Guidelines for Managing Recurrent Epistaxis

Initial Assessment and Management

The American Academy of Otolaryngology-Head and Neck Surgery recommends that clinicians distinguish patients requiring prompt management from those who do not, assessing for airway compromise and hemodynamic stability 1, 2
For active bleeding, applying firm sustained compression to the lower third of the nose for 5-15 minutes with the patient seated and head tilted slightly forward can be effective 3, 4
Patients should breathe through the mouth and spit out blood rather than swallowing it 3, 4
After compression, cleaning the nasal cavity of clots and applying a topical vasoconstrictor (oxymetazoline or phenylephrine) can stop bleeding in 65-75% of cases 3, 4

Clinicians should document factors that increase frequency or severity of bleeding for any patient with epistaxis, including use of anticoagulant or antiplatelet medications 2, 3, 5
Common risk factors include hypertension 6, nasal trauma or digital manipulation 1, dry nasal mucosa 4, and hereditary conditions like hereditary hemorrhagic telangiectasia (HHT) 7

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying moisturizing or lubricating agents (petroleum jelly) to the nasal mucosa to prevent recurrence 3, 4
Regular use of saline nasal sprays is recommended to keep the nasal mucosa moist 3, 4
Nasal cautery should be considered if a specific bleeding site is identified 2, 5
Tranexamic acid has shown efficacy in reducing epistaxis in hereditary hemorrhagic telangiectasia patients 7

Assess for nasal telangiectasias and/or oral mucosal telangiectasias in patients with recurrent bilateral nosebleeds or family history of recurrent nosebleeds to rule out hereditary hemorrhagic telangiectasia 2, 7

Document the outcome of intervention within 30 days 2, 3
Educate patients about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care 2, 3

Avoid bilateral simultaneous septal cautery as it may increase risk of septal perforation 6, 8
Don't underestimate the importance of simple measures like nasal moisturization, which can be highly effective in preventing recurrence 4