Most Likely Diagnosis: Posterior Epistaxis Due to Hypertension
The most likely diagnosis is posterior epistaxis due to hypertension (Option A), given the patient's history of hypertension, prolonged bleeding episode (30 minutes), pallor suggesting significant blood loss, and recurrent nasal congestion/obstruction. 1
Clinical Reasoning
Why Posterior Epistaxis is Most Likely
Hypertension is strongly associated with posterior epistaxis, with patients having a 1.47 times increased risk of epistaxis requiring hospital visits and 4.58 times higher likelihood of requiring posterior nasal packing compared to normotensive patients 2
The 30-minute bleeding duration and pallor indicate severe hemorrhage, which is characteristic of posterior epistaxis rather than the brief, self-limited anterior bleeds typical of benign conditions 3
Posterior epistaxis accounts for 5-10% of all nosebleeds and is more common in older patients with hypertension, often presenting as more difficult to control bleeding 4
Recurrent nasal obstruction is a key feature - 68.4% of posterior epistaxis patients present within 12 hours of onset, and the bleeding is described as moderate to severe in 88% of cases 3
Why NOT Hereditary Hemorrhagic Telangiectasia (HHT)
HHT requires visible telangiectasias on nasal or oral mucosa, which are not mentioned in this presentation 5
HHT typically presents with recurrent bilateral nosebleeds starting in childhood or adolescence, not as an acute severe episode in an adult with known hypertension 5
The prevalence of underlying coagulation disorders in epistaxis patients is only 0.9%, making this far less likely than hypertension-related bleeding 4
Why NOT Nasal Hemangioma
Nasal hemangiomas would present with a visible mass lesion on examination, typically causing unilateral obstruction with associated symptoms like facial pain 1
Hemangiomas are uncommon causes of epistaxis and would be evident on anterior rhinoscopy or endoscopy 1
The bilateral nature of symptoms (recurrent nasal congestion) makes a unilateral mass lesion less likely 1
Critical Management Considerations
Immediate Assessment Priorities
Identify bleeding location - posterior epistaxis originates from sites not visible on anterior rhinoscopy, requiring nasal endoscopy for definitive diagnosis 4, 1
Monitor but do NOT aggressively lower blood pressure acutely, as excessive reduction can cause renal, cerebral, or coronary ischemia in patients with chronic hypertension 1
Assess for anticoagulation status - 15% of epistaxis patients are on long-term anticoagulation, which significantly impacts management 4
Common Pitfalls to Avoid
Do not assume anterior bleeding - the severity and duration strongly suggest posterior source requiring specialized intervention 3
Do not delay definitive treatment - posterior epistaxis has a 29.6% rebleeding rate, with 44.1% occurring within 24 hours of admission 3
Do not overlook complications - 19.8% require surgical intervention, 21% develop acute sinusitis, and 12.3% need blood transfusions 3
Avoid premature pack removal - removing packing within 48 hours increases rebleeding risk (OR 3.07) 3