What is the most likely diagnosis for a patient with a history of hypertension presenting with recurrent nasal congestion and an episode of epistaxis, appearing pale with nasal obstruction?

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—all classic features of posterior epistaxis in hypertensive patients. 1

Clinical Reasoning

Why Posterior Epistaxis Due to Hypertension is Most Likely

• Hypertension is strongly associated with posterior epistaxis, with patients having a 1.47-fold increased risk of epistaxis requiring hospital visits compared to normotensive individuals 2
• Posterior epistaxis accounts for 5-10% of all nosebleeds and is characteristically more common in older patients with hypertension, presenting as more difficult to control bleeding 1, 3
• The 30-minute bleeding duration meets criteria for severe epistaxis, which is significantly associated with posterior sources in hypertensive patients (odds ratio 2.53) 3
• Pallor indicates hemodynamic compromise from blood loss, a common feature of posterior epistaxis that often requires hospitalization and more aggressive interventions 1, 3
• Hypertensive patients with epistaxis are 2.69 times more likely to use emergency departments and 4.58 times more likely to require posterior nasal packing compared to normotensive patients 2

Why the Other Options Are Less Likely

Hereditary Hemorrhagic Telangiectasia (HHT) - Option C:

• HHT requires visible telangiectasias on nasal or oral mucosa, which are not mentioned in this presentation 1
• HHT typically presents with recurrent bilateral nosebleeds starting in childhood or adolescence, not as a new presentation in an adult with hypertension 1
• The absence of family history of recurrent nosebleeds and visible vascular lesions makes this diagnosis unlikely 4

Nasal Hemangioma - Option B:

• Nasal hemangiomas 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 identified on anterior rhinoscopy 1
• The clinical presentation lacks the characteristic unilateral mass effect expected with hemangioma 4

Important Clinical Considerations

The Hypertension-Epistaxis Relationship

• While the causal relationship between hypertension and epistaxis remains controversial, the association is well-established with prevalence rates of hypertension among epistaxis patients ranging from 17-67% 5, 6
• Hypertension does not initiate epistaxis but makes bleeding more difficult to control once started 6, 7
• Systolic blood pressure is an independent factor associated with persistent epistaxis (odds ratio 1.03 per mmHg increase) 7

Critical Management Pitfall to Avoid

• Do NOT aggressively lower blood pressure acutely during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia in patients with chronic hypertension 1, 4
• Blood pressure should be monitored but decisions about control must be based on bleeding severity and individual comorbidities 4

Expected Clinical Course

• 19.8% of posterior epistaxis patients require surgical intervention after admission 3
• 29.6% experience rebleeding, with 44% of rebleeding episodes occurring within 24 hours of admission 3
• 21% develop acute sinusitis and 12.3% require blood transfusions as complications 3