What is the management approach for a patient with recurrent epistaxis (nosebleeds) and a history of seizures, with normal ENT examination findings?

Management of Recurrent Epistaxis with Normal ENT Examination and Seizure History

This patient requires systematic evaluation for underlying bleeding disorders and medication-related causes, with initial management focused on nasal moisturization and documentation of risk factors, while the seizure history necessitates careful review of anticonvulsant medications that may contribute to bleeding. 1

Immediate Assessment Priorities

Document all factors that increase bleeding frequency or severity, specifically:

• Personal or family history of bleeding disorders 1
• Current anticonvulsant medications (many antiepileptic drugs affect platelet function or coagulation) 1
• Any anticoagulant or antiplatelet medication use 1
• Intranasal drug use 1

The normal ENT examination does not exclude significant pathology—perform anterior rhinoscopy after removing any blood clots to identify the bleeding source, as this is essential even when initial examination appears normal 1

Critical Evaluation for Hereditary Hemorrhagic Telangiectasia (HHT)

Given the lifelong history of frequent bilateral nosebleeds, assess for nasal and oral mucosal telangiectasias, as HHT commonly presents with recurrent epistaxis from childhood 1. This is a critical diagnosis not to miss, as it requires multidisciplinary management and screening for visceral arteriovenous malformations 2.

Examine specifically for:

• Small vascular malformations on conjunctiva, oropharynx, tongue, lips, and palate 2
• Family history of recurrent nosebleeds 1
• History of anemia requiring iron supplementation or transfusions 2

First-Line Management Strategy

Initiate preventive measures immediately:

• Apply petroleum jelly or saline gel to anterior nasal septum 1-3 times daily, particularly before bedtime 3, 4
• Regular saline nasal sprays to maintain mucosal moisture 3, 4
• Bedside humidification during sleep 3

These simple interventions prevent 65-75% of recurrent epistaxis and should be started before more invasive procedures 4, 5.

Medication Review Related to Seizure History

Critical pitfall: Many anticonvulsant medications affect hemostasis. Valproic acid, carbamazepine, and phenytoin can cause thrombocytopenia or platelet dysfunction. Do not discontinue seizure medications without neurology consultation, but document their potential contribution to bleeding 1.

If the patient is on anticoagulation for seizure-related complications (e.g., stroke prevention), initiate first-line treatments before considering reversal or withdrawal of anticoagulation 6, 4.

Advanced Diagnostic Evaluation

Since the patient has recurrent bleeding despite normal initial ENT examination, perform or refer for nasal endoscopy to:

• Identify posterior bleeding sites not visible on anterior rhinoscopy 1
• Evaluate for unrecognized pathology (masses, vascular malformations) 1
• Guide targeted treatment if bleeding recurs 1

This is particularly important because nasal malignancies and vascular tumors can present with recurrent epistaxis and normal initial examination 1.

Treatment of Identified Bleeding Sites

When a specific bleeding site is identified through endoscopy:

• Apply topical vasoconstrictors (oxymetazoline or phenylephrine), which resolve 65-75% of nosebleeds 4, 5
• Consider nasal cautery with proper anesthetization, restricting application only to the active bleeding site 1, 4
• Use 75% silver nitrate rather than 95% concentration if chemical cautery is chosen 3
• Avoid bilateral simultaneous septal cautery due to septal perforation risk 3

Escalation for Refractory Cases

If bleeding persists despite initial measures:

• Refer to otolaryngology for consideration of surgical arterial ligation or endovascular embolization 1
• Endoscopic sphenopalatine artery ligation is more effective than conventional packing (97% vs 62% success) 5
• Embolization achieves 80% success rate for intractable cases 5

Patient Education and Follow-Up

Educate the patient on:

• Proper first aid technique: firm sustained compression to lower third of nose for 5-15 minutes, seated with head tilted slightly forward 6, 3
• Breathing through mouth and spitting out blood rather than swallowing 6
• Avoiding digital trauma and forceful nose blowing for at least one week after treatment 3
• When to seek emergency care: bleeding not controlled after 15 minutes of compression 3

Document the outcome of intervention within 30 days to assess treatment effectiveness 1, 3, 4.

Key Clinical Pitfall

The combination of lifelong recurrent bilateral epistaxis with seizure history raises concern for underlying systemic conditions (HHT, coagulopathy, medication effects). Do not attribute bleeding solely to local nasal factors when the history suggests systemic disease 1, 2. The normal ENT examination does not exclude these diagnoses and should prompt further investigation rather than reassurance 1.