What are the treatment options for frequent epistaxis (nosebleeds)?

Treatment Options for Frequent Epistaxis

For patients with frequent nosebleeds, initiate firm sustained nasal compression for 5-15 minutes as first-line treatment, followed by topical vasoconstrictors (oxymetazoline or phenylephrine), which resolve 65-75% of cases, and then proceed to nasal cautery or packing only if bleeding persists. 1, 2

Immediate First-Line Management

Apply firm, sustained compression to the lower third of the nose for at least 5 minutes (up to 15 minutes) with the patient sitting upright and head tilted slightly forward. 1, 3 This simple maneuver resolves most nosebleeds and must be performed without releasing pressure prematurely. 1

• Position the patient to breathe through the mouth and spit out blood rather than swallowing it to prevent nausea and accurately assess blood loss. 3
• After removing blood clots, perform anterior rhinoscopy to identify the bleeding site. 1

Second-Line Pharmacologic Treatment

If compression fails, apply topical vasoconstrictors immediately:

• Use oxymetazoline or phenylephrine nasal spray (2 sprays in the bleeding nostril), which stops 65-75% of nosebleeds in emergency settings. 1, 2
• Consider topical tranexamic acid, which promotes hemostasis in 78% of patients compared to 35% with oxymetazoline alone. 2

Procedural Interventions for Persistent Bleeding

When pharmacologic measures fail, escalate to procedural interventions:

• Perform nasal cautery (chemical with silver nitrate or electrical) after proper anesthetization if a specific bleeding site is identified. 1, 3 Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs. 35.1%). 2
• Restrict cautery only to the active bleeding site to minimize mucosal damage. 3

Nasal Packing Options

If cautery is unsuccessful or the bleeding site cannot be identified:

• Use resorbable packing materials (Nasopore, Surgicel, Floseal, gelatin sponge) rather than traditional non-resorbable gauze. 1, 3 These newer hemostatic materials are more effective with fewer complications. 2
• Non-resorbable options include petroleum jelly gauze, BIPP gauze, PVA tampons (Merocel), or balloon devices (Rapid-Rhino). 2
• Document the outcome within 30 days and educate patients about packing care and warning signs requiring reassessment. 1, 3

Advanced Interventions for Refractory Cases

Perform nasal endoscopy when bleeding is difficult to control, there is concern for unrecognized pathology, or the patient has recurrent bleeding despite prior treatment. 1, 3

For persistent or recurrent bleeding not controlled by packing or cauterization:

• Endoscopic sphenopalatine artery ligation is more effective than conventional nasal packing (97% vs. 62% success rate). 2
• Endoscopic cauterization of identified vessels is more effective than ligation alone. 2
• Angiographic embolization using gelatin sponge, foam, PVA particles, or coils achieves 80% success rate with comparable efficacy to surgical methods. 2, 4

Prevention and Long-Term Management

Educate all patients about preventive measures to reduce recurrence: 1, 3

• Apply petroleum jelly or saline gel inside nostrils 1-3 times daily to prevent mucosal dryness. 1, 5
• Use saline nasal spray regularly to maintain nasal moisture. 3, 5
• Run a bedside humidifier, especially in dry climates or during winter. 5
• Avoid nose picking, forceful nose blowing, and excessive nasal decongestant use. 5

Special Population: Patients on Anticoagulation/Antiplatelet Therapy

In the absence of life-threatening bleeding, continue anticoagulation therapy and initiate first-line local treatments rather than reversing or withdrawing anticoagulation. 3, 5

• Do not transfuse platelets or reverse anticoagulation if bleeding can be controlled with local measures. 5
• Preferentially use resorbable packing materials if packing becomes necessary due to their anticoagulant use. 3, 5
• Coordinate with the prescribing physician before any medication changes, as discontinuation significantly increases cardiovascular risk. 5

Special Population: Hereditary Hemorrhagic Telangiectasia (HHT)

Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent epistaxis. 1, 3

• HHT occurs in 1 in 5,000-18,000 individuals and causes nosebleeds in >90% of affected patients. 6
• Use resorbable packing exclusively, as removal of non-resorbable packing irritates the nasal cavity and increases rebleeding risk. 6
• Consider topical medications: thalidomide improves severity/frequency and hemoglobin levels; tranexamic acid decreases severity but not hemoglobin; bevacizumab (intravenous or local infiltration) improves multiple clinical factors. 6
• Refer to an HHT Center of Excellence or provider with HHT expertise for comprehensive management. 6

Critical Assessment Points

Document factors that increase bleeding frequency or severity: 1, 3

• Personal or family history of bleeding disorders
• Use of anticoagulant/antiplatelet medications
• Intranasal drug use (cocaine)
• Hypertension and atherosclerosis (more common in posterior epistaxis) 7

Common Pitfalls to Avoid

• Releasing nasal compression prematurely before 5 minutes have elapsed. 1
• Cauterizing both sides of the nasal septum simultaneously, which risks septal perforation. 3
• Discontinuing anticoagulation without consulting the prescribing physician in non-life-threatening bleeding. 5
• Using non-resorbable packing in patients with HHT or on anticoagulation. 6, 3
• Failing to perform endoscopy in recurrent cases, missing underlying pathology. 1