What is the best course of action for a 20-year-old female with a history of menorrhagia, who presented with frank epistaxis 1 month after septoplasty, and has a mildly prolonged International Normalized Ratio (INR) of 1.26 and normal Liver Function Tests (LFTs)?

Management of Post-Septoplasty Epistaxis with Mild INR Elevation and Menorrhagia History

This patient requires immediate local hemostatic measures without FFP or reversal agents, combined with urgent investigation for an underlying bleeding disorder, most likely von Willebrand disease given the combination of menorrhagia and post-surgical epistaxis. 1, 2

Immediate Epistaxis Management

Do not correct the mildly elevated INR of 1.26 with fresh frozen plasma or other blood products. 1 The American Academy of Otolaryngology-Head and Neck Surgery guidelines clearly state that treatment should be based on bleeding severity in combination with INR, and an INR of 1.26 is only minimally elevated and does not meet criteria for reversal therapy. 1 Furthermore, evidence from cirrhosis guidelines demonstrates that INR values do not predict post-procedural bleeding risk, and FFP transfusion does not meaningfully improve hemostatic capacity. 1

Local Control Measures (First-Line)

• Apply firm sustained compression to the lower third of the nose for 5-15 minutes as the initial intervention. 2, 3
• Remove blood clots by suction or gentle nose blowing to identify the bleeding source. 2, 3
• Apply topical vasoconstrictors (oxymetazoline 0.05%, 2-3 sprays per nostril) after clot removal. 2, 3
• Perform anterior rhinoscopy and nasal endoscopy to identify the specific bleeding site and exclude surgical complications from the recent septoplasty. 2, 3
• If a discrete bleeding point is identified, perform chemical cautery with 75% silver nitrate. 2, 4

Critical Diagnostic Evaluation

The combination of menorrhagia, post-surgical epistaxis, and mildly prolonged PT/INR with normal liver function strongly suggests an underlying bleeding disorder, particularly von Willebrand disease. 5

Essential Laboratory Workup

• Obtain complete blood count to assess hemoglobin (looking for ≥2 g/dL drop indicating severe bleeding) and platelet count. 1, 3
• Order von Willebrand factor antigen, von Willebrand factor activity (ristocetin cofactor), factor VIII level, and bleeding time or PFA-100. 5
• Consider additional coagulation studies including fibrinogen level and mixing studies if initial workup is inconclusive. 5
• Assess for hereditary hemorrhagic telangiectasia (HHT) by examining for nasal and oral mucosal telangiectasias, given the recurrent nature of bleeding. 1, 2

Von Willebrand disease is the most common inherited bleeding disorder and characteristically presents with mucocutaneous bleeding including epistaxis and menorrhagia. 5 The mildly prolonged PT/INR may reflect decreased factor VIII levels in type 2N von Willebrand disease or may be an incidental finding. 5

Severity Assessment and Escalation Criteria

This patient's bleeding does not currently meet criteria for severe epistaxis requiring reversal agents, which include: 1

• Posterior nosebleed with hemodynamic instability
• Hemoglobin decrease ≥2 g/dL or transfusion requirement of ≥2 units RBCs
• Bleeding inaccessible to local control

If bleeding cannot be controlled with local measures alone, proceed to endoscopic sphenopalatine artery ligation rather than prolonged nasal packing. 2, 4 Endoscopic sphenopalatine artery ligation has the highest immediate success rate, shortest hospital stay, lowest recurrence rate, and highest patient satisfaction compared to other interventions. 2

Post-Septoplasty Considerations

• Technical factors from the recent septoplasty (1 month ago) are more likely contributors to bleeding than the mild INR elevation. 1
• Examine the surgical site endoscopically for exposed vessels, septal perforation, or inadequate healing. 1, 2
• Ensure the patient is not using intranasal corticosteroids, which increase epistaxis risk with a relative risk of 2.74. 2

Prevention and Follow-Up

• Prescribe aggressive nasal mucosal moisturization with petroleum jelly twice daily and regular saline nasal sprays. 2, 3
• Instruct the patient to avoid nose picking, vigorous nose-blowing, and nasal manipulation for 7-10 days. 3
• Schedule follow-up within 30 days to assess for recurrent epistaxis and review bleeding disorder workup results. 2, 3
• If von Willebrand disease is confirmed, treatment options include desmopressin (DDAVP) for mild bleeding episodes or von Willebrand factor/factor VIII concentrates for severe episodes. 5

Common Pitfalls to Avoid

• Do not transfuse FFP based solely on the INR of 1.26 - this minimally elevated value does not predict bleeding risk and FFP will not improve hemostasis. 1
• Do not overlook the underlying bleeding disorder - the combination of menorrhagia and post-surgical bleeding mandates hematologic evaluation. 5
• Do not use prolonged nasal packing - modern endoscopic surgical approaches are more effective with lower recurrence rates. 2, 4
• Do not attribute all bleeding to anticoagulation - bleeding with a therapeutic or near-normal INR often indicates underlying pathology. 1