What is the best approach for managing recurrent epistaxis (nosebleeds)?

Management of Recurrent Epistaxis

For patients with recurrent epistaxis, implement a stepwise approach starting with nasal moisturization and identification of bleeding sites, progressing to cautery for localized sources, and reserving surgical intervention for refractory cases. 1, 2

Immediate Assessment and Initial Management

When a patient presents with recurrent epistaxis, first distinguish whether they require prompt management by assessing for active bleeding, airway compromise, and hemodynamic stability. 1

For active bleeding episodes:

• 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
• Have the patient breathe through the mouth and spit out blood rather than swallowing it 2, 4
• After compression, clean the nasal cavity of clots and apply topical vasoconstrictor (oxymetazoline 2-3 sprays per nostril, not more often than every 10-12 hours) 2, 5, 6
• This approach stops bleeding in 65-75% of cases 6, 3

Risk Factor Documentation and Modification

Document all factors that increase bleeding frequency or severity: 1, 2

• Anticoagulant or antiplatelet medications (aspirin, warfarin, apixaban, clopidogrel) 1, 4
• Hypertension 2
• Nasal trauma or digital manipulation 2
• Dry nasal mucosa 2
• Intranasal corticosteroids or drugs of abuse 1

Assess for hereditary hemorrhagic telangiectasia (HHT) in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds by examining for nasal and oral mucosal telangiectasias. 1, 2

Prevention Strategies for Recurrent Cases

Primary prevention measures to reduce recurrence: 1, 2

• Apply petroleum jelly to the nasal mucosa regularly to maintain moisture 2, 4
• Use saline nasal sprays regularly to keep nasal mucosa moist 2, 4
• Educate patients about avoiding nasal trauma and digital manipulation 1

Diagnostic Evaluation

Perform anterior rhinoscopy after removing any blood clots to identify the bleeding source. 1

For patients with recurrent bleeding despite prior treatment with packing or cautery, or with recurrent unilateral bleeding, perform nasal endoscopy (or refer to a specialist who can) to identify the bleeding site and guide further management. 1, 4

Nasal endoscopy is particularly important to rule out:

• Nasal masses (pyogenic granuloma, juvenile nasopharyngeal angiofibroma in adolescent males, malignancies) 1
• Nasal foreign bodies in children 1
• Septal deviation or perforation 1

Treatment Based on Bleeding Site Identification

When a specific bleeding site is identified: 1

• Anesthetize the bleeding site 1
• Apply nasal cautery restricted only to the active or suspected site(s) of bleeding 1
• Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 1, 2
• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 6

Consider topical tranexamic acid as an alternative or adjunct:

• Topical tranexamic acid promotes hemostasis in 78% of patients versus 35% with oxymetazoline alone 6
• Reduces bleeding time and rebleeding compared to nasal packing 7
• Particularly effective in HHT patients 2
• Moderate-quality evidence shows it stops bleeding within 10 minutes in 70% of cases compared to 30% with other hemostatic agents 8

Management for Patients on Anticoagulation

In the absence of life-threatening bleeding, initiate first-line treatments (compression, vasoconstrictors, cautery) prior to transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications. 1, 4

If nasal packing becomes necessary in anticoagulated patients, use resorbable packing materials (such as Nasopore, Surgicel, Floseal, or Spongostan) rather than non-resorbable materials. 1, 4, 6

Escalation for Refractory Cases

For persistent or recurrent bleeding not controlled by packing or nasal cauterization, evaluate candidacy for: 1

• Surgical arterial ligation (particularly sphenopalatine artery), which is more effective than conventional nasal packing (97% vs 62%) 6
• Endoscopic cauterization, which is more effective than ligation 6
• Endovascular embolization using gelatin sponge, foam, PVA, or coils with 80% success rate 6

Follow-Up and Documentation

Document the outcome of intervention within 30 days or document transition of care for patients treated with nonresorbable packing, surgery, or arterial ligation/embolization. 1, 2

Educate patients about: 1, 2

• Preventive measures (nasal moisturization, avoiding trauma)
• Home treatment techniques (proper compression technique)
• Indications to seek additional medical care (persistent bleeding >15 minutes despite compression, signs of significant blood loss)

Critical Pitfalls to Avoid

• Never perform bilateral simultaneous septal cautery due to septal perforation risk 1, 2
• Don't discontinue anticoagulation prematurely in non-life-threatening bleeding; use first-line measures first 1, 4
• Don't underestimate simple nasal moisturization, which is highly effective for prevention 2
• Don't miss HHT in patients with recurrent bilateral epistaxis or positive family history 1, 2