List I - Core Conditions Flashcards
1
Q
What is epistaxis?
A
- Bleeding from the nose
- 80-90% of cases, epistaxis originates from Little’s area on the anterior nasal septum, which contains the Kiesselback plexus of vessels
- Less
2
Q
Where does the bleeding come from in epistaxis?
A
- 80-90% of cases, epistaxis originates from Little’s area on the anterior nasal septum, which contains the Kiesselback plexus of vessels
- Less commonly, epistaxis originates from branches of the sphenopalatine artery in the posterior nasal cavity
3
Q
Which people do posterior nosebleeds more commonly occur in?
A
- Older people
- Posterior nose bleeds are also commonly more profuse, result in bleeding from both nostrils, and the bleeding site cannot be identified on examination
4
Q
What causes epistaxis?
A
- Superficial blood vessels in the nose are more easily damaged, local causes of damage can include:
- Trauma
- Inflammation
- Topical drugs
- Vascular causes
- Post-operative bleeding
- Tumours
- Nasal oxygen therapy
- More general causes of damage may include:
- Atherosclerosis
- Increased venous pressure from mitral stenosis
- Haematological conditions affecting clotting such as thrombocytopenia, platelet dysfunction, VW disease, leukaemia and haemophilia
- Environmental factors such as temperature, humidity, altitude, exposure to irritants such as dust, certain chemicals and cigarette smoke
- Systemic drugs - including anticoagulants and anti-platelet drugs (aspirin and clopidegrel)
- Excessive alcohol consumption
- Hypertension is common in people who present with epistaxis; however there is insufficient evidence to establish a causal relationship
- Prevalence of hypertension in people with epistaxis is up to 64%
5
Q
What is the prognosis of epistaxis?
A
- Most episodes are self limiting and do not require medical treatment
6
Q
What are the possible complications of epistaxis?
A
- Rare complications include
- Hypovolaemia
- Anaemia
- Aspiration from dislodgement or malpositioning
- Death
- Possible complications of nasal packing include
- Sinusitis
- Septal haematoma or abscess
- Pressure necrosis (secondary to excessively tight packing)
- Toxic shock syndrome (prolonged packing)
- Apnoeic episodes (associated with bilateral anterior or posterior nasal packs)
- Possible complication of nasal cautery treatment is septal perforation due to a direct effect of the silver nitrate stick
7
Q
How should a person with acute epistaxis be assessed?
A
- Be aware that complications are most likely if the bleeding is severe and/or the person is older, unwell or frail
- Clinical judgement should be used to determine if it is necessary to assess the persons ABC
- If the person becomes haemodynamically compromised, arrange immediate transfer to A and E
- If the person is not haemodynamically compromised, ask:
- When the bleeding started and from which nostril
- How much blood has been lost - light or heavy bleeding - how many cups
- Has a temporary pack (such as cotton wool) been used before seeking medical help
- Any previous episodes of epistaxis and how were they treated
- Examine both nasal passages (ideally with adequate lighting and a nasal speculum)
- Where clinically appropriate ask the person to gently blow the nose to clear old blood and large clots
- Look for a bleeding point - it will look like a small red dot (less than 1 mm) and may not be actively bleeding
- Suspect a posterior bleed if bleeding is profuse, from both nostrils, the bleeding site cannot be identified on speculum examination, and/or if bleeding first started down the throat (however, be aware that if bleeding commenced while the person was supine, blood is likely to have drained to the throat regardless of the bleeding site
8
Q
How can you determine if there might be an underlying cause of epistaxis, particularly in children younger than 2 years of age?
A
- Ask about the following:
- History of surgery or recent trauma (consider non-accidental injury) - be aware that epistaxis in children under the age of two year has been associated with intentional or non-intentional asphyxia
- Symptoms suggestive of a tumour including nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy (for example facial numbness or double vision)
- Be aware that nasal, sinus, and nasopharyngeal cancers are most common in people older than 50 year of age, in those with occupational exposure to wood dust or chemicals and (for nasopharyngeal cancer) in people of South Chinese or North African family origin
- Other nasal symptoms that may be suggestive of allergic rhinitis or bacterial rhinosinusitis, nasal polyps, or nasal foreign body
- Current medications e.g. aspirin, warfarin or nasally administered drugs
- If the person is taking warfarin, check the INR or admit to hospital if bleeding is difficult to control
- Conditions predisposing to bleeding (such as haemophilia or leukaemia)
- Symptoms or family history of bleeding disorders (hereditary haemorrhagic telangiectasia - suggested by red or purple spots on the fingertip pads, lips, lining of the nose, gut and occasionally the ears and face
- Environmental factors such as cold dry weather, low humidity
9
Q
What investigations are required for epistaxis?
