NOSE BLEEDS Flashcards
Whats the function of the nose?
Filtration via hairs, mucus, cilia
Warming
Humidifcation
Olfaction
Vocal resonance via sinuses
What is the internal anatomy of the nose lined with?
Ciliated epithelium
Where’s the final common pathway for sinus draining in the nose?
Around the middle turbinate
Whats the function of the turbinates?
They promote laminar flow of air from the nose to the lungs - this is more organised and efficient than turbulent flow
Blood supply to the nose
Posterior ethmoidal artery
Branch of the anterior eithmoidal artery
Very extensive anastamoses!
What is Little’s area?
Aka kiesselbach’s plexus
an anastomosis of 5 arteries: anterior ethmoidal artery, posterior ethmoidal artery, sphenopalatine artery, greater palatine artery, and the septal branch of the superior labial artery
What are the sinuses?
Anterior - Frontal, maxillary and anterior ethmoid
Posterior - Posterior ethmoids and sphenoidal sinuse
Where do thr anterior sinuses drain?
To the middle meatus
Where do the posterior sinuses drain to?
Superior meatus/ sphenoethmoidal recess
Which sinuses are not present in children and when do they develop?
Frontal sinus - Around the age of 7
Sphenoid sinus - fully developed by adolescent
Functions of the sinuses?
Decreases relative weight of front of skull
Increases resonance of voice
Provides a buffer against blows to face - crumple zone
Insulates sensitive structures like dental roots and eyes from rapid temperature fluctuations in the nasal cavity
Humidifying and heating of inhaled air because of slow air turnover in this region
Regulation of intranasal and serum gas pressures
Immunological defence
What can cause a nasal obstruction?
Congenital/acquired
Deviated septum
Rhinitis
Rhinosinusitis
Polyps
FB
Neoplasm
Red flag symptoms for nasal neoplasia?
Unilateral nasal obstruction
Unilateral constant nasal bleeding
How can you examine the obstructed nose?
The ability to mist a speculum in front of nose to test patency of nostrils
Anterior rhinoscopy
Flexi/regid scope +/- anaesthetics
Check oropharynx and larynx
Check CN too
Pathophysiology of acute sinusitis?
Inflammation of the mucous membranes of the paranasal sinuses which can lead to blockag
Treatment of acute sinusitis?
Analgesia
Intranasal decongestants or nasal saline - evidence is limited
Intranasal corticosteroids if symptoms present for >10 days
Antibiotics only if systemically unwell and high risk of complications!!
Sometimes surgery for sinus washout is required but this is rare
What is the diagnoses:
Newborn baby has difficulty breathing from birth and having intermittent central cyanosis. An NG tube cannot be passed.
B/L choanal atresia
What is the choanae?
the posterior nasal aperture, separated by the vomer.
It is the opening between the nasal cavity and the nasopharynx.
How does U/L choanal atresia present?
Usually missed in childhood
Picked up in late teeens/early adulthood when pt cannot breathe through 1 nostril
there’s often unilateral discharge
What is CHARGE syndrome?
Coloboma
Heart defects
Choanal atresia
Retardede growth
Genital defects
Ear defects
What are the 3 types of allergic rhinitis?
seasonal: symptoms occur around the same time every year e.g. hay fever
perennial: symptoms occur throughout the year
occupational: symptoms follow exposure to particular allergens within the work place
Treatment of allergic rhinitis?
Avoidance of triggers
Intranasal steroids and antihistamines
Sodium cromoglycate
Desensitisation
How common is chronic rhinosinusitis?
1 in 10 people
Symptoms of chronic rhinosinusitis?
Facial pain - usually frontal pressure worse on bending forward
Nasal obstruction/moutn breathing
Nasal discharge - usually clear (if thick then suggests secondary infection)
Post nasal drip which may produce a chronic cough
What is chronic rhinosinusitis?
And inflammatory disorder of the paranasal sinuses lasting >12 weeks
How do you manage chronic rhinosinusitis?
Avoid allergen
Intranasal corticosteroids
Nasal irrigation with saline solution
Types of nasal polyps?
Bilateral - more common
Unilateral - may suggest something sinister
How are nasal polyps treated?
All should be referred to ENT for a full examination!
Medical - topical steroids shrink polyp size in around 80% of pts
Surgery if medical fails but warn pt they do come back
Do normal polyps float or sink when the scrub nurse checks after they have been removed?
They should sink!
Pathophysilogy of nasal polyps?
Outpouching of nose usually from chronic inflammation
More rarely they can be caused by neoplasms, CF or idiopathic
What is SAMTERS triad?
Aspirin sensitivity
Asthma
Nasal polyposis
Nasal trauma complications/
Nasal skin lacerations
Nasal fracture
Other facial fractures
Septal haematoma
Traumatic epistaxis
CSF leak
Anosmia
Treatment for epistaxis?
Cauterise local bleeding spots
If that doesn’t work then a tamponade can be inserted
Posterior packing
SPA , anterior ethmodal artery ligation
Ver rarely external carotid artery ligation may be done
What usually causes periorbital cellulitis?
Infection from nearby sites e.g. skin infections, sinusitis or RTI
Usually staph aureus, staph epidermidis, streptococci or anaerobic bacteria
Symptoms of periorbital cellulitis?
Red, swollen painful eye of acute onset
Fever
Partial or complete ptosis of eye due to swelling
(Importantly no orbital signs!! As this indicates orbital cellulitis)
Symptoms of nasopharyngeal carcinoma?
Nasal obstruction, discharge or epistaxis
Cervical lymphadenopathy
Unilateral serous otitis media
Otalgia
Cranial nerve palsies
Risk factors for nasopharyngeal carcinoma?
