What is the treatment for nasal bleeding (epistaxis)?

Treatment of Nasal Bleeding (Epistaxis)

For epistaxis, first-line treatment should include firm sustained compression to the lower third of the nose for 10-15 minutes, followed by topical vasoconstrictors such as oxymetazoline if bleeding persists, with cauterization preferred over nasal packing when a specific bleeding site can be identified. 1

Initial Management

First Aid Measures

• Apply firm sustained compression to the lower third of the nose for 10-15 minutes
• Patient should be positioned leaning forward (to prevent blood aspiration)
• Apply ice packs to help constrict blood vessels

Topical Vasoconstrictors

• Oxymetazoline (Afrin) or phenylephrine can be applied via spray or on cotton pledgets
• Success rate: 65-75% of patients have resolution with oxymetazoline 2, 3
• Caution: May be associated with cardiac complications in susceptible individuals 2

Treatment Algorithm for Identified Bleeding Site

When a specific bleeding site is identified, the American Academy of Otolaryngology-Head and Neck Surgery recommends the following approach:

1. Cauterization:

   • Preferred over nasal packing when a specific site is identified 1
   • Electrocautery (especially bipolar) is more effective than chemical cautery 1
   • Usually performed under local anesthesia in office setting
   • Caution: Avoid excessive or extensive cautery to prevent septal damage 2

2. Topical Hemostatic Agents:

   • Tranexamic acid shows promising results with 78% hemostasis rate (vs. 35% with oxymetazoline) 3
   • Particularly effective in patients on antiplatelet therapy 1, 4

3. Nasal Packing (if cautery unsuccessful):

   • Options include:
     • Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel)
     • Absorbable materials: Nasopore
     • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal)
   • Complications include infection risk, decreased blood flow, septal perforations, and worsening of obstructive sleep apnea 1

Management of Refractory Epistaxis

For persistent bleeding not controlled by above measures:

1. Endoscopic Arterial Ligation:

   • Primarily targeting the sphenopalatine artery (SPA)
   • More effective than conventional nasal packing (97% vs. 62%) 3

2. Embolization:

   • For intractable cases with ~80% success rate
   • Higher risk of serious complications including stroke (0.9-1.6%) 1

Prevention of Recurrence

• Nasal moisturization with saline gel or spray 1-3 times daily 1
• Humidification in dry environments
• Avoid digital trauma (nose picking) and vigorous nose blowing
• Address underlying conditions (hypertension, coagulation disorders)

Special Considerations

Antiplatelet Therapy

• For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with prescribing physician 1
• Resume therapy as soon as bleeding is controlled (usually within 24-48 hours) 1

When to Refer

Refer to otolaryngology or emergency department for:

• Posterior epistaxis
• Bleeding not controlled with anterior packing
• Recurrent epistaxis despite treatment
• Suspected underlying pathology requiring endoscopic evaluation 1

Warning Signs Requiring Immediate Attention

• Return of blood from nose or mouth
• Fever over 101°F
• Increasing pain
• Vision changes
• Shortness of breath
• Loss of color around the skin of the nose
• Swelling of the face 1

The most recent evidence strongly supports a stepwise approach to epistaxis management, with proper compression technique as the foundation, followed by targeted interventions based on bleeding site identification and severity.