A
- FBC - if bleeding has been heavy or recurrent or anaemia is suspected
- Coagulation studies should be requested only if a clotting disorder is suspected or an INR is required
10
Q
How should a person with acute epistaxis be managed?
A
- If the person is assessed to be haemodynamically compromised, arrange transfer to A and E
- Use first aid measures to control the bleeding while awaiting hospital transfer
- Ask the person to:
- Sit with their upper body tilted forward and their mouth open - avoid lying down unless they are feeling faint
- Leaning forward decreases blood flow through the nasopharynx, allows spitting out of blood, and minimises swallowing blood that drains into the pharnyx
- Pinch the cartilaginous (soft) part of the nose firmly and hold it for 10-15 minutes without releasing the pressure, whilst breathing through their mouth
- If the person is assessed to be haemodynamically stable, use first aid measures to control the bleeding
- If bleeding from the posterior area of the nose is suspected (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination, admit the person to hospital
11
Q
If the bleeding from epistaxis stops with first aid measures, how should the patient be managed?
A
- Consider applying a topical antiseptic preparation to reduce crusting and vestibulitis - prescribe Naseptin (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days, if compliance is a problem, advise that it can be used twice daily for up to 2 weeks
- If the person is allergic to neomycin, peanut or soya, do not prescribe Naseptin - consider mupirocin nasal ointment 2-3 times a day for 5-7 days
- Consider whether admission or referral to secondary care is needed e.g. underlying cause in children under 2 years or co-morbid condition such as coronary artery disease or severe hypertension
12
Q
If the bleeding from epistaxis does not stop after 10-15 minutes of nasal pressure and the appropriate expertise and facilities are available in primary, how should the patient be managed?
A
- Nasal cautery - if the bleeding point can be seen and the procedure can be tolerated (for example in adults and older children, but not younger children)
- Nasal packing - if nasal cautery is ineffective or the bleeding point cannot be seen e.g. posterior
- Admit the person to hospital if a nasal pack has been inserted in primary care
- If the bleeding does not stop and the appropriate expertise and facilities for cautery or packing are not available in primary care, transfer the person to A and E immediately
13
Q
If first aid measures or nasal cautery used in primary care has resulted in cessation of bleeding, offer self care advice as follows:
A
- Recommend for 24 hours, where practical, the person should avoid activities which may increase the risk of re-bleeding including:
- Blowing or picking the nose
- Heavy lifting
- Strenuous exercise
- Lying flat
- Drinking alcohol or hot drinks
- Advise the person that if bleeding restarts and does not respond to first aid measures they should seek urgent medical advice
- If there is a history of recurrent epistaxis, consider whether referral is necessary
14
Q
How are patients considered for nasal cautery in primary care?
A
Consider for cautery in primary care if:
- First aid measures have not worked, and
- The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available, and
- It can be tolerated (for example in adults and older children, but not younger children).
15
Q
How should patients be prepared prior to cautery?
A
- Ask the person to blow their nose to clear any clots and allow local anaesthetic to be applied. This may restart the bleeding.
- Use a topical local anaesthetic spray, preferably with a vasoconstrictor (such as lidocaine with phenylephrine [Co-phenylcaine®]), prior to cauterizing the area. Wait 3–4 minutes for the full effect. The vasoconstrictor may stop the bleeding, but once the effects have worn off, the bleeding may start again.
16
Q
How should cautery be performed?
A
- Identify the bleeding point — it will look like a small red dot (less than 1 mm) and may not be actively bleeding.
- Lightly apply the silver nitrate stick to the bleeding point for 3–10 seconds until a grey-white colour develops.
- Only cauterize one side of the septum to avoid nasal septal perforation.
- Avoid touching areas which do not need treatment (for example facial skin).
17
Q
How should patients be managed after cautery?
A
- Dab the cauterized area with a clean cotton bud to remove excess chemical or blood.
- Apply a topical antiseptic preparation to the area:
- Prescribe Naseptin® (chlorhexidine and neomycin) cream first line, to be applied to the nostrils four times daily for 10 days.
- If the person is allergic to neomycin, peanut, or soya, do not prescribe Naseptin®. Consider prescribing mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.
- Do not routinely pack the affected side.
- Advise the person to avoid blowing their nose for a few hours to prevent straining of the nostril.
18
Q
How are patients considered for nasal packing in primary care?
A
Consider nasal packing in primary care if:
- Nasal cautery has been ineffective or the bleeding point cannot be seen, and
- The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available.
