Recurrent epistaxis in adults affects 5–8% of the population, yet its causes often remain unrecognized, and patients receive only local treatment for years without a proper systemic work‑up. This review aims to summarize current evidence on the etiology, diagnosis, and consequences of recurrent epistaxis and to propose a practical diagnostic algorithm for primary care physicians. A narrative review of the literature was conducted using PubMed, Scopus, and E-Library databases over the last 15 years, focusing on systemic causes, diagnostic algorithms, and psychosocial outcomes. In 15-20% of adults with recurrent epistaxis, previously undiagnosed systemic disorders are identified, including hereditary hemorrhagic telangiectasia (HHT), von Willebrand disease, thrombocytopenias, chronic liver diseases, vasculitides, or iatrogenic coagulopathies. Key red flags include telangiectasias on the skin and mucous membranes, a family history of bleeding diatheses, bleeding from other sites, use of anticoagulants or antiplatelets, and systemic symptoms (arthralgias, renal or pulmonary involvement). Minimum laboratory work‑up comprises a complete blood count with platelets, coagulation tests, and liver function tests; when indicated, von Willebrand factor assays, genetic testing for HHT, and vasculitis serology should be performed. Chronic post‑hemorrhagic anemia develops in 40–55% of patients, while psychosocial disturbances (anticipatory anxiety, social isolation, occupational impairment) are found in over 60% of patients but are rarely addressed. Recurrent epistaxis should be regarded as a potential marker of systemic disease. The proposed diagnostic algorithm and differential diagnosis table can serve as practical tools for early detection of treatable conditions and for improving patients' quality of life.
Introduction
Recurrent epistaxis (nosebleeds) in adults is a common reason for visiting otorhinolaryngologists, general practitioners, and emergency departments (Schmidtman et al., 2022; Hadar et al., 2026). According to epidemiological studies, up to 60% of adults experience at least one nosebleed in their lifetime. However, the recurrent form – defined as three or more episodes per month or repeated bleeding over more than three months – occurs in 5–8% of adults (Singh et al., 2023; Dispenza et al., 2024). In most cases, an acute episode is successfully managed with local methods (finger compression, anterior packing, cauterization), and patients do not receive a systemic work up (Pulpă et al., 2025). Nevertheless, the recurrent nature of bleeding can be the first and only manifestation of serious systemic diseases. These include hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease), von Willebrand disease, thrombocytopenias, chronic liver diseases with coagulopathy, vasculitides, as well as iatrogenic hemostatic disorders associated with anticoagulant and antiplatelet use (Lynch et al., 2024; Du et al., 2025).
Despite the clinical significance of this problem, underdiagnosis of systemic causes of recurrent epistaxis persists in real world practice. Physicians often limit themselves to stating "weak vessels," prescribing moisturizers, and performing repeated cauterizations. Meanwhile, the patient continues to suffer from frequent episodes, chronic post hemorrhagic anemia, and significant psycho emotional discomfort for years (Benaim et al., 2025; McDonald et al., 2026). The lack of a unified diagnostic algorithm and clear criteria for referral to advanced testing leads to delayed diagnosis of conditions such as hereditary hemorrhagic telangiectasia. In this condition, early detection of visceral arteriovenous malformations can prevent disabling complications (pulmonary bleeding, ischemic stroke, brain abscesses) (Tabassom & Dahlstrom, 2022; Al-Samkari et al., 2025).
The purpose of this review is to systematize current data on the epidemiology, etiology, diagnosis, and consequences of recurrent epistaxis in adults (Karunakaran et al., 2023; Maktabi et al., 2023; Poornachitra & Maheswari, 2023; Akhmedov et al., 2024). It also aims to propose a practical diagnostic algorithm (checklist) for primary care physicians, otorhinolaryngologists, internists, and hematologists. Special attention is given to "red flags" that point to systemic diseases, as well as to the psychosocial consequences of chronic blood loss, which often remain outside the clinician's field of view. The review is intended for practicing physicians, clinical residents, and senior medical students.
Epidemiology and Burden of Recurrent Epistaxis in Adults
Recurrent epistaxis is among the most common reasons for visiting an otorhinolaryngologist and an emergency department. It affects up to 15–20% of the adult population during their lifetime (Ruhela et al., 2023; Al-Samkari et al., 2024). Unlike single episodes, which are usually associated with trauma or dry air, the recurrent form (defined as three or more episodes per month or repeated bleeding for more than three months) occurs in approximately 5–8% of adults. Its prevalence increases with age (Pr & Shankar, 2024). Age distribution is bimodal. The first peak occurs in children and adolescents (mostly idiopathic or traumatic bleeding). The second peak occurs after age 50, where systemic vascular changes, arterial hypertension, use of anticoagulants and antiplatelets, as well as diseases such as hereditary hemorrhagic telangiectasia and chronic liver disease dominate (Ahn & Min, 2022; Stanković et al., 2022). Among elderly patients taking antithrombotic drugs, the frequency of recurrent epistaxis reaches 30–35%. This group also has a higher risk of severe bleeding requiring hospitalization and invasive hemostatic methods (Yaniv et al., 2021).
The economic and social burden of recurrent epistaxis is often underestimated. In the United States, more than 350,000 emergency department visits for epistaxis are recorded annually. About 20% of these are repeat episodes in the same patients (Zloczower et al., 2024). Hospitalization is required in 6–10% of cases. The average hospital stay is 2–3 days. Direct medical costs per patient can reach several thousand dollars (Maina & Ooi, 2022). The situation is similar in European countries. Recurrent epistaxis is one of the main reasons for referral from primary care to an ENT specialist, creating additional burden on outpatient services (Burke et al., 2024). Indirect costs related to temporary disability, reduced productivity, and psychological discomfort are less studied (Garbarova & Vartiak, 2024; Pham, 2024; Rohmani et al., 2024). However, available data indicate that patients with frequent nosebleeds miss an average of 2–3 working days per year due to the episodes themselves or subsequent examinations (Valencia-Sanchez & Donaldson, 2026). Moreover, the anxiety of waiting for the next bleeding can lead to refusal to travel, physical activity, and even changing jobs, which significantly reduces quality of life (Yang et al., 2023).
Etiology of Recurrent Epistaxis: From Local Disorders to Systemic "Red Flags"
Understanding the causes of recurrent epistaxis requires a distinction between local and systemic factors. Local causes, most often identified by anterior rhinoscopy or endoscopic examination, include anatomical abnormalities (marked nasal septum deviation, spurs and ridges), inflammatory diseases (chronic rhinitis, atrophic rhinitis including ozena), trauma (including habitual nose picking), iatrogenic damage (after intubation, nasogastric tube, surgical interventions), as well as benign and malignant neoplasms (hemangioma, juvenile angiofibroma, carcinoma) (Mrzljak et al., 2021; Cappello et al., 2024). Atrophic rhinitis, whether primary or post radiation, is characterized by thinning of the mucous membrane, crust formation, and increased capillary fragility. This creates a favorable background for repeated bleeding (Lewandowska, 2025). However, in adult patients, especially those over 40 years old, one cannot limit the search to local pathology alone, because a systemic disease may be hidden behind the recurrent course (Weyand & Flood, 2021).
Among systemic causes, disorders of the hemostatic system occupy a leading position. The most common inherited coagulopathy is von Willebrand disease, which occurs in 0.6–1.3% of the population. In its mild forms, it often remains undiagnosed until recurrent nosebleeds or menorrhagia appear (James et al., 2024). In such patients, bleeding usually begins in childhood but may manifest in adulthood after trauma or surgery (Harris et al., 2022). Thrombocytopenias of various origins (immune, drug induced, hypersplenism, aplastic) also present with petechial rash, gum bleeding, and recurrent nosebleeds (Chitsuthipakorn et al., 2023). Hemophilia A and B in adults are rare causes, but they should be excluded in cases of isolated prolongation of activated partial thromboplastin time and a history of hemorrhagic syndrome since childhood (Thiele et al., 2023).
Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease) is a classic example of a disease in which recurrent nosebleeds are the earliest and most common symptom, occurring in 90–95% of patients by age 30 (Hammill et al., 2021). The diagnosis is based on the Curaçao criteria: spontaneous recurrent nosebleeds, multiple telangiectasias on the skin and mucous membranes, visceral arteriovenous malformations, and a family history (Abiri et al., 2020). Even a single telangiectasia on the lips, tongue, or fingertips, combined with recurrent nosebleeds, strongly suggests a diagnosis of HHT (Ficany et al., 2025).
