What is the cause of recurrent epistaxis (nose bleeds) in a 21-year-old male and who should he be referred to for evaluation and treatment?

Daily Nocturnal Epistaxis with Choking in a 21-Year-Old Male

This patient requires urgent referral to an otolaryngologist (ENT specialist) for comprehensive evaluation, including nasal endoscopy to identify the bleeding source and assess for underlying pathology, as daily severe epistaxis causing choking represents a serious condition that demands prompt specialist assessment. 1, 2

Immediate Severity Assessment

This clinical presentation is concerning for several reasons:

• Daily bleeding with choking indicates severe epistaxis requiring prompt evaluation, as bleeding duration >30 minutes over 24 hours, bilateral bleeding, or bleeding causing airway symptoms warrants urgent assessment 1, 2
• Nocturnal bleeding with aspiration risk suggests posterior source or significant volume, which is more dangerous than simple anterior bleeds 3, 4
• The young age (21 years) with recurrent bilateral pattern should raise suspicion for hereditary hemorrhagic telangiectasia (HHT) or other systemic conditions 1

Who to Refer To

Primary referral: Otolaryngologist (ENT specialist) 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery guidelines clearly state that patients with recurrent epistaxis despite initial treatment, or recurrent unilateral/bilateral bleeding, require nasal endoscopy to identify the bleeding site and guide management 1. An ENT specialist can:

• Perform nasal endoscopy to visualize posterior nasal cavity and nasopharynx 1, 2
• Identify bleeding source that may not be visible on anterior rhinoscopy alone 1
• Rule out concerning pathology (masses, tumors, vascular malformations) 1
• Provide definitive treatment (cautery, arterial ligation, or embolization if needed) 1, 5

Key Differential Considerations

Hereditary Hemorrhagic Telangiectasia (HHT)

This diagnosis must be actively considered given the patient's age and recurrent bilateral pattern 1:

• HHT causes recurrent epistaxis in >90% of patients, often starting in young adulthood 1
• The ENT should assess for nasal and oral mucosal telangiectasias during examination 1, 2
• If HHT is suspected or confirmed, referral to an HHT Center of Excellence is essential for comprehensive management of this complex systemic disease 1

Posterior Bleeding Source

• Posterior epistaxis is more severe, harder to control, and associated with higher complication rates (19.8% requiring surgical intervention, 12.3% requiring transfusion) 4
• Cannot be adequately visualized without endoscopy 1, 2
• More common in patients with hypertension or coagulopathy, though can occur in young patients 3, 4

Underlying Pathology

The ENT must evaluate for 1:

• Nasal masses (pyogenic granuloma, polyps)
• Juvenile nasopharyngeal angiofibroma (presents with profuse unilateral epistaxis in 60-76% of adolescent males) 1
• Nasal malignancies (present with epistaxis in 55% of cases)
• Structural abnormalities (septal deviation, perforation)

Essential History to Document Before Referral

Document these critical risk factors 1, 2, 6:

• Medication history: Anticoagulants, antiplatelets, NSAIDs, intranasal drug use
• Bleeding disorder assessment: Personal history of bleeding from other sites, easy bruising, family history of bleeding disorders or recurrent nosebleeds
• Comorbidities: Hypertension, liver disease, kidney disease, anemia
• Bleeding characteristics: Unilateral vs bilateral, duration, frequency, estimated volume, triggers

Immediate Management While Awaiting ENT Evaluation

First-line measures 1, 6:

• Nasal compression: Firm sustained pressure to lower third of nose for 5-15 minutes
• Topical vasoconstrictors: Oxymetazoline or phenylephrine spray after clearing clots
• Nasal saline gel/spray: For moisturization and prevention between episodes
• Humidification: Bedside humidifier to prevent mucosal drying

Preventive education 1:

• Avoid digital trauma (nose picking) and vigorous nose blowing
• Maintain nasal moisture with saline gel 1-3 times daily
• Avoid aspirin and NSAIDs unless medically necessary

Critical Pitfalls to Avoid

• Do not assume this is simple anterior epistaxis requiring only cautery—daily severe bleeding with choking demands endoscopic evaluation 1, 2
• Do not delay ENT referral for "conservative management"—this severity and frequency pattern requires specialist assessment 1, 2
• Do not overlook HHT screening—missing this diagnosis has significant implications for systemic complications and family screening 1
• Do not attempt blind nasal packing without identifying the source—this can worsen posterior bleeds and increase aspiration risk 1, 4

Urgency of Referral

This should be an urgent (within days) rather than routine referral given:

• Daily frequency indicating failed natural hemostasis 1, 2
• Choking episodes suggesting significant volume and aspiration risk 1, 6
• Young age requiring definitive diagnosis and treatment to prevent long-term morbidity (anemia, transfusion dependence, reduced quality of life) 1

If the patient experiences hemodynamic instability, signs of significant blood loss, or airway compromise, direct to emergency department immediately rather than outpatient ENT referral 1, 2, 6.