What is the best treatment for chronic anterior epistaxis?

Management of Chronic Anterior Epistaxis

For chronic anterior epistaxis, the best treatment is regular application of nasal saline gel or petroleum jelly to the anterior nasal mucosa 2-3 times daily, combined with identification and cauterization of any visible bleeding site after proper anesthesia. 1, 2

Initial Diagnostic Approach

Perform anterior rhinoscopy after removing any blood clot to identify the bleeding source, which is typically located at Kiesselbach's plexus on the anterior nasal septum. 3 If the source remains unclear or bleeding recurs despite treatment, proceed to nasal endoscopy, which localizes the bleeding site in 87-93% of cases. 3

Key History Elements to Document

• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia, easy bruising, prolonged bleeding from minor cuts) 3
• All anticoagulant and antiplatelet medications (warfarin, aspirin, clopidogrel, direct oral anticoagulants, NSAIDs), including recent dosage changes 3
• Intranasal medication use, particularly nasal corticosteroids, which increase epistaxis risk 2.74-fold 3
• Intranasal drug abuse (cocaine, other recreational inhalants) 3
• Bilateral recurrent nosebleeds or family history of recurrent nosebleeds, which may indicate hereditary hemorrhagic telangiectasia 3, 1

Definitive Treatment Algorithm

Step 1: Mucosal Moisturization (Primary Prevention)

Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2-3 times daily to maintain moisture and prevent recurrence. 1, 2 This simple intervention achieved 93.2% cessation of epistaxis at 3 months in anticoagulated patients with recurrent anterior epistaxis. 4

• Use saline nasal sprays frequently throughout the day to keep nasal mucosa moist 1
• Recommend humidifier use in dry environments, as dry heat creates fragile, hyperemic mucosa that bleeds easily 1, 5

Step 2: Cauterization of Identified Bleeding Sites

When a focal bleeding point is identified on anterior rhinoscopy:

• Anesthetize the bleeding site with topical lidocaine or tetracaine before cautery 3, 2
• Apply cautery only to the active or suspected bleeding site(s) 3
• Silver nitrate cauterization achieves 80% initial success and has the lowest recurrence rate (14.5%) compared to other modalities 6
• Electrocautery is more effective than chemical cauterization (14.5% vs 35.1% recurrence) 2, 6

Critical pitfall: Never perform bilateral simultaneous septal cautery, as this markedly increases the risk of septal perforation. 3, 2

Step 3: Topical Vasoconstrictors (Adjunctive)

Apply oxymetazoline or phenylephrine spray (2 sprays) to the bleeding site if active bleeding is present, which stops bleeding in 65-75% of emergency department cases. 1, 2 However, avoid repeated or prolonged use, as this precipitates rhinitis medicamentosa, loss of efficacy, and worsening nasal obstruction. 1

Management of Medication-Related Epistaxis

Nasal Corticosteroids

Consider cessation of nasal corticosteroids in patients with recurrent or severe nosebleeds, given the 2.74-fold increased risk. 3

Anticoagulants and Antiplatelets

Do not discontinue anticoagulant or antiplatelet medications for chronic anterior epistaxis unless bleeding is life-threatening. 3, 1 Initiate first-line local treatments (moisturization, cautery, vasoconstrictors) before considering medication withdrawal. 3, 2

• For warfarin patients, check INR to ensure therapeutic range 3
• NSAIDs and aspirin should be continued in patients at high cardiovascular risk, as survival benefits outweigh bleeding risks 1

When to Escalate Care

Indications for Nasal Endoscopy

Refer for nasal endoscopy in patients with: 3

• Recurrent bleeding despite prior packing or cautery
• Recurrent unilateral nasal bleeding (to exclude masses, foreign bodies, or malignancy)
• Difficult-to-control bleeding when anterior rhinoscopy fails to identify the source

Indications for Specialist Referral

Refer to otolaryngology for: 1

• Persistent bleeding despite appropriate cauterization and moisturization
• Need for evaluation of surgical arterial ligation or endovascular embolization
• Suspected hereditary hemorrhagic telangiectasia (bilateral recurrent bleeds with nasal/oral telangiectasias)

Common Pitfalls to Avoid

• Do not cauterize without adequate anesthesia and hemostasis, as this increases discomfort and may worsen bleeding 2
• Do not use cauterization in the absence of acute bleeding in anticoagulated patients, as it does not address the underlying mucosal dryness and may extend mucosal disruption 4
• Do not overlook underlying pathology in patients with recurrent unilateral bleeding—nasal masses, juvenile nasopharyngeal angiofibroma (in adolescent males), and malignancies can present with epistaxis 3
• Do not routinely lower blood pressure in patients with acute nosebleeds, as excessive reduction may cause renal, cerebral, or coronary ischemia 3

Patient Education

Instruct patients to: 1, 2

• Apply nasal moisturizers 2-3 times daily indefinitely
• Use saline sprays frequently
• Avoid picking or rubbing the nose to allow healing
• Avoid vigorous nose-blowing for 7-10 days after cautery
• Return if bleeding persists >15 minutes despite proper compression, or if >3 episodes occur