How should I evaluate and manage a patient with frequent epistaxis?

Evaluation and Management of Frequent Epistaxis

For patients with recurrent nosebleeds, begin with firm continuous compression of the soft lower nose for 10–15 minutes without checking, apply topical vasoconstrictors if bleeding persists, then perform anterior rhinoscopy to identify and cauterize the bleeding site, while implementing daily nasal moisturization to prevent recurrence. 1

Initial Assessment and Risk Stratification

Document critical risk factors that increase bleeding frequency or severity:

• Anticoagulant or antiplatelet medications (warfarin, aspirin, clopidogrel, direct oral anticoagulants, NSAIDs) 1
• Personal or family history of bleeding disorders (von Willebrand disease, hemophilia, easy bruising, prolonged bleeding from minor cuts) 1
• Intranasal drug use (nasal corticosteroids increase risk 2.7-fold, cocaine, other inhalants) 1, 2
• Nasal oxygen therapy or CPAP use 2
• Prior nasal or sinus surgery 2
• Recurrent bilateral nosebleeds (suggests hereditary hemorrhagic telangiectasia) 1

Obtain baseline blood pressure because approximately 33% of epistaxis patients have undiagnosed hypertension 1. However, do not acutely lower blood pressure during active bleeding, as excessive reduction can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension 2.

Immediate Management Algorithm

Step 1: Direct Compression (First-Line)

• Position the patient seated upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1
• Apply firm, continuous pressure to the soft lower third of the nose for a full 10–15 minutes without intermittent checking; premature release is the most common cause of treatment failure 1
• Instruct the patient to breathe through the mouth and spit out blood rather than swallow it 1
• Compression alone resolves the vast majority of anterior epistaxis cases 1

Step 2: Topical Vasoconstrictors (If Compression Fails)

• Apply oxymetazoline or phenylephrine spray (2 sprays into the bleeding nostril) after clearing blood clots 1
• Resume firm compression for another 5–10 minutes after applying the vasoconstrictor 1
• Vasoconstrictor application stops bleeding in 65–75% of emergency department cases 1, 3
• Caution: Obtain baseline blood pressure before using vasoconstrictors in patients with cardiovascular risk factors; avoid repeated or prolonged use to prevent rhinitis medicamentosa 1

Step 3: Identify the Bleeding Source

• Perform anterior rhinoscopy after clot removal to locate the bleeding site, most commonly the Kiesselbach plexus on the anterior nasal septum 1, 2
• If the source remains unclear or bleeding is difficult to control, proceed to nasal endoscopy, which localizes the bleeding site in 87–93% of cases 1

Step 4: Definitive Treatment Based on Source

When a focal bleeding point is identified:

• Anesthetize the site with topical lidocaine or tetracaine 1
• Cauterize only the active bleeding point; electrocautery is more effective with fewer recurrences (14.5%) compared to chemical cauterization (35.1%) 1, 3
• Avoid bilateral simultaneous septal cautery because it markedly increases the risk of septal perforation 1

Step 5: Nasal Packing (If Other Measures Fail)

Indications for nasal packing:

• Bleeding persists after 15–30 minutes of proper compression with vasoconstrictors 1
• Life-threatening hemorrhage 1
• Posterior bleeding source suspected 1

Packing material selection:

• For patients on anticoagulants or antiplatelet medications, use only resorbable materials (Nasopore, Surgicel, Floseal) to minimize trauma during removal 1
• For patients without bleeding risk factors, either resorbable or non-resorbable materials may be used 1

Prevention of Recurrence

Implement daily nasal moisturization:

• Apply petroleum jelly or nasal saline gel to the anterior nasal mucosa 2–3 times daily to maintain moisture and reduce recurrence 1
• Use saline nasal sprays frequently throughout the day to keep the nasal mucosa moist 1
• Recommend a humidifier in dry environments, especially during sleep 1, 4

Behavioral modifications:

• Avoid digital trauma (nose picking) and forceful nose blowing for at least 7–10 days after treatment 1, 4
• Counsel for nicotine cessation if applicable, as nicotine induces direct vasoconstriction and mucosal drying 2

Medication Management

For patients on antiplatelet agents (aspirin, clopidogrel):

• Do not discontinue aspirin or other antiplatelet agents solely for epistaxis treatment unless bleeding is life-threatening 1
• If the patient is at high cardiovascular risk (recent MI, stents), continue aspirin despite epistaxis 1
• Attempt first-line local interventions (compression, vasoconstrictors, cautery, packing) before considering medication withdrawal 1

For patients on anticoagulants:

• Do not reverse anticoagulation in hemodynamically stable patients with controlled bleeding 1
• For patients on warfarin, verify INR is within therapeutic range 2
• Reversal is indicated only for life-threatening hemorrhage with hemodynamic instability 1

Indications for Specialist Referral

Refer to otolaryngology when:

• Bleeding persists despite appropriate nasal packing 1
• Recurrent bleeding occurs despite correct local treatment and preventive measures 1
• Three or more recent episodes of epistaxis 1
• Unilateral bleeding with nasal obstruction (suggests mass lesion, juvenile nasopharyngeal angiofibroma in adolescent males) 2, 4
• Bilateral recurrent nosebleeds with visible telangiectasias (suggests hereditary hemorrhagic telangiectasia) 1, 4
• Nasal endoscopy is needed but unavailable 1

Advanced Interventions for Refractory Cases

For persistent or recurrent bleeding not controlled by packing or cautery:

• Evaluate candidacy for surgical arterial ligation or endovascular embolization 1
• Endoscopic sphenopalatine artery ligation has a 97% success rate compared to 62% for conventional packing 1, 3
• Endovascular embolization has an 80% success rate with recurrence rates less than 10% compared to 50% for nasal packing 1, 3

Common Pitfalls to Avoid

• Do not check for bleeding cessation during the initial 10–15 minutes of compression; premature release is the most common cause of failure 1
• Do not aggressively lower blood pressure acutely, as this can cause end-organ ischemia 2
• Do not perform bilateral simultaneous septal cautery due to high risk of septal perforation 1
• Do not use non-resorbable packing in patients on anticoagulants or antiplatelet agents 1
• Do not overlook hereditary hemorrhagic telangiectasia screening in patients with recurrent bilateral epistaxis 1
• Do not discontinue aspirin in high-risk cardiovascular patients 1

Follow-Up

Document treatment outcomes within 30 days to assess effectiveness and detect underlying pathology 1, 4. Routine follow-up is recommended for patients who have undergone invasive treatments (nasal packing, surgical ligation, embolization) to assess for complications and recurrent bleeding 1.