Recurrent severe epistaxis in a patient with normal test results

What should be the diagnostic workup of a patient with recurrent severe epistaxis and normal results of the ear, nose, and throat (ENT) examination, complete blood count (CBC), and coagulation tests?

Alfonso Iorio, MD, PhD: This is a different case because the epistaxis is recurrent, there is no local cause. Particularly, if the epistaxis is bilateral and does not occur on a single side, it might be appropriate to proceed ruling out von Willebrand disease by testing von Willebrand factor. The mild form of type 1 von Willebrand disease can have a completely normal screening test result.

Testing for factor XIII deficiency—again, the standard screening test can be normal but the disease is there. Of course, before proceeding to testing, you would appropriately investigate familiality. If you do it insistently, you will very often find something.

Essentially yes, in this case I would proceed with testing.