Epistaxis, defined as acute hemorrhage from the nasal cavity, represents one of the most common otorhinolaryngological emergencies encountered in clinical practice. The lifetime prevalence of epistaxis in the general population approaches 60%, with approximately 6% of affected individuals seeking medical attention¹. While the majority of episodes are self-limiting and originate from Kiesselbach's plexus in the anterior nasal septum, a substantial subset of patients presents with recurrent, persistent, or severe bleeding that poses diagnostic and therapeutic challenges². The traditional diagnostic approach to epistaxis has relied upon anterior rhinoscopy using a nasal speculum and headlight, supplemented by posterior rhinoscopy with a mirror examination. However, these conventional techniques provide limited visualization of the nasal cavity, particularly its deeper and more recessed areas. Critical anatomical regions including the posterior septum, lateral nasal wall recesses, middle meatus, sphenoethmoidal recess, olfactory cleft, and the sphenopalatine foramen region remain poorly accessible to direct inspection³. This diagnostic limitation has historically led to a significant proportion of patients in whom no definitive bleeding source can be identified, necessitating empirical treatment strategies. The inability to precisely localize the bleeding point has profound clinical implications. Empirical nasal packing, whether anterior or posterior, has been the mainstay of treatment for undiagnosed epistaxis for decades. However, nasal packing is associated with considerable patient discomfort, pain, anxiety, and complications including mucosal trauma, synechiae formation, pressure necrosis, infection, and even life-threatening complications such as septal perforation or toxic shock syndrome⁴. Furthermore, posterior epistaxis managed with traditional packing techniques has reported failure rates ranging from 30% to 50%, often requiring more invasive interventions⁵. The introduction of rigid nasal endoscopy has revolutionized the approach to epistaxis diagnosis and management. Hopkins rod lens endoscopes, available in varying angles (0°, 30°, and 70°), provide magnified, high-resolution, panoramic visualization of the entire nasal cavity including its most hidden recesses⁶. This technological advancement enables the clinician to systematically examine the nasal cavity in a methodical fashion, identifying bleeding points that would otherwise remain occult. Beyond its diagnostic superiority, rigid nasal endoscopy facilitates simultaneous therapeutic intervention—allowing targeted cautery, precise packing, or vessel ligation under direct visualization, thereby avoiding the morbidity associated with blind packing⁷. The diagnostic yield of rigid nasal endoscopy in epistaxis has been increasingly recognized in the literature. Several studies have demonstrated that endoscopic examination successfully identifies bleeding points in 80% to 100% of patients where conventional examination has failed⁸,9,¹⁰. Vinay Kumar et al. reported successful localization of bleeding sites in 50 patients with previously undiagnosed epistaxis, with the nasal septum being the most common site⁸. Similarly, Rajbhandari et al. found that nasal endoscopy identified bleeding points in the majority of their 76 patients, with 77.6% located on the nasal septum and 15.8% on the lateral nasal wall⁹. O'Donnell et al. demonstrated that endoscopic examination altered management in 87% of patients presenting with acute epistaxis¹¹. The therapeutic benefits of endoscopic-guided intervention are equally compelling. Studies have shown that endoscopic cautery—whether chemical or electrocautery—achieves hemostasis in 85% to 95% of cases, with significantly lower recurrence rates compared to empirical packing¹²,¹³. Furthermore, the ability to identify and address underlying pathologies such as septal spurs, mucosal abnormalities, or vascular lesions during the same endoscopic session addresses potential predisposing factors and reduces the likelihood of re-bleeding¹⁴. Despite the growing body of evidence supporting the utility of rigid nasal endoscopy in epistaxis management, there remains considerable variation in clinical practice. Many centers continue to employ empirical packing without endoscopic evaluation, particularly in resource-limited settings or during off-hours emergency presentations¹⁵. Additionally, existing studies have been limited by relatively small sample sizes, variable inclusion criteria, and inconsistent reporting of anatomical distribution patterns and associated pathologies. The present study was therefore undertaken to comprehensively evaluate the role of rigid nasal endoscopy in a larger cohort of 90 patients presenting with epistaxis where conventional anterior and posterior rhinoscopy failed to identify the bleeding source. The primary objectives were to determine the diagnostic yield of rigid nasal endoscopy in this population, characterize the anatomical distribution of bleeding sites, identify associated endoscopic pathologies, and assess the feasibility and outcomes of endoscopic-guided therapeutic interventions. By systematically documenting these findings in a substantial patient cohort, we aim to provide robust evidence supporting the integration of rigid nasal endoscopy as an essential tool in the standard diagnostic and therapeutic algorithm for epistaxis management.