Arterial hypertension has long been considered a direct cause of nosebleeds. However, modern meta analyses show a weak association between blood pressure levels and the frequency of episodes (adjusted odds ratio approximately 1.53). This association is likely explained by common risk factors (atherosclerosis, age, anticoagulant use) (Platton et al., 2024). Nevertheless, in patients with hypertension, nosebleeds are often more severe and more frequently require hospitalization (García & Jaramillo, 2023; Nezhadrahim et al., 2023; Poornachitra & Maheswari, 2023; Abdel-Qader et al., 2024; Chen et al., 2024; Saputra et al., 2024). Therefore, blood pressure control is an important component of prevention (Aggarwal et al., 2025). Chronic liver disease, especially at the stage of cirrhosis with portal hypertension and coagulopathy, is also associated with increased bleeding, including nosebleeds, which may be the first sign of liver failure (Ukawat et al., 2024).
Use of medications that affect hemostasis is another common systemic cause (Bergeron et al., 2024; Jabir & Rajab, 2024). Studies report that up to 53% of adults with recurrent nosebleeds take anticoagulants (warfarin, rivaroxaban, apixaban, dabigatran) or antiplatelets (acetylsalicylic acid, clopidogrel, ticagrelor) (Modesti et al., 2024). The risk is particularly high in patients receiving dual antiplatelet therapy or a combination of an anticoagulant and an antiplatelet agent (Matsuura & Imajo, 2023). Non steroidal anti inflammatory drugs, especially with long term use, can also increase bleeding by inhibiting thromboxane synthesis and impairing platelet aggregation (Hermann et al., 2025).
Among rare but important causes are vasculitides, primarily granulomatosis with polyangiitis (Wegener's disease). In this condition, nosebleeds are combined with ulcerative necrotic changes of the nasal septum, purulent bloody discharge, and later with a saddle nose deformity (Ortman & Ortolani, 2024). According to clinical series, up to 11% of patients with granulomatosis with polyangiitis seek medical attention precisely because of recurrent nosebleeds (Génin et al., 2025). Other systemic diseases, such as amyloidosis, systemic lupus erythematosus, and antiphospholipid syndrome, may present with a hemorrhagic syndrome, including nosebleeds, but this is usually part of a more extensive clinical picture (Krol et al., 2023). Vitamin C and K deficiencies are rare in developed countries but may be relevant in patients with alcoholism, malabsorption, or severe diets (Steinke & Welkoborsky, 2022). A detailed differential diagnosis of causes, red flags, and minimum diagnostic tests is presented in Table 1.
Table 1. Causes of recurrent epistaxis in adults: red flags and minimum diagnostic work‑up
|
Category |
Disease/condition |
Key red flags (history, examination) |
Minimum diagnostic tests |
|
Vascular anomalies |
Hereditary hemorrhagic telangiectasia (Osler–Weber–Rendu disease) |
Telangiectasias on lips, tongue, fingers, mucous membranes; family history; recurrent bleeding since childhood |
Skin and mucous membrane examination; contrast echocardiography; genetic counseling |
|
Hematological |
Von Willebrand disease |
Menorrhagia, easy bruising, gum bleeding; family history |
VWF:Ag, VWF:RCo, factor VIII; PFA‑100 |
|
Thrombocytopenias (immune, drug‑induced, hypersplenism) |
Petechiae, ecchymoses, gum bleeding; hepatosplenomegaly |
CBC with platelet count; blood smear microscopy; trephine biopsy if needed |
|
|
Hemophilia A and B (rare but possible in adults) |
Prolonged aPTT; bleeding after invasive procedures; childhood history |
aPTT, factor VIII, factor IX; inhibitor screening |
|
|
Systemic and metabolic |
Arterial hypertension |
Frequent association with severe bleeding; not always a direct cause |
Blood pressure monitoring; ECG; echocardiography (if LV hypertrophy) |
|
Chronic liver disease (coagulopathy, portal hypertension) |
Jaundice, trunk telangiectasias, ascites, esophageal varices |
Liver function tests (ALT, AST, GGT, bilirubin, albumin); coagulation tests (INR, PT); abdominal ultrasound |
|
|
Chronic kidney disease (uremic platelet dysfunction) |
Edema, azotemia, arterial hypertension; bleeding worsens with high urea |
Creatinine, GFR; bleeding time assessment (optional) |
|
|
Inflammatory and autoimmune |
Granulomatosis with polyangiitis (Wegener's) |
Purulent‑bloody discharge, septal ulceration, saddle‑nose deformity; arthralgias, lung or kidney involvement |
c‑ANCA (anti‑PR3); sinus X‑ray/CT; nasal mucosal biopsy |
|
Systemic lupus erythematosus |
Rash, photosensitivity, arthritis, serositis; thrombocytopenia or antiphospholipid syndrome |
ANA, anti‑dsDNA; CBC; coagulation tests (lupus anticoagulant) |
|
|
Drug‑induced |
Anticoagulants (warfarin, DOACs) |
Drug use; INR above therapeutic range (for warfarin); sudden onset at stable dose |
INR (warfarin); renal function assessment (DOACs); discontinuation/adjustment under supervision |
|
Antiplatelets (aspirin, clopidogrel, ticagrelor) |
Drug use usually does not cause isolated bleeding, but it worsens other causes. |
Platelet function tests (not routine); clinical assessment |
|
|
NSAIDs (long‑term use) |
Especially in elderly patients with comorbidities, gastropathy |
Clinical assessment; trial discontinuation |
|
|
Local anatomical |
Nasal septum deviation + Kiesselbach's area |
Bleeding from one nostril; dryness, crusts; history of trauma or surgery |
Anterior rhinoscopy; nasal endoscopy |
|
Atrophic rhinitis (primary, post‑radiation, post‑surgical) |
Mucosal thinning, crusts, foul odor (ozena), recurrent bleeding |
Rhinoscopy; sinus CT (if bone changes suspected) |
Note to the table: This list is not exhaustive but covers the most clinically significant causes. The choice of tests depends on availability and clinical context. For each patient, one should start with non‑invasive methods (CBC, coagulation tests, biochemistry) and expand the search in the presence of "red flags."
Diagnostic Work Up: From Initial Examination to Specialized Tests
The diagnostic algorithm for recurrent epistaxis begins with confirming the recurrent nature of bleeding and assessing the patient's hemodynamic status. Initial examination includes measuring blood pressure and heart rate, evaluating the skin for pallor (a sign of anemia) or petechiae, and performing anterior rhinoscopy to identify the source of bleeding (Thangavelu et al., 2021; Janapala et al., 2022). If a source is found (for example, a visible vessel in Kiesselbach's area) and bleeding can be stopped with local methods (silver nitrate cauterization, electrocoagulation, packing), this does not rule out the need for further investigation in cases of recurrent bleeding (Matti et al., 2021; Li et al., 2023). Nasal endoscopy is the gold standard for visualization. It allows examination of the posterior nasal cavity, choanae, sinus ostia, and detection of telangiectasias, vascular malformations, or neoplasms that are not accessible by anterior rhinoscopy (Coggins et al., 2023).
Laboratory testing is performed in stages. The first (screening) level includes a complete blood count with platelet count, coagulation tests (prothrombin time, activated partial thromboplastin time, international normalized ratio, fibrinogen), and biochemical analysis with liver function tests (ALT, AST, GGT, bilirubin, albumin) and creatinine with urea (Choi et al., 2017; Bate et al., 2023; Wei et al., 2024; Soudry et al., 2026). This panel allows detection of thrombocytopenia, coagulopathy, liver or kidney failure. The second level is indicated when basic test results are normal, but recurrences persist, or clinical suspicion remains. It includes platelet function testing (light transmission aggregometry or PFA-100), measurement of von Willebrand factor antigen and activity, and factors VIII and IX (if aPTT is prolonged) (Lechien et al., 2025). The third level involves genetic tests: sequencing of the ENG, ACVRL1, and SMAD4 genes when HHT is suspected; analysis of the F8 and F9 genes for hemophilia; and VWF gene testing for von Willebrand disease (Lou et al., 2025a, 2025b).
