What is the best course of action for a 17-year-old female college student with a history of recurrent epistaxis (nosebleeds) since early childhood, now experiencing monthly episodes of severe epistaxis, headaches, and sinus congestion without cold symptoms, despite recent treatment for sinusitis with antibiotics?

Management of Recurrent Severe Epistaxis in a 17-Year-Old Female

This patient requires immediate anterior rhinoscopy to identify the bleeding source, followed by nasal endoscopy given the recurrent unilateral pattern and severity, with specialist referral to otolaryngology for comprehensive evaluation of potential underlying pathology. 1

Immediate Clinical Assessment

Perform anterior rhinoscopy after removing any blood clots to identify the bleeding site, as this is the essential first diagnostic step for any patient with nosebleeds. 1 The monthly pattern of severe bleeding ("gushes out lots of blood") with associated sinus symptoms warrants more than basic first-aid measures.

Key historical factors to document immediately:

• Any intranasal corticosteroid use from her recent sinusitis treatment, as these substantially increase nosebleed risk (relative risk 2.74) and should be discontinued if present 1
• Anticoagulant or antiplatelet medications (including NSAIDs, aspirin) 1
• Personal or family history of bleeding disorders, particularly given her lifelong history since age 1-2 2
• Specific characteristics: unilateral vs bilateral bleeding, associated nasal obstruction, facial pain, or visual changes 3

Critical Red Flags Requiring Urgent Action

The combination of recurrent unilateral epistaxis with sinus congestion and headaches raises concern for underlying pathology that must be ruled out. 3 Specifically:

• Unilateral epistaxis with nasal obstruction or facial pain may indicate a mass lesion requiring immediate investigation 3
• The recurrence pattern after childhood resolution is atypical and demands thorough evaluation 1
• Monthly severe bleeding episodes causing significant blood loss warrant assessment for hemodynamic stability 4

Diagnostic Workup Required

Nasal endoscopy is mandatory for this patient given:

• Recurrent bleeding despite prior treatment (antibiotics for sinusitis) 1
• Unilateral presentation pattern 3
• Need to identify posterior bleeding sources not visible on anterior rhinoscopy 2
• Evaluation for unrecognized pathology (tumors, vascular malformations) 3

Additional investigations to consider:

• Complete blood count to assess for anemia from recurrent blood loss 4
• Coagulation studies if bleeding disorder suspected given lifelong history 2
• Assessment for hereditary hemorrhagic telangiectasia (HHT) if there is family history of recurrent nosebleeds or evidence of mucosal telangiectasias 4, 2

Immediate Treatment Approach

While arranging specialist evaluation, provide first-aid education:

Proper compression technique: Firm, continuous pressure to the soft lower third of the nose for 10-15 minutes without checking if bleeding has stopped, sitting upright with head tilted slightly forward 4

Topical vasoconstrictors: Oxymetazoline or phenylephrine spray (2 sprays into bleeding nostril), which stops bleeding in 65-75% of emergency department cases 4, 2

Nasal moisturization: Apply petroleum jelly or lubricating agents to nasal mucosa and prescribe regular saline nasal sprays to prevent recurrence 4

Specialist Referral - Mandatory

Refer to otolaryngology immediately based on multiple guideline criteria 1:

• Recurrent sinusitis refractory to usual antibiotic treatment 1
• Recurrent epistaxis despite appropriate first-line management 1, 2
• Need for nasal endoscopy to identify bleeding source and guide treatment 1
• Sinusitis significantly affecting quality of life (college student missing classes) 1

Management of Concurrent Sinusitis

The sinus congestion and headaches without cold symptoms suggest chronic rhinosinusitis (symptoms >12 weeks would meet criteria). 5 However:

• Do NOT restart intranasal corticosteroids if previously prescribed, as these substantially increase epistaxis risk 1, 6
• Consider saline irrigation as maintenance therapy 5
• Avoid repeat antibiotics without imaging confirmation of bacterial sinusitis, as overdiagnosis and unnecessary antibiotic treatment is a significant concern 1
• Appropriate antibiotic criteria require symptoms for 10-14 days OR severe symptoms (high fever with purulent discharge, facial pain/tenderness) 1

Critical Pitfalls to Avoid

Do not dismiss this as simple recurrent epistaxis - the unilateral pattern with sinus symptoms requires investigation for structural abnormalities, tumors, or vascular malformations 3

Do not continue nasal corticosteroids if they were part of her sinusitis treatment, as cessation should be considered in patients with recurrent or severe nosebleeds 1

Do not delay specialist referral - this patient meets multiple criteria for otolaryngology consultation and requires endoscopic evaluation that cannot be deferred 1

Do not assume this is benign childhood epistaxis returning - the pattern change (resolution then recurrence years later with increased severity) suggests acquired pathology requiring investigation 1, 3

Follow-Up Timeline

Otolaryngology referral should occur within 1-2 weeks maximum given the severity and frequency of bleeding. 4 Document outcomes within 30 days to assess treatment effectiveness. 2