Nasal Trauma/Emergencies Flashcards
What is a septal haematoma?
boggy swelling of the septum beneath the perichondrium causing near total nasal obstruction
usually bilateral
may be preceded by relatively minor trauma
What is the management of a septal haematoma?
urgent incision and drainage
IV antibiotics
Describe the vasculature in the nose
runs just under mucosa
arterial to venous anastomoses
internal and external carotid artery flow
What is an epistaxis?
nose bleed
What is the first aid for an epistaxis?
external pressure to nose
ice
cautery
nasal packing
What is the initial management for an epistaxis?
resuscitate on arrival if necessary
arrest/slow flow - ice, topical vasoconstrictor (lidocaine, adrenaline, co-phenylcaine)
remove clot - suction, nose blowing
anterior rhinoscopy
cautery/pack
30 degree rigid nasendoscopy
cauterise vessel (Silver nitrate/diathermy)
What is the next step if initial management has controlled the bleeding in epistaxis?
arrange admission if packed or poor social circumstances
FBC
group and screen blood test
What is the next step if initial management hasn’t controlled the bleeding in epistaxis?
consider arterial ligation
What is the systemic treatment for epistaxis?
reversal of effect of anticoagulants
correction of clotting abnormalities
platelet transfusion
treatment of hypertension
What is important to exclude in a nasal fracture?
significant head trauma or C spine injury
What is the main cause of a nasal fracture?
direct trauma - e.g. punch, clash of heads, fall
What are the clinical features of a nasal fracture?
new nasal deformity \+/- facial swelling black eyes short epistaxis
Are XRs required in nasal fractures?
no but may help exclude other facial fracture
What is the management of a nasal fracture?
treat epistaxis and septal haematoma if present
advise analgesia and ice
close any skin injury
review in ENT clinic in 5-7 days - once swelling has resolved
if manipulation under anaesthesia is required it can be performed in 10-21 days after injury - before nasal bones set
What are the possible complications of a nasal fracture?
epistaxis - particularly at ethmoid artery
CSF rhinorrhoea
anosmia
How can a nasal fracture cause anosmia?
cribriform plate fracture
How can a nasal fracture cause CSF rhinorrhoea?
ethmoid fracture disrupting dura and arachnoid
What does CSF rhinorrhoea look like?
very watery runny nose
How is CSF rhinorrhoea diagnosed?
nasal CSF discharge +ve glucose (blood test) and β2 (tau) transferrin >0.5mL
What is the management of CSF rhinorrhoea?
7-10 days bedrest with head elevated at 15-30degrees +/- lumbar drain
avoid coughing, sneezing and blowing nose
cover with antibiotics and pneumococcal vaccine - risk of meningitis
surgery if doesn’t settle in 10 days
What should be considered if there is CSF rhinorrhoea without trauma?
tumour
What is important to ask in a history for nasal trauma?
mechanism of injury when loss of consciousness epistaxis breathing
What is important to include in examination of nose trauma?
bruising swelling tenderness deviation epistaxis infraorbital sensation cranial nerves
Where does epistaxis caused by trauma most commonly originate from?
anterior nasal septum - contains little’s area - site of Kiesselbach’s plexus - supplied by 4 arteries
What are the symptoms of nasal septal haematoma?
sensation of nasal obstruction
+/-
pain
rhinorrhoea
What can cause an epistaxis from the sphenopalatine artery?
Underlying pathology e.g. hypertension, old age
What are the complications of an untreated septal haematoma?
septal necrosis within 3-4 days - due to pressure related ischaemia of the cartilage - saddle nose deformity
What is a common trigger to restart a nosebleed?
coughing
How long can nosebleeds commonly last?
up to 10 minutes
What is the most suitable management for epistaxis where the bleed site is difficult to locate?
anterior pack insertion
