Nasal Trauma/Emergencies

Question 1

What is a septal haematoma?

Answer 1

boggy swelling of the septum beneath the perichondrium causing near total nasal obstruction
usually bilateral
may be preceded by relatively minor trauma

Question 2

What is the management of a septal haematoma?

Answer 2

urgent incision and drainage

IV antibiotics

Question 3

Describe the vasculature in the nose

Answer 3

runs just under mucosa
arterial to venous anastomoses
internal and external carotid artery flow

Question 4

What is an epistaxis?

Answer 4

nose bleed

Question 5

What is the first aid for an epistaxis?

Answer 5

external pressure to nose
ice
cautery
nasal packing

Question 6

What is the initial management for an epistaxis?

Answer 6

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)

Question 7

What is the next step if initial management has controlled the bleeding in epistaxis?

Answer 7

arrange admission if packed or poor social circumstances
FBC
group and screen blood test

Question 8

What is the next step if initial management hasn’t controlled the bleeding in epistaxis?

Answer 8

consider arterial ligation

Question 9

What is the systemic treatment for epistaxis?

Answer 9

reversal of effect of anticoagulants
correction of clotting abnormalities
platelet transfusion
treatment of hypertension

Question 10

What is important to exclude in a nasal fracture?

Answer 10

significant head trauma or C spine injury

Question 11

What is the main cause of a nasal fracture?

Answer 11

direct trauma - e.g. punch, clash of heads, fall

Question 12

What are the clinical features of a nasal fracture?

Answer 12

new nasal deformity 
\+/- 
facial swelling 
black eyes 
short epistaxis

Question 13

Are XRs required in nasal fractures?

Answer 13

no but may help exclude other facial fracture

Question 14

What is the management of a nasal fracture?

Answer 14

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

Question 15

What are the possible complications of a nasal fracture?

Answer 15

epistaxis - particularly at ethmoid artery
CSF rhinorrhoea
anosmia

Question 16

How can a nasal fracture cause anosmia?

Answer 16

cribriform plate fracture

Question 17

How can a nasal fracture cause CSF rhinorrhoea?

Answer 17

ethmoid fracture disrupting dura and arachnoid

Question 18

What does CSF rhinorrhoea look like?

Answer 18

very watery runny nose

Question 19

How is CSF rhinorrhoea diagnosed?

Answer 19

nasal CSF discharge +ve glucose (blood test) and β2 (tau) transferrin >0.5mL

Question 20

What is the management of CSF rhinorrhoea?

Answer 20

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

Question 21

What should be considered if there is CSF rhinorrhoea without trauma?

Answer 21

tumour

Question 22

What is important to ask in a history for nasal trauma?

Answer 22

mechanism of injury 
when 
loss of consciousness 
epistaxis 
breathing

Question 23

What is important to include in examination of nose trauma?

Answer 23

bruising 
swelling 
tenderness 
deviation 
epistaxis 
infraorbital 
sensation
cranial nerves

Question 24

Where does epistaxis caused by trauma most commonly originate from?

Answer 24

anterior nasal septum - contains little’s area - site of Kiesselbach’s plexus - supplied by 4 arteries

Question 25

What are the symptoms of nasal septal haematoma?

Answer 25

sensation of nasal obstruction
+/-
pain
rhinorrhoea

Question 26

What can cause an epistaxis from the sphenopalatine artery?

Answer 26

Underlying pathology e.g. hypertension, old age

Question 27

What are the complications of an untreated septal haematoma?

Answer 27

septal necrosis within 3-4 days - due to pressure related ischaemia of the cartilage - saddle nose deformity

Question 28

What is a common trigger to restart a nosebleed?

Answer 28

coughing

Question 29

How long can nosebleeds commonly last?

Answer 29

up to 10 minutes

Question 30

What is the most suitable management for epistaxis where the bleed site is difficult to locate?

Answer 30

anterior pack insertion