Epistaxis with Hypertension: Differential Diagnosis and Management
Differential Diagnosis
In an adult with hypertension presenting with epistaxis, the primary differential includes local causes (anterior bleeding from Kiesselbach's plexus, posterior bleeding from lateral nasal wall vessels), medication-related bleeding (anticoagulants/antiplatelets), coagulation disorders, and less commonly hereditary hemorrhagic telangiectasia or nasal masses. 1
Local/Anatomic Causes
- Anterior epistaxis from Kiesselbach's plexus (most common) caused by digital trauma, mucosal dryness, inflammation, or localized infection 1
- Posterior epistaxis (5-10% of cases) originates from posterior lateral nasal wall or septum, more common in older hypertensive patients, more difficult to control, and carries higher morbidity 1, 2
- Unilateral masses should be suspected if epistaxis is accompanied by nasal obstruction, facial pain, or visual changes 1
Medication-Related Causes
- Anticoagulants: 15% of epistaxis patients are on long-term anticoagulation, with warfarin requiring INR checking and potential reversal for severe refractory bleeding 1, 2
- Antiplatelet agents (aspirin, clopidogrel) can cause persistent epistaxis 1
- Intranasal drug use including topical medication overuse or illicit drug snorting 1
Systemic Causes
- Coagulation disorders: von Willebrand disease, hemophilia, or other bleeding disorders 1
- Hereditary hemorrhagic telangiectasia (HHT): Consider if recurrent bilateral epistaxis with visible telangiectasias on nasal/oral mucosa or positive family history 1, 2
- Chronic kidney or liver disease 1
Hypertension's Role
- No definitive causal relationship exists between hypertension and epistaxis initiation, despite longstanding assumptions 3, 4
- Hypertension can exacerbate bleeding from pre-existing vulnerable vessels and is associated with more severe, persistent bleeding requiring emergency intervention 1, 3, 5
- Elevated blood pressure at presentation may reflect stress/white coat phenomenon rather than causation 6
- However, systolic blood pressure is independently associated with persistent epistaxis (OR 1.03 per mmHg increase) 7
Management Algorithm
Immediate First-Line Intervention (All Patients)
Apply firm, sustained compression to the soft lower third of the nose for a minimum of 5 minutes without interruption, with patient sitting upright and head tilted slightly forward to prevent blood from flowing into the airway. 1, 3
- Do not check if bleeding has stopped during the 5-10 minute compression period 1
- This single intervention controls most anterior epistaxis 8
If Bleeding Persists After 5-10 Minutes
Perform anterior rhinoscopy after removing blood clots to identify the bleeding site, then apply topical vasoconstrictors (oxymetazoline or phenylephrine spray) directly to the bleeding site. 1, 3
- Vasoconstrictors achieve hemorrhage control in 65-75% of cases through local vasoconstriction 1
- Clear any blood clots before attempting to visualize the bleeding source 1
Definitive Treatment Based on Bleeding Site
If a specific bleeding site is identified, perform nasal cautery after anesthetizing the area with topical lidocaine or tetracaine. 1, 3
- Restrict cautery only to the active bleeding site in the affected nostril 1
- Never perform bilateral simultaneous septal cautery to prevent septal perforation 8, 1
If Bleeding Site Cannot Be Identified or Bleeding Persists
Proceed to nasal packing using resorbable materials (Nasopore, Surgicel, Floseal) as first choice. 1
- Consider nasal endoscopy for persistent or recurrent bleeding, especially in elderly hypertensive patients who are at high risk for posterior sources 1, 2
- Posterior epistaxis requires nasal endoscopy for definitive diagnosis as it originates from sites not visible on anterior rhinoscopy 2
Critical Blood Pressure Management Considerations
DO NOT routinely or aggressively lower blood pressure acutely during active epistaxis. 1, 3
- Excessive BP reduction can cause or worsen renal, cerebral, or coronary ischemia in patients with chronic hypertension 1, 3
- Monitor blood pressure but prioritize direct local hemostatic measures over systemic BP management 1, 3
- Decisions about BP control should be based on bleeding severity, inability to control bleeding, individual comorbidities, and risks of BP reduction 1
Special Considerations for Hypertensive Patients
Risk Assessment
- Advanced age with hypertension dramatically increases epistaxis severity and complications, with significantly higher rates of posterior epistaxis 1
- Document anticoagulation/antiplatelet status, prior nasal surgery, nasal oxygen/CPAP use, intranasal medications, and personal/family history of bleeding disorders 1
Anticoagulation Management
- Check INR if on warfarin to evaluate therapeutic range 1, 2
- Supratherapeutic levels may require specialty consultation, medication discontinuation, or reversal agents for severe refractory bleeding 1
- Direct oral anticoagulants (DOACs) have limited reversal options 1
Indications for Emergency Department Transfer
- Bleeding duration >30 minutes with signs of hemodynamic instability (tachycardia, hypotension, orthostatic changes, pallor, syncope) 1
- Inability to control bleeding with compression, vasoconstrictors, and cautery 1
- Suspected posterior epistaxis requiring advanced interventions 2
Post-Treatment Management
- Apply petroleum jelly or other moisturizing agents to the nasal mucosa 1
- Prescribe regular saline nasal sprays to maintain mucosal moisture 1
- Arrange follow-up within 30 days to assess outcome 1
Common Pitfalls to Avoid
- Do not aggressively lower blood pressure acutely - this can cause end-organ ischemia in elderly patients with chronic hypertension 1, 3
- Do not overlook anticoagulation status - check INR if on warfarin and consider reversal for severe refractory bleeding 1
- Do not perform bilateral septal cautery - this risks septal perforation 8, 1
- Do not interrupt nasal compression prematurely - maintain pressure for full 5-10 minutes 1, 3