What is the evaluation for recurrent epistaxis (nosebleeds)?

From the Guidelines

Frequent nosebleeds should be evaluated by a healthcare provider if they occur more than once weekly, last longer than 20 minutes, or cause significant blood loss. Start by applying direct pressure to the nose by pinching the soft part for 10-15 minutes while leaning slightly forward. For evaluation, your doctor will examine your nasal passages, possibly using an endoscope, and may order blood tests to check for clotting disorders or anemia. Treatment options include cauterization of bleeding vessels, nasal packing, or addressing underlying causes. Common causes include dry air (treated with saline sprays or humidifiers), trauma, hypertension, blood thinning medications, or rarely, bleeding disorders. To prevent recurrence, use saline nasal sprays 2-3 times daily, apply petroleum jelly inside the nostrils with a cotton swab, use a humidifier in your bedroom, avoid nose picking, and consider using an over-the-counter antihistamine if allergies contribute to your symptoms. Nosebleeds occur frequently because the nose contains many blood vessels close to the surface that can rupture easily when the nasal tissue becomes dry or irritated, as noted in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.

Some key points to consider in the evaluation and management of frequent nosebleeds include:

• The clinician should distinguish the nosebleed patient who requires prompt management from the patient who does not, and document factors that increase the frequency or severity of bleeding for any patient with a nosebleed 1.
• The clinician should evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization 1.
• The clinician should assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients who have a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds 1.
• The clinician should educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care 1.

Overall, the management of frequent nosebleeds requires a comprehensive approach that includes evaluation, treatment, and prevention of recurrence, with the goal of improving patient outcomes and reducing morbidity and mortality, as emphasized in the clinical practice guideline: nosebleed (epistaxis) executive summary 1.

From the Research

Evaluation of Frequent Nosebleeds

• Frequent nosebleeds, also known as epistaxis, can be evaluated and managed using various methods, including medical and surgical interventions 2, 3, 4, 5, 6.
• The lifetime prevalence of epistaxis is approximately 60%, and 6-10% of affected individuals require medical attention 3.
• Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 5.

Treatment Options

• Compressive therapy is the first step to controlling anterior epistaxis, and oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1:1,000 may be useful adjuncts 5.
• Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 5.
• Topical therapy and nasal packing can be used if other methods are unsuccessful, and posterior nasal packing is often associated with pain and a risk of aspiration if it is dislodged 5.
• Tranexamic acid has been shown to reduce the risk of re-bleeding in patients with epistaxis, and its use as an adjunct to standard treatments may reduce the need for further intervention 2.
• Oxymetazoline has been found to be superior to tranexamic acid and epinephrine-lidocaine in achieving rapid hemostasis and reducing recurrence in epistaxis 4.

Management of Epistaxis

• Most cases of epistaxis can be managed in the outpatient setting, and more than 90% of cases arise from the anterior nasal circulation 5.
• Patients with posterior epistaxis are more likely to require hospitalization and twice as likely to need nasal packing 5.
• Interdisciplinary collaboration between primary care physicians, emergency physicians, and otolaryngologists is necessary for the effective management of severe or recurrent epistaxis 3.