What is the management approach for frequent epistaxis (nosebleeds)?

Management of Frequent Epistaxis

For patients with frequent epistaxis, the priority is identifying and treating the bleeding site with nasal endoscopy, followed by targeted interventions including topical vasoconstrictors, nasal cautery, and moisturizing agents to prevent recurrence. 1

Initial Assessment

• Assess hemodynamic stability first: Check for airway compromise, tachycardia, hypotension, or signs of significant blood loss that would require urgent intervention 2
• Document risk factors that increase bleeding frequency: anticoagulant/antiplatelet medications, hypertension, nasal trauma, digital manipulation, dry nasal mucosa, and family history suggesting hereditary hemorrhagic telangiectasia (HHT) 3, 2
• Screen for HHT in patients with recurrent bilateral nosebleeds or family history by assessing for nasal and oral mucosal telangiectasias 3, 2

Acute Bleeding Control

• Apply firm sustained compression to the lower third of the nose for 10-15 minutes with the patient seated and head tilted slightly forward 4, 3
• Patient should breathe through the mouth and spit out blood rather than swallowing it 4, 3
• Do not check if bleeding has stopped before the full 10-15 minutes of compression—insufficient compression time is a common error 4

If Bleeding Persists After Compression:

• Clear clots from the nasal cavity 4, 3
• Apply topical vasoconstrictor (oxymetazoline or phenylephrine) by spraying 2 times in the bleeding nostril 4
• Continue compression for an additional 5 minutes 4
• This approach resolves 65-75% of epistaxis cases 1, 5

Definitive Management for Recurrent Cases

Nasal Endoscopy (Essential Step):

• Perform nasal endoscopy to identify the bleeding site in all patients with frequent epistaxis 1, 3
• Endoscopy localizes the bleeding site in 87-93% of cases 1
• Posterior epistaxis can originate from the septum (70%) or lateral nasal wall (24%), making targeted therapy difficult without endoscopic identification 1

Treatment Based on Identified Bleeding Site:

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

• Nasal cautery: Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) 5

  • Use local anesthesia and restrict cautery only to the active bleeding site 3
  • Avoid bilateral simultaneous septal cautery as it increases risk of septal perforation 2

• Topical vasoconstrictors: Oxymetazoline or phenylephrine for acute control 1

• Moisturizing/lubricating agents: Apply petroleum jelly to the nasal mucosa after bleeding stops to prevent recurrence 1, 3, 2

Prevention of Recurrence (Critical for Frequent Epistaxis)

• Regular saline nasal sprays to keep nasal mucosa moist 4, 3, 2
• Humidifier use, especially in dry environments 4
• Petroleum jelly application to the nasal mucosa 3, 2
• Patient education about avoiding nasal trauma, digital manipulation, and recognizing when to seek care 3, 2

Special Populations

Patients on Anticoagulation:

• Continue anticoagulation in the absence of life-threatening bleeding and initiate first-line treatments rather than reversing anticoagulation 4, 3
• Use resorbable nasal packing materials if packing becomes necessary 4, 3
• Do not consider transfusion or reversal of anticoagulation before attempting first-line treatments 4

Patients with HHT:

• Consider tranexamic acid, which promotes hemostasis in 78% of HHT patients versus 35% with oxymetazoline and 31% with nasal packing 5

Advanced Interventions for Refractory Cases

If bleeding persists despite the above measures 3, 2:

• Nasal packing with newer hemostatic materials (Floseal, Surgicel, Spongostan, fibrin glue) which are more effective with fewer complications than traditional materials 5
• Endoscopic arterial ligation (primarily sphenopalatine artery), which is more effective than conventional nasal packing (97% vs 62%) 5
• Endoscopic cauterization, which is more effective than ligation 5
• Arterial embolization for intractable cases, with 80% success rate and comparable efficacy to surgical methods 5

Follow-Up

• Document outcome within 30 days of intervention 3, 2
• Reassess if bleeding recurs despite preventive measures 2
• Consider ENT referral if bleeding is not controlled by initial measures 4, 3

Common Pitfalls to Avoid

• Insufficient compression time (must be full 10-15 minutes uninterrupted) 4
• Neglecting nasal moisturization for prevention—this simple measure is highly effective 2
• Bilateral simultaneous septal cautery (increases perforation risk) 2
• Discontinuing anticoagulation prematurely in non-life-threatening bleeding 4, 3