How should I evaluate and manage a patient with chronic recurrent epistaxis (lasting weeks to months), including initial pressure, topical vasoconstrictor, cautery, packing, anticoagulation adjustment, and referral criteria?

Management of Chronic Recurrent Epistaxis

For chronic recurrent epistaxis lasting weeks to months, begin with firm sustained compression to the lower third of the nose for 10-15 minutes, followed by topical vasoconstrictors if needed, then proceed to anterior rhinoscopy and nasal endoscopy to identify the bleeding source, with cautery or packing as indicated, while reserving anticoagulation adjustment only for life-threatening bleeding. 1

Initial Triage and Risk Stratification

Identify patients requiring urgent intervention by assessing for:

• Active bleeding with hemodynamic instability (tachycardia, hypotension) 1
• Bleeding duration >30 minutes over 24 hours 1, 2
• Bilateral bleeding or bleeding from the mouth 2
• History of prior hospitalization or transfusion for epistaxis 2
• More than 3 recent bleeding episodes 2

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

• Personal or family history of bleeding disorders 3
• Anticoagulant or antiplatelet medication use 3
• Intranasal drug use 3
• Chronic kidney or liver disease 2
• Hypertension and cardiopulmonary disease 2

Stepwise Treatment Algorithm

Step 1: Direct Nasal Compression (First-Line)

Apply firm, continuous pressure to the soft lower third of the nose for a full 10-15 minutes without intermittently checking for cessation – premature release is the most common cause of treatment failure 1. This maneuver alone resolves the vast majority of anterior epistaxis cases 1.

• Position the patient seated with head tilted slightly forward to prevent blood from entering the airway or stomach 1
• Instruct the patient to breathe through the mouth and expectorate blood rather than swallow it 1
• Compression can be performed by the patient, caregiver, or clinician 1

Step 2: Topical Vasoconstrictors (If Compression Fails)

Apply oxymetazoline or phenylephrine spray (2 sprays into the bleeding nostril) and resume firm compression for another 5-10 minutes 1. Vasoconstrictors stop bleeding in 65-75% of emergency department cases 1, 4.

Critical pitfall: Obtain baseline blood pressure before using topical vasoconstrictors, as approximately one-third of epistaxis patients have undiagnosed hypertension and vasoconstrictors carry increased risk of cardiac or systemic complications in this population 1.

Step 3: Identify the Bleeding Source

After clot removal by suction or gentle nose blowing, perform anterior rhinoscopy to identify the bleeding source 1, 5. This is the primary diagnostic procedure for epistaxis 5.

If anterior rhinoscopy fails to identify the source or bleeding is difficult to control, proceed to nasal endoscopy 1, 5. Endoscopy localizes the bleeding site in 87-93% of cases 1, 5.

Step 4: Targeted Cautery (When Focal Source Identified)

When a focal bleeding point is found:

• Anesthetize the site with topical lidocaine 1
• Apply cautery only to the active bleeding point to minimize mucosal injury 1
• Never perform bilateral simultaneous septal cautery – this markedly increases the risk of septal perforation 1

Electrocautery is more effective than chemical cauterization, with fewer recurrences (14.5% vs 35.1%) 1, 4.

Step 5: Nasal Packing (If Bleeding Persists)

Initiate nasal packing when:

• Bleeding persists after 15-30 minutes of proper compression combined with vasoconstrictors 1
• Life-threatening hemorrhage is present 1
• A posterior bleeding source is suspected 1

Selection of packing material is critical:

For patients on anticoagulants or antiplatelet medications: Use only resorbable/absorbable materials (Nasopore, Surgicel, Floseal) to avoid trauma during removal 3, 1, 2.

For patients without bleeding risk factors: Either resorbable or non-resorbable materials may be used 1.

Patient education after packing placement must include 3, 2:

• Type of packing placed
• Timing and plan for removal (if not resorbable)
• Post-procedure care instructions
• Warning signs requiring immediate reassessment (active bleeding despite packing, fever >101°F, vision changes, hemodynamic instability) 1

Management of Anticoagulation/Antiplatelet Therapy

Do NOT discontinue anticoagulant or antiplatelet agents before attempting first-line local measures (compression, vasoconstrictors, cautery, packing) unless bleeding is life-threatening 1, 2. This is a critical principle that prevents unnecessary thrombotic complications.

For aspirin specifically: Continue aspirin despite epistaxis if the patient is at high risk for cardiovascular events – the survival benefits outweigh bleeding risks in patients with recent MI or stents 1.

Reversal of anticoagulation is indicated only for life-threatening bleeding 1:

• Warfarin: 4-factor prothrombin complex concentrate (PCC) provides faster INR correction than fresh frozen plasma 1
• Direct oral anticoagulants: 4-factor PCC; idarucizumab specifically for dabigatran 1
• Platelet inhibitors: Platelet transfusion (effectiveness depends on timing of last dose) 1

Prevention of Recurrence

After hemostasis is achieved:

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2-3 times daily 1
• Use saline nasal sprays frequently throughout the day to maintain mucosal moisture 1
• Recommend humidifier use in dry environments 1
• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7-10 days after treatment 1

Referral Criteria to Otolaryngology

Refer when:

• Bleeding persists despite appropriate nasal packing 1, 2
• Recurrent epistaxis occurs despite correct local treatment and preventive measures 1, 2
• Bilateral recurrent nosebleeds with concern for hereditary hemorrhagic telangiectasia (HHT) – assess for nasal and oral mucosal telangiectasias 1, 2
• Persistent bleeding necessitates evaluation for surgical arterial ligation or endovascular embolization 1, 2

Advanced interventions for refractory cases:

• Endoscopic sphenopalatine artery ligation has a 97% success rate versus 62% for conventional packing 1, 4
• Endovascular embolization has an 80% success rate with recurrence rates <10% compared to 50% for nasal packing 1, 4

Follow-Up and Documentation

Document outcomes within 30 days for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization 3, 2. This allows assessment for underlying conditions when treatments are ineffective or bleeding recurs 1.

Common pitfall to avoid: Do not delay local control measures while waiting for laboratory results – compression, vasoconstrictors, and direct visualization take priority over blood work 5. Routine coagulation studies are not needed in patients with isolated, easily controlled epistaxis and no bleeding history 5.