A patient with hypertension, presenting with recurrent nasal congestion, a 30-minute episode of epistaxis, pallor, and nasal obstruction, what is the most likely diagnosis?

Diagnosis: Posterior Epistaxis Due to Hypertension

The most likely diagnosis is posterior epistaxis due to hypertension (Option A), given the patient's hypertensive history, prolonged 30-minute bleeding episode, pallor suggesting significant blood loss, and recurrent symptoms—all classic features of posterior epistaxis in hypertensive patients. 1

Clinical Reasoning

Why Posterior Epistaxis Due to Hypertension is Most Likely

• Hypertension is strongly associated with posterior epistaxis, with 48% of posterior epistaxis patients having a history of hypertension, and this patient population experiences more severe, difficult-to-control bleeding. 1, 2

• The 30-minute bleeding duration indicates severe epistaxis, as posterior epistaxis accounts for 5-10% of all nosebleeds but presents with more difficult-to-control bleeding requiring hospitalization. 1

• Pallor suggests significant blood loss, which is characteristic of posterior epistaxis where 12.3% of patients require blood transfusions due to severity. 2

• Recurrent nasal congestion and obstruction are consistent with posterior bleeding that is not visible on anterior examination and requires nasal endoscopy for definitive diagnosis. 1

• The age and hypertension combination dramatically increases epistaxis severity and complications, with elderly hypertensive patients at high risk for posterior sources. 3

Why NOT Hereditary Hemorrhagic Telangiectasia (Option C)

• 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 a hypertensive adult. 1

• The unilateral presentation with nasal obstruction does not fit the classic bilateral pattern of HHT. 3

Why NOT Nasal Hemangioma (Option B)

• Nasal hemangiomas 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 identified during anterior rhinoscopy or endoscopy. 1

• The recurrent nature without mention of a mass makes this diagnosis unlikely. 3

Critical Management Considerations

Blood Pressure Management Pitfall

• Do NOT aggressively lower blood pressure acutely during active epistaxis, as excessive reduction can cause or worsen renal, cerebral, or coronary ischemia in patients with chronic hypertension. 1, 3

• Blood pressure should be monitored but decisions about control must be based on bleeding severity and individual comorbidities. 1

Immediate Next Steps

• This patient requires emergency department evaluation given the bleeding duration >30 minutes, signs of hemodynamic instability (pallor), and potential need for posterior packing or endoscopy. 3

• Check anticoagulation status, as 15% of epistaxis patients are on long-term anticoagulation, which significantly impacts management. 1

• Assess for hemodynamic compromise including tachycardia, hypotension, or orthostatic changes, as these indicate significant blood loss requiring hospital-level care. 3