When should I consider referring a patient with recurrent epistaxis to an ENT specialist?

Consider referring a patient with recurrent epistaxis to an ear, nose, and throat (ENT) specialist if:

• They have recurrent episodes of epistaxis accompanied by signs or symptoms suggestive of a serious underlying cause, such as nasal obstruction and severe bleeding suggestive of angiofibroma (typically in males aged 12–20 years).
• There are features suggestive of cancer, including nasal obstruction, facial pain, hearing loss, eye symptoms (such as proptosis or double vision), or persistent lymphadenopathy, especially in people over 50 years or with relevant occupational or ethnic risk factors.
• There are signs of telangiectasia, such as red or purple spots on the fingertips, lips, nasal lining, or face, possibly with a family history of hereditary haemorrhagic telangiectasia.
• The patient is a child younger than 2 years old presenting with epistaxis, to rule out underlying causes and consider maltreatment.
• There is suspicion of a posterior nosebleed, which carries higher risk of complications.
• There is an underlying cause for bleeding that requires specialist management.

For patients not at high risk of serious underlying causes, discuss treatment options in primary care first.

Summary: Refer recurrent epistaxis patients to ENT if serious underlying pathology is suspected, if they are very young children, or if bleeding is posterior or complicated by comorbidities or underlying causes requiring specialist care ¹,².