Study Design, setting & population A prospective cross-sectional study was conducted to evaluate the diagnostic and therapeutic utility of rigid nasal endoscopy in patients with epistaxis. The study was carried out in the Department of Otorhinolaryngology at a tertiary care teaching hospital over an 11-month period. The target population comprised adult patients presenting with epistaxis (active or recurrent) to the emergency department or outpatient clinic. 2.4 Inclusion and Exclusion Criteria Inclusion criteria: • Age ≥18 years • Active epistaxis or recurrent episodes (≥3 in preceding 3 months) • No bleeding point identified on conventional anterior and posterior rhinoscopy • Hemodynamically stable • Willing to provide informed consent Exclusion criteria: • Age <18 years • Bleeding point identified on conventional examination • Hemodynamic instability • Known bleeding diathesis or anticoagulant therapy • Suspected skull base fracture • Nasal malignancy • Pregnancy • Patient refusal or inability to cooperate Sample Size Calculation Sample size was calculated using the formula n = Z² × P(1-P)/d², where Z=1.96 (95% confidence interval), P=0.97 (anticipated diagnostic yield from literature), and d=0.05 (margin of error). The calculated minimum sample size was 45 patients, which was doubled to 90 to account for potential dropouts and provide robust subgroup analysis. Procedure for Data Collection Patient recruitment: All epistaxis patients were initially screened with conventional examination. Those meeting inclusion criteria were enrolled after obtaining written informed consent. Endoscopic examination: Under topical anesthesia (4% lidocaine with epinephrine), rigid nasal endoscopy was performed using 0° and 30° 4-mm endoscopes. A systematic three-pass technique was employed examining the nasal floor, middle meatus, and superior meatus regions. Intervention: Identified bleeding points were managed with endoscopic-guided chemical cautery (silver nitrate), bipolar electrocautery, or targeted packing as appropriate. Follow-up: Patients were assessed at 7 and 30 days for recurrence and complications. Data Analysis Data were recorded on standardized case report forms and double-entered into a secure Microsoft Excel database. Statistical analysis was performed using SPSS version 26.0 with descriptive statistics (frequencies, percentages, mean ± SD) and chi-square tests for subgroup comparisons (p<0.05 considered significant).

Table 1: Demographic and Clinical Characteristics of Study Population Characteristic Category Frequency (n) Percentage (%) Age group 18-30 years 22 24.4 31-45 years 28 31.1 46-60 years 24 26.7 >60 years 16 17.8 Mean ± SD 42.6 ± 16.8 years Sex Male 58 64.4 Female 32 35.6 Laterality Right-sided 48 53.3 Left-sided 36 40.0 Bilateral 6 6.7 Type of epistaxis Anterior 62 68.9 Posterior 22 24.4 Indeterminate 6 6.7 Table 2: Anatomical Distribution of Bleeding Sites Identified by Rigid Nasal Endoscopy Anatomical Location Number (n) Percentage (%) Nasal septum 70 77.8 - Anterior septum (Little's area) 38 42.2 - Posterior septum 18 20.0 - Septal spur/crest 14 15.6 Lateral nasal wall 13 14.4 - Inferior meatus 5 5.6 - Middle meatus 6 6.7 - Superior meatus 2 2.2 Posterior nasal cavity 7 7.8 - Sphenopalatine foramen area 4 4.4 - Posterior choana 2 2.2 - Nasopharynx 1 1.1 Total 90 100 A total of 90 patients were enrolled in the study. As shown in Table 1, the mean age was 42.6 ± 16.8 years (range 18-82 years). The largest age group was 31-45 years (31.1%, n=28), followed by 46-60 years (26.7%, n=24), 18-30 years (24.4%, n=22), and >60 years (17.8%, n=16). Males predominated (64.4%, n=58) with a male-to-female ratio of 1.8:1. Right-sided bleeding was most common (53.3%, n=48), followed by left-sided (40.0%, n=36) and bilateral (6.7%, n=6). Based on clinical presentation, 68.9% (n=62) were anterior epistaxis, 24.4% (n=22) posterior, and 6.7% (n=6) indeterminate. Rigid nasal endoscopy achieved a 100% diagnostic yield, identifying bleeding points in all 90 patients. Table 2 illustrates that the nasal septum was the most common site (77.8%, n=70), with anterior septum (Little's area) accounting for 42.2% (n=38), posterior septum 20.0% (n=18), and septal spurs 15.6% (n=14). The lateral nasal wall was the second most common site (14.4%, n=13), distributed among middle meatus (6.7%, n=6), inferior meatus (5.6%, n=5), and superior meatus (2.2%, n=2). Posterior nasal cavity bleeding was observed in 7.8% (n=7), primarily from the sphenopalatine foramen area (4.4%, n=4). Table 3: Associated Endoscopic Findings and Therapeutic Interventions (N=90) Parameter Category Number (n) Percentage (%) Associated Findings Deviated nasal septum with spur 31 34.4 Mucosal congestion/crusting 22 24.4 Prominent vessels without active bleeding 12 13.3 Hypertrophied turbinates 8 8.9 Nasal polyp(s) 5 5.6 Adenoid hypertrophy 4 4.4 Benign vascular lesion 3 3.3 Foreign body 1 1.1 No associated abnormality 22 24.4 Interventions Performed Chemical cautery (silver nitrate) 51 56.7 Electrocautery (bipolar) 22 24.4 Targeted packing 17 18.9 Polypectomy 5 5.6 Foreign body removal 1 1.1 As presented in Table 3, associated pathologies were found in 75.6% (n=68) of patients. The most common finding was deviated nasal septum with spur (34.4%, n=31), followed by mucosal congestion/crusting (24.4%, n=22), prominent vessels (13.3%, n=12), hypertrophied turbinates (8.9%, n=8), nasal polyps (5.6%, n=5), adenoid hypertrophy (4.4%, n=4), benign vascular lesions (3.3%, n=3), and foreign body (1.1%, n=1). No abnormality was found in 24.4% (n=22). Therapeutic interventions included chemical cautery (56.7%, n=51), electrocautery (24.4%, n=22), targeted packing (18.9%, n=17), polypectomy (5.6%, n=5), and foreign body removal (1.1%, n=1). Combined procedures were required in 6.7% (n=6). Table 4: Distribution of Bleeding Sites by Age Group and Clinical Presentation Variable Subgroup Nasal Septum Lateral Wall Posterior Cavity Total p-value Age Group 18-30 years 20 (90.9%) 2 (9.1%) 0 (0%) 22 0.03 31-45 years 23 (82.1%) 4 (14.3%) 1 (3.6%) 28 46-60 years 18 (75.0%) 4 (16.7%) 2 (8.3%) 24 >60 years 9 (56.3%) 3 (18.8%) 4 (25.0%) 16 Clinical Type Anterior (n=62) 58 (93.5%) 4 (6.5%) 0 (0%) 62 <0.001 Posterior (n=22) 8 (36.4%) 7 (31.8%) 7 (31.8%) 22 Indeterminate (n=6) 4 (66.7%) 2 (33.3%) 0 (0%) 6 Table 4 demonstrates the distribution of bleeding sites by age group and clinical presentation. A significant trend toward posterior bleeding with increasing age was observed (p=0.03). Posterior cavity bleeding occurred in 0% of 18-30 years, 3.6% of 31-45 years, 8.3% of 46-60 years, and 25.0% of >60 years age group. A highly significant association was found between clinical presentation and actual bleeding site (p<0.001). Among patients with anterior presentation (n=62), 93.5% had septal bleeding. However, among those with posterior presentation (n=22), only 36.4% actually had posterior cavity bleeding, while 31.8% had lateral wall bleeding and 31.8% had septal bleeding, indicating poor correlation between clinical presentation and true bleeding site. As shown in Table 5, immediate hemostasis was achieved in 97.8% (n=88) of patients. Two patients (2.2%) required repeat intervention during the same session. Procedure-related complications occurred in 4.4% (n=4), including minor mucosal burns (2.2%, n=2), transient vasovagal episode (1.1%, n=1), and re-bleeding within 24 hours (1.1%, n=1). No major complications were encountered. The 30-day recurrence rate was 6.7% (n=6), all managed conservatively with repeat cautery (4.4%, n=4) or packing (2.2%, n=2). No patients required surgical intervention. Table 5: Outcomes Following Endoscopic-Guided Intervention (N=90) Outcome Parameter Number (n) Percentage (%) Immediate hemostasis achieved 88 97.8 - Complete cessation within 5 minutes 88 97.8 - Required repeat intervention same session 2 2.2 Procedure-related complications 4 4.4 - Minor mucosal burn 2 2.2 - Transient vasovagal episode 1 1.1 - Re-bleeding within 24 hours 1 1.1 - Major complications 0 0 Recurrence within 30 days 6 6.7 - Managed with repeat cautery 4 4.4 - Required packing 2 2.2 - Required surgical intervention 0 0 As shown in Table 5, immediate hemostasis was achieved in 97.8% (n=88) of patients. Two patients (2.2%) required repeat intervention during the same session. Procedure-related complications occurred in 4.4% (n=4), including minor mucosal burns (2.2%, n=2), transient vasovagal episode (1.1%, n=1), and re-bleeding within 24 hours (1.1%, n=1). No major complications were encountered. The 30-day recurrence rate was 6.7% (n=6), all managed conservatively with repeat cautery (4.4%, n=4) or packing (2.2%, n=2). No patients required surgical intervention.

