What is the cause of dizziness and frequent epistaxis (nosebleeds) in an elderly male?

Dizziness and Frequent Nosebleeds in an Elderly Male

The most likely cause is uncontrolled hypertension, which is strongly associated with both posterior epistaxis (accounting for 5-10% of nosebleeds in older patients) and cardiovascular-related dizziness (the second most common cause of vertigo in the elderly). 1, 2

Primary Diagnostic Considerations

Hypertension as the Unifying Diagnosis

• Hypertension is present in 33% of patients presenting with epistaxis and is independently associated with more severe bleeding requiring emergency intervention. 1, 3
• The prevalence of hypertension among epistaxis patients ranges from 17-67%, with elderly hypertensive patients at particularly high risk for posterior bleeding sources. 1
• Cardiovascular diseases account for 20.4% of vertigo cases in the elderly population, making it the second most common etiology after audio-vestibular disorders. 2
• Elderly patients (>85 years) are 3.24 times more likely to present to emergency departments for epistaxis compared to those under 65 years. 4, 3

Posterior Epistaxis Characteristics

• Posterior epistaxis originates from sites not visible on anterior rhinoscopy and is more common in older patients, more difficult to control, and carries a 30-day all-cause mortality rate of 3.4%. 4, 1
• These patients require nasal endoscopy for definitive diagnosis and localization of the bleeding source. 1

Critical Medication Assessment

Anticoagulation Status Must Be Evaluated Immediately

• 15% of epistaxis patients are on long-term anticoagulation, which significantly impacts both bleeding severity and management approach. 1, 3
• Warfarin causes nosebleeds as a recognized adverse effect, and elderly patients (≥60 years) exhibit greater than expected anticoagulant response. 5
• If on warfarin, check INR immediately—supratherapeutic levels may require specialty consultation, medication discontinuation, or reversal agents for severe refractory bleeding. 3
• Antiplatelet agents (aspirin, clopidogrel) can cause persistent epistaxis and should be documented. 3

Other Medications Contributing to Dizziness

• Many medications cause presyncope-type dizziness, and medication regimens should be thoroughly assessed in elderly patients with these symptoms. 6
• Antihypertensives, sedatives, and polypharmacy are common culprits in this age group. 6

Differential Diagnosis Framework

Audio-Vestibular Causes (Most Common for Dizziness)

• Audio-vestibular disorders represent 28.4% of vertigo cases in the elderly, including benign paroxysmal positional vertigo (BPPV), Meniere disease, vestibular neuritis, and labyrinthitis. 2, 6
• These conditions do not typically cause epistaxis, making them less likely as the unifying diagnosis in this case. 2

Neurological Causes (Third Most Common)

• Neurological diseases account for 15.1% of vertigo cases in elderly patients and represent potential life-threatening conditions requiring urgent evaluation. 2
• Stroke or transient ischemic attack should be considered, particularly if dizziness is acute-onset, persistent, or associated with other neurological symptoms. 2

Metabolic and Hematologic Disorders

• Coagulation disorders (von Willebrand disease, hemophilia) are present in 0.9% of epistaxis patients and can cause both bleeding and dizziness from anemia. 3
• Chronic kidney or liver disease should be documented as risk factors. 3

Immediate Management Priorities

Blood Pressure Management—Critical 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 elderly patients with chronic hypertension. 1, 3
• Blood pressure should be monitored, with control decisions based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of blood pressure reduction. 1, 3

Epistaxis Control

• Apply firm sustained compression to the lower third of the nose for at least 5 minutes without interruption, with the patient sitting upright and head tilted slightly forward. 3
• If bleeding persists, perform anterior rhinoscopy after removing blood clots to identify the bleeding site. 3
• Apply topical vasoconstrictors (oxymetazoline or phenylephrine) directly to the bleeding site, achieving control in 65-75% of cases. 3
• If a specific site is identified, perform chemical or electrocautery after topical anesthesia. 3, 7
• Nasal packing with resorbable materials (Nasopore, Surgicel, Floseal) should be used if bleeding persists despite compression and vasoconstrictors. 3

When to Refer or Hospitalize

• Hospital admission should be considered for patients with significant comorbid conditions, complications of blood loss, or bleeding duration >30 minutes with signs of hemodynamic instability. 3, 7
• Referral to otolaryngology is appropriate when bleeding is refractory to initial measures or when posterior packing/endoscopy is required. 1, 7
• Posterior epistaxis patients have higher likelihood of requiring hospitalization and specialized interventions. 4

Recommended Diagnostic Workup

Essential Initial Tests

• Orthostatic blood pressure testing to evaluate for orthostatic hypotension causing presyncope. 6, 8
• Complete blood count to assess for anemia from blood loss. 7
• INR if on warfarin; coagulation studies if bleeding disorder suspected. 3, 5
• Anterior rhinoscopy followed by nasal endoscopy if bleeding site not identified or if recurrent unilateral bleeding. 1, 3

Dizziness-Specific Examination

• Evaluation for nystagmus to identify vestibular causes. 6
• Dix-Hallpike maneuver if BPPV suspected (most common vestibular cause). 6
• Cardiovascular and neurological examination to identify life-threatening causes. 2

When Laboratory Testing and Imaging Are Indicated

• Laboratory testing and radiography play little role in routine dizziness diagnosis but should be ordered for patients with abnormal physical examination findings suggesting serious causes. 6, 8
• Neuroimaging should be considered if neurological deficits are present or if central causes are suspected. 2

Common Clinical Pitfalls

• Failing to check anticoagulation status before attempting cautery or aggressive interventions. 3
• Aggressively lowering blood pressure during active bleeding, risking end-organ ischemia. 1, 3
• Overlooking medication-induced causes of both dizziness and bleeding tendency. 3, 6
• Assuming all epistaxis is anterior without performing adequate examination for posterior sources in elderly patients. 1
• Not recognizing that 45% of hospitalized epistaxis patients have underlying systemic diseases contributing to bleeding. 3