• Hydrogen peroxide or acetone. Place warmed acetone or 3% hydrogen peroxide in the canal for 10 minutes, then peel or flush it out. This is for superglue or gum. Warm the liquid first and never use it when the drum may be perforated or its status is unknown, because of ototoxicity.^[7]
• Superglue. Cyanoacrylate on a cotton-tipped applicator applied for 30 seconds can pluck out a non-graspable object that blocks the whole canal, but care is needed because it sets in seconds on a damp ear.^[7]
• Microsuction. Useful for spherical objects, friable material and dead insects; warn the patient about the loud noise and the small risk of injury. Antibiotic drops (fluoroquinolones only if the drum may be perforated) are used if the skin has been traumatised.^[7]

SSNHL is a true emergency: most recoveries happen early, and the window for useful treatment is measured in days.

• Look for the red flags in the history. Unilateral deafness with tinnitus and sometimes vertigo, waking to one dead ear, or a hearing drop noticed after a cold or loud noise. Ask about recent infection, vascular risk factors, new medicines, neurological symptoms, headache and eye or brain symptoms.
• Distinguish sensorineural from conductive loss at the bedside. Use tuning fork tests (Rinne and Weber) or bedside otoscopy; a blocked ear canal or middle ear problem is a different diagnosis. A gently impacted wax plug can mimic deafness; do not assume, check.
• Risk factors and associations. It is more common with older age and vascular risk, and both herpes viruses and SARS-CoV-2 have been associated with it in small studies.^[5]

Investigations follow the AAO‑HNS 2019 guideline:

• Audiometry as soon as possible, and within 14 days of onset, to confirm sensorineural loss, measure how much and which frequencies.- No routine head CT. Routine CT of the head is not recommended; it does not help and delays care. Targeted imaging is a different matter.^[4]
• No routine blood tests. Laboratory panels do not help in a typical case.^[4]
• MRI of the internal auditory meatus or brain (or an auditory brainstem response if MRI is not possible) should be arranged to exclude a retrocochlear mass, done as an outpatient when the patient is stable.^[4]
• Follow-up audiometry at the end of treatment and again within 6 months.^[4]

Treatment, discussed and agreed with the patient:

• Systemic (oral) corticosteroids may be offered as initial therapy within 2 weeks of onset.^{[4] [5]}
• Systemic steroids are optional, not automatic: the best evidence is limited and the benefit, where it exists, is modest, so decision making should be shared.^[4][5]
• The usual regimen in review data is oral prednisone 60 mg a day for 14 days or oral prednisolone 1 mg/kg a day (maximum 60 mg) for 7 to 14 days. Discuss with the local formulary and the patient's comorbidities (diabetes, hypertension, peptic ulcer, psychiatric history).- Intratympanic steroid can be used as initial, combined or salvage therapy. As primary monotherapy it is non‑inferior to oral steroids, with mean improvements of about 29 dB versus 31 dB in one multicentre trial; salvage use after a failed systemic course carries the strongest evidence (odds ratio 6.04, number needed to treat about 3). Combined initial therapy improves outcomes more than oral steroids alone. Intratympanic methylprednisolone 40 mg/mL is given in four injections over two weeks in the monotherapy trial data. The intratympanic route avoids systemic side effects, so it is attractive when diabetes or hypertension make oral steroids risky.^[5]
• The AAO‑HNS option is intratympanic steroid for incomplete recovery 2 to 6 weeks after onset. ^[4]
• Hyperbaric oxygen combined with steroid therapy is an option within 2 weeks of onset, or as salvage within 1 month. ^[4]
• The guideline recommends against routine antivirals, thrombolytics, vasodilators and vasoactive agents in idiopathic SSNHL. ^[4]
• Shared decision making and counselling about natural history, the limits of the evidence and audiologic rehabilitation for people left with hearing loss or tinnitus are strong recommendations. ^[4]

Both quinsy (peritonsillar abscess) and epiglottitis are clinical diagnoses in which the airway decides the outcome. Full detail lives on the MedGrasp pages on retropharyngeal and peritonsillar abscess and on croup, epiglottitis and bacterial tracheitis; the cross-check below is the emergency essentials.

• Typical patient: adolescent or young adult with fever, severe one-sided sore throat, muffled "hot potato" voice, trismus and a uvula pushed away from the affected side. Needle aspiration or incision and drainage is usually needed, with broad intravenous antibiotics and a single dose of intravenous dexamethasone as adjunct. Small abscesses without muffled voice, drooling or trismus can sometimes be treated without drainage. Most deep neck infections get broad intravenous antibiotics directed at oral flora, with upgrades for sepsis or MRSA risk. Full detail and local doses are on the MedGrasp page on retropharyngeal and peritonsillar abscess.### Epiglottitis

