Epistaxis, or bleeding from the nose, is a common event in sport, usually caused by a direct blow to the face in contact and collision sports such as rugby, football, boxing and martial arts, and sometimes happening spontaneously. Most nosebleeds are minor and settle with simple first aid, but some are heavier or persistent, and a nosebleed can be the visible sign of a more serious problem, from a nasal or facial fracture to a head injury, or a marker of a bleeding tendency.
Three messages run through the topic. Most bleeds come from the front of the nose and are controlled by leaning forward and pinching the soft part of the nose, so getting the first aid right stops the great majority. The pitchside priority is to control the bleeding while checking for associated injury. And a few features, a posterior bleed, heavy blood loss, a septal haematoma, or a suspected fracture or head injury, need escalation. For the sport and exercise medicine (SEM) clinician, the role is to control the bleed with correct first aid, recognise the minority that need cautery, packing or referral, look for and act on a septal haematoma, and assess for associated facial and head injury and for return to play.
The lining of the nose has a rich blood supply, and most nosebleeds arise at the front of the nasal septum from a meeting point of small vessels known as Little's area, which contains Kiesselbach's plexus. These anterior bleeds are the common type in sport, are usually visible from the front, and are generally straightforward to control with pressure. A smaller number of bleeds are posterior, arising further back from larger vessels around the sphenopalatine artery, and these tend to bleed more heavily, run down the throat, and are harder to see and control. They are more common in older, hypertensive or anticoagulated people, so they more often need specialist care.
In sport the usual cause is direct trauma to the nose, but other factors contribute and are worth considering, particularly with recurrent or heavy spontaneous bleeds. These include digital trauma from nose picking, dry or cold air and an inflamed nasal lining, and systemic factors such as anticoagulant or antiplatelet medication or a bleeding disorder. High blood pressure is associated with persistent or severe bleeding rather than being a proven direct cause.
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