Nose

Question 1

Where does anterior epistaxis usually arise?

Answer 1

Septal - Little’s Area (Kiesselbach’s plexus)

• Area where anterior ethmoidal, sphenopalatine and facial arteries anastamose for form anterior anastamotic arcade.

Question 2

Why are posterior bleeds more serious?

Answer 2

More invasive procedures may be required

• Examination under anaesthesia – if discrete bleeding point is found it can be treated with diathermy.
• Arterial ligation – endoscopic ligation of sphenopalatine artery
• Embolization – of internal maxillary or facial artery (can be life-saving but can cause stroke)

Question 3

Causes of epistaxis?

Answer 3

• Local trauma (nosepicking)
• Facial trauma
• Dry/cold weather
• Dyscrasia/haemophilia
• Septal perforation

Question 4

Things to ask in epistaxis history? Bloods?

Answer 4

Which side? Trauma? How much loss? Warfarin/aspirin? PMH?

FBC, G+S/X-match, coagulation

Question 5

Management steps in epistaxis?

Answer 5

1. Resuscitation (if low BP or dizzy on standing)
2. General
   
   • Pinch lower part of nose for 20 mins. Breathe throuh mouth, spit blood into bowl.
   • Ice pack on dorsum of nose.
3. Cauterisation
4. Nasal packing
5. After bleed care

Question 6

Cauterisation in epistaxis?

Answer 6

With Silver Nitrate

• Look inside and remove clots
• Apply cotton ball soaked in 1:200,000 adrenaline for 2 mins or use LA spray
• Find bleeding points (with Thudicum nasal speculum) –> apply cautery for 2 sec at a time, starting from edge of bleeding point moving in a circle
  
  • Avoid using if actively bleeding as this will wash the chemical away and cause unwanted burns to lips or throat.
  • Never cauterise both sides of septum à risk of perforation.

If bleeding point can’t be seen –> refer to ENT.

Question 7

Anterior nasal packing?

Answer 7

Rapid Rhino; Merocel

• Lubricate/soak pack as instructed; advance into nose horizontally and parallel to hard palate (not up)
• Inflate if required, and tape securely to face.
• Remove after 24h if bleeding stops. If not, try postnasal pack.

Question 8

Postnasal packing?

Answer 8

Foley urinary catheter (16-18G) is effective

• Pass via nostril into nasopharynx. Inflate balloon with >10mL water and pull anteriorly through mouth to occlude the posterior choana (junction between nasal cavity and nasopharynx)
• Clamp (with padding over the skin) at the nasal vestibule, to prevent it falling backwards into the airway.

Question 9

Advice for after epistaxis?

Answer 9

• Don’t pick or blow
• If you sneeze, send it through open mouth
• Avoid bending, lifting or straining
• No hot food or drink
• If it restarts, apply ice to bridge of nose and hold soft lower part continuously for 20 mins; get help if this fails

Question 10

How does a nasal fracture present?

How does septal haematoma present?

Answer 10

New nasal deformity, often with associated facial swelling and black eyes. X-rays not required by may help exclude other facial fracture.

Septal Haematoma

• Boggy swelling on septum causing near-total nasal obstruction –> requires urgent incision and drainage.

Question 11

How to treat nasal fracture?

Answer 11

• Advise on analgesia/using ice
• Reassess 5-7 post-injury (once swelling has resolved)
• If manipulation (MUA) is required à perform 10-14 days post-injury (before nasal bones set)

Question 12

What causes CSF rhinorrhoea?

Management?

Answer 12

Ethmoid fractures disrupting dura and arachnoid –> CSF leak

Management

• Conservative management –> spontaneous resolution. 7-10 days bedrest (head elevated) +/- lumbar drain.
• Cover with antibiotics and pneumococcal vaccine.

Question 13

Management of nasal foreign bodies in children?

Answer 13

• Ask child to blow nose (if able) – or ask parent to try ‘parental kiss’ by blowing into mouth whilst occluding other nostril (success rate >70%)
• If child co-operative it may be possible to grasp object with crocodile forceps (avoid pushing deeper into nose)
• Batteries need urgent removal –> refer to ENT if failed attempt or uncooperative patient.

Question 14

Definition of rhinosinusitis?

Answer 14

Defined as inflammation in the nose and paransal sinuses with ≥2 symptoms:

• MUST HAVE Nasal blockage/obstruction/congestion OR nasal discharge
• Facial pain or pressure
• Reduction or loss of smell

Question 15

Classification of rhinosinusitis?

