Recurrent Epistaxis Management

Initial Assessment and Causes

The American Academy of Otolaryngology-Head and Neck Surgery recommends systematically evaluating for underlying systemic causes, including coagulopathy, anticoagulant use, hereditary hemorrhagic telangiectasia, and structural nasal pathology, in patients with recurrent epistaxis 1, 2
Anticoagulant or antiplatelet medications, such as warfarin, apixaban, aspirin, and clopidogrel, can increase bleeding frequency or severity 3, 4
Bleeding disorders, including thrombocytopenia, hemophilia, and von Willebrand disease, should be considered in patients with recurrent epistaxis 1
Intranasal drug use, such as topical corticosteroids, cocaine, and nasal decongestant overuse, can contribute to epistaxis 5
Environmental factors, including dry climate, low humidity, and frequent nose picking, can also play a role in epistaxis 6

The American Academy of Otolaryngology-Head and Neck Surgery suggests performing anterior rhinoscopy after removing blood clots to identify the bleeding source 2, 4
Nasal endoscopy is essential to exclude serious pathology, such as tumors or foreign bodies, in patients with recurrent epistaxis 2, 5
Hereditary Hemorrhagic Telangiectasia (HHT) screening should be considered in patients with recurrent bilateral nosebleeds, family history of recurrent nosebleeds, or visible nasal or oral mucosal telangiectasias on examination [1, @7@]

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying firm sustained compression to the lower third of the nose for 5-15 minutes as first-line local control for epistaxis 5, 4
Topical vasoconstrictors, such as oxymetazoline or phenylephrine spray, can be used to stop bleeding in 65-75% of emergency department cases 6
Chemical cautery with 75% silver nitrate can be performed if a specific bleeding site is identified 4, 6
Aggressive nasal mucosal moisturization, including petroleum jelly and saline nasal sprays, is the cornerstone of prevention for recurrent epistaxis [@7@, 5]

Endoscopic sphenopalatine artery ligation (ELSA) has the best outcomes for persistent epistaxis, with the highest immediate success rate, shortest hospital stay, lowest recurrence rate, and highest patient satisfaction [@9@]
Surgical arterial ligation or endovascular embolization can be considered for patients with recurrent epistaxis who have failed conservative measures 6, 1

The American Academy of Otolaryngology-Head and Neck Surgery recommends continuing anticoagulation and aggressively pursuing local control measures first in patients with recurrent epistaxis who are on anticoagulants 5, 4
Withholding anticoagulation increases thrombotic risk, which carries higher morbidity and mortality than epistaxis itself 4
Temporary interruption of anticoagulation should only be considered in patients with life-threatening bleeding 4

The American Academy of Otolaryngology-Head and Neck Surgery recommends that intranasal corticosteroids be discontinued in patients with recurrent or severe epistaxis, as they increase the risk of nosebleed with a relative risk of 2.74 (range 1.88-4.00) 7
The patient's history of steroid treatment may have contributed to recurrent epistaxis, according to the American Academy of Otolaryngology-Head and Neck Surgery 7
The American Academy of Otolaryngology-Head and Neck Surgery suggests removing any blood clots by suction or gentle nose blowing to identify the bleeding site, and applying topical decongestant (oxymetazoline 0.05%, 2-3 sprays per nostril every 10-12 hours, not exceeding 2 doses in 24 hours) after clot removal 7
Directed cautery can be applied following blood clot removal if a specific bleeding site is identified, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery 7
Nasal endoscopy is indicated for recurrent epistaxis despite prior treatment, according to the American Academy of Otolaryngology-Head and Neck Surgery 7
The American Academy of Otolaryngology-Head and Neck Surgery recommends that patients with a history of steroid use and recurrent epistaxis should not continue intranasal corticosteroids 7
Do not overlook the autoimmune history and prior steroid use, as it may indicate underlying systemic disease contributing to both epistaxis and neurologic symptoms, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 7