How should a 62-year-old woman with recurrent anterior epistaxis requiring repeated nasal packing, chronic anemia (hemoglobin ~10.5 g/dL), and no known bleeding disorder be managed?

Management of Recurrent Anterior Epistaxis in a 62-Year-Old Woman

This patient requires urgent nasal endoscopy to identify the bleeding site, followed by definitive treatment with electrocautery or surgical intervention—repeated nasal packing alone is inadequate and carries a 50% recurrence rate. 1

Immediate Assessment and Stabilization

Critical Risk Stratification

• Document hemodynamic status immediately: check for tachycardia, hypotension, or orthostatic changes, as three episodes of bleeding requiring packing with hemoglobin of 10.5 g/dL suggests significant cumulative blood loss. 1
• Obtain baseline blood pressure, as approximately 33% of epistaxis patients have undiagnosed hypertension. 1
• Do NOT aggressively lower blood pressure acutely—excessive reduction can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 2

Mandatory History Documentation

• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia). 3, 1
• All anticoagulant or antiplatelet medications—if on warfarin, check INR immediately. 2, 4
• Intranasal drug use, nasal oxygen or CPAP use, prior nasal surgery. 1, 2
• Screen for hereditary hemorrhagic telangiectasia (HHT): assess for oral or nasal telangiectasias, family history of recurrent nosebleeds, or recurrent bilateral epistaxis. 3, 1, 4

Definitive Diagnostic Evaluation

Nasal Endoscopy is Mandatory

After three failed packing attempts, nasal endoscopy must be performed to identify the exact bleeding site and rule out underlying pathology. 3, 1, 4

• Endoscopy localizes the bleeding site in 87–93% of cases and is specifically recommended for recurrent bleeding despite prior packing. 3, 1, 4
• Critical red flag: Unilateral recurrent epistaxis warrants endoscopic evaluation to exclude nasal tumors, especially with associated nasal obstruction, facial pain, or visual changes. 2, 4
• Perform anterior rhinoscopy first after clot removal; if the source remains unclear, proceed immediately to full nasal endoscopy of the nasal cavity and nasopharynx. 3, 1

Definitive Treatment Strategy

Electrocautery is Superior to Repeat Packing

Once the bleeding site is identified, electrocautery is the treatment of choice—it has a 14.5% recurrence rate compared to 35.1% for chemical cauterization and 50% for nasal packing. 1, 4

• Anesthetize the bleeding site with topical lidocaine or tetracaine before cautery. 3, 1, 4
• Restrict cautery application strictly to the active bleeding site—avoid bilateral simultaneous septal cautery, which markedly increases septal perforation risk. 3, 1, 4
• Silver nitrate cauterization achieved 80% initial success in one large cohort, with the added benefit of no follow-up removal required. 5

Surgical Intervention for Refractory Cases

This patient meets criteria for evaluation for surgical arterial ligation or endovascular embolization after three failed packing attempts. 3, 1, 4

• 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 less than 10% compared to 50% for nasal packing. 1, 4
• Refer to otolaryngology immediately for persistent bleeding despite appropriate nasal packing or recurrent bleeding despite correct local treatment. 1, 4

Adjunctive Therapies

Topical Tranexamic Acid

• Topical tranexamic acid (500 mg in 5 mL applied to a pledget for 10–15 minutes) shortens time to hemostasis (6.7 minutes versus 11.5 minutes) and lowers recurrence rates (6% versus 20%) in patients on antiplatelet drugs. 1
• However, one large multicenter RCT found no significant benefit over placebo in reducing the need for nasal packing (43.7% versus 41.3%, p=0.59). 6
• Consider TXA as an adjunct in anticoagulated patients, but do not rely on it as sole therapy in this recurrent case. 7

If Further Packing is Required

• Use only resorbable packing materials (Nasopore, Surgicel, Floseal) to minimize trauma during removal, especially given the chronic anemia. 3, 1, 4
• Educate the patient about packing type, removal timing (if non-resorbable), post-procedure care, and warning signs requiring immediate reassessment. 3, 1

Management of Chronic Anemia

Transfusion Considerations

• Hemoglobin of 10.5 g/dL with recurrent bleeding warrants close monitoring, but initiate first-line local treatments before transfusion unless bleeding is life-threatening. 3, 1
• Assess for hemodynamic instability, ongoing blood loss, and cardiovascular comorbidities to guide transfusion decisions. 1

Prevention of Recurrence

Mucosal Moisturization Protocol

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily. 1, 4
• Prescribe regular saline nasal sprays throughout the day to maintain mucosal moisture. 1, 4
• Recommend humidifier use in dry environments. 1, 4

Post-Treatment Instructions

• Avoid nasal manipulation, vigorous nose-blowing, and nasal decongestants for 7–10 days after treatment. 1, 4
• Do NOT use topical vasoconstrictors long-term, as this precipitates rhinitis medicamentosa and worsening obstruction. 1

Follow-Up and Documentation

• Document treatment outcomes within 30 days or document transition of care for patients treated with non-resorbable packing, surgery, or arterial ligation/embolization. 3, 1, 4
• Arrange follow-up to assess for complications and underlying conditions if treatments are ineffective or bleeding recurs. 1, 4

Common Pitfalls to Avoid

• Do not continue repeated nasal packing cycles—this approach has a 50% recurrence rate and delays definitive treatment. 1, 4
• Do not perform bilateral septal cautery simultaneously due to perforation risk. 3, 1, 4
• Do not overlook HHT screening in patients with recurrent bilateral epistaxis or family history. 3, 1, 4
• Do not delay endoscopic evaluation after multiple packing failures—underlying pathology including tumors must be excluded. 3, 1, 2, 4
• Do not use non-resorbable packing if the patient has any bleeding risk factors or requires repeat packing. 3, 1, 4