Answer 15

Symptoms classified as mild, moderate or severe.

Acute, Chronic (>12 weeks) or Allergic

Question 16

Presentation of acute rhinosinusitis?

Answer 16

Common cold.

Acute post-viral sinusitis = ↑symptoms after 5 days or persistent symptoms >10 days

Question 17

Presentation of chronic rhinosinusitis?

Answer 17

Same as acute but persistent and +/- nasal polyps

Question 18

Presentation of allergic rhinosinusitis?

Answer 18

(IgE-mediated inflammation from allergen exposure to nasal muscosa –> mast cell degranulation)

House dust mites (perennial); pollens or animal dander (seasonal)

• Sneezing; pruritis; nasal discharge (bilateral); bilateral itchy red eyes

Question 19

Management of acute rhinosinusitis?

Answer 19

• Self-limiting (80% resolve within 14 days). Avoid abx.
• If >5 days, consider intranasal corticosteroids (non-systemically bioavailable – mometasone; fluticasone).

Question 20

Management of chronic rhinosinusitis?

Answer 20

• Intranasal corticosteroids + nasal saline irrigation
• If no improvement after 4 weeks consider micro cultures and long-term (>12 weeks) abx.
• CT if poor response to treatment consider surgery.

Question 21

Management of allergic rhinosinusitis (hay fever)?

Answer 21

General

• Allergen/irritant avoidance
• Nasal/saline irrigation (Patient sniffs a saline solution into the nostril)

Medical

• Antihistamines (non-sedating = loratadine)
• Intransal corticosteroid spray if no response
• Short course of prednisolone can help rapid resolution of severe symptoms (e.g. during exams)

Later

• Immunotherapy –> can induce long-term tolerance to allergens.

Question 22

Definition of sinusitis (acute bacterial?

Answer 22

At least 3 symptoms/signs of:

• Discoloured discharge (with unilateral predominance) and purulent secretion in the nasal cavity
• Severe local pain (with unilateral predominance)
• Fever (>38)
• Elevated ESR/CRP
• “Double sickening” (i.e. a deterioration after an initial milder phase of illness)

Question 23

Aetiology/causes of acute sinusitis?

Answer 23

Mostly follow viral infection. Other causes…

• Direct spread (dental root infection or diving/swimming in infected water)
• Odd anatomy (septal deviation, large ethmoidal bulla, polyps, large uncinated process)
• ITU (mechanical ventilation, recumbency, NG tubes)
• Systemic (Kartagener’s syndrome, immunodeficiency, general debility)

Bacterial = Strep, H.influenzae, Staph, Moraxella

Question 24

Complications of sinusitis?

Answer 24

1. Orbital cellulitis/Abscess
2. Intracranial involvement - meningitis, encephalitis, cerebral abscess, cavernous sinus thrombosis
3. Mucoceles - frontal sinus filled with mucous –> pus
4. Osteomyelitis - staph - frontal bone
5. Pott’s puffy tumour - Subperiosteal abscess arising from frontal osteomyelitis

Question 25

Investigations in recurrent sinusitis?

Answer 25

CT paranasal sinuses/Endoscopy – if recurrent (can identify anatomical problems and plan for surgery) ESS = endoscopic sinus surgery (if recurrent problems)

Question 26

Management of sinusitis?

Answer 26

98% cases viral, self-limiting in 2 weeks. * Simple analgesia * Nasal saline irrigation * Intra-nasal decongestants (ephedrine 0.5%) * **NOT antihistamines** – thicken secretions and complicate drainage If bacterial suspected --\> **amoxicillin or doxycycline**

Question 27

What are nasal polyps and what are they associated with?

Answer 27

* Swellings of the nasal or sinus mucosa prolapsing into the nasal cavity. Part of rhinosinusitis spectrum. * Prevalence = 2% * Associations * Allergic rhinitis, non-allergic rhinitis, chronic ethmoid sinusitis, CF, aspirin hypersensitivity, asthma

Question 28

Presentation of nasal polyps?

Answer 28

* Typically males \>40. Sites = usually bilateral. * Symptoms * Watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth-breathing, snoring, headaches

Question 29

Management of nasal polyps? How do you put drops in?

Answer 29

**_Investigations_** * Anterior rhinoscopy or nasal endoscopy **_Management_** * Topical steroids * Long-term abx * Surgery (ESS)