What is the best course of treatment for a patient with swollen turbinates, epistaxis, and newly diagnosed hypertension?

Management of Swollen Turbinates, Epistaxis, and Newly Diagnosed Hypertension

Prioritize immediate control of the epistaxis with local measures first, while monitoring—but not aggressively lowering—the blood pressure during active bleeding. 1

Immediate Epistaxis Management

The first priority is achieving hemostasis through a stepwise approach:

• Position the patient sitting upright with head tilted slightly forward to prevent blood from entering the airway or stomach 1, 2
• Apply firm sustained compression to the lower third of the nose for at least 10-15 minutes continuously without checking if bleeding has stopped 1, 2
• Have the patient breathe through their mouth and spit out blood rather than swallowing it 1

If bleeding persists after initial compression:

• Clear clots from the nose, then apply topical vasoconstrictor (oxymetazoline or phenylephrine spray) and continue compression for 5 minutes—this resolves 65-75% of cases that don't stop with compression alone 1
• Consider nasal packing with resorbable material if bleeding continues, especially given the patient's chronic hypertension 1
• The swollen turbinates may indicate the bleeding source is more difficult to visualize, so anterior rhinoscopy should be performed once initial hemostasis is achieved 3

Blood Pressure Management During Active Epistaxis

Avoid aggressive acute lowering of blood pressure during active epistaxis. 1 This is a critical pitfall that can cause significant harm.

• Monitor blood pressure but do not aggressively reduce it during active bleeding, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia 3, 1
• The relationship between epistaxis and hypertension remains controversial—hypertension prevalence in epistaxis patients ranges from 17-67%, but causality is unproven 1, 4, 5
• Hypertension does not cause epistaxis to start, but it does make bleeding more difficult to control 4, 6
• Base blood pressure control decisions on bleeding severity, inability to control bleeding with local measures, individual comorbidities, and risks of BP reduction 1

The key evidence here is that while elevated blood pressure is commonly found during epistaxis episodes (often 175/95 mmHg or higher) 7, this may reflect stress and "white coat" phenomenon rather than causation 5. Aggressively lowering BP acutely can precipitate end-organ ischemia 3, 1.

Post-Hemostasis Blood Pressure Evaluation

Once bleeding is controlled:

• Measure blood pressure again after the acute bleeding episode has resolved to determine if true hypertension exists versus stress-related elevation 6, 5
• If persistent hypertension is confirmed (≥140/90 mmHg) after bleeding cessation, initiate standard hypertension management 3, 6
• For confirmed hypertension (sustained BP ≥140/90 mmHg), start simultaneous combination of lifestyle interventions and pharmacological therapy with a two-drug combination—preferably a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker or thiazide diuretic, ideally as a fixed-dose single-pill combination 3
• Prescribe cardiovascular evaluation to screen for underlying hypertensive disease if persistent hypertension is found after severe epistaxis 6

Assessment of Swollen Turbinates

The swollen turbinates in the right nares require evaluation:

• Document whether the turbinate swelling is unilateral or bilateral, as unilateral findings with nasal obstruction, facial pain, or visual changes may indicate a mass lesion requiring immediate specialist evaluation 2
• Consider chronic rhinitis, allergic rhinitis, or structural abnormalities as contributing factors 3
• The turbinate swelling may make visualization of the bleeding source more difficult and increase risk of posterior epistaxis 3

Risk Stratification and Hospitalization Criteria

Consider hospitalization if any of the following are present:

• Bleeding not controlled after 15 minutes of continuous pressure 1, 2
• Hemodynamic instability (tachycardia, hypotension, orthostatic changes) 1, 2
• Severe bleeding (duration >30 minutes over 24 hours) 1
• Posterior bleeding source, which is more common in older hypertensive patients and accounts for 5% of epistaxis cases with a 30-day all-cause mortality rate of 3.4% 3, 1

Check anticoagulation status—15% of epistaxis patients are on long-term anticoagulation 3. Consider reversal agents only for severe refractory bleeding, and do not discontinue antiplatelet agents unless bleeding cannot be controlled with local measures 1.

Prevention of Recurrence

Once hemostasis is achieved:

• Apply petroleum jelly or other lubricating agents to the nasal mucosa 1, 2
• Recommend saline nasal sprays regularly to maintain mucosal moisture 1, 2
• Humidifier use in dry environments 1
• Control blood pressure medically in the waning phase to reduce risk of recurrence, as patients with a history of hypertension have a higher number of epistaxis attacks and recurrence within 72 hours 6, 7, 8

Follow-Up Plan

• Arrange follow-up within 30 days to assess blood pressure control and epistaxis recurrence 2
• Counsel on preventive measures, warning signs requiring emergency care, and the importance of hypertension management 2
• See the patient frequently (every 1-3 months) until blood pressure is controlled, preferably within 3 months 3

Critical Pitfalls to Avoid

• Insufficient compression time (checking too early) leads to uncontrolled bleeding 1
• Aggressively lowering BP acutely can cause end-organ ischemia 3, 1
• Overlooking anticoagulation status can lead to severe bleeding 1
• Neglecting posterior source evaluation can lead to uncontrolled bleeding in elderly hypertensive patients 1
• Assuming hypertension caused the epistaxis rather than recognizing it as a coincidental finding or stress response 4, 5