19
Q
How should patients be prepared prior to nasal packing?
A
- Anaesthetize the nasal cavity with topical local anaesthetic spray, preferably one with a vasoconstrictor (for example lidocaine with phenylephrine [Co-phenylcaine®]), if this has not already been done.
- Wait 3–4 minutes for the full effect.
20
Q
What are the available products for nasal packing?
A
- Nasal tampons (for example Merocel®) — effective and easy to use.
- Inflatable packs (for example Rapid-Rhino®) — effective and may be easier and more comfortable to insert and remove than nasal tampons.
- Ribbon gauze impregnated with Vaseline® or bismuth-iodoform paraffin paste — packing with ribbon gauze is not recommended in primary care without specific training
21
Q
How should the nasal packing be fitted?
A
- Pack the person’s nostril whilst they are sitting with their head tilted forward. Ensure that the person is holding a receptacle to spit blood out in, and is breathing through the mouth.
- Secure the pack (for example Merocel® packs have a string attached which can be taped to the cheek), and ensure there is no pressure on the cartilage around the nostril as this can cause a cosmetic defect.
- Check the oropharynx for signs of bleeding from the back of the nose. If bleeding is seen, consider packing the other nostril to increase pressure on the bleeding vessel
- Admit the person to hospital for observation, preferably to an ENT department
22
Q
What are the options for the management of acute epistaxis in secondary care?
A
- Resuscitation — this may include transfusion to replace blood volume and provide coagulation factors.
- Formal packing (may be under general anaesthetic).
- Endoscopic assessment and electrocautery.
- Examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment).
- Radiological arterial embolization.
- Intravenous or oral tranexamic acid
23
Q
How should a person with recurrent epistaxis be managed (if they are currently asymptomatic)?
A
- Advise on first aid measures to control bleeding during an acute episode and self care measures to be used afterwards to prevent re-bleeding
- Recommend that during a nose bleed they:
- Sit with their upper body tilted forward and their mouth open
- Avoid lying down unless they feel faint
- Pinch the cartilaginous (soft) part of the nose firmly and hold it for 10-15 minutes without releasing the pressure, whilst breathing through their mouth
- Recommend that for 24 hours after a nosebleed they avoid:
- Blowing or picking the nose.
- Heavy lifting.
- Strenuous exercise.
- Lying flat.
- Drinking alcohol or hot drinks.
- Offer written information on epistaxis (ENT UK)
- Determine if their is an underlying cause for epistaxis
- FBC
- Be aware that an under lying cause is likely in children younger than 2 years of age
- Consider referral to an ENT specialist if the person has recurrent episodes of epistaxis and signs and symptoms suggestive of a serious underlying cause such as:
- Angiofibroma
- Cancer
- Telangiectasia
- Consider referral to a paediatrician for children younger than 2 years of age who present with epistaxis
24
Q
If the person with recurrent epistaxis is not considered to be high risk of having a serious underlying cause, what are their options for treatment?
A
- Topical treatment with an antiseptic preparation to reduce crusting and vestibulitis.
- Prescribe Naseptin® (chlorhexidine and neomycin) cream to be applied to the nostrils four times daily for 10 days. If compliance is a problem, advise that it can be used twice daily for up to 2 weeks.
- If the person is allergic to neomycin, peanut, or soya, do not prescribe Naseptin®. Consider prescribing mupirocin nasal ointment to be applied to the nostrils two to three times a day for 5–7 days.
- Nasal cautery. This is similarly effective to Naseptin® antiseptic cream but may be more uncomfortable. Consider it for use in primary care only if:
- The appropriate expertise and facilities (good lighting, topical anaesthetic spray, and nasal speculum) are available, and
- The bleeding point can be identified, and
- It can be tolerated (for example adults and older children, but not younger children)
25
Q
What is allergic rhinitis?
A
- Inflammatory disorder of the nose where the nose becomes sensitized to allergens such as house dust mites and grass, tree and weed pollens
26
Q
How can rhinitis be classified?
A
- Seasonal - symptoms same time every year, occurs secondary to pollens
- Perennial - symptoms occur throughout the year
- Occupational - symptoms follow exposure to particular allergens within the work place
27
Q
How is allergic rhinitis mediated?
A
- IGE inflammatory disorder of the nose
- Occurs when the nasal mucosa becomes exposed and sensitised to allergens
- Triggers a release of histamine and other inflammatory mediators, which act on cells, nerve endings, and blood vessels to produce typical symptoms of sneezing, nasal itching, discharge (rhinorrhoea) and congestion
