Guideline sources The following summarized guidelines for the evaluation and management of epistaxis are prepared by our editorial team based on guidelines from the Hereditary Haemorrhagic Telangiectasia Working Group (HHT-WG 2020) and the American Academy of Otolaryngology- Head and Neck Surgery Foundation (AAO-HNSF 2020). 1 2 Guidelines 1. Diagnostic investigations Initial assessment: Distinguish patients with nosebleed requiring prompt management from patients who do not, at the time of initial contact. B Document factors increasing the frequency or severity of bleeding in patients with nosebleeds, including personal or family history of bleeding disorders, use of anticoagulant or antiplatelet medications, or intranasal drug use. B Anterior rhinoscopy: obtain anterior rhinoscopy to identify the source of bleeding after removal of any blood clot, if present, in patients with nosebleeds. B https://web.pathway.md/diseases/rec37bjWmUrl4yPpa 1/4 6/29/23, 4:18 AM Epistaxis Pathway 2. Diagnostic procedures Nasal endoscopy: Perform, or refer to a clinician who can perform, nasal endoscopy to identify the site of bleeding and guide further management in patients with recurrent nasal bleeding, despite prior treatment with packing or cautery, or with recurrent unilateral nasal bleeding. B Consider performing, or referring to a clinician who can perform, nasal endoscopy to examine the nasal cavity and nasopharynx in patients with epistaxis that is difficult to control or when there is concern for unrecognized pathology contributing to epistaxis. C 3. Medical management General principles: Treat patients with an identified site of bleeding with an appropriate intervention, which may include 1 of the following: moisturizing or lubricating agents topical vasoconstrictors nasal cautery. B 4. Nonpharmacologic interventions Nasal compression: apply firm sustained compression to the lower third of the nose, with or without the assistance of the patient or caregiver, for 5 minutes in patients with active nasal bleeding requiring prompt management. B Nasal packing: apply nasal packing in patients with ongoing active nasal bleeding when bleeding precludes identification of a bleeding site despite nasal compression. B Show 2 more 5. Therapeutic procedures Nasal cautery: anesthetize the bleeding site and restrict application of cautery only to the active or suspected site of bleeding when nasal cautery is chosen for treatment. B 6. Surgical interventions Ligation and embolization: evaluate, or refer to a clinician who can evaluate, candidacy for surgical arterial ligation or endovascular embolization in patients with persistent or recurrent bleeding not controlled by packing or nasal cauterization. B 7. Specific circumstances Patients on anticoagulant and antiplatelet therapy: Initiate first-line treatments before transfusion, reversal of anticoagulation, or withdrawal of anticoagulation/antiplatelet medications in patients using these medications, in the absence https://web.pathway.md/diseases/rec37bjWmUrl4yPpa 2/4 6/29/23, 4:18 AM Epistaxis Pathway of life-threatening bleeding. B Use resorbable packing for nasal packaging in patients using anticoagulation or antiplatelet medications. B Hereditary hemorrhagic telangiectasia (evaluation): assess, or refer to a specialist who can assess, the presence of nasal telangiectasias and/or oral mucosal telangiectasias in patients with a history of recurrent bilateral nosebleeds or a family history of recurrent nosebleeds for the diagnosis of HHT syndrome. B Patients with hereditary hemorrhagic telangiectasia (topical therapy): advise using moisturizing topical therapies humidifying the nasal mucosa to reduce epistaxis in patients with HHT-related epistaxis. B Patients with hereditary hemorrhagic telangiectasia (medical therapy): Consider administering oral tranexamic acid for the management of epistaxis not responding to moisturizing topical therapies in patients with HHT. B Consider administering systemic antiangiogenic agents for the management of epistaxis in patients with HHT failed to respond to moisturizing topical therapies, ablative therapies, and/or tranexamic acid. B Patients with hereditary hemorrhagic telangiectasia (ablative therapy): consider performing ablative therapies for nasal telangiectasias, including laser treatment, radiofrequency ablation, electrosurgery, and sclerotherapy, in patients with HHT failed to respond to moisturizing topical therapies. C Patients with hereditary hemorrhagic telangiectasia (surgery): Consider performing septodermoplasty for the management of epistaxis in patients with HHT failed to sufficiently respond to moisturizing topical therapies, ablative therapies, and/or tranexamic acid. C Consider performing nasal closure for the management of epistaxis in patients with HHT failed to sufficiently respond to moisturizing topical therapies, ablative therapies, and/or tranexamic acid. B 8. Patient education Patient education: educate patients with nosebleeds and their caregivers about preventive measures for nosebleeds, home treatment for nosebleeds, and indications to seek additional medical care. B 9. Follow-up and surveillance Follow-up: document the outcomes of intervention within 30 days or document transition of care in patients treated with non-resorbable packing, surgery, or arterial ligation/embolization. B References https://web.pathway.md/diseases/rec37bjWmUrl4yPpa 3/4 6/29/23, 4:18 AM Epistaxis Pathway 1. Marie E Faughnan, Johannes J Mager, Steven W Hetts et al. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med. 2020 Dec 15;173 12 989 1001. Open 2. David E Tunkel, Samantha Anne, Spencer C Payne et al. Clinical Practice Guideline: Nosebleed Epistaxis). Otolaryngol Head Neck Surg. 2020 Jan;162 1_suppl):S1 S38. Open https://web.pathway.md/diseases/rec37bjWmUrl4yPpa 4/4