A. Epistaxis is a common clinical problem that is usually mild and self-limited. However, epistaxis can become a severe and life-threatening emergency especially in the elderly.

B. Understanding the anatomy of the blood supply to the nose is essential.

1. The nose, like the rest of the face, has an abundant blood supply and may be principally divided into the following:

a. Branches from the internal carotid artery, namely the branches of the anterior and posterior ethmoid arteries from the ophthalmic artery.

b. Branches from the external carotid artery, namely branches from the maxillary artery (sphenopalatine and greater palatine arteries) and the facial artery (superior labial and angular arteries).

2. Internally, the lateral nasal wall is supplied posteroinferiorly by the sphenopalatine artery and superiorly by the anterior and posterior ethmoid arteries.

3. The nasal septum also derives its blood supply from the sphenopalatine and the anterior and posterior ethmoid arteries with the added contribution of the superior labial artery (anteriorly) and the greater palatine artery (posteriorly).

4. The Kiesselbach plexus (also called Little area) represents a region of the anteroinferior third of the cartilaginous nasal septum. It is an anastomotic network of vessels from the external and internal carotid arteries.

5. Anterior bleeding is most common and usually originates from Kiesselbach plexus.

6. Posterior bleeding usually originates from the sphenopalatine artery, is more common in the elderly, and is often more difficult to control.

A. Direct trauma to nasal mucosa is the most common cause of epistaxis.

1. Digital trauma (nose picking).

2. Nasogastric and feeding tube placement.

3. Nasotracheal intubation.

4. Blunt trauma (look for associated nasal fractures).

B. Primary and secondary coagulopathies are important considerations.

1. Nonsteroidal anti-inflammatory drugs (NSAIDs), anticoagulants.

2. von Willebrand disease.

3.

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