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

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 nature of symptoms. 1

Clinical Reasoning

Why Posterior Epistaxis Due to Hypertension is Most Likely

• The American Academy of Otolaryngology-Head and Neck Surgery identifies hypertension as a strong association with posterior epistaxis, with patients having an increased risk of epistaxis requiring hospital visits. 1

• 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. 1

• The 30-minute bleeding duration meets the threshold for "severe epistaxis" requiring prompt management, and pallor suggests possible hemodynamic compromise from blood loss. 2

• Hypertension is associated with epistaxis prevalence rates ranging from 17-67% among epistaxis patients, with the association being well-established despite ongoing debate about direct causation. 1

• Research demonstrates that 48% of posterior epistaxis patients have a history of hypertension, and 88% present with moderate to severe bleeding. 3

Why NOT Hereditary Hemorrhagic Telangiectasia (Option C)

• The American Academy of Otolaryngology-Head and Neck Surgery indicates that 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

• HHT assessment should only be pursued if there is history of recurrent bilateral epistaxis or family history of recurrent nosebleeds, neither of which are described here. 2

Why NOT Nasal Hemangioma (Option B)

• The American Academy of Otolaryngology-Head and Neck Surgery suggests that 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 expected to show specific physical findings not described in this case. 1

Critical Management Considerations

Immediate Assessment Priorities

• Check for tachycardia, hypotension, orthostatic changes, or syncope - any of these indicate significant blood loss requiring hospital-level care given the pallor and 30-minute bleeding duration. 2

• The patient likely requires emergency department evaluation given bleeding duration >30 minutes, signs of hemodynamic instability (pallor), and potential need for posterior packing, endoscopy, or advanced interventions. 2

Blood Pressure Management Pitfall

• Routine acute blood pressure lowering is NOT recommended during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia in patients with chronic hypertension. 2

• Blood pressure should be monitored but not aggressively lowered acutely, as the American Heart Association notes this can cause end-organ ischemia. 1, 2

Diagnostic Approach

• Nasal endoscopy is recommended for identifying posterior bleeding sources, as posterior epistaxis originates from sites not visible on anterior rhinoscopy. 1

• Elderly patients with hypertension are at high risk for posterior sources requiring endoscopic evaluation. 2