A 42-year-old hypertensive male presents with sudden-onset epistaxis. On examination, blood is seen draining posteriorly into the pharynx despite anterior nasal packing. Which is the most common cause of posterior epistaxis?

Explanation

## Most Common Cause of Posterior Epistaxis **Key Point:** Hypertension is the single most common cause of posterior epistaxis in adults, particularly in middle-aged and elderly patients with uncontrolled blood pressure. ### Pathophysiology of Hypertension-Induced Epistaxis 1. **Elevated arterial pressure** → increased transmural pressure in nasal vessels 2. **Endothelial damage** → loss of vessel wall integrity 3. **Rupture of sphenopalatine artery branches** → posterior epistaxis 4. **Recurrent bleeding** → chronic mucosal inflammation and friability ### Clinical Features of Hypertensive Epistaxis - **Onset:** Sudden, often spontaneous (no preceding trauma) - **Location:** Posterior nasal cavity (blood drains into pharynx) - **Severity:** Moderate to severe; difficult to control with anterior packing alone - **Associated findings:** Elevated BP (often >160/100 mmHg at presentation) - **Age group:** Typically >50 years ### Comparison: Common Causes of Epistaxis | Cause | Frequency | Type | Age Group | Severity | Key Feature | |-------|-----------|------|-----------|----------|-------------| | **Hypertension** | Most common (posterior) | Spontaneous | >50 years | Moderate–severe | Posterior location, recurrent | | **Trauma** | Most common (anterior) | Induced | Any age | Mild–moderate | History of nose-picking or injury | | **Coagulopathy** | Moderate | Spontaneous | Variable | Severe, prolonged | Bleeding from multiple sites | | **HHT** | Rare | Spontaneous | Young–middle age | Recurrent, chronic | Telangiectasias on lips/mucosa | | **Anticoagulants** | Moderate | Spontaneous | >60 years | Moderate–severe | History of warfarin/DOAC use | **High-Yield:** In an older patient with posterior epistaxis and elevated BP, hypertension is the diagnosis until proven otherwise. Treat both the epistaxis AND the underlying hypertension to prevent recurrence. ### Management Approach ```mermaid flowchart TD A[Posterior Epistaxis + Hypertension]:::outcome --> B{Bleeding controlled?}:::decision B -->|No| C[Posterior packing or endoscopic hemostasis]:::action B -->|Yes| D[Antihypertensive therapy]:::action C --> E[ICU/HDU admission]:::action D --> F[BP target <140/90 mmHg]:::action E --> G[Monitor for rebleeding]:::outcome F --> G ``` **Clinical Pearl:** Do NOT aggressively lower BP in acute epistaxis (risk of syncope and rebleeding); aim for gradual control (target <140/90 mmHg) once hemostasis is achieved. **Warning:** Hypertension alone does NOT cause epistaxis — it is a permissive factor. Always investigate for underlying mucosal pathology (telangiectasia, tumor, granuloma) in recurrent cases.