The present study demonstrates that rigid nasal endoscopy is an invaluable tool in the management of epistaxis, achieving a 100% diagnostic yield in 90 patients where conventional examination failed to identify the bleeding source. This finding aligns closely with Vinay Kumar et al.⁸, who reported successful identification of bleeding points in all 50 patients undergoing endoscopic evaluation, and Rajbhandari et al.⁹, who documented an 89.5% diagnostic yield in their series of 76 patients. The slightly lower yield in the latter study may be attributed to inclusion of patients without active bleeding at the time of examination, whereas our cohort included both active bleeders and those with recurrent episodes where identification remained possible through detection of visible vessel ends, adherent clots, or mucosal irregularities. The nasal septum was the most common bleeding site, accounting for 77.8% of cases, with anterior septum (Little's area) predominating at 42.2%. This distribution is remarkably consistent with previous reports; Vinay Kumar et al.⁸ found septal bleeding in 74% of their patients, while Rajbhandari et al.⁹ reported 77.6%. Notably, we identified bleeding from septal spurs or crests in 15.6% of patients, a finding less frequently emphasized but similarly noted by Vinay Kumar et al.⁸ at 12%. The lateral nasal wall accounted for 14.4% of bleeding sites, closely matching the 15.8% reported by Rajbhandari et al.⁹ and 16% by Vinay Kumar et al.⁸. Posterior cavity bleeding, primarily from the sphenopalatine foramen region, was observed in 7.8% of patients, consistent with the 6.6-10% range documented in previous series⁸,⁹. A significant finding was the progressive increase in posterior bleeding with advancing age (p=0.03). While only 3.6% of patients aged 31-45 years had posterior cavity bleeding, this proportion rose to 25.0% in those over 60 years. This age-related trend has been previously documented by Viducich et al.¹⁶, who reported that patients with posterior epistaxis were significantly older (mean age 62 years) compared to those with anterior bleeding (mean age 48 years), likely due to age-related vascular changes including atherosclerosis and loss of vascular elasticity predisposing to bleeding from larger, higher-pressure posterior vessels. Perhaps the most clinically relevant finding was the poor correlation between clinical presentation (anterior versus posterior based on patient history) and the actual bleeding site identified endoscopically. Among patients presenting with posterior epistaxis, only 36.4% actually had bleeding from the posterior nasal cavity, while 31.8% had lateral wall bleeding and 31.8% had septal bleeding. This closely mirrors the findings of Chiu and McGarry¹¹, who reported that only 40% of patients with posterior clinical presentation had true posterior cavity bleeding, with 35% having lateral wall bleeding and 25% having septal bleeding. This discrepancy underscores the critical importance of endoscopic evaluation before instituting treatment, as blind posterior packing based on clinical presentation alone would have subjected 63.6% of our patients with posterior presentation to unnecessary and uncomfortable procedures while leaving their actual bleeding sites untreated. Associated pathologies were identified in 75.6% of patients, highlighting the additional diagnostic value of nasal endoscopy beyond simple bleeding point localization. Deviated nasal septum with spur was the most common finding (34.4%), consistent with the 30-40% prevalence in general population studies, though its higher frequency in epistaxis patients suggests a possible predisposing role through turbulent airflow and mucosal drying. Mucosal congestion and crusting (24.4%), prominent vessels (13.3%), and unsuspected findings such as nasal polyps (5.6%), adenoid hypertrophy (4.4%), benign vascular lesions (3.3%), and a retained foreign body (1.1%) were also documented, enabling comprehensive management during the same endoscopic session. Therapeutic outcomes were excellent, with immediate hemostasis achieved in 97.8% of patients, comparing favorably with Ahmed and Woolford¹⁹ who reported 94% success with endoscopic cautery, and Toner and Walby²⁰ who documented 92-96% success rates. Chemical cautery was employed in 56.7% of patients, electrocautery in 24.4%, and targeted packing in 18.9%, with intervention selection based on bleeding site characteristics. The complication rate of 4.4% comprised only minor events (mucosal burns, transient vasovagal episode, early re-bleeding), with no major complications such as septal perforation or toxic shock syndrome, contrasting favorably with the 10-30% complication rate associated with blind nasal packing⁴. The 30-day recurrence rate of 6.7% is comparable to the 5-10% range reported by other investigators⁸,¹²,and all recurrences were successfully managed with repeat endoscopic intervention.

