What could be causing a patient's recurrent morning epistaxis (nosebleeds) occurring about 3 times a week?

Recurrent Morning Epistaxis: Causes and Evaluation

A patient experiencing nosebleeds 3 times per week in the morning requires systematic evaluation starting with anterior rhinoscopy to identify the bleeding site, assessment for environmental factors (particularly bedroom humidity and nasal dryness), and screening for hereditary hemorrhagic telangiectasia (HHT) if there is any family history of recurrent nosebleeds. 1, 2

Most Likely Causes in This Pattern

Environmental and Local Factors

• Mucosal dryness is the most common cause of recurrent morning epistaxis, exacerbated by dry bedroom air, mouth breathing during sleep, or nasal oxygen/CPAP use 2
• Digital trauma (nose picking) often occurs unconsciously during sleep or upon waking, causing anterior septal bleeding 2
• Intranasal medications, particularly topical corticosteroids or decongestant overuse, can precipitate recurrent bleeding 1

Systemic Considerations

• Anticoagulant or antiplatelet medications may cause bleeding that manifests preferentially in the morning due to overnight mucosal drying 2
• Hypertension can exacerbate bleeding from pre-existing vulnerable vessels, though blood pressure elevation alone does not cause epistaxis 2

Critical Red Flag: Hereditary Hemorrhagic Telangiectasia

• HHT must be assessed in any patient with recurrent nosebleeds, as it affects 1 in 5,000-18,000 individuals and is frequently underdiagnosed or diagnosed late 1
• Morning bleeding pattern is consistent with HHT, where nosebleeds occur in >90% of patients and often increase in frequency with age 1
• Look for nasal or oral mucosal telangiectasias, family history of recurrent epistaxis, or history of anemia requiring iron supplementation or transfusions 1

Diagnostic Approach

Immediate Examination

• Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site, which will be visible in 87-93% of anterior epistaxis cases 1, 3
• If anterior rhinoscopy fails to identify the source, proceed to nasal endoscopy, particularly if bleeding is unilateral or recurrent despite treatment 1, 2

Essential History Elements

• Document anticoagulant/antiplatelet medication use, personal or family history of bleeding disorders, hypertension, intranasal drug use (including prescribed nasal sprays), and prior nasal surgery 2, 3
• Ask specifically about bedroom humidity, use of nasal oxygen or CPAP, and whether the patient uses a humidifier 2
• Screen for HHT by asking about family history of recurrent nosebleeds and checking for visible telangiectasias on the nasal septum, tongue, lips, or hard palate 1, 4

Management Strategy

Definitive Treatment of Identified Bleeding Site

• Apply topical anesthesia (lidocaine or tetracaine) followed by targeted cauterization restricted only to the active bleeding site 3
• Avoid bilateral simultaneous septal cautery as this significantly increases septal perforation risk 3

Prevention of Recurrence: The Critical Component

• Prescribe petroleum jelly or nasal saline gel to be applied to the anterior nasal septum 1-3 times daily, particularly before bedtime 3
• Recommend regular saline nasal sprays throughout the day to maintain mucosal moisture 3
• Advise humidifier use in the bedroom during sleep, especially in dry climates 3
• Instruct patients to avoid digital trauma, vigorous nose blowing for 7-10 days after treatment, and nasal decongestant overuse (which can cause rebound congestion and worsen bleeding) 3, 5

Common Pitfalls to Avoid

• Do not dismiss recurrent epistaxis as "just dry air" without performing anterior rhinoscopy to identify the bleeding site 1, 3
• Do not overlook HHT screening, as early diagnosis allows for systemic screening of arteriovenous malformations in other organs and prevents complications 1
• Do not routinely discontinue anticoagulation for recurrent epistaxis if bleeding is controlled with local measures 3
• Do not prescribe topical vasoconstrictors (oxymetazoline) for chronic use, as prolonged use causes rebound congestion and worsening epistaxis 5

When to Refer

• Refer to otolaryngology if bleeding recurs despite appropriate cautery and preventive measures, as this may indicate unrecognized pathology requiring nasal endoscopy 1, 3
• Immediate referral is warranted if HHT is suspected based on family history, visible telangiectasias, or recurrent bilateral epistaxis 1