The Nose

Question 1

Epistaxis

Answer 1

epidemiology:

• 60% of general population
• most cases before age 10 or b/n 45-65

etiology:

• mostly arises from ant portion of nasal septum
• often due to dryness, vigorous nose rubbing, nose blowing, or nose picking, rhinitis, FB, facial trauma, intranasal steroids
• if pt has been using nasal corticosteroid spray, check technique to make sure not directing spray toward septum; if proper technique doesnt reduce nosebleeds, spray should be discontinued
• less common causes but serious: bleeding disorders, anticoagulation/ASA therapy, Osler-Weber-Rendu disease, aneurysm of the carotid artery (posterior bleed), nasal neoplasm, HTN (controversial)
• in <5% of cases, it is caused by bleeding disorder ie von Willebrand disease
• high blood pressure may rarely predispose to prolonged nosebleeds in kids
• nasopharyngeal angiofibroma may manifest as recurrent epistaxis
  
  • adolescent boys affected most exclusively
• herbs associated with bleeding = garlic, ginseng, ginger, ginkgo, turmeric, feverfew, chamomile, mother wort, dong quay

S:

• get a good medical history (personal and family)
• onset/duration
• attempts at control
• prior episodes
• sx/trauma
• meds/herbals
• bleeding or bruising problems

O/PE findings/characteristics:

• exam of ant septum usually reveals red, raw surface w/ fresh clots or old crusts
• presence of telangiectasias, hemangiomas, or varicosities should also be noted

Plan:

• hematologic workup is warranted if any of the following is present:
  
  • family h/o bleeding disorder
  • medical h/o easy bleeding, particularly w/circumcision or dental extraction
  • spontaneous bleeding at any site
  • bleeding that lasts for >30 mins or blood that will not clot w/direct pressure by clinician
  • onset before age 2 years
  • drop in Hct due to epistaxis
• if considering nasopharyngeal angiofibroma, CT scan w/contrast of the nasal cavity and nasopharynx is diagnostic
• diagnostic testing (reserve lab tests and bloodworm for prolonged, very heavy, significant or recurrent nosebleeds)
• Prothrombin time (PT) and international normalized ratio (INR) is NOT indicated as routine test but should be ordered for anti-coagulated pts
• +/- CBC if uncertain about the etiology of the nosebleed or if the bleed is massive/prolonged
• type and crossmatch for massive or prolonged hemorrhage

​TX:

• exam and initial tx:

be prepared!

gown and mask, suction, instruments, head lamp, meds, calm the pt and explain what you are doing

• Initial Tamponade
  1. ​pt should sit up and lean forward as to not swallow the blood (sit to decrease venous flow and lean forward to not swallow the blood as swallowed blood may cause N and hematemesis)
  2. nasal cavity cleared of clots by gentle blowing
  3. soft part of nose below nasal bones is pinched and held firmly enough to prevent arterial blood flow, w/ pressure over the bleeding site (ant septum)being maintained for 5-10 mins by clock
  4. one-time application of oxymetazoline into nasal cavity may help (nasal decongestant spray; shrinks edema and is vasoconstrictor) (often do this before 3 unless pt is less than 6 yo)
• ​Persistent Bleeds -
  
  • need to visualize bleeding site if bleeding continues
  • small piece of gelatin sponge (Gelfoam) or collagen sponge (Surgicel) or matrix sealant can be inserted over bleeding site and held in place
  • Friability (ability of a solid substance to be reduced to smaller pieces with little effort) of nasal vessels is often due to dryness and can be decreased by increasing nasal moisture
    
    • by daily application of water-based ointment to nose (pea-sized amt of ointment placed just inside nose and spread by gently squeezing nostrils)
    • BID nasal saline irrigation and humidifier use
  • ASA and ibuprofen should be avoided as well as nose picking and vigorous nose blowing
  • otolaryngology referral is indicated for refractory cases
  • cautery - electrical or chemical (silver nitrate stick); reserved for tx failures
  • fibrin glue (Dermabond, works on active bleeding)
  • nasal packing (nasal gauze, tampons, balloon catheters)
    
    • ​leave in for 24-48 hrs (usually 48)
    • need to put pt on oral abx when leave because can develop TSS
    • cannot use on ppl with nasal trauma
    • anterior packing (permeated with petroleum, pack posteriorly and laterally)
    • posterior packing is through mouth and pt has to be admimtted because airway is obstructed
  • nasal tampon (fill with water through tube to inflate/keep pressure while in nose)

Question 2

Nasal Trauma

Answer 2

etiology:

