Block 1- nasal topics

Question 1

Epistaxis Prognosis

Answer 1

• Most are a nuisance only
• Mortality rare
• With proper treatment: excellent Prognosis
• Greater morbidity with nasal packing: risk of infection, TSS, respiratory depression

Question 2

Epistaxis Treatment Patient Education

Answer 2

• Avoid straining, vigorous exercise, increased head pressure
• Keep nasal packing moist with nasal saline
• Avoid vasodilators: hot spicy foods, tobacco
• Avoid nasal trauma
• Increase home humidity
• Use lube in nares-petrolatum jelly/bacitracin (at night especially)
• IF nasal packing: abx cephalexin/clindamycin
• Refer for recurrency, large bleeding volume
• ED if not controlled with proper technique for 15 minutes

Question 3

if giving a pt a nasal packing for epistaxis, what antibiotics should you prescribe?

Answer 3

cephalexin/clindamycin

Question 4

epistaxis treatment

Answer 4

• Nasal saline spray
• Avoid increased pressure (sneeze with mouth open)
• No digital manipulation
• Avoid hot spicy foods, Smoking
• Avoid ASA/IBU

Question 5

epistaxis labs

Answer 5

• Mostly not helpful!!
• CBC (PLT, H&H)
• INR (PT/PTT)
• LFT
• Bleeding time, vWF
• Scope: fibreoptic endoscopy with flex/rigid
• CT/MR?

Question 6

epistaxis primary intervention failure

If anterior bleed not controlled and/or source not visualised, what should you do?

Answer 6

• Anterior- hemostatic sealant, pneumatic nasal tamponade, anterior packing
• Epistat (balloon pads)
• Life threatening bleed: endovascular embolisation interior maxillary artery or facial artery/Ligation external carotid (very rare)

Question 7

epistaxis intervention

Answer 7

• Most controlled with direct pressure within 15 minutes
• Sitting down vs lying down: less venous pressure
• Lean forward to decrease ingestion
• Short acting phenylephrine/vasoconstrictors
• Ice packs
• Topical 4% cocaine spray on cottons swab
• Topical decongestant oxymetazoline Afrin
• Cautery/silver nitrate/electrocautery
• Relaxation

Question 8

during epistaxis physical exam, what should you as patient about?

Answer 8

• Ask patient about: History, Onset/activities, Timing , Duration, A&A, Risk factors, Associated sxs, Severity

Question 9

if you see clot in epistaxis pt, what do you do?

Answer 9

If clot: have them blow it out

Question 10

in physical exam of epistaxis patient, what do you use to inspect?

Answer 10

Inspection w/nasal speculum

Question 11

what to look out for in physical exam of epistaxis pt

Answer 11

¥ Source? Bilateral?
¥ Masses? Persistent bleeding? Septal hematoma?
¥ Blood in oropharynx?

Question 12

etiology of epistaxis

Answer 12

• 10% no identifiable cause
• Nasal trauma/surgery
• Mucosal irritation: topical antihistamines/steroids
• Foreign body
• Forceful blowing
• Rhinitis/URI
• Nasal cannula supplemental oxygen
• Decreased humidity (winter/seasonal)
• Septal deviation
• Septal perforations
• Tumour
• Dyscrasias
• Liver disease
• Cocaine/ETOH
• HTN?
• Anticoagulant/Antiplatelet Therapy?
• Childhood migraines

Question 13

epistaxis epidemiology

Answer 13

• Bimodal: young 2-10yo, older 50-80yo
• Life long incidence: 60%
• Male 58%, Female 42%

Question 14

most common bleed in epistaxis pt

Answer 14

Unilateral anterior bleeds

Question 15

90% of bleeding in epistaxis patients occur from what area in nose?

Answer 15

occur in Kiesselbach’s Triangle (Little’s Area)

Question 16

percentage of posterior bleeds in epistaxis patients?

Answer 16

5%

Question 17

when to do Allergic Rhinitis Referral?

Answer 17

• For severe disease
• Poor response to pharmacotherapy
• Presence of comorbid conditions or complications