Serological tests are used when vasculitides or autoimmune diseases are suspected. These include detection of anti neutrophil cytoplasmic antibodies (c ANCA, p ANCA), antinuclear antibodies, anti double stranded DNA antibodies, and lupus anticoagulant (Johnsen, 2024). Imaging methods (computed tomography of the paranasal sinuses, magnetic resonance imaging of the brain, and angiography) are indicated when a neoplasm or arteriovenous malformation is suspected or when surgical treatment is planned (Nichols et al., 2008; James et al., 2009). Electrocardiography and echocardiography, as mentioned earlier, are not methods for identifying the cause of bleeding. However, they are necessary to assess the consequences of chronic anemia and to detect visceral malformations in HHT (Markussen et al., 2021; Girard et al., 2022). The diagnostic algorithm described above is summarized in the flowchart shown in Figure 1.
|
|
|
Figure 1. Diagnostic algorithm for recurrent epistaxis in adults |
Consequences of Recurrent Epistaxis
Chronic repeated blood loss from the nasal vessels inevitably leads to iron deficiency anemia. According to prospective cohort studies, in adults with nosebleeds more than once a week for six months, a drop in hemoglobin below 110 g/L is recorded in 40–55% of cases. Anemia develops faster in women of reproductive age due to additional menstrual blood loss (Al-Samkari, 2024; Kasthuri, 2025). Typical laboratory markers include hypochromia, microcytosis, low ferritin (<30 μg/L), and increased total iron‑binding capacity (Mozdon et al., 2023). In patients with hereditary hemorrhagic telangiectasia, anemia often reaches severe levels (hemoglobin <80 g/L). This requires red blood cell transfusions and intravenous iron (Pagella et al., 2021; Trevise et al., 2023). Prolonged iron deficiency is accompanied by extra‑hematological manifestations: dry skin, brittle nails, hair loss, distortion of taste and smell, as well as cognitive impairment (reduced concentration, memory loss), especially pronounced in older adults (Tunkel et al., 2020; Hayama et al., 2024).
The cardiovascular system is the next target of chronic anemia. Compensatory mechanisms include tachycardia, increased stroke volume, and reduced peripheral resistance (Basiari et al., 2024; Gong et al., 2024). With long‑standing anemia, especially in patients with pre‑existing dilated cardiomyopathy, coronary artery disease, or hypertension, high‑output heart failure develops. It presents with dyspnea, edema, and reduced exercise tolerance (Javed et al., 2024; Cerrone et al., 2025). ECG shows sinus tachycardia, flattened T waves, and sometimes ST depression (Eden et al., 2026). Echocardiography can assess ejection fraction and detect signs of pulmonary hypertension, which often accompanies severe anemia and arteriovenous malformations in HHT (Layton et al., 2007; Hessels et al., 2025).
The most severe and least noticeable consequence is the impact on the psycho‑emotional sphere. Studies using questionnaires (ESS, SF‑36, HADS) show that patients with frequent nosebleeds suffer from clinically significant anxiety and depression much more often than the general population (Gottlieb & Long, 2023; Gong et al., 2025). Anticipatory anxiety of the next bleeding becomes dominant. The patient is afraid to sneeze, blow their nose, bend over, or sleep on their side (Fisher & Fishman, 2024; McHugh et al., 2025). This leads to chronic exhaustion, difficulty falling asleep, and shallow sleep (Kolarich et al., 2021).
Social isolation is a direct consequence of this fear. Patients avoid public places (restaurants, theaters, public transport) and refuse to fly because of pressure changes (Crouch-Smith et al., 2021; Bickerton et al., 2025). They stop going to swimming pools and saunas, and avoid physical activity and even sexual activity (Gaetani et al., 2021; Gong et al., 2024). In the professional sphere, teachers, lecturers, and doctors experience chronic stress. According to survey data, 38% missed a workday in the last three months, and 12% changed jobs to a "safer" one (Andorfer et al., 2022; Kim et al., 2024).
Stigmatization makes the situation worse. Blood on the face is perceived by others as a sign of serious illness or aggression, causing shame (Andorfer et al., 2022; Álvarez-Hernández et al., 2023). In HHT, more than 60% of patients reported that nosebleeds affected their intimate relationships (Passali et al., 2024). In children and adolescents, school maladaptation and bullying are observed (Breton et al., 2024). It is important to emphasize that these consequences do not directly correlate with the volume of blood loss. Even rare but unpredictable episodes can cause severe anxiety (Al-Samkari et al., 2026). Unfortunately, these aspects are rarely discussed in routine practice. Correction requires teaching patients self‑help methods, prescribing moisturizers, and, for severe anxiety, consultation with a psychologist or psychiatrist (possibly SSRIs) (Bansal et al., 2024; Zhang et al., 2024).
Results and Discussion
This review systematizes data on the epidemiology, etiology, diagnosis, and consequences of recurrent epistaxis in adults. It offers a practical algorithm for primary care physicians. The key conclusion is the need for active searching for systemic diseases in patients with recurrent episodes. This is especially important when there is no local cause, local treatment is ineffective, or there are "red flags" (telangiectasias, family history, bleeding from other sites, use of anticoagulants, systemic symptoms) (Kasle et al., 2021; Koskinas et al., 2024). This approach is consistent with the Curaçao criteria for HHT and guidelines for von Willebrand disease (Berry et al., 2021). However, the evidence base for many diagnostic strategies remains limited, which opens up a field for further research (Bereda, 2023).
The role of arterial hypertension remains a controversial issue. Large meta-analyses have shown only a weak association between blood pressure levels and the frequency of episodes, even after adjusting for age and anticoagulants (Albarki & Rimmer, 2022; Shovlin et al., 2022). Nevertheless, clinical experience suggests that in uncontrolled hypertension, bleeding is more severe and recurs more often, possibly due to atherosclerotic vascular remodeling (Reed et al., 2021). Blood pressure control should be considered an important component of patient management, but not as a primary prevention measure (Casini et al., 2024).
Diagnostic value of laboratory tests: screening (CBC, coagulation tests, liver function tests) has high sensitivity for gross abnormalities, but may miss mild forms of von Willebrand disease and early stages of HHT (Giorgio et al., 2025; Palermo & Sturiale, 2026). Advanced testing requires resources, so a stepwise approach is optimal: basic tests for everyone, and in depth testing only when "red flags" are present (Yuan et al., 2024).
Psychosocial consequences deserve special attention. In the literature, disproportionately little space is devoted to this topic (Munro et al., 2023). The level of anxiety and depression in these patients is comparable to that in cancer patients, but doctors rarely assess mental status (Kumar et al., 2022). Standard quality of life questionnaires are not sufficiently sensitive to specific problems (fear of a public episode, avoidance of exertion) (Conde Díez et al., 2024).
Compared with previous reviews, most publications focus on narrow aspects (either HHT or anticoagulants). Our review combines local and systemic causes into a single algorithm, includes a detailed table, and, for the first time, discusses psychoemotional consequences in detail (Palma-Barqueros et al., 2021). Limitations: narrative nature, possible language bias, and lack of prospective validation of the algorithm (Devabalan et al., 2021).
Clinical Implications
Unresolved issues: optimal follow‑up intervals after negative basic tests; the need for prophylactic therapy in mild forms of von Willebrand disease; the long‑term effectiveness of local hemostasis methods; the impact of early detection of systemic disease on long‑term outcomes. Answers require prospective multicenter studies (Ahmed et al., 2021).
Conclusion
Recurrent epistaxis in adults is not an isolated local problem but an important clinical marker. In a significant proportion of cases, it masks systemic diseases: inherited coagulopathies (von Willebrand disease, hemophilia), hereditary hemorrhagic telangiectasia, chronic liver disease, vasculitides, and iatrogenic hemostatic disorders associated with anticoagulants and antiplatelet agents. Ignoring this fact leads to repeated visits over many years and progression of anemia, whereas timely diagnosis allows specific therapy to be initiated.
