A 68-year-old man with hypertension (BP 160/95 mmHg) and chronic aspirin use presents to the emergency department with profuse epistaxis for 2 hours. Anterior rhinoscopy reveals bleeding from the posterolateral wall of the nasal cavity. After failed anterior packing, the patient undergoes posterior packing. Which of the following is the most appropriate next step in management?

Explanation

## Management of Posterior Epistaxis — Refractory Case **Key Point:** Posterior epistaxis from the sphenopalatine artery territory (posterolateral nasal wall) that fails anterior packing requires systematic escalation: posterior packing → antibiotics → definitive haemostasis (endoscopic ligation or embolization). ### Clinical Reasoning This patient has: - **Posterolateral bleeding source** → sphenopalatine artery involvement (supplies 90% of posterior epistaxis) - **Failed anterior packing** → requires posterior packing - **Hypertension + aspirin** → dual risk factors for recurrent bleeding ### Management Algorithm ```mermaid flowchart TD A[Posterior epistaxis]:::outcome --> B[Posterior packing]:::action B --> C{Bleeding controlled?}:::decision C -->|Yes| D[Admit, antibiotics, monitor 48-72 hrs]:::action C -->|No| E[Persistent bleeding despite packing]:::urgent E --> F{Endoscopic capability available?}:::decision F -->|Yes| G[Endoscopic sphenopalatine artery ligation]:::action F -->|No| H[Arterial embolization]:::action G --> I[Definitive haemostasis]:::outcome H --> I ``` ### Key Management Points | Step | Rationale | Duration | |------|-----------|----------| | Posterior packing | Controls bleeding in 80–90% of posterior cases | 48–72 hours | | Prophylactic antibiotics | Prevents sinusitis/toxic shock syndrome (packing is foreign body) | Full duration of packing + 5 days | | Endoscopic sphenopalatine artery ligation (ESPAL) | Definitive, minimally invasive, success rate >95% | Single procedure | | Arterial embolization | Reserved if endoscopy unavailable or failed ESPAL | Single procedure | **Clinical Pearl:** Posterior packing is a **temporary measure** — it buys time for definitive intervention. Prolonged packing (>72 hours) increases risk of sinusitis, otitis media, and toxic shock syndrome. **High-Yield:** The sphenopalatine artery is the terminal branch of the maxillary artery and supplies the posterolateral nasal wall — this is the **most common site of posterior epistaxis**. Endoscopic ligation is now preferred over arterial embolization in most centres because it is safer and has lower morbidity. **Warning:** Simply discharging the patient with packing in place for 7 days is dangerous — risk of infection, airway compromise, and rebound bleeding on removal. [cite:Dhingra 8e Ch 5]