What is the best treatment approach for a patient with recurrent epistaxis (nose bleeds)?

Treatment of Recurrent Epistaxis

For patients with recurrent nosebleeds, perform nasal endoscopy to identify the bleeding site, then treat with targeted nasal cautery after anesthesia, combined with regular application of nasal moisturizing agents (petroleum jelly or saline gel) to prevent future episodes. 1

Initial Assessment for Recurrent Cases

When evaluating a patient with recurrent epistaxis, you must:

• Perform nasal endoscopy to identify the exact bleeding site and guide management, as this localizes bleeding in 87-93% of cases 2
• Document risk factors including personal or family history of bleeding disorders, anticoagulant/antiplatelet medication use, and intranasal drug use 1, 3
• Assess for unilateral versus bilateral pattern—recurrent unilateral bleeding warrants endoscopic evaluation to rule out nasal pathology including tumors 1, 4
• Screen for hereditary hemorrhagic telangiectasia (HHT) if there is recurrent bilateral epistaxis or family history of recurrent nosebleeds 2

Definitive Treatment Strategy

Primary Intervention: Nasal Cautery

When a bleeding site is identified through endoscopy, cautery is the definitive treatment of choice: 1

• Anesthetize the bleeding site with topical lidocaine or tetracaine before cautery 1, 2
• Restrict cautery application only to the active or suspected bleeding site(s) 1
• Electrocautery is superior to chemical cauterization, with recurrence rates of 14.5% versus 35.1% 2, 5
• Critical pitfall to avoid: Never perform bilateral simultaneous septal cautery as this increases risk of septal perforation 2

Prevention of Recurrence: Moisturizing Agents

After controlling acute bleeding, prescribe regular application of moisturizing agents—this is essential for preventing recurrence: 1, 2

• Apply petroleum jelly or nasal saline gel to the nasal mucosa regularly 1, 2
• In anticoagulated patients with recurrent anterior epistaxis, nasal saline gel as monotherapy achieved cessation of bleeding in 93.2% of patients at 3 months 6
• Prescribe regular saline nasal sprays to maintain mucosal moisture 2
• Recommend humidifier use to prevent mucosal dryness 2

Alternative and Adjunctive Treatments

Tranexamic Acid

Consider tranexamic acid for patients with recurrent bleeding despite standard measures:

• Oral tranexamic acid reduces re-bleeding risk from 69% to 49% over 10 days (moderate-quality evidence) 7
• Topical tranexamic acid stops bleeding in 78% of patients versus 35% with oxymetazoline and 31% with nasal packing 5
• Topical tranexamic acid is superior to other topical agents in stopping bleeding within 10 minutes (70% versus 30%) 7

Nasal Packing

For recurrent bleeding not controlled by cautery:

• Use resorbable packing materials (Nasopore, Surgicel, Floseal) for patients on anticoagulation or with bleeding disorders 1, 2
• Educate patients about packing type, removal timing (if non-resorbable), post-procedure care, and warning signs 1
• Newer hemostatic materials (hemostatic gauzes, thrombin matrix, gelatin sponge, fibrin glue) are more effective with fewer complications than traditional packing 5

Management of Persistent or Refractory Cases

If bleeding recurs despite packing or cautery, escalate to surgical intervention:

• Evaluate candidacy for surgical arterial ligation or endovascular embolization 1
• Endoscopic sphenopalatine artery ligation has 97% success rate versus 62% for conventional packing 2, 5
• Endovascular embolization has 80% success rate with recurrence rates <10% compared to 50% for nasal packing 2, 5
• Endoscopic cauterization is more effective than ligation for identified bleeding sites 5

Special Considerations for Anticoagulated Patients

In patients on anticoagulation or antiplatelet medications:

• Initiate first-line treatments (compression, vasoconstrictors, cautery) before considering anticoagulation reversal or withdrawal, unless bleeding is life-threatening 1
• Use only resorbable packing materials to avoid trauma during removal 1, 2
• Nasal saline gel monotherapy is highly effective (93.2% success) in anticoagulated patients with recurrent anterior epistaxis 6
• Check INR if patient is on warfarin; supratherapeutic levels may require specialty consultation 4

Patient Education and Follow-Up

Provide comprehensive education on prevention and self-management:

• Teach patients to avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days after treatment 2
• Instruct on proper application of moisturizing agents at first sign of dryness or minor bleeding 6
• Document treatment outcomes within 30 days or document transition of care 1, 2
• Arrange follow-up to assess for complications and underlying conditions if treatments are ineffective 2, 4

Common Pitfalls to Avoid

• Do not use cauterization in the absence of acute bleeding without addressing underlying mucosal dryness, as this may worsen the condition by extending mucosal disruption 6
• Do not perform bilateral septal cautery simultaneously due to perforation risk 2
• Do not use non-resorbable packing in anticoagulated patients 1, 2
• Do not overlook HHT screening in patients with recurrent bilateral epistaxis 2
• Do not delay endoscopic evaluation in patients with recurrent unilateral bleeding, as this may indicate underlying pathology including tumors 1, 4