Based on this analysis, the following practical algorithm is proposed. First step: confirm the recurrent nature (three or more episodes per month or repeated bleeding for more than three months) and assess hemodynamics. Second step: take a history – family history of bleeding diatheses, medication use, gum bleeding, gastrointestinal bleeding, menorrhagia, systemic symptoms (arthralgias, rash, renal or pulmonary involvement). Third step: physical examination – anterior rhinoscopy and search for telangiectasias on the lips, tongue, fingers, petechiae, and hematomas. Fourth step: minimum laboratory panel – complete blood count with platelets, coagulation tests (PT, aPTT, INR), liver function tests (ALT, AST, GGT, bilirubin, albumin), and ferritin level. If abnormalities or "red flags" are present, advanced testing is indicated: von Willebrand factor assay, aggregometry, genetic tests for HHT, anti‑neutrophil antibodies, as well as nasal endoscopy, contrast echocardiography, sinus CT, and abdominal ultrasound.
Chronic post‑hemorrhagic anemia develops in most patients with frequent recurrences and requires iron replacement (orally or intravenously), and in severe cases, red blood cell transfusions. Cardiovascular complications (high‑output heart failure) occur mainly in elderly patients with concomitant cardiac disease and require joint management by a cardiologist and hematologist. Psychological and‑emotional consequences (anticipatory anxiety, social isolation, occupational maladjustment) are found in most patients but are rarely discussed. It is enough for a physician to ask two questions – about fear of the next bleeding and about activity limitation – to suspect clinically significant anxiety, which can be corrected by teaching self‑help methods, prescribing moisturizers, and, if necessary, cognitive‑behavioral therapy or anxiolytics.
The presented diagnostic algorithm (Figure 1) and differential diagnosis table (Table 1) are practical tools for otorhinolaryngologists, internists, and emergency physicians. However, they require prospective validation in real‑world practice. Until such data are available, the proposed algorithm should be considered a reasonable clinical guide based on the best available evidence.
Acknowledgments: The authors would like to thank the medical librarians at Dagestan State Medical University (Makhachkala, Republic of Dagestan, Russia) for their assistance with the literature search.
Conflict of interest: None
Financial support: None
Ethics statement: As this article is a narrative literature review and does not involve original data collection from human participants or animals, ethical approval was not required. All cited studies were conducted in accordance with their respective ethical standards and the principles of the Declaration of Helsinki.
Abdel-Qader, D. H., AbuRuz, S., Sawan, H. M., Mazrouei, N. A., Ibrahim, O. M., Hamadi, S., & Silverthorne, J. (2024). Evaluation of the characteristics of iron metabolism markers in patients with CHF-related anemia in Jordan. Journal of Advanced Pharmacy Education & Research, 14(1), 26–33. doi:10.51847/9blTRBhr6V
Abiri, A., Goshtasbi, K., Maducdoc, M., Sahyouni, R., Wang, M. B., & Kuan, E. C. (2020). Laser-assisted control of epistaxis in hereditary hemorrhagic telangiectasia: A systematic review. Lasers in Surgery and Medicine, 52(4), 293–300. doi:10.1002/lsm.23147
Aggarwal, S., Shivgotra, D., Kumar, A., Podder, A., & Kumar, J. (2025). The relationship between epistaxis and stages of hypertension: A prospective observational study of 250 cases in emergency medicine. Cureus, 17(6), e86722. doi:10.7759/cureus.86722
Ahmed, J., Leopard, D., Teasdale, A., Cheah, W., & Marnane, C. (2021). Management of epistaxis: A guide for junior doctors. British Journal of Hospital Medicine, 82(7), 1–8. doi:10.12968/hmed.2021.0071
Ahn, E. J., & Min, H. J. (2022). Age-specific associations between environmental factors and epistaxis. Frontiers in Public Health, 10, 966461. doi:10.3389/fpubh.2022.966461
Akhmedov, M. Y., Akhmedova, A. T., Demirov, Z. A., Demirov, M. A., Magomedova, M. G., Magomedov, K. N., Abduragimova, M. A., & Kitalaev, K. Z. (2024). Fluorescent diagnostics of microscopic damage to tooth enamel using an innovative mixture of silver nanoparticles. Annals of Dental Specialty, 12(3), 48–52. doi:10.51847/iWg8hdqiSl
Albarki, H., & Rimmer, J. (2022). The use of beta-blockers in hereditary hemorrhagic telangiectasia-related epistaxis: A systematic review. American Journal of Rhinology & Allergy, 36(6), 890–896. doi:10.1177/19458924221118131
Al-Samkari, H. (2024). How I treat bleeding in hereditary hemorrhagic telangiectasia. Blood, 144(9), 940–954. doi:10.1182/blood.2023021765
Al-Samkari, H., Kasthuri, R. S., Iyer, V. N., Pishko, A. M., Decker, J. E., Weiss, C. R., Whitehead, K. J., Conrad, M. B., Zumberg, M. S., Zhou, J. Y, et al. (2026). Validation and clinical application of the hereditary hemorrhagic telangiectasia-specific quality of life scale. Journal of Thrombosis and Haemostasis, 24(1), 108–118. doi:10.1016/j.jtha.2025.09.024
Al-Samkari, H., Kasthuri, R. S., Iyer, V. N., Pishko, A. M., Decker, J. E., Weiss, C. R., Whitehead, K. J., Conrad, M. B., Zumberg, M. S., Zhou, J. Y., et al. (2024). Pomalidomide for epistaxis in hereditary hemorrhagic telangiectasia. New England Journal of Medicine, 391(11), 1015–1027. doi:10.1056/NEJMoa2312749
Al-Samkari, H., Kasthuri, R. S., Mager, H. J., Zhou, J. Y., Serra, M. M., Samuelson-Bannow, B. T., Van Doren, L. N., Piccirillo, J. F., Clancy, M. S., McCrae, K. R., et al. (2025). Standardization of terminology, definitions, and outcome criteria for bleeding in hereditary hemorrhagic telangiectasia: International consensus report. American Journal of Hematology, 100(10), 1813–1827. doi:10.1002/ajh.70011
Álvarez-Hernández, P., Patier, J. L., Marcos, S., Gómez Del Olmo, V., Lorente-Herraiz, L., Recio-Poveda, L., Botella, L. M., Viteri-Noël, A., & Albiñana, V. (2023). Tacrolimus as a promising drug for epistaxis and gastrointestinal bleeding in HHT. Journal of Clinical Medicine, 12(23), 7410. doi:10.3390/jcm12237410
Andorfer, K. E. C., Seebauer, C. T., Dienemann, C., Marcrum, S. C., Fischer, R., Bohr, C., & Kühnel, T. S. (2022). HHT-related epistaxis and pregnancy: A retrospective survey and recommendations for management from an otorhinolaryngology perspective. Journal of Clinical Medicine, 11(8), 2178. doi:10.3390/jcm11082178
Andorfer, K. E. C., Seebauer, C. T., Koller, M., Zeman, F., Berneburg, M., Fischer, R., Vielsmeier, V., Bohr, C., & Kühnel, T. S. (2022). TIMolol nasal spray as a treatment for epistaxis in hereditary hemorrhagic telangiectasia (HHT) – Study protocol of the prospective, randomized, double-blind, controlled cross-over TIM-HHT trial. Clinical Hemorheology and Microcirculation, 80(3), 307–315. doi:10.3233/CH-211253
Bansal, B. B., Kambala, S., & Nesiama, J. A. (2024). Acute epistaxis: A comprehensive overview in the acute care setting. Pediatric Emergency Medicine Practice, 21(6), 1–16
Basiari, L., Komnos, I., Litsou, E., Michali, M., Oikonomou, P., & Psychogios, G. (2024). Pyogenic granuloma gravidarum of the nasal cavity causing recurrent epistaxis: A case report and review of the literature. Maedica, 19(1), 160–164. doi:10.26574/maedica.2024.19.1.160
