A 68-year-old man with a 10-year history of hypertension (BP 165/95 mmHg today) presents to the emergency department with sudden-onset epistaxis from the right nostril. The bleeding is profuse and originates from the posterolateral wall of the nasal cavity. He denies trauma, recent nasal surgery, or use of anticoagulants. On examination, the bleeding point is not visible anteriorly. What is the most likely source of bleeding and the most appropriate initial management?

Explanation

## Clinical Diagnosis **Key Point:** Posterior epistaxis (bleeding from posterolateral nasal wall, not visible on anterior rhinoscopy) in an elderly hypertensive patient is classically due to **sphenopalatine artery (SPA) rupture**, which supplies the posterior nasal cavity via its terminal branches. ## Anatomical Basis The sphenopalatine artery is the terminal branch of the maxillary artery and enters the nasal cavity through the sphenopalatine foramen. It supplies: - Posterior nasal septum - Posterolateral nasal wall - Superior and middle turbinates (posteriorly) This location explains why the bleeding point cannot be visualized on anterior rhinoscopy. ## Management Algorithm ```mermaid flowchart TD A[Posterior Epistaxis Suspected]:::outcome --> B{Anterior packing feasible?}:::decision B -->|Yes, try first| C[Anterior packing + tilted position]:::action C --> D{Bleeding controlled?}:::decision D -->|Yes| E[Observe, discharge if stable]:::action D -->|No| F[Escalate to posterior packing]:::urgent B -->|No or failed| F F --> G{Posterior pack tolerated?}:::decision G -->|Yes| H[ICU admission, 48-72 hrs]:::action G -->|No or complications| I[Endoscopic SPA ligation or cauterization]:::action ``` ## Why Posterior Packing or Endoscopic Intervention? **High-Yield:** Posterior epistaxis from SPA does NOT respond to anterior packing alone because the bleeding source is behind the posterior nasal aperture. Posterior packing (Foley catheter or commercial balloon) or **endoscopic sphenopalatine artery cauterization/ligation** is the definitive approach. **Clinical Pearl:** Endoscopic cauterization or ligation of the SPA is now preferred over posterior packing in many centres because it: - Avoids morbidity of posterior packing (airway obstruction, sinusitis, palatal necrosis) - Provides direct visualization and hemostasis - Allows earlier discharge and better patient tolerance ## Role of Hypertension Uncontrolled hypertension (BP 165/95) is a major risk factor for epistaxis, particularly posterior bleeding. Blood pressure control is essential adjunctive therapy. ## Why Not the Other Options? - **Anterior ethmoidal artery:** Supplies anterior superior nasal cavity; bleeding would be visible on anterior rhinoscopy and occur higher in the nose. - **Septal/superior labial branches:** Supply anterior septum; these cause anterior epistaxis visible on rhinoscopy. - **Silver nitrate cauterization:** Appropriate only for anterior epistaxis under direct visualization; posterior bleeding cannot be reached this way.