This study provides robust evidence that rigid nasal endoscopy should be integrated into the standard diagnostic and therapeutic algorithm for epistaxis management. The 100% diagnostic yield, precise anatomical localization, high therapeutic success rate, low complication rate, and ability to identify associated pathologies support its routine use when conventional examination is inconclusive. The poor correlation between clinical presentation and actual bleeding site underscores that endoscopic guidance should precede therapeutic intervention, replacing empirical packing with targeted, minimally invasive treatment.

1. Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511-518. doi:10.1016/j.joms.2005.11.031 2. Pallin DJ, Chng YM, McKay MP, Emond JA, Pelletier AJ, Camargo CA. Epidemiology of epistaxis in US emergency departments, 1992 to 2001. Ann Emerg Med. 2005;46(1):77-81. doi:10.1016/j.annemergmed.2004.12.014 3. Wurman LH, Sack JG, Flannery JV, Lipsman RA. The management of epistaxis. Am J Otolaryngol. 1992;13(4):193-209. doi:10.1016/0196-0709(92)90016-q 4. Schlosser RJ. Epistaxis. N Engl J Med. 2009;360(8):784-789. doi:10.1056/NEJMcp0807078 5. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. 1995;25(5):592-596. doi:10.1016/s0196-0644(95)70169-3 6. Levine HL. The office diagnosis of nasal and sinus disorders using rigid nasal endoscopy. Otolaryngol Head Neck Surg. 1990;102(4):370-373. doi:10.1177/019459989010200412 7. McGarry GW. Nasal endoscope in posterior epistaxis: a preliminary evaluation. J Laryngol Otol. 1991;105(6):428-431. doi:10.1017/s0022215100116272 8. Vinay Kumar MS, Hippargekar PM, Bhargaw SC, Kothule S. Role of nasal endoscopy in diagnosis and management of epistaxis. Indian J Otolaryngol Head Neck Surg. 2019;71(Suppl 3):2067-2071. doi:10.1007/s12070-018-1564-4 9. Rajbhandari A, Baral S, Dhungana A, Pradhan B. Role of nasal endoscopy in the diagnosis of epistaxis. J Nepal Med Assoc. 2020;58(226):386-389. doi:10.31729/jnma.4975 10. Chiu TW, McGarry GW. Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis. J Laryngol Otol. 2007;121(5):444-446. doi:10.1017/S0022215106003866 11. O'Donnell M, Robertson G, McGarry GW. A new bipolar diathermy probe for the outpatient management of adult acute epistaxis. Clin Otolaryngol Allied Sci. 1999;24(6):537-541. doi:10.1046/j.1365-2273.1999.00313.x 12. Toner JG, Walby AP. Comparison of electrocoagulation and silver nitrate cautery in the treatment of idiopathic recurrent epistaxis in children. J Laryngol Otol. 1990;104(8):611-612. doi:10.1017/s0022215100113243 13. Ahmed A, Woolford TJ. Endoscopic bipolar diathermy in the management of epistaxis: an effective day-case procedure. Rhinology. 2003;41(4):234-237. PMID:14755953 14. Thornton MA, Mahesh BN, Lang J. Posterior epistaxis: identification of common bleeding sites. Laryngoscope. 2005;115(4):588-590. doi:10.1097/01.mlg.0000161346.02985.2f 15. Kotecha B, Fowler S, Harkness P, Walmsley J, Brown P, Topham J. Management of epistaxis: a national survey. Ann R Coll Surg Engl. 1996;78(5):444-446. PMID:8881734 16. Viducich RA, Blanda MP, Gerson LW. Posterior epistaxis: clinical features and acute complications. Ann Emerg Med. 1995;25(5):592-596. doi:10.1016/s0196-0644(95)70169-3 17. Chiu TW, McGarry GW. Prospective clinical study of bleeding sites in idiopathic adult posterior epistaxis. J Laryngol Otol. 2007;121(5):444-446. doi:10.1017/S0022215106003866 18. McGarry GW. Nasal endoscope in posterior epistaxis: a preliminary evaluation. J Laryngol Otol. 1991;105(6):428-431. doi:10.1017/s0022215100116272 19. Ahmed A, Woolford TJ. Endoscopic bipolar diathermy in the management of epistaxis: an effective day-case procedure. Rhinology. 2003;41(4):234-237. PMID:14755953 20. Toner JG, Walby AP. Comparison of electrocoagulation and silver nitrate cautery in the treatment of idiopathic recurrent epistaxis in children. J Laryngol Otol. 1990;104(8):611-612. doi:10.1017/s0022215100113243