A 68-year-old man with a 10-year history of hypertension (currently on amlodipine 5 mg daily) presents to the emergency department with sudden-onset epistaxis from the right nostril. He denies trauma, recent nasal surgery, or use of anticoagulants. On examination, blood pressure is 168/98 mmHg. Anterior rhinoscopy reveals active bleeding from the posterolateral aspect of the nasal septum in the region of Kiesselbach's triangle. After initial control with topical epinephrine and anterior nasal packing, bleeding recurs within 2 hours. What is the most appropriate next step in management?

## Clinical Assessment This patient presents with **recurrent epistaxis** despite initial anterior packing. The bleeding is described as originating from the **posterolateral aspect of the nasal septum**, which, despite being in the region of Kiesselbach's triangle anteriorly, can have contributions from posterior vessels — particularly the **sphenopalatine artery (SPA)** and its septal branches. Recurrence within 2 hours of anterior packing signals failure of conservative anterior management. **Key Point:** When anterior packing fails in recurrent epistaxis, the standard stepwise approach per Scott-Brown's Otorhinolaryngology and Cummings Otolaryngology is to escalate to **posterior nasal packing** before proceeding to definitive surgical or endoscopic intervention. ## Management Algorithm The stepwise approach to recurrent epistaxis after failed anterior packing: 1. **Anterior packing** (first-line) → failed in this patient 2. **Posterior nasal packing** (next step) — addresses posterior nasal cavity bleeding and provides tamponade to the SPA territory 3. **Sphenopalatine artery ligation** (endoscopic) — if posterior packing fails or bleeding recurs after removal ## Why Posterior Packing Followed by SPA Ligation (Option D)? **High-Yield:** The standard management ladder for epistaxis that fails anterior packing is: - **Posterior packing** (Foley catheter balloon or formal posterior pack) is the accepted next step before surgical intervention. It provides circumferential tamponade and is less invasive than immediate surgery. - If posterior packing fails or bleeding recurs after pack removal, **endoscopic sphenopalatine artery ligation** is the definitive procedure of choice, with success rates >90% (Cummings Otolaryngology, 7th ed.). - Skipping posterior packing and proceeding directly to endoscopic SPA ligation is practiced at high-volume tertiary centers but is **not universally the standard first escalation step** after failed anterior packing. **Clinical Pearl (Scott-Brown's / Cummings):** Posterior packing is indicated when anterior packing fails, regardless of whether the initial bleeding site appeared anterior. The SPA supplies the posterolateral nasal wall and septal branches; posterior tamponade addresses this territory effectively before committing to surgery. ## Why Not Immediate Endoscopic SPA Ligation (Option B)? While endoscopic SPA ligation is the definitive surgical option, proceeding **immediately** to surgery without a trial of posterior packing bypasses a well-established, less-invasive step in the management ladder. Most guidelines (ENTUK, AAO-HNS) recommend posterior packing as the next escalation before surgical ligation. Immediate surgery is appropriate only if posterior packing fails. ## Why Not Repeat Anterior Packing (Option A)? The patient has already failed anterior packing. Repeating the same intervention without escalation is unlikely to succeed and delays appropriate management. ## Why Not CT Angiography (Option C)? CT angiography is reserved for suspected **vascular malformation, hereditary hemorrhagic telangiectasia (HHT), or tumor**. This patient has hypertensive epistaxis without clinical features suggesting these diagnoses; imaging would delay definitive management. **High-Yield:** The correct answer is **D — Posterior nasal packing followed by sphenopalatine artery ligation if bleeding persists**, reflecting the standard stepwise escalation endorsed by Cummings Otolaryngology and Scott-Brown's Otorhinolaryngology.