Management of Frequent Epistaxis

Immediate Assessment and Risk Stratification

The American Academy of Otolaryngology-Head and Neck Surgery recommends documenting critical risk factors that increase bleeding frequency or severity, including anticoagulant or antiplatelet medications, personal or family history of bleeding disorders, and hypertension, in patients with frequent epistaxis 1
Patients with frequent nosebleeds should be assessed for hereditary hemorrhagic telangiectasia (HHT) if they report recurrent bilateral nosebleeds or have a family history of recurrent epistaxis, as this requires specialized management 1

The American Academy of Otolaryngology-Head and Neck Surgery recommends performing anterior rhinoscopy after removing any blood clots to identify the bleeding source in all patients with recurrent epistaxis 1
Nasal endoscopy should be considered if bleeding is difficult to control despite initial treatments, or if there are concerning features such as unilateral bleeding with nasal obstruction, facial pain, or visual changes 1

Daily nasal saline spray or gel applied multiple times daily can resolve up to 65% of recurrent epistaxis cases and is the cornerstone of prevention, according to the American Academy of Otolaryngology-Head and Neck Surgery 2
Environmental humidification, particularly during winter months or in dry climates, can help prevent mucosal desiccation and reduce the risk of epistaxis 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends applying firm, sustained compression to the soft lower third of the nose for a full 5-10 minutes without interruption as first-line treatment for acute epistaxis 1
If bleeding persists after compression, oxymetazoline 0.05% (Afrin) or phenylephrine nasal spray can be applied directly to the bleeding site, followed by resumption of firm compression for another 5 minutes 2

If a specific bleeding site is identified on rhinoscopy, nasal cautery can be performed after anesthetizing the area with topical lidocaine or tetracaine, according to the American Academy of Otolaryngology-Head and Neck Surgery 1

Patients should be educated about preventive measures, such as daily saline moisturization and humidification, and home treatment for acute bleeding, including proper compression technique, according to the American Academy of Otolaryngology-Head and Neck Surgery 1
Outcome should be documented within 30 days or at follow-up to assess treatment effectiveness 1

Patients with persistent or recurrent bleeding despite nasal packing or cauterization, suspected HHT, or unilateral bleeding with concerning features should be referred to an ENT specialist, according to the American Academy of Otolaryngology-Head and Neck Surgery 1

Aggressively lowering blood pressure during active epistaxis can cause end-organ ischemia and should be avoided, according to the American Academy of Otolaryngology-Head and Neck Surgery 3
Anticoagulation status should not be overlooked, and INR should be checked if the patient is on warfarin, with consideration of reversal only for severe refractory bleeding 1