Bate, G. B., Adeleye, A. O., Ijanu, E. M., Olalere, E. O., Amoo, A. O., Asaju, C. I., Shiaka, P. G., & Yerima, M. B. (2023). Quality assessment of wastewater: Physicochemical and bacteriological evidence from Dutse Abattoir, North-West Nigeria. World Journal of Environmental Biosciences, 12(3), 58–66. doi:10.51847/5xxrD8Fbka
Benaim, E. H., Kallenberger, E. M., Mirmozaffari, Y., Klatt-Cromwell, C., Ebert, C. S., Jr., Kimple, A. J., Senior, B. A., Kasthuri, R. S., & Thorp, B. D. (2025). Surgical management of moderate to severe epistaxis in hereditary hemorrhagic telangiectasia: Systematic review and meta-analysis. American Journal of Rhinology & Allergy, 39(2), 159–168. doi:10.1177/19458924241308952
Bereda, G. (2023). Hypertensive urgency and anterior epistaxis caused by antihypertensive medication noncompliance: A case report. Open Access Emergency Medicine, 15, 47–51. doi:10.2147/OAEM.S400167
Bergeron, S., Boopathy, R., Nathaniel, R., Corbin, A., & LaFleur, G. (2024). A review of the reasons for increasing the antibiotic-resistant bacteria presence in drinking water. World Journal of Environmental Biosciences, 13(2), 6–12. doi:10.51847/xXkJ6gfNwB
Berry, D., Carlson, J. N., Singletary, E., Zideman, D. A., & Ring, J. (2021). Use of cryotherapy for managing epistaxis in the first aid setting: A scoping review. Cureus, 13(5), e14832. doi:10.7759/cureus
Bickerton, R., Gera, R., Ross, T., & Rennie, C. (2025). Is nasal closure an effective treatment for severe refractory epistaxis in HHT? A scoping review and narrative synthesis. Rhinology, 63(2), 153–162. doi:10.4193/Rhin24.448
Breton, J., Cambier, S., Adeyemi, O. J., Allirand, J., Chatrenet, A., Nez, F., Saturnin, A., Schmidt, J., Dutheil, F., & Bouillon-Minois, J. B. (2024). Length of stay among patients consulting for spontaneous epistaxis in the emergency department. Indian Journal of Otolaryngology and Head & Neck Surgery, 76(6), 5183–5187. doi:10.1007/s12070-024-04934-y
Burke, K. S., Kong, X., Haymart, B., DeCamillo, D., Ali, M., Barnes, G., & Kaatz, S. (2024). Comparing rates of clinically relevant epistaxis in patients taking warfarin versus direct oral anticoagulants. Research and Practice in Thrombosis and Haemostasis, 8(8), 102630. doi:10.1016/j.rpth.2024.102630
Cappello, Z. J., Arbor, T. C., & Potts, K. L. (2024). Anatomy, pterygopalatine fossa. In StatPearls Publishing (Ed.), StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513269/
Casini, A., Al-Samkari, H., Hayward, C., & Peyvandi, F. (2024). Rare bleeding disorders: Advances in management. Haemophilia, 30(Suppl. 3), 60–69. doi:10.1111/hae.14986
Cerrone, A., Buscarini, E., Berté, R., Alicante, S., Bertolazzi, S., Moreschi, O., Griffanti, P., & Manfredi, G. (2025). Hereditary hemorrhagic telangiectasia: On the brink of a new treatment era? Seminars in Thrombosis and Hemostasis, 51(1), 91–97. doi:10.1055/s-0044-1800834
Chen, W., Zhao, M., Wang, L. N., Zhang, H., Li, J., & Yu, X. (2024). Patient-reported outcomes in orthodontic–periodontal interdisciplinary care. Asian Journal of Periodontics and Orthodontics, 4, 175–184. doi:10.51847/24kc17FkhQ
Chitsuthipakorn, W., Hoang, M. P., Kanjanawasee, D., Seresirikachorn, K., & Snidvongs, K. (2023). Treatments of epistaxis in hereditary hemorrhagic telangiectasia: Systematic review and network meta-analysis. Current Allergy and Asthma Reports, 23(12), 689–701. doi:10.1007/s11882-023-01116-8
Choi, J. W., Joo, Y. H., Jeong, W. S., & Jang, Y. J. (2017). Free-flap reconstruction for the management of life-threatening hereditary hemorrhagic telangiectasia. Auris Nasus Larynx, 44(5), 607–611. doi:10.1016/j.anl.2016.08.005
Coggins, J. M., Quinlan, B. P., Schmidt, M. L., Wang, R. A., & Hughes, C. A. (2023). Large angiomatous nasal polyp presents with epistaxis imitating juvenile nasopharyngeal angiofibroma. Cureus, 15(9), e45239. doi:10.7759/cureus.45239
Conde Díez, S., de Las Cuevas Allende, R., & Conde García, E. (2024). Anemia of inflammation and iron metabolism in chronic diseases. Revista Clínica Española, 224(9), 598–608. doi:10.1016/j.rceng.2024.09.002
Crouch-Smith, H. A., Fenn, K. J., & Williams, S. P. (2021). Epistaxis in people with hereditary hemorrhagic telangiectasia: Surgical management and psychological impact. British Journal of Hospital Medicine, 82(11), 1–10. doi:10.12968/hmed.2020.0688
Devabalan, Y., Cereceda-Monteoliva, N., Lorenz, H., Magill, J. C., Unadkat, S., Ferguson, M., & Rennie, C. (2021). Coronavirus disease 2019: Changing the future of emergency epistaxis management. Journal of Laryngology & Otology, 135(8), 675–679. doi:10.1017/S0022215121001456
Dispenza, F., Lorusso, F., Di Vincenzo, S. A., Dolce, A., Immordino, A., Gallina, S., Maniaci, A., Lechien, J. R., Calvo-Henriquez, C., Saibene, A. M., et al. (2024). Management of uncontrolled/recurrent epistaxis by ligation or cauterization of the sphenopalatine artery: A scoping review. European Archives of Oto-Rhino-Laryngology, 281(12), 6229–6238. doi:10.1007/s00405-024-08852-1
Du, X., Lu, Y., Luo, X., & Cao, X. (2025). Epistaxis due to hereditary hemorrhagic telangiectasia: A case report and literature review. Journal of International Medical Research, 53(9), 3000605251374630. doi:10.1177/03000605251374630
Eden, R. E., Daley, S. F., & Coviello, J. M. (2023). Vitamin K deficiency. In StatPearls Publishing (Ed.), StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK536983/
Ficany, A., Del Alamo, M., Bernabeu, C., Shovlin, C. L., & Rossi, E. (2025). Epistaxis prevention, treatment, and future perspectives for hereditary hemorrhagic telangiectasia. Journal of Clinical Medicine, 14(21), 7724. doi:10.3390/jcm14217724
Fisher, E. W., & Fishman, J. (2024). Preparing juniors for on-call ENT, handicap in vestibular schwannoma, nasal packs in epistaxis, and sleep apnoea in young children. Journal of Laryngology & Otology, 138(6), 591. doi:10.1017/S0022215124000793
Gaetani, E., Agostini, F., Di Martino, L., Occhipinti, D., Passali, G. C., Santantonio, M., Marano, G., Mazza, M., Pola, R., & on Behalf of the Multidisciplinary Gemelli Group for Hht. (2021). Beneficial effects of remote medical care for patients with hereditary hemorrhagic telangiectasia during the COVID-19 pandemic. Journal of Clinical Medicine, 10(11), 2311. doi:10.3390/jcm10112311
García, E., & Jaramillo, S. (2023). Telescopic retention in prosthodontics: A digital approach for enhanced patient outcomes. Asian Journal of Periodontics and Orthodontics, 3, 25–29. doi:10.51847/zpD7lrfE1t
Garbarova, M., & Vartiak, L. (2024). Support of human entrepreneurial capital in creative industries. Journal of Organizational Behavior Research, 9(1), 1–14. doi:10.51847/jl6y7AimXu
Génin, V., Rouau, G., Agard, C., Malard, O., & Néel, A. (2025). Ear, nose and throat manifestations in ANCA-associated vasculitis. La Revue de Médecine Interne, 46(11), 635–643. doi:10.1016/j.revmed.2025.06.017
Giorgio, V., Di Foggia, C., Quatrale, G., Margiotta, G., Stella, G., Proli, F., Leoni, C., Onesimo, R., Passali, G. C., Contegiacomo, A., et al. (2025). Family phenotypic profile in hereditary hemorrhagic telangiectasia: Genotype-phenotype correlation in a pediatric Italian population. Italian Journal of Pediatrics, 51(1), 268. doi:10.1186/s13052-025-02087-4