• subluxation of quadrangular cartilage of the septum
  
  • top of the nose deviates to one side, inferior septal border deviates to other side, columella leans, and nasal tip is unstable (rare in newborns)
  • must be distinguished from congenital more common transient flattening of nose caused by birth process (reductions performed most likely by otolaryngologists under anesthesia or in nursery)
• most blows to nose result in epistaxis w/o fracture

PE findings/characteristics (O):

• after nasal trauma, essential to examine inside of nose with nasal speculum even if no active bleeding
• hematoma of nasal septum dx confirmed by abrupt onset of nasal obstruction following trauma and presence of boggy, widened nasal septum (NL septum is only 2-4 mm thick)
• cotton swab can be used to palpate septum
• persistent nosebleed s/p trauma, crepitus, instability of nasal bones, and external deformity of nose = fracture (refer to ENT for f/u 48-72 hrs)

Assessment/Plan (A):

• hematoma of nasal septum must be r/o as it poses considerable risk of septal necrosis, leading to permanent deformity
• hematoma = immediate referral to otolaryngologist for evacuation of hematoma and packing of nose
• septal injury cannot be r/o by radiography and can only be r/o by careful intranasal examination
• pt w/ suspected nasal fx should be referred to otolaryngologist for definitive therapy
• since nasal bones begin healing w/n 7 days, child must ideally be seen by otolaryngologist w/n 48-72 hrs of injury to allow time for fx reduction b4 bones become immobile

Question 3

Foreign Bodies in the Nose

Answer 3

epidemiology:

• children ages 2-4 yo
• notived by caregiver/parent

S:

• most are asx
• nasal d/c, usually unilateral, halitosis, epistaxis, septal perforation, ingestion/aspiration of FB
• types of FB: food, toys, beads, rock, paper, disk-type batteries, paired disk magnets

PE findings/charactersitics (O):

• if dx is delayed, unilateral foul-smelling rhinorrhea, halitosis (bad breath), bleeding, or nasal obstruction often result

Plan/TX (P):

• workup
  
  • direct visualization
  • fiber optic examination (rare)
  • sinus x-rays )rare)
  • rarely is a CT required
• removal of foreign body
  
  • vigorous nose blowing if child is old enough
  • next step = nasal decongestion, good lighting, correct instrumentation, physical restraint
  • topical tetracaine or lidocaine can be used for anesthesia/vasocontrictor (reduces swelling) in young kids 5 mins before removal
  • nasal decongestion by topical phenylephrine or oxymetazoline (nasal spray ie Afrin)
  • when child properly restrained, most nasal foreign bodies can be removed using pair of alligator forceps or R-angle instrument through an operating head otoscope
  • Parental “Big Kiss” method for kids = positive pressure; blow into mouth of child with contralateral nostril occluded
    
    • can also use oxygen mask in opposite nostril
  • balloon catheter (pass, inflate, withdraw)
  • suction catheter
  • dermabond on cotton applicator
  • magnet?
  • if object seems unlikely to be removed on 1st attempt, is wedged in, or is quite large, pt should be referred to otolaryngologist rather than worsening through attempts at removal
  • electrical current generated by disk type batteries can cause necrosis of mucosa and cartilage destruction in <4 hrs(because nose is moist cavity) = foreign body emergency
    
    • dont use vasoconstrictor or liquids at all in nose if disk battery is FB

Question 4

Acute Rhinosinusitis

Answer 4

etiology:

• allergens and environmental irritants
• bacteria
• fungi
• viral infection
• = inflammation of lining of nasal mucosa and paranasal sinuses

S:

• viral infection =
  
  • nasal d/c = clear at first then becomes thicker and purulent after a few days
    
    • return to clear and watery w/o abx
  • congestion
  • cough
  • sore throat
  • addnl sxs: HA, myalgias
  • fever early in illness
  • sxs lasting 5-7 days
• bacterial infection =
  
  • triad of sxs = HA, facial pain, fever
  • common sxs: nasal congestion, purulent rhinorrhea, facial pain or pressure
  • persistent sxs lasting more than 10 days w/ no improvement
  • onset w/ severe sxs including fever of T=102 F or higher
  • purulent nasal d/c at onset
  • “double sickening” pattern = new onset fever, HA, or increase in rhinorrhea that worsen or return after 5-6 day viral presentation that was initially improving

P:

• primarily look to relieve sxs of nasal obstruction and rhinorrhea
• bacterial = abx
  
  • first line =
• both = increase fluids, rest, good hygeine
• saline spray to soften secretions and improve mucociliary clearance
• mucolytic agents, decongestants, and antihistamines not recommended
• Acetaminophen or NSAID may be used for pain