What criteria should I use to determine whether a patient with epistaxis requires referral to an ENT specialist?

Referral to an ear, nose, and throat (ENT) specialist should be considered for patients with epistaxis who have any of the following criteria:

• Suspected posterior nosebleed, due to higher risk of complications such as bradycardia, hypotension, hypoventilation, or aspiration from dislodgement or malpositioning.
• Children younger than 2 years of age presenting with epistaxis, as it is rare in this age group and often associated with injury or serious illness.
• Recurrent episodes of epistaxis accompanied by signs or symptoms suggestive of a serious underlying cause, including:
• Angiofibroma (suggested by nasal obstruction and severe epistaxis, typically in males aged 12–20 years).
• Suspected cancer (suggested by nasal obstruction, facial pain, hearing loss, eye symptoms such as proptosis or double vision, and/or persistent lymphadenopathy), especially in people over 50 years, those with occupational exposure to wood dust or chemicals, or of South Chinese or North African family origin.
• Telangiectasia (suggested by red or purple spots on fingertip pads, lips, nasal lining, ears, or face, possibly with a family history of hereditary haemorrhagic telangiectasia).
• Presence of an underlying cause for bleeding that requires specialist management.
• Patients with significant comorbidities such as coronary artery disease, severe hypertension, clotting disorders, or significant anaemia, who may require hospital admission.

Additionally, referral to a paediatrician is recommended for children under 2 years to rule out underlying causes and consider the possibility of maltreatment.

For patients not at high risk of serious underlying causes, treatment options can be discussed in primary care.

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