ENT - Nose

Question 1

Where do nosebleeds (epistaxis) most commonly originate from?

Answer 1

Kiesselbach’s plexus (also known as Little’s area)

Question 2

Anterior vs posterior nose bleed? Which is most common?

Answer 2

Anterior:

• Most common
• Nosebleeds originate toward the front of the nose and cause blood to flow out through the nostrils

Posterior:

• Posterior nosebleeds originate toward the back of the nasal passage, near the throat
• More serious

Question 3

What is a primary nosebleed?

Answer 3

Majority of bleeds, no clear and obvious cause

Question 4

What is a 2ary nosebleed?

Answer 4

When there is a clearly identifiable factor

Question 5

Give some factors causing a 2ary nosebleed

Answer 5

• Alcohol
• Antiplatelet agents (e.g. clopidogrel)
• Aspirin and NSAIDs
• Anticoagulants (e.g. warfarin)
• Coagulopathy (e.g. haemophilia, von WiIlebrand’s disease)
• Trauma (e.g. nasal fracture)
• Tumours
• Surgery
• Septal perforation
• Intranasal drugs (e.g. decongestants, steroids, illicit drugs)

Question 6

Management of a serious nosebleed?

Answer 6

• ABCDE resuscitation approach
• Identify site of bleed.
• 1) Direct compression of nasal alae (cartilaginous part)
  
  • Most anterior bleeds resolve after 10-15 minutes of compression
  • Sit patient up and lean them forwards – minimise blood entering oral cavity and pharynx
• 2) Nasal cautery
  
  • Chemical (silver nitrate) or electrical (thermal)
• 3) Nasal packing (if cautery fails or severe bleeding)
  
  • Nasal tampons, inflatable packs, ribbon gauze impregnated with Vaseline)

Question 7

What is next management step if direct compression of nasal alae in a nosebleed does not work?

Answer 7

Nasal cautery

Question 8

What is next management step if direct compression of nasal cautery in a nosebleed does not work?

Answer 8

Nasal packing

Question 9

Complications of severe epistaxis?

Answer 9

• Hypovolaemic shock
• Aspiration
• Intranasal adhesions
• Mucosal damage from excessive cautery
• Infected nasal packing

Question 10

Nasal trauma can result in a septal haematoma. What is this?

Answer 10

Bleeding under the perichondrium lining the septal cartilage

Question 11

What is the danger of a septal haematoma?

Answer 11

• As the septal cartilage receives blood supply from the overlying mucosa, the haematoma can disrupt blood flow
• Damage to septal cartilage can occur within 24 hours and if untreated → irreversible septal perforation and necrosis, saddle nose deformity

Question 12

A septal haematoma can lead to which nose deformity?

Answer 12

Saddle nose deformity

Question 13

3 major complications of nasal trauma?

Answer 13

1. Septal haematoma
2. Nasal obstruction e.g. due to septal deviation
3. Epistaxis

Question 14

Which investigation can be used in a septal haematoma?

Answer 14

Anterior rhinoscopy → will show bilateral cherry-red swelling arising from the nasal septum (septal haematoma)

Question 15

Management of a septal haematoma?

Answer 15

• ENT referral for emergency incision and drainage
• Emergency incision & drainage → prevents life-threatening infective complications and severe cosmetic nasal deformity

Question 16

What does nasal blockage involve?

Answer 16

Encompasses nasal obstruction and nasal congestion.

Question 17

Causes of nasal blockage?

Answer 17

• Viral infection (influenza, rhinovirus)
• Allergic rhinitis
• Rhinosinusitis
• Nasal polyps
• Septal haematoma
• Tumours

Question 18

Foreign bodies in the nose are most commonly seen in which patient population?

Answer 18

• Most common in young children
• Higher prevalence among young children with ADHD and adults with neurodevelopmental disorders

Question 19

Organic vs inorganic foreign bodies that can get stuck in the nose?

Answer 19

• Organic – food, bugs
• Inorganic – nails, paper, stones etc

Question 20

Do organic or inorganic foreign objects tend to cause more symptoms when stuck in the nose?

Answer 20

Organic

Question 21

Symptoms of organic foreign body in the nose?

Answer 21

• Can cause local inflammatory reactions and 2ary infection e.g. sinusitis
• Unilateral purulent and foul-smelling discharge
• Nasal obstruction
• Facial pain from sinusitis

Question 22

Symptoms of inorganic foreign body in the nose?

Answer 22

Tend to be asymptomatic unless large enough to cause nasal obstruction

Question 23

Which foreign body requires emergency removal if stuck in the nose?

Answer 23

Button batteries

Question 24

Why do button batteries require emergency removal if ingested/lodged in the nose?

Answer 24

Button batteries require emergency removal as they can cause tissue necrosis through electrolysis at the negative battery pole.

If up nose:

• Can cause septal perforation
• Purulent discharge
• Epistaxis
• Tissue necrosis, black discharge, facial swelling and pain, fever

Question 25

What is rhinosinusitis?

Answer 25

Inflammation of the **nose and paranasal sinuses** with greater than 2 symptoms; one of which must be **nasal congestion** and **nasal discharge**. Other symptoms can be **facial pain** or **heaviness** and reduction of **olfaction**. Can be acute of chronic (\>12 weeks).

Question 26

Most common organism causing rhinosinusitis?

Answer 26

* Streptococcus pneumonia (most common) * Haemophilus influenzae

Question 27

What does rhinosinusitis typically follow?

Answer 27

Typically follows common cold.

Question 28

Symptoms of rhinosinusitis?

Answer 28

* Pain * Nasal congestion/obstruction * Nasal discharge

Question 29

What should you always check in a patient presenting with rhinosinusitis?

Answer 29

The eyes !

Question 30

Ophthalmologic complications of rhinosinusitis?

Answer 30

* Preseptal cellulitis * Orbital cellulitis * Subperiosteal abscess (Pott’s puffy tumour) * Orbital abscess * Cavernous sinus thrombosis

Question 31

Other complications of rhinosinusitis?

Answer 31

* Persistent infection * Intracranial involvement: meningitis and encephalitis * Mucoceles * Osteomyelitis

Question 32

Pharmacological management of rhinosinusitis?

Answer 32

* Nasal corticosteroids * Saline nasal irrigation

Question 33

What is the most common cause of **hereditary** nose bleeds?

Answer 33

Hereditary hemorrhagic telangiectasia (HHT)