How should I assess and manage recurrent epistaxis in a patient with no identifiable underlying cause?

Assessment: For a patient with recurrent epistaxis and no identifiable underlying cause, first ensure the patient is haemodynamically stable. Consider arranging a full blood count to exclude any haematological abnormalities. Evaluate for any signs or symptoms suggestive of serious underlying causes such as nasal obstruction, facial pain, or visible lesions, which would warrant referral to an ear, nose, and throat (ENT) specialist. In children under 2 years, consider referral to a paediatrician to rule out underlying causes and maltreatment.

Management: Advise the patient on first aid measures during acute episodes: sit with the upper body tilted forward, mouth open, and firmly pinch the soft part of the nose for 10–15 minutes without releasing pressure, breathing through the mouth. After bleeding stops, recommend avoiding nose blowing or picking, heavy lifting, strenuous exercise, lying flat, and consuming alcohol or hot drinks for 24 hours.

For recurrent epistaxis without serious underlying cause, discuss topical treatment options to reduce crusting and vestibulitis. Prescribe Naseptin® cream (chlorhexidine and neomycin) applied four times daily for 10 days, or twice daily for up to 2 weeks if compliance is an issue, unless the patient is allergic to neomycin, peanut, or soya. Alternatively, mupirocin nasal ointment can be applied two to three times daily for 5–7 days. Advise patients to check the formulation of Naseptin® as it was reformulated in 2023 to remove peanut oil.

Observe the patient for at least 30 minutes after bleeding stops to monitor for recurrence. Consider referral or admission if there are risk factors such as age under 2 years, frailty, likely underlying bleeding disorders, anticoagulant use, or comorbidities.