• Adult and paediatric presentation: sudden onset over hours of fever, sore throat, drooling, dysphagia, muffled voice, stridor and the characteristic tripod posture. The child (or adult) sits forward with the neck extended and tongue out to keep the airway open; drooling is the hallmark. Hib disease is now uncommon after routine vaccination; non-typeable and non-b strains and other organisms still cause it.^[6]

• Do not examine the throat with a tongue depressor, do not lay the patient flat, and do not distress them. Airway work must come first. Keep them upright, calm, nil by mouth, with an experienced airway team immediately available. ^[6]

• Antibiotics. Start intravenous empirically to cover the expected organisms: a third-generation cephalosporin (ceftriaxone) plus an anti-staphylococcal agent with MRSA cover (clindamycin). ^[6]

• Steroids as adjunct reduce oedema intravenously or as the patient improves; imaging supports but should not delay treatment, and the lateral neck film may show the enlarged, rounded epiglottis ("thumbprint" sign). ^[6]

• In severe paediatric detail, see the MedGrasp page on croup, epiglottitis and bacterial tracheitis.

• Epistaxis. Recurrent bleeding, anaemia, haemodynamic compromise and, rarely, posterior bleed with aspiration. Packing can cause pain, mucosal injury, infection, pressure necrosis and, rarely, toxic shock. Packs must be removed on time and checked for the second side. ^[1]
• Nasal foreign bodies. Epistaxis (93.18%), rhinitis (30.68%), sinusitis (34.09%), adenoid hypertrophy (21.02%), nasal adhesion, and septal perforation (17.61%) after button batteries. Unrecognised batteries lodge for weeks and damage the septum. ^[8]
• Aural foreign bodies. Canal abrasion, infection, tympanic membrane perforation, vertigo, retained fragments and, rarely, middle-ear damage. Prophylactic antibiotic drops only after trauma (fluoroquinolone only if the drum is or may be perforated). ^[7]
• SSNHL. Permanent unilateral hearing loss in a significant proportion; significant tinnitus, reduced quality of life and, in an older or at-risk patient, an underlying cerebellopontine or vascular cause that must not be missed (MRI). ^[4][5]
• Quinsy and epiglottitis. Airway obstruction, aspiration, mediastinitis, internal jugular vein thrombosis and Lemierre syndrome; sepsis and, with epiglottitis, a mortality quoted at 1 to 20% overall. ^[6]

Most anterior nosebleeds stop with emergency care or simple treatment. For SSNHL, earlier treatment is better: corticosteroids within the first 2 weeks and salvage intratympanic steroid within 2 to 6 weeks can improve hearing, and fast follow-up protects against a missed serious cause. ^[4][5] Button battery and airway emergencies do well when recognised and treated quickly.

• Dryness prevention reduces recurrent anterior epistaxis: saline douches, humidification and short fingernails. Treat chronic rhinitis and allergy.
• Hib and, where available, pneumococcal vaccination have transformed epiglottitis; keep the vaccination schedule complete. ^[6]
• Teach parents that any small button battery is a near-emergency if it is in the ear or nose, and that nuts, beads and other small objects should be kept away from toddlers.
• Recurrent unilateral epistaxis or hearing loss should be investigated for a local cause.

• Children. Nasal and aural foreign bodies dominate. Button batteries, superglue in the ear and punctured tympanic membranes are the classic pitfalls. Use restraint, good light, small instruments and a low threshold for general anaesthesia.
• Adults. Posterior bleeds, epistaxis on anticoagulants and SSNHL (which is an adult condition in the guideline) are more common. Shared decision making with patients on warfarin or direct oral anticoagulants is important.
• Pregnancy and older adults. Hormonal rhinitis can bleed. Avoid non-essential irradiation. Follow local formulary for drug choices.

• Epistaxis. Pinching the soft nose for 10 to 15 minutes costs nothing and works for most cases; a topical vasoconstrictor and a working light are the next affordable steps. Silver nitrate cautery and simple anterior packing are cheap and effective for persistent bleeding; posterior packs are harder and need referral. ^[1]
• Foreign bodies. A headlight or torch, a good speculum and improvised hooks can remove most objects. Avoid risky tools without magnification; refer after one failed attempt.
• SSNHL. A tuning fork and bedside otoscopy establish sensorineural loss cheaply; audiometry should be arranged urgently where possible. Treatment choices should follow what the local formulary and audiology service can support.
• Airway emergencies. Position, oxygen, dexamethasone where appropriate and intravenous antibiotics are universal; safe airway management needs trained staff and equipment, so transfer early before collapse.

Plain text (no links): croup, epiglottitis and bacterial tracheitis; retropharyngeal and peritonsillar abscess; foreign body aspiration and choking; acute pharyngitis; acute sinusitis; unconscious patient and coma; allergic reaction and anaphylaxis; sepsis; cardiac arrest and life support; general anaesthesia and airway management; ENT surgery basics; otitis externa; childhood hearing and vision disorders. Additional MedGrasp topics on cerumen impaction, epistaxis cauterisation pathways and hereditary haemorrhagic telangiectasia will expand cross-linking once published.