What are the guidelines for managing recurrent epistaxis?

Guidelines for Managing Recurrent Epistaxis

The management of recurrent epistaxis should follow a structured approach focusing on both immediate control of bleeding and long-term prevention strategies to reduce recurrence.

Initial Assessment and Management

• At the time of initial contact, clinicians should distinguish patients requiring prompt management from those who do not, assessing for airway compromise and hemodynamic stability 1
• For active bleeding, apply firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward 2, 3
• Patients should breathe through the mouth and spit out blood rather than swallowing it 2, 3
• After compression, clean the nasal cavity of clots and apply a topical vasoconstrictor (oxymetazoline or phenylephrine) which can stop bleeding in 65-75% of cases 2, 3, 4

Identifying and Documenting Risk Factors

• Clinicians should document factors that increase frequency or severity of bleeding for any patient with epistaxis 1
• Common risk factors include:
  • Use of anticoagulant or antiplatelet medications 2
  • Hypertension 1
  • Nasal trauma or digital manipulation 1
  • Dry nasal mucosa 3
  • Hereditary conditions like hereditary hemorrhagic telangiectasia (HHT) 1

Treatment Options for Recurrent Epistaxis

First-Line Interventions

• Moisturizing or lubricating agents (petroleum jelly) should be applied to the nasal mucosa to prevent recurrence 2, 3
• Regular use of saline nasal sprays is recommended to keep the nasal mucosa moist 2, 3
• Nasal saline gel has shown 93.2% effectiveness in preventing recurrent epistaxis in anticoagulated patients over a 3-month period 5
• In the absence of life-threatening bleeding, continue anticoagulation therapy while initiating first-line treatments rather than reversing or withdrawing anticoagulation 2

Second-Line Interventions

• If a specific bleeding site is identified, nasal cautery should be considered 1
• When nasal cautery is chosen:
  • Properly anesthetize the bleeding site 1
  • Restrict application only to the active or suspected site(s) of bleeding 1
  • 75% silver nitrate is preferable to 95% as it causes less pain and is more effective in the short term 6
• For patients on anticoagulants or with bleeding disorders, use resorbable packing materials if packing becomes necessary 2, 3

Advanced Management

• Perform nasal endoscopy to identify the bleeding site and guide further management in patients with recurrent bleeding 1, 2
• For persistent or recurrent bleeding not controlled by packing or nasal cauterization, evaluate for surgical arterial ligation or endovascular embolization 1, 2
• Tranexamic acid has shown efficacy in reducing epistaxis in hereditary hemorrhagic telangiectasia patients 1

Special Considerations

• Assess for nasal telangiectasias and/or oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds to rule out hereditary hemorrhagic telangiectasia 1
• For children with recurrent idiopathic epistaxis, the optimal management remains unclear, though moisturization and avoiding digital trauma are reasonable first steps 6

Follow-up Recommendations

• Document the outcome of intervention within 30 days 1, 2
• Educate patients about:
  • Preventive measures for nosebleeds 1, 2
  • Home treatment for nosebleeds 1, 2
  • Indications to seek additional medical care 1, 2
• If nasal packing was used, educate about care and signs/symptoms warranting reassessment 1, 2

Common Pitfalls to Avoid

• Avoid bilateral simultaneous septal cautery as it may increase risk of septal perforation 1
• Avoid cauterization in anticoagulated patients with anterior epistaxis in the absence of active bleeding as it may worsen the condition by extending mucosal disruption 5
• Don't underestimate the importance of simple measures like nasal moisturization, which can be highly effective in preventing recurrence 3, 5