Girard, A., Lopez, C. D., Chen, J., Perrault, D., Desai, N., Bruckman, K. C., Bartlett, S. P., & Yang, R. (2022). Epistaxis after orthognathic surgery: Literature review and three case studies. Craniomaxillofacial Trauma & Reconstruction, 15(2), 147–163. doi:10.1177/19433875211008086
Gong, A. J., Bolsegui, M. L., Lee, E. E., Mathai, S. C., & Weiss, C. R. (2024). Assessing the psychometric validity of the Epistaxis Severity Score: Internal consistency and test-retest reliability. American Journal of Rhinology & Allergy, 38(1), 38–46. doi:10.1177/19458924231207137
Gong, A. J., Bolsegui, M. L., Lee, E. E., Tan, M. R., Zeng, Y., Ma, J., Gowda, P. C., Garg, T., & Weiss, C. R. (2025). Quantifying the burden of hereditary hemorrhagic telangiectasia on quality of life and psychological health: A cross-sectional study. Orphanet Journal of Rare Diseases, 20(1), 109. doi:10.1186/s13023-025-03620-8
Gong, A. J., Garg, T., Khalil, A., Gowda, P. C., Mathai, S. C., Rowan, N. R., Merlo, C. A., & Weiss, C. R. (2024). Health-related quality of life outcome measures in individuals with hereditary hemorrhagic telangiectasia: A scoping review. American Journal of Rhinology & Allergy, 38(1), 60–76. doi:10.1177/19458924231207123
Gottlieb, M., & Long, B. (2023). Managing epistaxis. Annals of Emergency Medicine, 81(2), 234–240. doi:10.1016/j.annemergmed.2022.07.002
Green, M., Tailor, H., & Keh, S. (2023). Historical use of silver nitrate for the management of epistaxis – Evidence-based practice? Journal of Laryngology & Otology, 137(9), 962–964. doi:10.1017/S0022215122002146
Hadar, A., Shaul, C., Ghantous, J., Tarnovsky, Y., Cohen, A., Zini, A., & Peleg, U. (2026). Risk factors for severe clinical course in epistaxis patients. Ear, Nose & Throat Journal, 105(2), NP135–NP140. doi:10.1177/01455613231189056
Hammill, A. M., Wusik, K., & Kasthuri, R. S. (2021). Hereditary hemorrhagic telangiectasia (HHT): A practical guide to management. Hematology: American Society of Hematology Education Program, 2021(1), 469–477. doi:10.1182/hematology.2021000281
Harris, N. S., Pelletier, J. P., Marin, M. J., & Winter, W. E. (2022). Von Willebrand factor and disease: A review for laboratory professionals. Critical Reviews in Clinical Laboratory Sciences, 59(4), 241–256. doi:10.1080/10408363.2021.2014781
Hayama, M., Maeda, Y., Obata, S., Tsuda, T., Takeda, K., Nishida, T., & Inohara, H. (2024). Understanding hereditary hemorrhagic telangiectasia: From genetic anomalies to systemic manifestations, quality of life, and epistaxis management – Exploring the otolaryngologist's integral role. Auris Nasus Larynx, 51(2), 305–312. doi:10.1016/j.anl.2023.11.002
Hermann, R., Shovlin, C. L., Kasthuri, R. S., Serra, M., Eker, O. F., Bailly, S., Buscarini, E., & Dupuis-Girod, S. (2025). Hereditary hemorrhagic telangiectasia. Nature Reviews Disease Primers, 11(1), 1. doi:10.1038/s41572-024-00585-z
Hessels, J., Post, M. C., Boerman, S., Droege, F., Dupuis, O., ePAG, Geisthoff, U. W., Haahr, P. D., Kjeldsen, A. D., Mager, J. J., Dupuis-Girod, S., et al. (2025). Family planning, sexual activity and contraception in hereditary hemorrhagic telangiectasia: A European survey study. Orphanet Journal of Rare Diseases, 20(1), 395. doi:10.1186/s13023-025-03887-x
Jabir, S. A., & Rajab, N. A. (2024). Lasmiditan nanoemulsion as intranasal in situ gel: Relative bioavailability study. Journal of Advanced Pharmacy Education & Research, 14(4), 99–104. doi:10.51847/fDJ0Hclt4M
James, A. H., Kouides, P. A., Abdul-Kadir, R., Edlund, M., Federici, A. B., Halimeh, S., Kamphuisen, P. W., Konkle, B. A., Martínez-Perez, O., McLintock, C., et al. (2009). Von Willebrand disease and other bleeding disorders in women: Consensus on diagnosis and management from an international expert panel. American Journal of Obstetrics and Gynecology, 201(1), 12.e1–8. doi:10.1016/j.ajog.2009.04.024
James, P., Leebeek, F., Casari, C., & Lillicrap, D. (2024). Diagnosis and treatment of von Willebrand disease in 2024 and beyond. Haemophilia, 30(Suppl. 3), 103–111. doi:10.1111/hae.14970
Janapala, R. N., Tran, Q. K., Patel, J., Mehta, E., & Pourmand, A. (2022). Efficacy of topical tranexamic acid in epistaxis: A systematic review and meta-analysis. American Journal of Emergency Medicine, 51, 169–175. doi:10.1016/j.ajem.2021.10.043
Javed, A., Zhyzhneuskaya, S., Khalid, N., & Rajabally, H. (2024). Granulomatosis with polyangiitis in an autistic patient with depression: Challenges in diagnosis and management. Cureus, 16(11), e73037. doi:10.7759/cureus.73037
Johnsen, J. (2024). Von Willebrand disease. Updated 2024 Nov 14. In M. P. Adam, S. Bick, G. M. Mirzaa, R. A. Pagon, S. E. Wallace, & A. Amemiya (Eds.), GeneReviews® [Internet]. University of Washington, Seattle. 1993–2026.
Karunakaran, N., Maiti, S., Jayaraman, S., & Paulraj, J. (2023). Assessment of bone turnover markers prior to dental implant placement for osteoporosis patient – A case-control study. Annals of Dental Specialty, 11(2), 57–61. doi:10.51847/Z8ruHjG41y
Kasle, D. A., Fujita, K., & Manes, R. P. (2021). Review of clinical practice guideline: Nosebleed (epistaxis). JAMA Surgery, 156(10), 974–975. doi:10.1001/jamasurg.2021.2873
Kasthuri, R. S. (2025). What's new in hereditary hemorrhagic telangiectasia? Hematology: American Society of Hematology Education Program, 2025(1), 131–136. doi:10.1182/hematology.2025000698
Kim, D. H., Basurrah, M. A., Kim, S. W., & Kim, S. W. (2024). Surgical and Regenerative Treatment Options for Empty Nose Syndrome: A Systematic Review. Clinical and Experimental Otorhinolaryngology, 17(3), 241–252. doi:10.21053/ceo. 2023.00038
Kolarich, A. R., Solomon, A. J., Bailey, C., Latif, M. A., Rowan, N. R., Galiatsatos, P., & Weiss, C. R. (2021). Imaging manifestations and interventional treatments for hereditary hemorrhagic telangiectasia. RadioGraphics, 41(7), 2157–2175. doi:10.1148/rg.2021210100
Koskinas, I., Terzis, T., Georgalas, C., Chatzikas, G., Moireas, G., Chrysovergis, A., Triaridis, S., Constantinidis, J., & Karkos, P. (2024). Posterior epistaxis management: Review of the literature and proposed guidelines of the Hellenic Rhinological-Facial Plastic Surgery Society. European Archives of Oto-Rhino-Laryngology, 281(4), 1613–1627. doi:10.1007/s00405-023-08310-4
Krol, R. M., Remmelts, H. H. F., Klaasen, R., Frima, A., Hagen, E. C., Kamalski, D. M. A., Heijstek, M. W., & Spierings, J. (2023). Systemic and local medical or surgical therapies for ear, nose and/or throat manifestations in ANCA-associated vasculitis: A systematic literature review. Journal of Clinical Medicine, 12(9), 3173. doi:10.3390/jcm12093173
Kumar, A., Sharma, E., Marley, A., Samaan, M. A., & Brookes, M. J. (2022). Iron deficiency anemia: Pathophysiology, assessment, practical management. BMJ Open Gastroenterology, 9(1), e000759. doi:10.1136/bmjgast-2021-000759
Layton, K. F., Kallmes, D. F., Gray, L. A., & Cloft, H. J. (2007). Endovascular treatment of epistaxis in patients with hereditary hemorrhagic telangiectasia. American Journal of Neuroradiology, 28(5), 885–888.
