What is the most likely cause of a 30-minute nosebleed in a patient with a history of nasal congestion, presenting with pallor and anxiety?

Most Likely Diagnosis: Posterior Epistaxis Due to Hypertensive Vasculopathy

The most likely diagnosis is posterior epistaxis due to hypertensive vasculopathy (Option C), given the 30-minute duration of bleeding, pallor suggesting significant blood loss, and anxiety indicating hemodynamic concern—all hallmarks of severe posterior bleeding that occurs more commonly in older patients with hypertension. 1, 2

Clinical Reasoning

Why Posterior Epistaxis is Most Likely

• Duration and severity: The 30-minute bleeding duration meets the threshold for "severe epistaxis" requiring urgent management, and posterior epistaxis (5-10% of cases) is characteristically more difficult to control and has higher likelihood of requiring hospitalization. 1, 2

• Hemodynamic compromise: Pallor and anxiety suggest possible hemodynamic compromise from blood loss, which is typical of posterior bleeding that tends to be more severe than anterior sources. 2

• Hypertension association: Posterior epistaxis occurs more frequently in elderly patients and is commonly associated with hypertension and atherosclerosis, with reported prevalence of 24-64% in patients presenting with epistaxis. 2, 3

• Nasal congestion history: While nasal congestion can indicate chronic mucosal inflammation predisposing to bleeding, it is a nonspecific finding that does not point to a specific diagnosis but rather represents a risk factor for epistaxis in general. 2

Why NOT Nasal Angiofibroma (Option A)

• Demographics: Juvenile nasopharyngeal angiofibroma typically affects adolescent males, not the general adult population. 1

• Presentation pattern: Angiofibromas present with progressive unilateral nasal obstruction and recurrent unilateral epistaxis, not acute severe bilateral bleeding. 2

• Missing key features: There is no mention of nasal mass, facial swelling, or visual changes that would suggest a tumor. 2

Why NOT Hereditary Hemorrhagic Telangiectasia (Option B)

• Presentation pattern: HHT characteristically presents with recurrent bilateral epistaxis, not a single acute episode. 4, 5

• Missing diagnostic criteria: The American Academy of Otolaryngology-Head and Neck Surgery recommends assessing for HHT when there is recurrent bilateral epistaxis, family history of recurrent nosebleeds, or visible telangiectasias on nasal septum, lateral nasal walls, tongue, lips, or hard palate—none of which are mentioned in this case. 4, 5

• Epidemiology: HHT occurs in only 1 in 5,000-18,000 individuals, making it far less common than hypertensive posterior epistaxis in the general population. 4

Immediate Management Algorithm

First-Line Intervention (Do This Now)

• Position the patient sitting upright with head tilted slightly forward to prevent blood from flowing into the airway. 2

• Apply firm, continuous compression to the soft lower third of the nose for a full 10-15 minutes without interruption. 4, 2

• Check vital signs immediately: Assess for tachycardia, hypotension, or orthostatic changes—any of these indicate significant blood loss requiring hospital-level care. 2

If Bleeding Persists After 10-15 Minutes

• Clear the nasal cavity of blood clots by suction or gentle nose blowing. 4, 2

• Perform anterior rhinoscopy to identify the bleeding source. 4, 2

• Apply topical vasoconstrictor (oxymetazoline or phenylephrine spray) directly to the bleeding site, which achieves hemorrhage control in 65-75% of cases. 2, 6

• Resume firm compression for another 5-10 minutes. 4

Definitive Treatment Based on Findings

• If anterior bleeding site identified: Perform chemical cautery with silver nitrate after topical anesthesia with lidocaine or tetracaine. 2, 3

• If posterior bleeding or no site identified: Proceed to nasal packing using resorbable materials (Nasopore, Surgicel, Floseal) as first choice. 2, 6

• Avoid bilateral septal cautery to prevent septal perforation. 4, 2

Emergency Department Transfer Indications

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

Critical Pitfalls to Avoid

• Do not aggressively lower blood pressure acutely: Excessive reduction can cause or worsen renal, cerebral, or coronary ischemia, especially in elderly patients with chronic hypertension. 4, 2

• Do not interrupt compression prematurely: Apply pressure for the full 10-15 minutes without checking if bleeding has stopped. 4, 2

• Do not miss posterior bleeding: If anterior rhinoscopy shows no obvious source, assume posterior origin and escalate care accordingly. 3, 7

• Do not overlook anticoagulation status: Document any anticoagulant or antiplatelet medications, though this should not delay first-line local hemostatic measures. 2, 5