What are the causes and treatments for frequent epistaxis (nosebleeds)?

Frequent Nosebleeds: Causes and Treatment

For patients with frequent epistaxis, systematically identify and document risk factors—particularly anticoagulant/antiplatelet medications, intranasal drug use, bleeding disorders, and hereditary hemorrhagic telangiectasia—then implement aggressive nasal moisturization as the cornerstone of prevention while treating acute episodes with firm nasal compression for 5-15 minutes combined with topical vasoconstrictors. 1, 2

Key Risk Factors to Document

The American Academy of Otolaryngology-Head and Neck Surgery mandates documentation of specific factors that increase bleeding frequency or severity 1:

• Anticoagulant/antiplatelet medications (warfarin, apixaban, aspirin, clopidogrel) - these substantially increase nosebleed risk and require checking INR for warfarin patients 1
• Intranasal medications, especially nasal corticosteroids which increase epistaxis risk 2.74-fold compared to placebo 1, 3
• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia, thrombocytopenia) 1
• Environmental/mechanical factors: nasal cannula oxygen, CPAP use, digital trauma, dry climate 1
• Prior nasal/sinus surgery or facial trauma 1
• Chronic kidney or liver disease 1

Critical Diagnostic Consideration: Hereditary Hemorrhagic Telangiectasia (HHT)

You must assess for HHT in patients with recurrent bilateral nosebleeds or family history of recurrent epistaxis 1, 2:

• Examine for nasal and oral mucosal telangiectasias - these appear as small red vascular lesions 1
• HHT occurs in 1 in 5,000-18,000 individuals but is significantly underdiagnosed 1
• 90% of HHT patients have nosebleeds as their main symptom, with frequency increasing with age leading to anemia and need for transfusions 1
• Refer patients with suspected HHT to specialists experienced in HHT management 1

Acute Treatment Algorithm

First-Line Management (Home or Office)

1. Firm sustained compression of the lower third of the nose for 5-15 minutes without releasing pressure 1, 4, 2

   • Patient should sit upright, lean slightly forward 4
   • Breathe through mouth, spit out blood rather than swallowing 4

2. Topical vasoconstrictors after initial compression 1, 4, 2:

   • Oxymetazoline (Afrin) or phenylephrine spray: 2 sprays in bleeding nostril 4
   • This stops bleeding in 65-75% of emergency department cases 2, 5
   • Continue holding pressure for another 5 minutes after application 4

3. Chemical cautery with 75% silver nitrate if specific bleeding site identified 2, 5

When to Seek Emergency Care

Immediate evaluation required if 4, 2:

• Bleeding continues despite 15-30 minutes of proper compression
• Lightheadedness, weakness, or feeling faint
• Difficulty breathing due to blood in airway
• Severe blood loss (filling a cup or more)

Advanced Interventions

• Nasal packing: Use resorbable materials (Nasopore, Floseal, Surgicel) preferentially, especially for patients on anticoagulants or with HHT 1, 2, 5
• Endoscopic sphenopalatine artery ligation has the highest success rate, shortest hospital stay, and lowest recurrence for persistent epistaxis 2
• Angiographic embolization for failed surgical interventions with 80% success rate 5

Prevention Strategy: The Critical Foundation

Aggressive nasal mucosal moisturization is the cornerstone of preventing recurrent epistaxis 1, 2:

• Apply petroleum jelly (Vaseline) or saline gel inside nostrils 1-3 times daily 3, 4, 2
• Use saline nasal spray regularly 3, 4, 2
• Run a humidifier at bedside 3, 4
• Avoid nose picking, forceful nose blowing, and nasal trauma 3, 4

Special Populations: Critical Management Pitfalls

Patients on Anticoagulants/Antiplatelets

Do NOT stop anticoagulation without cardiology consultation—thrombotic risk carries higher morbidity and mortality than epistaxis itself 4, 2:

• Continue anticoagulation and pursue aggressive local control measures first 4, 2
• Only consider temporary interruption for life-threatening bleeding 2
• Use resorbable packing materials if packing necessary 4
• Do not reverse anticoagulation or transfuse platelets if bleeding controlled with local measures 4

Patients Using Intranasal Corticosteroids

Consider cessation of nasal corticosteroids in patients with recurrent or severe nosebleeds 3:

• If continuing therapy, use lowest effective dose (1 spray per nostril daily rather than 2) 3
• Direct spray away from nasal septum 3
• Implement concurrent aggressive moisturization 3
• Discontinue immediately if bleeding worsens or becomes more frequent 3
• Consider safer alternatives: intranasal antihistamines (azelastine) or oral antihistamines 3

Patients with HHT

• Prefer resorbable packing as removal of nonresorbable packing irritates nasal cavity and increases rebleeding risk 1
• Consider topical medications: thalidomide, tranexamic acid, or bevacizumab for severe cases 1
• Refer to HHT specialty centers for comprehensive management 1

Common Pitfalls to Avoid

• Do not routinely lower blood pressure in acute epistaxis—no causal relationship established and rapid reduction risks end-organ ischemia 1
• Do not perform bilateral nasal cautery if epistaxis worsens—increases septal perforation risk 3
• Do not ignore recurrent unilateral bleeding in adolescent males—consider juvenile nasopharyngeal angiofibroma 1
• Do not delay HHT screening in patients with recurrent bilateral epistaxis—underdiagnosis is common 1