ENT - Nose Flashcards
Where do nosebleeds (epistaxis) most commonly originate from?
Kiesselbach’s plexus (also known as Little’s area)
Anterior vs posterior nose bleed? Which is most common?
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
What is a primary nosebleed?
Majority of bleeds, no clear and obvious cause
What is a 2ary nosebleed?
When there is a clearly identifiable factor
Give some factors causing a 2ary nosebleed
- 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)
Management of a serious nosebleed?
- 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)
What is next management step if direct compression of nasal alae in a nosebleed does not work?
Nasal cautery
What is next management step if direct compression of nasal cautery in a nosebleed does not work?
Nasal packing
Complications of severe epistaxis?
- Hypovolaemic shock
- Aspiration
- Intranasal adhesions
- Mucosal damage from excessive cautery
- Infected nasal packing
Nasal trauma can result in a septal haematoma. What is this?
Bleeding under the perichondrium lining the septal cartilage
What is the danger of a septal haematoma?
- 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
A septal haematoma can lead to which nose deformity?
Saddle nose deformity
3 major complications of nasal trauma?
- Septal haematoma
- Nasal obstruction e.g. due to septal deviation
- Epistaxis
Which investigation can be used in a septal haematoma?
Anterior rhinoscopy → will show bilateral cherry-red swelling arising from the nasal septum (septal haematoma)
Management of a septal haematoma?
- ENT referral for emergency incision and drainage
- Emergency incision & drainage → prevents life-threatening infective complications and severe cosmetic nasal deformity
What does nasal blockage involve?
Encompasses nasal obstruction and nasal congestion.
Causes of nasal blockage?
- Viral infection (influenza, rhinovirus)
- Allergic rhinitis
- Rhinosinusitis
- Nasal polyps
- Septal haematoma
- Tumours
Foreign bodies in the nose are most commonly seen in which patient population?
- Most common in young children
- Higher prevalence among young children with ADHD and adults with neurodevelopmental disorders
Organic vs inorganic foreign bodies that can get stuck in the nose?
- Organic – food, bugs
- Inorganic – nails, paper, stones etc
Do organic or inorganic foreign objects tend to cause more symptoms when stuck in the nose?
Organic
Symptoms of organic foreign body in the nose?
- Can cause local inflammatory reactions and 2ary infection e.g. sinusitis
- Unilateral purulent and foul-smelling discharge
- Nasal obstruction
- Facial pain from sinusitis
Symptoms of inorganic foreign body in the nose?
Tend to be asymptomatic unless large enough to cause nasal obstruction
Which foreign body requires emergency removal if stuck in the nose?
Button batteries
Why do button batteries require emergency removal if ingested/lodged in the nose?
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
What is rhinosinusitis?
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).
Most common organism causing rhinosinusitis?
- Streptococcus pneumonia (most common)
- Haemophilus influenzae
What does rhinosinusitis typically follow?
Typically follows common cold.
Symptoms of rhinosinusitis?
- Pain
- Nasal congestion/obstruction
- Nasal discharge
What should you always check in a patient presenting with rhinosinusitis?
The eyes !
Ophthalmologic complications of rhinosinusitis?
- Preseptal cellulitis
- Orbital cellulitis
- Subperiosteal abscess (Pott’s puffy tumour)
- Orbital abscess
- Cavernous sinus thrombosis
Other complications of rhinosinusitis?
- Persistent infection
- Intracranial involvement: meningitis and encephalitis
- Mucoceles
- Osteomyelitis
Pharmacological management of rhinosinusitis?
- Nasal corticosteroids
- Saline nasal irrigation
What is the most common cause of hereditary nose bleeds?
Hereditary hemorrhagic telangiectasia (HHT)