Southern china - partly genetic and also to do with their diet of dried, salted, smoked fish
EBV
Treatment of nasopharyngeal carcinoma?
Radiotherapy
(Little place for surgery!)
What type of cell is afefcted in nasopharyngeal carcinoma?
SCC
How is nasopharyngeal carcinoma diagnosed?
CT and MRI
History taking from acute epistaxis?
When it started
Which nostril
How much blood is lost
Whether any temporary pack has been used
Previous episodes of epistaxis and how they were treated
History of surgery or recent trauma
Symptoms of tumour - nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy or cranial neuropathy
Foreign body insertion
Symptoms of sinusitis, rhinitis or nasal polyps
Current meds - anticoagulants
Conditions predisposing to bleeding - personal or family
When should you suspect a posterior bleed?
If bleeding is profuse from both nostrils, bleeding site cannot be identified on speculum examination or if bleeding first started down the throat
First aid management of acute epistaxis?
upper body tilted forward, mouth open, pinch cartilaginous part of nose firmly and hold for 10-15 minutes without releasing
If bleeding from posterior nose is suspected or pt is not stable admit to A&E
How should you manage acute epistaxis if bleeding stops with first aid measures?
Consider applying a topical antiseptic to nostrils to reduce crusting and vestibulitis e.g. a septic
How should you manage acute epistaxis if bleeding does not stop with first aid measures after 10-15 minutes?
Nasal cautery if bleeding point can be seen
Nasal packing and admit to hospital
If these dont work admit to A&E
What treatments can secondary care do for acute epistaxis?
Resuscitation
Formal packing which may be under GA
Endoscopic assessment and electrocautery
Examination under anaesthesia, and surgical intervention (such as diathermy, septal surgery, arterial ligation, and laser treatment).
Radiological arterial embolization.
tranexamic acid
What advice should be given to a pt with recurrent nosebleeds?
Recommend that during a nosebleed they:
Sit with their upper body tilted forward and their mouth open.
Avoid lying down, unless they are feeling 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.
What is an angiofibroma?
A rare, benign nasal tumour in males aged 12-21 that causes nasal obstruction and severe epistaxis
What can cause nosebleeds?
Trauma e.g. nose bleeds, nasal fractures, trauma, vigorous nose blowing
Inflammation e.g. infection, rhinosinusitis or nasal polyps
Topical drugs e.g. cocaine or decongestants
Vascular e.g. hereditary telangiectasia or GPA
Post-op
Coag disorders or anticoagulants
Tumours e.g. angiofibroma or SCC
Nasal oxygen therapy
When a pt present with haematemesis?
If they swallow blood during acute epistaxis e.g. posterior nose bleed
What does bleeding from both nostrils indicate?
Bleeding posteriorly
When is naseptin nasal cream contraindicated?
In peanut or soya allergy
What are the most common infectious agents seen in acute sinusitis?
Streptococcus pneumoniae, Haemophilus influenzae and rhinoviruses.
What are predisposing factors for sinusitis?
nasal obstruction e.g. septal deviation or nasal polyps
recent local infection e.g. rhinitis or dental extraction
swimming/diving
smoking
Symptoms of sinusitis?
Facial pain - typically frontal pressure pain which is worse on bending forward
Nasal discharge thick and purple not
Nasal obstruction
Predisposing factors for chronic rhinosinusitis?
atopy: hay fever, asthma
nasal obstruction e.g. Septal deviation or nasal polyps
recent local infection e.g. Rhinitis or dental extraction
swimming/diving
smoking
What is allergic rhinitis?
An IgE-mediated inflammatory disorder of the nose that occurs when the nasal mucosa becomes exposed to and sensitised to allergens
Features of allergic rhinitis?
sneezing
bilateral nasal obstruction
clear nasal discharge
post-nasal drip
nasal pruritus
How common are nasal polyps? who usually gets them?
1% of adults in the UK
2-4x more common in men and are not commonly seen in children or elderly
What are nasal polyps associated with?
asthma (particularly late-onset asthma)
aspirin sensitivity
infective sinusitis
cystic fibrosis
Kartagener’s syndrome
Churg-Strauss syndrome
Possible clinical features of nasal polyps?
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
What is a nasal septal haematoma?
The development of a haematoma between the septal cartilage and the overlying perichondrium.
Features of a nasal septal haematoma?
may be precipitated by relatively minor trauma
the sensation of nasal obstruction is the most common symptom
pain and rhinorrhoea are seen
on examination, classically a bilateral, red swelling arising from the nasal septum
this may be differentiated from a deviated septum by gently probing the swelling. Nasal septal haematomas are typically boggy whereas septums will be firm
Management of a nasal septal haematoma?
Surgical drainage
IV antibiotics
Why is it vital to recognise and treat a nasal septal haematoma?
If untreated irreversible septal necrosis may develop within 3-4 days. This is thought to be due to pressure-related ischaemia of the cartilage resulting in avascular necrosis. This may result in a ‘saddle-nose’ deformity
How are nasal fractures managed?
Manipulation under anaesthesia with LA or GA can happen 14-21 days of injury
If aesthetic result is unsatisfactory then further definitive surgery can be performed e.g. rhinoplasty or septoplasty
How can nasal trauma lead to CSF leak?
A fracture of the cribiform plate can result in leakage of CSF out the nose
How can nasal trauma cause anosmia?
in the acute setting, this is typically due to the nasal passages being blocked with blood, however if post-traumatic anosmia persists, it is likely a result of damage to olfactory structures and unfortunately is unlikely to resolve.
