ENT Flashcards
What are 5 common causes of epistaxis?
What’s 2 congenital causes?
Whats a drug cause?
dry weather or low humidity, barotrauma, nasal or facial fracture/trauma eg. nosepicking, nasal polyp, nasal irritants eg. dust/smoke
Familial Hereditary Haemorrhagic Telangiectasia, septal deviation
Cocaine, topical nasal drugs eg. nasal corticosteroids
What are the 2 types of epistaxis?
90% are Anterior:
- originates from Kiesselbach’s plexus (vascular anastamosis in Little’s area)
Posterior:
- produce more active bleeding
How would you investigate epistaxis?
FBC, Coagulation studies and INR and prothrombin time
Nasal endoscopy and nasopharyngoscopy to identify source
nasal or sinus Xray to show fracture
How would you initially manage epistaxis? (active bleeding)
- apply pressure to anterior bleeding sites by pinching the lower compressible cartilage of the nose
- applying a vasoconstrictor/decongestant ( eg. oxymetazoline) helps encourage haemaostasis
- topical anaesthetic (eg. lidocaine) can help
Describe the steps you take once the bleeding source has been visualised
- anterior epistaxis = silver nitrate cautery
- ** avoid cautery on same area on either side of septum as it can result in deprivation of blood supply and septal perforation ***
- petroleum jelly after
Describe the steps you take if the cautery fails?
- anterior nasal packing
- give co-amoxi antibiotics as there is impaired sinus drainage = infection risk
if the bleeding persists:
- endoscopy = surgical clip ligation of sphenopalatine artery
- angiography + embolisation with interventional radiology
- open surgery ligation
What if you suspect a posterior bleed?
- posterior packing
- double balloon epistaxis device OR traditional gauze anterior pack with Foley urinary catheter placed posteriorly
- IV analgesia and antiemetics
A man comes in with acute bacterial sinusitis. What part of the history makes you think this?
How would an acute viral sinusitis present?
4 weeks> Symptoms >10 days
** viral sinusitis progresses to bacterial so viral sinusitis will present with <10 days symptoms. Then initial improvement, then secondary bacterial infection **
Symptoms: purulent nasal mucus, nasal congestion, facial pain eg. headache
Virus specific symptoms: myalgia, sore throat, fever
How would you manage acute viral sinusitis?
Analgesia/antipyretic = Paracetamol/ibuprofen
Decongestant = topical Oxymetazoline nasal
saline spray OR Corticosteroids for congestion = Mometasone nasal
Topical anticholinergics for rhinorrhoea = Ipratropium nasal
Mucolytics = Guaifenesin
How would you treat acute bacterial sinusitis?
wait 10 days before antibiotics!!!
- amoxi or co-amoxi or phenomethylpenicillin
- analgesia, decongestant, mucolytics, ipratropium, saline spray, etc as needed.
If immunocompromised:
- high dose co-amoxi
- for penicillin allergy, give clindamycin + cefixime
- for beta lactam allergy, give doxycycline
When do you refer sinusitis to ENT?
Over 4 episodes per year
What is chronic sinusitis and how is it differentiated?
Paranasal sinus inflammation lasting >12 weeks.
There is with and without polyps
How does chronic sinusitis happen?
Usually due to an anatomical obstruction of the osteomeatal complex, resulting in inadequate sinus drainage of mucus.
Acute exacerbation:
1) Inflammation of the sinonasal mucosa occurs due to allergies, viral infections, pollutants.
2) Results in additional swelling in narrow osteomeatal channels.
3) Pooling of mucus means resp cilia cannot clear it. It thickens and microorganisms grow.
How would you manage acute exacerbations?
1st line = co-amoxi or cefuroxime
Nasal saline irrigations
Intranasal corticosteroids eg. budesonide, mometasone, etc
(ensure proper spraying technique or epistaxis risk!)
Decongestants eg. ometazoline nasal spray
Prednisoline oral to shrink polyps
Antihistamines eg. Loratadine, cetrizine, chlorphenamine for allergic rhinitis
Endoscopic sinus surgery last resort
What are common bacterial organisms that cause acute sinusitis?
strep pneumoniae
haem influenzae
moraxella catarrhalis