Lechien, J. R., Saxena, S., Vaira, L. A., Hans, S., & Maniaci, A. (2025). Artificial intelligence-assisted diagnosis of an unusual cause of periodic epistaxis: A case report. Ear, Nose & Throat Journal, 1455613251335385. doi:10.1177/01455613251335385 Advance online publication.
Lewandowska, M. (2025). Promise, pitfalls, and precision: Standardizing clinical framework for hereditary hemorrhagic telangiectasia and a call for cost-conscious innovation. American Journal of Hematology, 100(10), 1719–1721. doi:10.1002/ajh.70036
Li, H. Y., Luo, T., Li, L., Liu, Y., Zhai, X., & Wang, X. D. (2023). Etiology and clinical characteristics of primary epistaxis. Annals of Translational Medicine, 11(2), 96. doi:10.21037/atm-22-6590
Lou, Z., Lou, Z., & Chen, Z. (2025). Comparison of radiofrequency coagulation and silver nitrate cauterization for the treatment of recurrent anterior epistaxis associated with allergic rhinitis in pediatric patients. Journal of Otolaryngology – Head & Neck Surgery, 54, 19160216251390302. doi:10.1177/19160216251390302
Lou, Z., Lou, Z., & Chen, Z. (2025). Comparison of two coagulation techniques for the control of pediatric recurrent anterior epistaxis with allergic rhinitis: Semi-randomized clinical trial. International Journal of Pediatric Otorhinolaryngology, 194, 112394. doi:10.1016/j.ijporl.2025.112394
Lynch, J. M., Stevens, E., & Meek, M. E. (2024). Medical and interventional management of hereditary hemorrhagic telangiectasia. Seminars in Interventional Radiology, 41(4), 325–335. doi:10.1055/s-0044-1791186
Maina, G., & Ooi, E. (2022). A retrospective review of spontaneous epistaxis outcomes for patients on novel oral anticoagulants compared to antiplatelets and warfarin. American Journal of Otolaryngology, 43(4), 103488. doi:10.1016/j.amjoto.2022.103488
Maktabi, H. M. A., Mater, A. E., Takroni, G. S. A., Alanazi, W. A., & Alanazi, O. S. (2023). Role of artificial intelligence in prosthodontics to assess its effectiveness and success: A systematic review. Annals of Dental Specialty, 11(4), 43–51. doi:10.51847/xmc7F5Am6c
Markussen, D. L., Hagen, J. E., Tvedt, A., & Steihaug, O. M. (2021). Epistaxis after testing for COVID-19. Tidsskrift for Den norske legeforening, 141(7). doi:10.4045/tidsskr.21.0114
Matsuura, H., & Imajo, K. (2023). Pale man with recurrent epistaxis. Emergency Medicine Journal, 40(10), 725–738. doi:10.1136/emermed-2022-212680
Matti, E., Lizzio, R., Ugolini, S., Maiorano, E., Zaccari, D., De Silvestri, A., De Sando, E., Marseglia, G. L., Benazzo, M., Olivieri, C., et al. (2021). Nasal endoscopy in the clinical diagnosis of hereditary hemorrhagic telangiectasia. Journal of Pediatrics, 238, 74–79.e2. doi:10.1016/j.jpeds.2021.07.007
McDonald, J., Gossage, J. R., & Stevenson, D. A. (2026). Hereditary hemorrhagic telangiectasia. Updated 2026 Feb 19. In M. P. Adam, S. Bick, G. M. Mirzaa, R. A. Pagon, S. E. Wallace, & A. Amemiya (Eds.), GeneReviews® [Internet]. University of Washington, Seattle. https://www.ncbi.nlm.nih.gov/books/NBK1351/
McHugh, N., Lyons, R. E., Keogh, I., & Flaherty, G. T. (2025). Ear, nose, and throat disorders and international travel. Tropical Diseases, Travel Medicine and Vaccines, 11(1), 3. doi:10.1186/s40794-024-00238-9
Modesti, C. L., Testa, G., Salvetti, M., Paini, A., Riviera, M., Bazza, A., Bertacchini, F., Aggiusti, C., Lombardi, D., Rampinelli, V., et al. (2024). Epistaxis and clinic blood pressure values: Is there a relationship? High Blood Pressure & Cardiovascular Prevention, 31(5), 493–500. doi:10.1007/s40292-024-00669-7
Mozdon, M. A., Ponomarev, R. V., Tsvetaeva, N. V., Shabrin, A. V., Ermachenkova, E. I., Larichev, S. E., & Lukina, E. A. (2023). Iron deficiency anemia in a patient with hereditary hemorrhagic telangiectasia: Case report [Russian]. Terapevticheskii Arkhiv, 95(7), 580–585. doi:10.26442/00403660.2023.07.202303
Mrzljak, A., Popić, J., & Ožanić Bulić, S. (2021). Digital clubbing in hereditary hemorrhagic telangiectasia/juvenile polyposis syndrome. Acta Dermatovenerologica Croatica, 29(1), 56–57
Munro, M. G., Mast, A. E., Powers, J. M., Kouides, P. A., O'Brien, S. H., Richards, T., Lavin, M., & Levy, B. S. (2023). The relationship between heavy menstrual bleeding, iron deficiency, and iron deficiency anemia. American Journal of Obstetrics and Gynecology, 229(1), 1–9. doi:10.1016/j.ajog.2023.01.017
Nezhadrahim, A., Shahri, M. M., & Akbari, N. N. (2023). Effects of the Roux-en-Y gastric bypass on DM and renal function in obese patients. Journal of Advanced Pharmacy Education & Research, 13(1), 1–5. doi:10.51847/c60nSRP6Q7
Nichols, W. L., Hultin, M. B., James, A. H., Manco-Johnson, M. J., Montgomery, R. R., Ortel, T. L., Rick, M. E., Sadler, J. E., Weinstein, M., & Yawn, B. P. (2008). Von Willebrand disease (VWD): Evidence-based diagnosis and management guidelines, the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel report (USA). Haemophilia, 14(2), 171–232. doi:10.1111/j.1365-2516.2007.01643.x
Ortman, C., & Ortolani, E. (2024). Hereditary hemorrhagic telangiectasia: A pediatric-focused review. Seminars in Pediatric Neurology, 52, 101167. doi:10.1016/j.spen.2024.101167
Pagella, F., Maiorano, E., Ugolini, S., Lizzio, R., Sovardi, F., Mirabella, R., Nanfito, L., Tinelli, C., De Silvestri, A., Olivieri, C., et al. (2021). Epidemiological, clinical and endoscopic features of epistaxis severity and quality of life in hereditary hemorrhagic telangiectasia: A cross-sectional study. Rhinology, 59(6), 577–584. doi:10.4193/Rhin21.286
Palermo, M., & Sturiale, C. L. (2026). Cerebrovascular malformations associated with hereditary hemorrhagic telangiectasia and HHT-like syndromes: A comparative overview. European Journal of Neurology, 33(2), e70523. doi:10.1111/ene.70523
Palma-Barqueros, V., Revilla, N., Sánchez, A., Zamora Cánovas, A., Rodriguez-Alén, A., Marín-Quílez, A., González-Porras, J. R., Vicente, V., Lozano, M. L., et al. (2021). Inherited platelet disorders: An updated overview. International Journal of Molecular Sciences, 22(9), 4521. doi:10.3390/ijms22094521
Passali, G. C., Santantonio, M., Vecchioli, N., Sollazzo, M., Rolesi, R., Marotta, I., Corina, L., Riccioni, M. E., Gaetani, E., & Galli, J. (2024). Surgery or no surgery? Exploring the dilemma of epistaxis management in patients with HHT. Journal of Clinical Medicine, 13(6), 1688. doi:10.3390/jcm13061688
Pham, T. T. (2024). Linking family supports and Vietnamese employee performance: The mediator role of work engagement. Journal of Organizational Behavior Research, 9(1), 15–31. doi:10.51847/W3DMjBBfqq
Platton, S., Baker, P., Bowyer, A., Keenan, C., Lawrence, C., Lester, W., Riddell, A., & Sutherland, M. (2024). Guideline for laboratory diagnosis and monitoring of von Willebrand disease: A joint guideline from the United Kingdom Hemophilia Center Doctors' Organization and the British Society for Hematology. British Journal of Haematology, 204(5), 1714–1731. doi:10.1111/bjh.19385
