What are the best management options for a 15-year-old patient experiencing frequent epistaxis (nose bleeds)?

Management of Frequent Epistaxis in a 15-Year-Old

For a 15-year-old with frequent nosebleeds, begin with firm sustained compression to the soft lower third of the nose for 10-15 minutes without interruption, followed by aggressive nasal moisturization with petroleum jelly and saline sprays to prevent recurrence. 1, 2

Immediate Management During Active Bleeding

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway or being swallowed 1, 3
• Apply continuous firm pressure to the soft lower third of the nose for a full 10-15 minutes without checking if bleeding has stopped—this resolves the vast majority of anterior epistaxis cases 1, 2, 3
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 3

If Bleeding Persists After 10-15 Minutes

• Clear the nasal cavity of blood clots by suction or gentle nose blowing to identify the bleeding source 1, 2
• Apply topical vasoconstrictor spray (oxymetazoline or phenylephrine) 2 sprays into the bleeding nostril, which stops bleeding in 65-75% of emergency department cases 2, 3, 4
• Resume firm compression for another 5-10 minutes after applying the vasoconstrictor 3
• Perform anterior rhinoscopy after clot removal to identify the specific bleeding site 1, 2

Definitive Treatment When Bleeding Site is Identified

• Apply chemical cautery with silver nitrate after anesthetizing the area with topical lidocaine or tetracaine 1, 2
• Restrict cautery only to the active bleeding site—avoid bilateral septal cautery as this increases risk of septal perforation 1, 2
• Electrocautery is more effective than chemical cauterization with fewer recurrences (14.5% vs 35.1%) if available 4

Prevention Strategy: The Critical Component

Aggressive nasal mucosal moisturization is the cornerstone of preventing recurrent epistaxis in adolescents. 5

• Apply petroleum jelly to the nasal mucosa twice daily to maintain moisture 1, 2, 3
• Use saline nasal sprays regularly (3-4 times daily) to keep nasal mucosa moist 1, 2, 3
• Use a humidifier in the bedroom, especially in dry climates or during winter months 3
• Instruct the patient to avoid nose picking, vigorous nose blowing, and nasal manipulation for at least 7-10 days after any bleeding episode 3

Assessment for Underlying Causes

Since this is recurrent epistaxis, systematically evaluate for contributing factors: 5

Local Factors to Assess

• Digital trauma (nose picking) is the most common cause in this age group 2
• Dry environment or nasal oxygen use contributing to mucosal dryness 2
• Intranasal drug use including nasal decongestant overuse or illicit drug snorting 2, 5
• Recent nasal trauma or foreign body 2

Systemic Factors to Document

• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia, thrombocytopenia) 1, 5
• Medication use including NSAIDs, aspirin, or anticoagulants 1, 5
• Chronic medical conditions including liver disease, renal disease, or hypertension 1

Red Flags Requiring Further Investigation

• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggests possible mass lesion requiring nasal endoscopy 2
• Recurrent bilateral nosebleeds or family history of recurrent nosebleeds warrants assessment for hereditary hemorrhagic telangiectasia (HHT) by examining for nasal and oral mucosal telangiectasias 1, 2, 5

When to Escalate Care

Indications for Nasal Packing

• Bleeding continues despite 15-30 minutes of proper compression with vasoconstrictors 3
• Life-threatening bleeding or suspected posterior bleeding source 3
• Use resorbable packing materials (Nasopore, Surgicel, Floseal) if the patient has any bleeding risk factors 1, 3

Indications for Specialist Referral

• Recurrent bleeding despite appropriate local treatment and preventive measures requires ENT evaluation 1, 5
• Nasal endoscopy is indicated for recurrent epistaxis to exclude serious pathology and identify posterior bleeding sources 1, 2, 5
• Consider surgical arterial ligation or endovascular embolization for persistent bleeding not controlled by packing or cautery—endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 5, 4

Common Pitfalls to Avoid

• Do not interrupt compression before 10-15 minutes have elapsed—checking too early restarts bleeding 1, 3
• Do not perform bilateral septal cautery simultaneously—this significantly increases septal perforation risk 1, 2
• Do not neglect preventive moisturization—this is the most important factor in preventing recurrence in adolescents 5
• Do not apply ice packs—current evidence does not support this as it does not significantly change nasal blood flow 3

Follow-Up

• Arrange follow-up within 30 days to assess outcome and document response to treatment 2
• Educate the patient and caregivers about preventive measures, home treatment techniques, and indications to seek additional medical care 1
• If treatments are ineffective or bleeding recurs despite appropriate management, this warrants assessment for underlying conditions 2