We report a patient with epistaxis who used cotton wool to pack his nose before reaching the hospital, and underwent further packing in the accident and emergency department, which probably pushed the cottonwool further back. This led to the formation of foreign body granuloma inside the nasal cavity. It is difficult to examine the nose without proper equipment and experience, and the examination is more difficult in the presence of active bleeding to find a foreign body such as cotton wool. Hence, it is important to ask the patient about any temporary pack they have used in the nose and to look for and remove it before inserting a proper pack. It is also important for trainees to have a better understanding of the different levels of management of epistaxis. Hence, we propose the term "epistaxis management ladder" for easy understanding of the treatment of epistaxis.