What is the treatment for repeated epistaxis (nosebleeds)?

Treatment of Repeated Epistaxis

For patients with repeated epistaxis, first-line treatment should include proper nasal compression with the head tilted slightly forward for 10-15 minutes, followed by nasal cauterization or topical treatments for recurrent cases. 1

Initial Management of Active Nosebleeds

First Aid Measures

• Proper positioning: Have the patient sit upright with head tilted slightly forward (to prevent blood from entering the airway or stomach) 1
• Nasal compression: Pinch the soft part of the nose (lower third) continuously for 10-15 minutes 1
• Breathing technique: Instruct patient to breathe through the mouth and spit out any blood 1
• Ice application: The usefulness of applying ice for epistaxis is unknown based on current evidence 1

When to Seek Medical Attention

• Bleeding that doesn't stop after 15 minutes of continuous pressure 1
• Patient becomes lightheaded during bleeding 1
• Trauma-related nosebleeds with signs of brain injury, nasal deformity, or facial fracture 1
• Patients on anticoagulant/antiplatelet medications or with blood clotting disorders should seek professional care unless bleeding has completely stopped 1

Medical Management of Recurrent Epistaxis

Topical Treatments

• Vasoconstrictors: Oxymetazoline nasal spray can be effective for controlling active bleeding in 65-75% of cases 2
• Tranexamic acid: Topical application promotes hemostasis in approximately 78% of patients (compared to 35% with oxymetazoline) 2, 3
• Nasal moisturizers: Regular use of saline sprays and nasal lubricants can help prevent recurrent epistaxis by maintaining mucosal moisture 1

Cauterization Options

• Chemical cautery: Silver nitrate application for visible bleeding vessels
• Electrocautery: More effective than chemical cauterization with fewer recurrences (14.5% vs. 35.1%) 2
• Important caution: Avoid bilateral simultaneous cauterization as it may increase risk of septal perforation 1

Nasal Packing

For cases not responding to compression and cauterization:

• Non-absorbable materials: Petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel) 2
• Absorbable materials: Dissolvable packing (Nasopore) 2
• Newer hemostatic materials: Hemostatic gauzes (Surgicel), thrombin matrix (Floseal), gelatin sponge (Spongostan) 2

Advanced Interventions for Persistent Cases

For severe or persistent epistaxis not responding to standard treatments:

• Endoscopic arterial ligation: Particularly of the sphenopalatine artery, with 97% effectiveness (vs. 62% for conventional packing) 2
• Endoscopic cauterization: More effective than ligation in some studies 2
• Embolization: For intractable cases, with approximately 80% success rate 2

Special Considerations

Patients on Anticoagulants

• Patients on anticoagulant/antiplatelet medications should seek medical attention for epistaxis 1
• Medication adjustment may be necessary in consultation with the prescribing physician 1

Underlying Conditions

• Evaluate for underlying conditions like hereditary hemorrhagic telangiectasia (HHT), blood disorders, or intranasal tumors in cases of recurrent epistaxis 1
• Hypertension management may be important in patients with recurrent epistaxis 1

Follow-up Care

• Follow-up within 30 days is recommended after treatment for recurrent epistaxis 1
• Patients should be educated about secondary symptoms requiring additional follow-up (persistent nasal blockage, pain, severe crusting) 1
• Routine follow-up is particularly important for patients who have undergone invasive treatments 1

Prevention of Recurrence

• Nasal moisturization: Regular use of saline sprays and petroleum-based ointments
• Humidification: Use of room humidifiers in dry environments
• Avoid digital trauma: Discourage nose picking and aggressive nose blowing
• Manage underlying conditions: Control hypertension, optimize anticoagulation therapy if applicable

Remember that while most nosebleeds are self-limited, recurrent episodes warrant medical evaluation to identify and address underlying causes.