What could be causing recurrent morning epistaxis (nosebleeds) in a 15-year-old, occurring 3-4 times a week, with blood sometimes flowing down the throat and causing choking?

Recurrent Morning Epistaxis in a 15-Year-Old

This adolescent requires prompt medical evaluation to identify the bleeding site and implement targeted treatment, as recurrent epistaxis occurring 3-4 times weekly with posterior blood flow represents a pattern that warrants specialist assessment rather than continued observation alone. 1

Immediate Evaluation Priorities

The clinician should document specific factors that increase bleeding frequency or severity in this patient, including: 1

• Time of day pattern (morning bleeds suggest nocturnal nasal drying or digital trauma during sleep) 1
• Unilateral versus bilateral bleeding (unilateral bleeding in an adolescent male could indicate juvenile nasopharyngeal angiofibroma, a vascular tumor requiring imaging) 1
• Medication use including aspirin, NSAIDs, or any anticoagulants (even over-the-counter products can significantly worsen epistaxis) 2
• Family history of recurrent nosebleeds (raises concern for hereditary hemorrhagic telangiectasia) 1
• Environmental factors (dry air, heating systems that reduce humidity) 3

Diagnostic Approach

The clinician should perform anterior rhinoscopy to identify the bleeding source, as most adolescent epistaxis originates from the anterior nasal septum (Kiesselbach's plexus). 1 However, given the frequency (3-4 times weekly) and posterior flow pattern, nasal endoscopy should be performed or the patient referred to a specialist who can perform endoscopy to examine the nasal cavity and nasopharynx for unrecognized pathology. 1

Critical Red Flags Requiring Urgent Specialist Referral:

• Unilateral bleeding with nasal obstruction in an adolescent male (juvenile nasopharyngeal angiofibroma until proven otherwise) 1
• Bilateral recurrent bleeding with visible telangiectasias on nasal or oral mucosa (hereditary hemorrhagic telangiectasia) 1
• Bleeding that cannot be localized despite adequate examination 1

Treatment Algorithm

First-Line Management (Once Bleeding Site Identified):

The clinician should treat the identified bleeding site with appropriate intervention, which may include: 1

1. Topical vasoconstrictors (oxymetazoline or phenylephrine spray) applied directly to the bleeding site 3
2. Nasal cautery with proper anesthesia, restricting application only to the active bleeding site (75% silver nitrate is more effective and less painful than 95% silver nitrate in adolescents) 4
3. Moisturizing or lubricating agents (petroleum jelly applied 1-3 times daily to prevent recurrence) 1, 3

Preventive Measures (Essential for Recurrent Cases):

The clinician should educate the patient and caregivers about preventive measures: 1

• Apply petroleum jelly or saline gel to the nasal septum 1-3 times daily, especially before bedtime 1, 3
• Use a humidifier in the bedroom during sleep 3
• Avoid digital trauma (nose picking, which is extremely common in adolescents) 1
• Avoid nose blowing forcefully for at least one week after treatment 1

If Initial Treatment Fails:

The clinician should evaluate, or refer to a specialist who can evaluate, candidacy for surgical arterial ligation or endovascular embolization for patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. 1

Common Pitfalls to Avoid

• Insufficient treatment of the underlying cause: Simply stopping acute bleeding without addressing nasal mucosal dryness leads to recurrence 5
• Missing juvenile nasopharyngeal angiofibroma: Any unilateral bleeding in an adolescent male with nasal obstruction requires imaging before attempting cautery or biopsy (these tumors bleed profusely) 1
• Inadequate follow-up: The outcome of intervention should be documented within 30 days to assess treatment effectiveness 1
• Overlooking medication history: Even occasional aspirin or NSAID use significantly increases epistaxis severity and recurrence 2

Home Management Instructions for Active Bleeding

When bleeding occurs, the patient should: 3, 6

• Sit upright with head tilted slightly forward (not backward, which causes blood to flow into the throat) 3
• Pinch the soft lower part of the nose firmly for 10-15 minutes without releasing to check if bleeding has stopped 3, 6
• Breathe through the mouth and spit out blood rather than swallowing it 3
• Apply topical vasoconstrictor spray (if available) after clearing clots, then continue compression for 5 minutes 3

When to Seek Emergency Care

The patient should go to the emergency department or call 911 if: 3

• Bleeding does not stop after 15 minutes of continuous pressure 3
• Dizziness or lightheadedness occurs (suggesting significant blood loss) 3
• Bleeding is severe (>30 minutes duration over 24 hours) 3

Given the frequency of 3-4 episodes weekly with posterior flow causing choking, this patient has already met criteria for specialist evaluation and should not continue with observation alone. 1