What is the treatment for recurrent epistaxis not due to a coagulation disorder?

Treatment for Recurrent Epistaxis Not Due to Coagulation Disorder

For patients with recurrent epistaxis not due to coagulation disorders, first-line treatment should include nasal moisturization with saline gel or spray 1-3 times daily, along with humidification and avoidance of digital trauma, while identifying and treating the specific bleeding site with appropriate interventions including topical vasoconstrictors, nasal cautery, or moisturizing agents. 1, 2

Initial Assessment and Management

Identify the Bleeding Site

• Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site 1
• If bleeding site cannot be identified or is suspected to be posterior, perform nasal endoscopy 1, 2
• Document factors that increase frequency or severity of bleeding 1

First-Line Treatment for Active Bleeding

1. Nasal compression: Apply firm sustained compression to the lower third of the nose for at least 5 minutes 1, 2
2. Topical vasoconstrictors: Apply medications like oxymetazoline which stops 65-75% of nosebleeds 3
3. Topical tranexamic acid: Consider for active bleeding as it promotes hemostasis in 78% of patients (versus 35% with oxymetazoline) 2, 3

Site-Specific Treatment

For Identified Bleeding Sites

When a specific bleeding site is identified, the American Academy of Otolaryngology-Head and Neck Surgery recommends one or more of the following 1:

1. Nasal cautery:

   • Anesthetize the bleeding site first
   • Restrict cautery application only to the active or suspected site of bleeding
   • Silver nitrate cautery at 75% concentration is preferable to 95% as it causes less pain while being more effective 4

2. Topical vasoconstrictors:

   • Apply directly to bleeding site

3. Moisturizing/lubricating agents:

   • Nasal saline gel has shown 93.2% effectiveness in preventing recurrent epistaxis when applied to the anterior nasal vault 5
   • Apply 1-3 times daily for prevention 2

Management of Persistent Bleeding

If bleeding persists despite first-line measures:

1. Nasal packing:

   • Use resorbable packing for patients with suspected increased bleeding risk 1
   • Options include:
     • Non-absorbable materials: petroleum jelly, BIPP gauze, PVA nasal tampons (Merocel)
     • Absorbable materials: nasal tampon (Nasopore)
     • Newer hemostatic materials: hemostatic gauzes (Surgicel), thrombin matrix (Floseal) 3

2. Surgical options for persistent/recurrent bleeding not controlled by packing or cauterization:

   • Endoscopic arterial ligation (primarily sphenopalatine artery) with 97% success rate 2, 3
   • Endovascular embolization for intractable cases (80% success rate) 2

Prevention of Recurrence

1. Daily nasal moisturization:

   • Saline gel or spray 1-3 times daily 2
   • Nasal saline gel applied to the anterior nasal vault at first sign of bleeding 5

2. Environmental modifications:

   • Use humidification, especially during dry seasons or in dry climates 2
   • Avoid digital trauma (nose picking) 2

3. Patient education:

   • Proper nasal moisturization techniques
   • Home treatment methods
   • When to seek additional medical care 1, 2

Follow-up Care

• Document outcome of intervention within 30 days 1
• Schedule follow-up within 3-5 days to assess for recurrence 2
• Provide clear instructions on when to seek emergency care (bleeding lasting >30 minutes or signs of hypovolemia) 2

Important Caveats

• Avoid excessive or repeated cauterization which may worsen mucosal disruption 5
• In the absence of life-threatening bleeding, initiate first-line treatments prior to considering withdrawal of anticoagulation/antiplatelet medications 1
• For patients on dual antiplatelet therapy with persistent bleeding, consider temporary discontinuation of one agent (preferably clopidogrel) in consultation with the prescribing physician 2
• Consider referral to an otolaryngologist for patients with recurrent epistaxis despite appropriate treatment 1, 2