What is the best course of action for a patient with recurrent epistaxis (nosebleeds) since childhood, a history of seizures and syncope, previous steroid treatment, normal platelet levels, and a normal CT scan?

Management of Recurrent Epistaxis with Seizures, Syncope, and Prior Steroid Use

This patient requires immediate cessation of any intranasal corticosteroids if currently in use, comprehensive evaluation for underlying bleeding disorders despite normal platelet count, and urgent neurologic workup for the seizure/syncope history which may represent a separate but critical condition. 1, 2

Immediate Actions for Epistaxis Management

Stop Intranasal Corticosteroids

• Intranasal corticosteroids increase nosebleed risk with a relative risk of 2.74 (range 1.88-4.00) and should be discontinued in patients with recurrent or severe epistaxis. 1
• The patient's history of steroid treatment (stopped due to moon face) suggests possible prior systemic or intranasal corticosteroid use that may have contributed to recurrent epistaxis 1

Perform Anterior Rhinoscopy

• Remove any blood clots by suction or gentle nose blowing to identify the bleeding site 1
• Apply topical decongestant (oxymetazoline 0.05%, 2-3 sprays per nostril every 10-12 hours, not exceeding 2 doses in 24 hours) after clot removal 1, 3
• Directed cautery can be applied following blood clot removal if a specific bleeding site is identified 1

Consider Nasal Endoscopy

• Nasal endoscopy is indicated for recurrent epistaxis despite prior treatment, which this patient clearly has with childhood-onset bleeding. 1, 2
• Endoscopy examines the nasal cavity and nasopharynx to exclude unrecognized pathology (nasal masses, juvenile nasopharyngeal angiofibroma in adolescent males, nasal malignancies, or foreign bodies) 1
• Endoscopy can localize the bleeding site in 87-93% of cases 4

Critical Diagnostic Workup

Evaluate for Bleeding Disorders Beyond Platelet Count

• Normal platelet count does NOT exclude bleeding disorders—qualitative platelet function disorders like Glanzmann's thrombasthenia can present with recurrent epistaxis and normal platelet counts. 5, 6
• Order platelet aggregation studies and referral to hematology for advanced assessment 5
• Screen for von Willebrand disease, hemophilia, and other coagulation disorders through coagulation testing 2, 7
• Document personal and family history of bleeding disorders, easy bruising, or prolonged bleeding from minor trauma 2, 5

Screen for Hereditary Hemorrhagic Telangiectasia (HHT)

• Assess for nasal and oral mucosal telangiectasias on examination in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds. 2, 7
• HHT screening is essential given the childhood onset and recurrent nature of this patient's epistaxis 2, 7

Address the Seizure and Syncope History

• The one-year history of seizures and syncope represents a separate critical condition requiring urgent neurologic evaluation—this is NOT explained by epistaxis alone. 8, 9
• Syncope with seizures suggests possible cardiac arrhythmia, structural cardiac disease, or primary neurologic disorder requiring electrocardiography, echocardiography, and neurologic consultation 8, 9
• The normal CT scan excludes space-occupying lesions but does not rule out other causes of seizures/syncope 8, 9
• Measure orthostatic blood pressure and perform careful cardiovascular evaluation 9

Preventive Measures

Nasal Mucosal Moisturization

• Aggressive nasal mucosal moisturization with petroleum jelly and saline nasal sprays is the cornerstone of prevention for recurrent epistaxis. 2, 4, 7
• Apply petroleum jelly or lubricating agents to nasal mucosa regularly 2, 4
• Use saline nasal sprays to maintain mucosal moisture 2, 4
• Recommend humidifier use in dry environments 4

Patient Education

• Avoid nose picking, vigorous nose-blowing, and nasal manipulation for at least 7-10 days after bleeding episodes 4
• Teach proper nasal compression technique: firm sustained pressure to the lower third of the nose for 10-15 minutes without checking 2, 4
• Instruct patient to sit upright with head tilted slightly forward during bleeding to prevent blood from flowing into airway 2, 4

Escalation Plan if Conservative Measures Fail

Surgical Options

• Endoscopic sphenopalatine artery ligation (ELSA) has the highest immediate success rate (97%), shortest hospital stay, lowest recurrence rate (<10%), and highest patient satisfaction for persistent epistaxis. 2, 4
• Consider surgical arterial ligation or endovascular embolization (80% success rate) for recurrent bleeding not controlled by packing or cauterization 2, 4

Common Pitfalls to Avoid

• Do not assume normal platelet count excludes all bleeding disorders—qualitative platelet defects require specialized testing. 5, 6
• Do not overlook the autoimmune history and prior steroid use—this may indicate underlying systemic disease contributing to both epistaxis and neurologic symptoms 1
• Do not dismiss the seizure/syncope history as secondary to blood loss—this requires independent urgent evaluation for potentially life-threatening cardiac or neurologic conditions. 8, 9
• Do not continue intranasal corticosteroids in patients with recurrent epistaxis 1