S19C239 - Epistaxis, nasal fractures, rhinosinusitis

Question 1

Causes of epistaxis

Answer 1

• local: trauma, deviated septum, neoplasia, irritants

- systemic: CKD, alcoholism, HTN, vascular malformation, coagulopathy

Question 2

Signs of posterior bleed

Answer 2

• elderly pt
• coagulopathy
• hemorrhage visible in posterior nasopharynx
• blood from b/l nares
• uncontrolled with anterior packing

Question 3

Methods of controlling epistaxis

Answer 3

• blow nose to clear clots
• topical vasocontrictor (phenylephrine, cocaine, txa)
• pressure for 10-15mins x2
• silver nitrate cautery (ensure anesthetized with 4% lido)
• packing

Question 4

Posterior bleed: tx

Answer 4

• rapid rhino with 2 balloons
• 12F to 14F foley catheter with 30cc balloon (20cc anterior and 10cc posterior)
• all posterior packing should be accompanied by an anterior pack

Question 5

Nasal fracture: indications for reduction

Answer 5

• cosmesis
• nasal obstruction
• determined clinically, not from radiographs
• if too swollen at presentation, have pt f/u with ENT 6-10d later (4d if peds)
• use soaked cotton pledgets with lido and infraorbital and supratrochlear blocks to do it

Question 6

Nasal Septal hematoma

Answer 6

• I+D

- complications: necrosis of septum leading to saddle deformity and obstruciton or abscess dvpt

Question 7

Rhinosinusitis: defn of acute/chronic

Answer 7

• rhinitis almost always occurs with sinusitis-

- acute 12w

Question 8

Rhinosinusitis: etiology

Answer 8

• acute: usually viral
• h flu, strep pneum
• chronic: anaerobes, gm-, staph aureus, fungi

Question 9

Rhinosinusitis: Symptoms

Answer 9

• nasal congestion
• facial pain/pressure
• hyposmia
• anterior/posterior d/c
• tooth pain, fever, sinus pressure, tender over sinuses with percussion

Question 10

Rinosinusitis: complications

Answer 10

• meningitis
• cavernous sinus thrombosis
• intracranial abscess
• 75% of orbital cellulitis are related to sinusitis
• osteomyelitis

Question 11

Rhinosinusitis: Dx

Answer 11

• acute: clinical, radiographs not needed
• chronic: CT to check for extension of infxn and for neoplasms

-DDx: migraine, craniofacial neoplasm, FB, dental caries

Question 12

Rhinosinusitis: Tx

Answer 12

• acute: saline irrigation, nasal decongestants x3d, topical corticosteroids, abx if Sx >7d and purulent d/c with severe Sx (amoxicillin)
• pcn allergy: macrolide (erythromycin) or septra
• if abx in past 4-6w: amox clav or fluoroquinolone

-chronic: ENT referral