Nose Flashcards
nasal trauma
peri orbital cellulitis definition
an infection of the periorbital soft tissue characterised by erythema and oedema
peri orbital cellulitis epidemiology
0-15 yrs old
peak <10 yrs
males more common
bi-modal seasonal variation - peak in late winter/early spring
occurs in 35% of children with sinus related infections
types of peri orbital cellulitis
pre septal and post septal, separated by orbital septum
occurs as a result of contigious spread from surrounding periorbital structures such as paranasal sinuses…ethmoidal sinusitis most common cause
why children peri orbital cellulitis
the thinner and dehiscent bone surface of their lamina papyracea and increased diploic venous supply in comparison with adulthood, in addition to relatively incomplete immunologic development in this age group
causes peri orbital cellulitis
sinus infection
dacrocystitis, dental infection, endophthalmitis, trauma, foreign bodies, insect bites, skin infections (impetigo), eyelid lesions (chalazia, hordeola), and iatrogenic causes such as eyelid and oral procedures
organisms peri orbital cellulitis
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, group A streptococcus, and upper respiratory tract anaerobes. Staphylococcus aureus is usually the most common pathogen.
clinical features peri orbital cellulitis
eyelid oedema
erythema of upper eyelid
re-septal cellulitis will present with normal vision, absence of proptosis, and full ocular motility without pain on movement.
worsening oedema
purulent discharge from ipsilateral osteomeatal complex and sphenoethmoidal recess
signs orbital cellulitis
Proptosis
Ophthalmoplegia
Decreased visual acuity
Loss of red colour vision – first sign of optic neuropathy
Chemosis
Painful diplopia
peri orbital cellulitis classification
chandler classification
pre
post
subperiosteal abscess
intra orbital abscess
cavernous sinus thrombosis
examination peri orbital cellulitis
Assessment of routine vital signs
Dentition
Anterior rhinoscopy
Appearance of the nasal mucosa in general and middle meatus area
Discharge should be swabbed and sent for culture
comprehensive opthalmic examination
sepsis screen
CT scan
ddx peri orbital cellulitis
Vesicles of herpes zoster ophthalmicus
Erythematous irritation of contact dermatitis
Raised, dry plaques of atopic dermatitis
tx peri orbital cellulitis
Mild pre-septal cellulitis in adults and children older than 1 year of age, treatment is typically rendered on an outpatient basis with empiric broad spectrum oral antibiotic
IV fluids, analgesia
tx underlying cause - sinusitis
early drainage or orbital abscess
complications periorbital cellulitis
visual related - vision loss, papilloedema, neuritis and atrophy, impaired ocular motility, eyelid inflammation
life threatening - meningitis, encephalomeningitis, cavernous sinus thrombosis, sepsis IC abscess, vomiting, seizures
most common cause of epistaxis in children
nose picking
narrower nasal airways - mor prone to bleeding and inflammation in general
Mucosal irritation – e.g. dry air, URTIs, steroid use
Clotting abnormalities – either hereditary or acquired. Epistaxis is usually the major presenting feature of common clotting abnormalities such as Von-Willebrand’s disease or genetic conditions such as hereditary haemorrhagic telangiectasia (HHT)
<2 children epistaxis
rare
referred to ENT for investigation
pathophysiology epistaxis
most comes from little’s area - confluence of vessels originating from ICA and external carotid arteries
recurrent epistaxis
underlying coagulopathy and a full clinical and family history should be explored. Recurrent epistaxis can rarely be caused by an underlying JNA (juvenile nasal angiofibroma) which are most common in males aged 12-20
risk factors epistaxis
Activities involving altitude e.g. skiing
Strenuous physical activities with risk of nasal trauma or straining/raising ICP e.g. rugby, gymnastics
Coagulopathies
Hayfever or regular URTIs
Medication use (rare)
examination epistaxis
see source on anterior septum of affected side
see evidence of septal haematoma
septal haematoma tx
urgent review by ENT and drainage to avoid permanent disfigurement
ddx epistaxis
foreign body - ruled out in unilateral offensive nasal discharge
investigations epistaxis
rarely needs investigating
if large vols - blood tests - underlying coagulopathy
recurrent epistaxis - me nostril or in males aged 12-20 should be referred to ENT for flexible nasal endoscopy (FNE) to exclude a JNA or other unilateral pathology e.g. polyp
initial management epistaxis
lean child first
spit blood out
pinch the soft part of nose and hold for 15 mins at least
check for cessation of bleeding
apply ice pack
primary acre/A and E management epistaxis
look for bleeding points inside nose using bright light
local anaesthetic/decongestant spray - co-phenylcaine
nasal cautery with silver nitrate - can stain skin
circular motion with silver nitrate sitkc from outside to centre of bleeding point
if continues - anterior or posterior nasal packing
reduction of any nasal fractures
FBC, clotting profile
definitive management epistaxis
pts should be discharged with naseptin ointment BD for 2 weeks
- must check for peanut allergy so must be checked
reoccurrence risks
-Strenuous physical activity
-Bending forwards e.g. to tie shoelaces
-Hot drinks/food/showers (steam can irritate the inside of the nose)
-Blowing their nose
-Picking their nose
-Spicy food
red flags epistaxis
-Persistent unilateral bleeding
-Weight loss
-Visual disturbance
-Facial pain
