Abstract
Background and Objective. Epistaxis is a frequent bleeding manifestation in patients receiving antithrombotic therapy, and its management falls between otolaryngology and cardiology guidance. We aimed to translate the evidence into an operational framework for joint decisions. Methods. PubMed/MEDLINE, Scopus, Embase, and the Cochrane Library were searched (January 2015 through August 2026), current ESC, ACC/AHA, EHRA, AAO-HNS, and SFORL guidance were analyzed, and national clinical protocols of different countries were screened; 67 sources were included. Results. Direct oral anticoagulants were consistently associated with fewer clinically relevant epistaxis events than warfarin, and minor epistaxis led to permanent anticoagulant discontinuation more often than minor bleeding at other sites. No guideline defines epistaxis severity, and guidance diverges on protected dual antiplatelet therapy, bleeding-risk assessment, and the sequence of local hemostasis and drug interruption. We propose a three-tier severity classification (minor, clinically relevant non-major, major) informed by ISTH and BARC definitions, a pragmatic thrombotic risk stratification, and an algorithm with agent-specific decisions. Conclusions. In minor and most clinically relevant non-major episodes, antithrombotic therapy can usually be continued while local hemostasis is achieved; interruption, de-escalation, or reversal should be individualized and reserved for uncontrolled or major bleeding. Effective local hemostasis can help avoid unnecessary interruption of antithrombotic therapy, and otolaryngologists should be part of multidisciplinary teams managing such bleeding.