Poornachitra, P., & Maheswari, U. (2023). Analysis of clinical symptoms in patients with oral submucous fibrosis. Annals of Dental Specialty, 11(1), 1–6. doi:10.51847/iRUEgUex6m
Poornachitra, P., & Maheswari, U. (2023). Identifying non-specific symptoms in oral submucous fibrosis patients: A clinical perspective. Asian Journal of Periodontics and Orthodontics, 3, 18–24. doi:10.51847/xLpm4TfyCA
Pr, R., & Shankar, G. (2024). Clinical study and management of epistaxis. Indian Journal of Otolaryngology and Head & Neck Surgery, 76(5), 4348–4355. doi:10.1007/s12070-024-04857-8
Pulpă, R. O., Aliuș, R. O., Rusescu, A., Ioniță, I. G., Hainăroșie, R., Voiosu, C., & Zainea, V. (2025). A retrospective study on triggering factors and management of epistaxis – Our experience in a tertiary ENT clinic. Journal of Medicine and Life, 18(8), 759–765. doi:10.25122/jml-2025-0107
Reed, A., Barnes, M., & Howard, C. (2021). Management of non-traumatic epistaxis in adults in the emergency department. British Journal of Hospital Medicine, 82(6), 1–6. doi:10.12968/hmed.2021.0033
Rohmani, S., Astirin, O. P., Marliyana, S. D., & Handayani, N. (2024). Analysis of flavonoid content and antioxidant activity of Curcuma caesia Roxb grown in different geographical areas. Journal of Advanced Pharmacy Education & Research, 14(4), 69–75. doi:10.51847/yy1abuEXOj
Ruhela, S., Mittal, H. K., Bist, S. S., Luthra, M., Kumar, L., & Agarwal, V. K. (2023). Clinico-etiological evaluation of epistaxis. Indian Journal of Otolaryngology and Head & Neck Surgery, 75(Suppl. 1), 828–835. doi:10.1007/s12070-022-03458-7
Saputra, T. A., Fuadi, I., & Abdul, I. (2024). Total intravenous anesthesia in patient with tuberculous myeloradiculopathy undergoing cervicosternotomy: A case report. Journal of Advanced Pharmacy Education & Research, 14(4), 18–22. doi:10.51847/ZRnvtUdLHL
Schmidtman, D. C., Blaseg, N. A., & Likness, M. M. (2022). Recurrent epistaxis throughout the lifespan: A clinical review. South Dakota Medicine, 75(5), 224–228.
Shovlin, C. L., Buscarini, E., Sabbà, C., Mager, H. J., Kjeldsen, A. D., Pagella, F., Sure, U., Ugolini, S., Torring, P. M., Suppressa, P., et al. (2022). The European rare disease network for HHT frameworks for management of hereditary haemorrhagic telangiectasia in general and speciality care. European Journal of Medical Genetics, 65(1), 104370. doi:10.1016/j.ejmg.2021.104370
Singh, S., Bhandari, A., Handa, S., & Mahajan, R. (2023). Recurrent epistaxis and purple vascular stains in an elderly patient. Indian Dermatology Online Journal, 15(1), 123–125. doi:10.4103/idoj.idoj_28_23
Soudry, E., Amitai, N., Elmograbi, A., Vainer, I., & Mei-Zahav, M. (2026). Novel simplified nasal endoscopy grading system for hereditary hemorrhagic telangiectasia patients. Laryngoscope, 136(2), 652–657. doi:10.1002/lary.70074
Stanković, P., Hoch, S., Rudhart, S., Obradović, D., Dagres, N., & Wilhelm, T. (2022). Direct oral anticoagulants versus vitamin K antagonists in epistaxis patients: A systematic review and meta-analysis. Clinical Otolaryngology, 47(2), 255–263. doi:10.1111/coa.13898
Steinke, K. V., & Welkoborsky, H. J. (2022). Granulomatose mit Polyangiitis – Manifestationen im Kopf-Hals-Bereich [Granulomatosis with polyangiitis – Manifestations in the head and neck area]. Laryngo-Rhino-Otologie, 101(2), 112–119. doi:10.1055/a-1580-7037
Tabassom, A., & Dahlstrom, J. J. (2026). Epistaxis. In StatPearls Publishing (Ed.), StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK435997/
Thangavelu, K., Köhnlein, S., Eivazi, B., Gurschi, M., Stuck, B. A., & Geisthoff, U. (2021). Epistaxis – Overview and current aspects. HNO, 69(11), 931–942. doi:10.1007/s00106-021-01110-4
Thiele, B., Abdel-Aty, Y., Marks, L., Lal, D., & Marino, M. (2023). Sclerotherapy for hereditary hemorrhagic telangiectasia-related epistaxis: A systematic review. Annals of Otology, Rhinology & Laryngology, 132(1), 82–90. doi:10.1177/00034894221078075
Trevise, L. A., Lopes Vieira Pinto, M. P., Hasselmann, G., Lammoglia, B. C., Leal, T. P., & Salles Rosa Neto, N. (2023). Multifocal abscesses, necrotizing fasciitis, iron deficiency anemia, and hypophosphatemia induced by ferric carboxymaltose infusions: Report of a case of hereditary hemorrhagic telangiectasia. Cureus, 15(8), e44020. doi:10.7759/cureus.44020
Tunkel, D. E., Anne, S., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J., Alikhaani, J. D., Benoit, M. M., Bercovitz, R. S., Brown, M. D., et al. (2020). Clinical practice guideline: Nosebleed (epistaxis). Otolaryngology–Head and Neck Surgery, 162(1_Suppl.), S1–S38. doi:10.1177/0194599819890327
Ukawat, L., Gupta, A., & Jain, K. (2024). Demographic profile and etiology of epistaxis. Indian Journal of Otolaryngology and Head & Neck Surgery, 76(4), 3172–3175. doi:10.1007/s12070-024-04638-3
Valencia-Sanchez, B. A., & Donaldson, A. M. (2026). Epistaxis. Medical Clinics of North America, 110(1), 17–30. doi:10.1016/j.mcna.2025.05.003
Wei, L., Li, F., Cai, D., Liu, Y., Luo, D., & Wen, Y. (2024). Studying the effectiveness of biochar suspension in improving the physicochemical characteristics of soil sensitive to erosion. World Journal of Environmental Biosciences, 13(1), 1–7. doi:10.51847/XG9lxsgsqY
Weyand, A. C., & Flood, V. H. (2021). Von Willebrand disease: Current status of diagnosis and management. Hematology/Oncology Clinics of North America, 35(6), 1085–1101. doi:10.1016/j.hoc.2021.07.004
Yang, X., Ren, H., Li, M., Zhu, Y., Zhang, W., & Fu, J. (2023). Treatment of intractable epistaxis in patients with nasopharyngeal cancer. Annals of Medicine, 55(1), 2200257. doi:10.1080/07853890.2023.2200257
Yaniv, D., Zavdy, O., Sapir, E., Levi, L., & Soudry, E. (2021). The impact of traditional anticoagulants, novel anticoagulants, and antiplatelets on epistaxis. Laryngoscope, 131(9), 1946–1951. doi:10.1002/lary.29417
Yuan, J., Wu, X., Zhao, J., Ding, Q., Dai, J., Wang, X., Lu, Y., & Li, J. (2024). Molecular mechanisms and clinical manifestations of hereditary hemorrhagic telangiectasia. Thrombosis Research, 241, 109117. doi:10.1016/j.thromres.2024.109117
Zhang, E., Virk, Z. M., Rodriguez-Lopez, J., & Al-Samkari, H. (2024). Hereditary hemorrhagic telangiectasia may be the most morbid inherited bleeding disorder in women. Blood Advances, 8(12), 3166–3172. doi:10.1182/bloodadvances.2023011961
Zloczower, E., Pinhas, S., Allon, R., Syn-Hershko, A., Raz Yarkoni, T., Marom, M., Kiderman, D., Cohen, O., & Warman, M. (2024). The impact of different anticoagulants and antiplatelet regimens on acute epistaxis outcomes. European Archives of Oto-Rhino-Laryngology, 281(9), 4863–4871. doi:10.1007/s00405-024-08718-6
