What is the best approach to manage a patient with chronic epistaxis (nose bleeds)?

Management of Chronic Nosebleeds

For patients with chronic/recurrent epistaxis, implement a stepwise approach starting with nasal moisturization and preventive measures, progressing through topical vasoconstrictors and cautery if bleeding recurs, and reserving surgical intervention for refractory cases. 1, 2

Initial Assessment and Risk Stratification

When a patient presents with chronic nosebleeds, immediately distinguish whether they require prompt management based on:

• Active bleeding with hemodynamic instability 1, 2
• History of hospitalization for epistaxis 2
• Bleeding duration and severity 2
• Airway compromise from blood in the oropharynx 1

Document critical risk factors that increase bleeding frequency or severity: 1, 2

• Personal or family history of bleeding disorders
• Anticoagulant or antiplatelet medication use
• Intranasal drug use
• Recurrent bilateral nosebleeds (suggests hereditary hemorrhagic telangiectasia) 1, 2

First-Line Prevention and Home Management

The cornerstone of chronic epistaxis management is preventing recurrence through nasal moisturization: 2

• Apply petroleum jelly or lubricating agents to the nasal mucosa regularly 2
• Use saline nasal sprays frequently throughout the day 2
• Employ humidifiers to maintain environmental moisture 2
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days after bleeding episodes 2

Educate patients on proper acute management technique: 2

• Sit with head slightly forward (not tilted back) to prevent blood from flowing into airway or stomach 2
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without checking 2
• Breathe through mouth and spit out blood rather than swallowing it 2

When Preventive Measures Fail: Active Bleeding Management

If bleeding recurs despite preventive measures:

Step 1: Clean and visualize 2

• Remove blood clots by suction or gentle nose blowing 2
• Perform anterior rhinoscopy to identify the bleeding source 2

Step 2: Apply topical vasoconstrictors 2, 3

• Use oxymetazoline or phenylephrine (2 sprays into bleeding nostril) 2
• This stops bleeding in 65-75% of emergency department cases 2
• Resume firm compression for another 5-10 minutes after application 2
• Caution: May cause cardiac or systemic complications in susceptible patients 2

Step 3: Cauterization if bleeding site identified 2, 3

• Electrocautery is superior to chemical cauterization (14.5% vs 35.1% recurrence rates) 2, 3
• Critical pitfall: Never perform bilateral simultaneous septal cautery—this increases septal perforation risk 2

Advanced Treatment for Persistent Bleeding

Nasal packing indications: 2

• Failure of compression, vasoconstrictors, and cautery after 15-30 minutes 2
• Life-threatening bleeding 2
• Suspected posterior bleeding source 2

Packing material selection is critical: 1, 2

• For patients on anticoagulants/antiplatelets: Use ONLY resorbable materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 1, 2
• For patients without bleeding risk factors: Either resorbable or non-resorbable materials acceptable 2

Post-packing patient education must include: 1, 2

• Type of packing placed
• Timing and plan for removal (if non-resorbable)
• Apply saline spray frequently to keep packing moist 2
• Warning signs requiring immediate reassessment: active bleeding from nose/mouth despite packing, hemodynamic instability, fever >101°F, vision changes, shortness of breath, or facial swelling 2

Evaluation for Underlying Pathology

Perform nasal endoscopy when: 1, 2

• Bleeding is difficult to control 1
• Recurrent bleeding occurs despite prior treatment 2
• Concern exists for unrecognized pathology 1
• Anterior rhinoscopy fails to identify the source 2

Endoscopy localizes the bleeding site in 87-93% of cases 2

Screen for hereditary hemorrhagic telangiectasia (HHT): 1, 2

• Assess for nasal and oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds 2
• These patients require specialized management 2

Surgical and Interventional Options for Refractory Cases

Evaluate candidacy for definitive intervention when: 1, 2

• Persistent or recurrent bleeding not controlled by packing or cauterization 1, 2
• Recurrence rates favor surgical intervention over repeated packing 2

Efficacy comparison of advanced treatments: 2, 3

• Endoscopic sphenopalatine artery ligation: 97% success rate vs 62% for conventional packing 2, 3
• Endovascular embolization: 80% success rate 2, 3
• Recurrence rates: <10% for surgical ligation or embolization vs 50% for nasal packing 2

Special Considerations for Anticoagulated Patients

Do NOT routinely reverse anticoagulation for patients who are: 2

• Hemodynamically stable 2
• Without significant blood loss 2
• Have controlled bleeding with local measures 2

Restart anticoagulation timing: 2

• Typically within 24-48 hours after confirmation of hemostasis 2
• Balance risk of thrombosis versus bleeding on individual basis 2

Follow-Up and Outcome Documentation

Routine follow-up is essential: 2

• Assess for complications and recurrent bleeding 2
• Investigate underlying conditions when treatments are ineffective 2
• Document outcomes within 30 days of intervention 2, 4

Common pitfall to avoid: Premature discontinuation of NSAIDs or aspirin 2

• Most epistaxis resolves with local measures alone 2
• For high-risk cardiovascular patients on aspirin, continue despite epistaxis—survival benefits outweigh bleeding risks 2