From the Guidelines
For a patient with recurrent self-limited nasal bleeds, begin with a thorough history and physical examination focusing on frequency, duration, severity, and associated symptoms, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) 1.
Initial Management
First-line management includes:
- Teaching proper nasal compression technique (pinching the soft part of the nose for 10-15 minutes while leaning forward)
- Avoiding nose picking
- Maintaining nasal mucosa hydration with saline sprays and petroleum jelly applied inside the nostrils
- Humidification of the home environment If bleeds persist, consider chemical cautery with silver nitrate sticks or electrocautery performed by an ENT specialist 1.
Further Evaluation and Management
For patients with recurrent significant bleeds, evaluate for underlying conditions such as:
- Hypertension
- Coagulation disorders
- Medication effects (especially anticoagulants like warfarin, DOACs, or antiplatelet agents) Laboratory testing may include:
- CBC
- Coagulation studies
- Liver function tests Patients with severe, recurrent, or posterior bleeds should be referred to an ENT specialist for possible nasal packing or more definitive interventions.
Diagnostic Considerations
Nasal endoscopy should be performed to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding 1. Recurrent epistaxis often results from dryness and trauma to the anterior nasal septum (Kiesselbach's plexus), which contains fragile blood vessels susceptible to rupture from environmental factors or mechanical irritation.
From the Research
Initial Assessment
- Evaluation of a patient presenting with epistaxis should begin with assessment of vital signs, mental status, and airway patency 2
- When examining the nose, a nasal speculum and a good light source, such as a headlamp, can be useful 2
Treatment Options
- Compressive therapy is the first step to controlling anterior epistaxis 2
- Oxymetazoline nasal spray or application of cotton soaked in oxymetazoline or epinephrine 1: 1,000 may be useful adjuncts to compressive therapy 2
- Directive nasal cautery, most commonly using silver nitrate, can be used to control localized continued bleeding or prominent vessels that are the suspected bleeding source 2, 3
- Topical therapy and nasal packing can be used if other methods are unsuccessful 2
- Inflatable anterior nasal balloon packs reliably control most nosebleeds, and addition of a Foley catheter nasopharyngeal balloon pack manages most posterior epistaxis 3
Management of Recurrent Self-Limited Nasal Bleeds
- Silver nitrate application to the decongested and anesthetized nasal mucosa addresses recurrent nosebleed in most cases 3
- Oxymetazoline 0.05% nasal spray provides the patient means to address rebleeding after discharge from treatment 3
- Topical moisturizing facilitates mucosal healing 3
- Use of an intranasal vasoconstrictor (oxymetazoline) could be used to effectively treat epistaxis, avoiding nasal packing in the majority of patients 4