What is the recommended management for a patient with recurrent epistaxis (nosebleeds)?

Management of Recurrent Epistaxis

For patients with recurrent epistaxis, perform nasal endoscopy to identify the bleeding site and guide targeted treatment, which should include a combination of cauterization of identified bleeding sites and daily application of nasal moisturizing agents to prevent future episodes. 1, 2

Initial Diagnostic Evaluation

When a patient presents with recurrent epistaxis, the priority is identifying the specific bleeding site rather than repeated empiric treatments:

• Perform anterior rhinoscopy first after removing any blood clots to visualize the anterior nasal cavity, as 87-93% of recurrent bleeding originates from identifiable anterior sites 1, 2
• Proceed to nasal endoscopy if anterior rhinoscopy fails to identify the source or if bleeding recurs despite prior cautery or packing, as endoscopy localizes the bleeding site in 87-93% of cases 1, 2
• Document critical risk factors including anticoagulant/antiplatelet medication use, personal or family history of bleeding disorders, hypertension, intranasal drug use, and prior nasal surgery 1, 2, 3

The American Academy of Otolaryngology-Head and Neck Surgery specifically recommends nasal endoscopy for all patients with recurrent epistaxis despite prior treatment, as this allows visualization of posterior bleeding sites that account for 70% of posterior epistaxis from the septum and 24% from the lateral nasal wall 1

Definitive Treatment Based on Identified Site

Once the bleeding site is identified through endoscopy:

• Apply topical anesthesia (lidocaine or tetracaine) to the bleeding site before any intervention 1, 2
• Perform targeted cauterization restricted only to the active or suspected bleeding site(s), as this prevents recurrent bleeding more effectively than empiric packing 1, 2
• Avoid bilateral simultaneous septal cautery as this significantly increases the risk of septal perforation 2, 4
• Consider electrocautery over chemical cauterization when available, as it demonstrates superior efficacy with 14.5% recurrence rates compared to 35.1% for chemical cauterization 2, 5

Prevention of Recurrence: Critical Component

Prevention is equally important as acute treatment for recurrent epistaxis:

• Prescribe petroleum jelly or nasal saline gel to be applied to the anterior nasal septum 1-3 times daily, particularly before bedtime 1, 2, 6
• Recommend regular saline nasal sprays to maintain mucosal moisture throughout the day 1, 2
• Advise humidifier use in the bedroom during sleep, especially in dry climates 2, 6
• Instruct patients to avoid digital trauma (nose picking), vigorous nose blowing for at least 7-10 days after treatment, and nasal decongestant overuse 2, 7

The guideline emphasizes that moisturizing agents are essential after bleeding control to prevent the recurrence cycle 1

Special Populations Requiring Additional Evaluation

Patients on Anticoagulation/Antiplatelet Therapy

• Do NOT routinely discontinue anticoagulation for recurrent epistaxis if bleeding is controlled with local measures 1, 2
• Use only resorbable packing materials (Nasopore, Surgicel, Floseal) if packing is required, to avoid trauma during removal 1, 2
• Check INR if on warfarin to ensure therapeutic range; supratherapeutic levels may require adjustment 2, 4
• Continue aspirin in high-risk cardiovascular patients despite epistaxis, as survival benefits outweigh bleeding risks 2

Assessment for Hereditary Hemorrhagic Telangiectasia (HHT)

• Examine for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or positive family history 2, 6
• Refer to specialized HHT centers if diagnosis is suspected, as these patients require different management strategies 2

Unilateral Recurrent Epistaxis Red Flags

• Suspect nasal foreign body in children, as epistaxis is the presenting symptom in 7% of cases and occurs in 30% during removal 1
• Consider intranasal tumor if unilateral bleeding is accompanied by nasal obstruction, facial pain, or visual changes 4
• Rule out juvenile nasopharyngeal angiofibroma in adolescent males with unilateral bleeding and obstruction 6

Escalation for Refractory Cases

If recurrent epistaxis persists despite appropriate cauterization and preventive measures:

• Evaluate candidacy for surgical arterial ligation (endoscopic sphenopalatine artery ligation), which has a 97% success rate compared to 62% for conventional packing 2, 5
• Consider endovascular embolization as an alternative with 80% success rate and recurrence rates less than 10% compared to 50% for nasal packing 2, 5
• Refer to otolaryngology for patients requiring these advanced interventions 1, 2

Common Pitfalls to Avoid

• Do not repeatedly pack without endoscopic evaluation, as this fails to address the underlying bleeding site and has a 50% recurrence rate 2, 5
• Do not aggressively lower blood pressure acutely during active epistaxis, as this can cause end-organ ischemia in elderly patients with chronic hypertension 2, 4
• Do not perform bilateral septal cautery simultaneously, even if bleeding sites are identified on both sides, due to perforation risk 2, 4
• Do not overlook the prevention component—failure to prescribe moisturizing agents is a major cause of continued recurrence 1, 2

Mandatory Follow-Up

• Document outcome within 30 days for all patients who received cautery, packing, or surgical intervention 1, 2
• Reassess if treatments are ineffective or bleeding recurs, as this may indicate unrecognized pathology requiring further investigation 2, 4