What is the best approach to diagnose a posterior nose bleed in a patient with a potential history of bleeding disorders, hypertension, or nasal trauma?

Diagnosing Posterior Nosebleed

Begin with anterior rhinoscopy after removing blood clots, then proceed to nasal endoscopy to visualize the posterior nasal cavity and lateral nasal wall—the most common sites of posterior bleeding—particularly when bleeding is difficult to control or when anterior rhinoscopy fails to identify a source. 1

Initial Diagnostic Steps

Anterior Rhinoscopy First

• Perform anterior rhinoscopy on all patients with epistaxis after removing any blood clot by suction or gentle nose blowing. 1 This is the mandatory first step even when posterior bleeding is suspected, as it may reveal an anterior source or contributing pathology.
• Look specifically for septal deviation, septal perforation, visible bleeding sites, masses, and foreign bodies. 1
• In young children, use an otoscope for visualization of the anterior nasal cavity. 1

Clinical Features Suggesting Posterior Source

• Blood flowing into the posterior pharynx without an identifiable anterior bleeding site is the hallmark of posterior epistaxis. 2
• Bleeding that is moderate to severe (88% of posterior cases) and fails to respond to anterior nasal compression or anterior packing. 2
• More common in elderly patients (mean age 64 years) with hypertension (48% of cases) or on anticoagulation/antiplatelet therapy. 2
• Posterior epistaxis accounts for only 5-10% of all epistaxis cases but carries significantly higher morbidity. 3, 2

Nasal Endoscopy: The Definitive Diagnostic Tool

When to Perform Endoscopy

• Perform nasal endoscopy (or refer to someone who can) in patients with recurrent epistaxis despite prior packing or cautery, recurrent unilateral bleeding, or when bleeding is difficult to control. 1 This is a formal recommendation from the American Academy of Otolaryngology-Head and Neck Surgery.
• Use endoscopy when anterior rhinoscopy fails to identify a bleeding source, as posterior sites are not visible on anterior examination alone. 1, 4
• Endoscopy localizes the bleeding site in 87-93% of cases. 5

Specific Anatomic Sites to Examine

• Focus on the posterior aspect of the lateral nasal wall—this is where 81% of posterior bleeding points are located. 6
• Examine the lateral wall of the inferior meatus (11% of cases) and the lateral surface of the inferior turbinate (19% of cases). 6
• Inspect the lateral wall of the middle meatus (22% of cases) and the lateral surface of the middle turbinate (28% of cases), noting that turbinates may contain grooves where bleeding points can be concealed. 6
• Check for posterior septal bleeding (20% of cases), including posterior spurs and posterior septal deviations with ulceration. 6, 4
• Look for pathology in crevices of the lateral nasal wall, congested polyps, enlarged adenoids, scabs, crusts, and masses. 4

Risk Factor Assessment

Document Critical History

• Record personal or family history of bleeding disorders (von Willebrand disease, hemophilia), use of anticoagulants (warfarin, DOACs) or antiplatelet medications (aspirin, clopidogrel), and intranasal drug use. 1, 7 This is mandatory per AAO-HNS guidelines.
• Document hypertension status, as it is present in 48% of posterior epistaxis cases, though blood pressure should NOT be acutely lowered during active bleeding due to risk of end-organ ischemia. 7, 2
• Ask about prior nasal/sinus surgery, nasal oxygen or CPAP use, chronic kidney or liver disease. 7

Red Flags Requiring Further Investigation

• Unilateral epistaxis with nasal obstruction, facial pain, or visual changes suggests a nasal or nasopharyngeal mass. 1, 7 Nasal malignancies present with epistaxis in 55% of cases and may not be visible on anterior rhinoscopy.
• In adolescent males with unilateral, unprovoked, profuse epistaxis, examine the posterior nasal cavity and nasopharynx for juvenile nasopharyngeal angiofibroma (presents with epistaxis in 60-76% of cases). 1, 5
• Recurrent bilateral epistaxis or positive family history warrants assessment for hereditary hemorrhagic telangiectasia (HHT), looking for nasal and oral mucosal telangiectasias. 5, 7

Common Pitfalls to Avoid

• Do not rely solely on anterior rhinoscopy for posterior epistaxis—endoscopy is essential as posterior bleeding sites are not visible anteriorly. 1, 4
• Do not assume bilateral packing is necessary; 81% of posterior bleeding is from the lateral nasal wall on one side, making bilateral packing rarely justified. 6
• Do not aggressively lower blood pressure during active epistaxis, as this can cause renal, cerebral, or coronary ischemia in elderly patients with chronic hypertension. 7
• Do not discharge patients with posterior epistaxis without adequate follow-up; rebleeding occurs in 30% of cases, with 44% of rebleeding episodes occurring within 24 hours of admission. 2

When Examination Under General Anesthesia is Needed

• If conservative measures and office-based endoscopy fail to identify or control bleeding, formal examination under general anesthesia is recommended, concentrating on the posterior lateral nasal wall and turbinate grooves. 6
• This approach identified bleeding points in 84% of cases where standard packing failed. 6