10.22
Nasal Disease
Assess epistaxis and pack the nose
Epistaxis
Common and may be life-threatening
Usually arises from the nasal septum
Septal blood supply:
 Internal carotid (anterior and posterior ethmoid arteries)
 External carotid (greater palatine, sphenopalatine and superior labial arteries)
Anastomose to form Kiesselbach’s plexus in the anterior septum (Little’s area)
This is the most common source of anterior bleeds (through the nostrils)
Posterior turbinate is the most common source of posterior bleeds (down the throat)
Treatment
Messy! Cover your clothes first and wear gloves
ABC
Consider IV fluids if severe/prolonged
Bleeding from Little’s area
Direct pressure on the lower nose to compress the
vessel on the septum
Cotton wool plug soaked in lidocaine &
phenylephedrine
Cauterize bleeding point with silver nitrate
Electric cautery or diathermy under local/GA.
(more effective in active bleeding).
Bleeding from an unidentified site
Direct digital pressure to nose for 10 mins.
Lean forwards to allow blood to trickle out of nose
Tell patient not to swallow or this will dislodge the
clot
Examine nose (spray with lidocaine and
phenylephrine)
Cauterize any visible bleeding sites
Nasal packing with nasal tampons or 1 inch
ribbon gauze. Introduce packing along floor of
nose. If ribbon gauze, build up in loops towards
the roof
Packing of the anterior nasal cavity using gauze strip impregnated with petroleum jelly. A. Gauze
is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal
speculum (not shown) used for exposure, the first packing layer is inserted along the floor of the
anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing
are added in an accordion-fold fashion, with the nasal speculum used to hold the positioned
layers down while a new layer is inserted. Packing is continued until the anterior nasal cavity is
filled. http://www.aafp.org/afp/20050115/305.html
Alternatively, a preformed nasal tampon (Merocel or Doyle sponge) may be used.12 The tampon
is inserted carefully along the floor of the nasal cavity, where it expands on contact with blood or
other liquid. Application of lubricant jelly to the tip of the tampon facilitates placement. After the
nasal tampon has been inserted, wetting it with a small amount of topical vasoconstrictor may
hasten effectiveness. It may be necessary to drip saline into the nostril to achieve full expansion
of the tampon if the bleeding has decreased at the time of insertion. Although one study15 found
no significant difference in patient comfort or efficacy with nasal tampons or ribbon gauze
packing, simplicity of placement makes the tampons highly useful in primary care settings. When
applied in the outpatient setting, nasal packing may be left in place for three to five days to ensure
formation of an adequate clot.
The treatment of severe nasal bleeding in the adult can be very difficult. Repeated nasal packing
is sometimes required. Nasal cautery can control the bleeding but only if the bleeding point can
be seen either directly or with a fiberoptic endoscope. Often the bleeding site is in the back of the
nose, hidden within the many sinus passageways. In this case, only nasal packing or ligation
(tying off one of the nasal arteries) can be used to stop the bleeding. Nasal packs are usually left
in the nose for a minimum of three days. Antibiotics should always be given to prevent toxicshock syndrome.
There are two types of nasal packs: 1) An anterior pack which is placed in the nasal cavity. An
anterior pack may be made of cloth or a nasal tampon. If the bleeding is severe a nasal balloon
can also be inserted. However, nasal balloons can exert a significant amount of pressure and
damage to the inside of the nose from pressure necrosis may take place. The pictures on the
right shows a tampon pack and 1/2" gauze which can be used as an anterior pack.
Various balloon systems are effective for managing posterior bleeding and are less complicated
than the packing procedure. The double-balloon device (Figure 2) is passed into the affected
nostril under topical anesthesia until it reaches the nasopharynx. The posterior balloon then is
inflated with 7 to 10 mL of saline, and the catheter extending out of the nostril is withdrawn
carefully so that the balloon seats in the posterior nasal cavity to tamponade the bleeding source.
Next, the anterior balloon is inflated with roughly 15 to 30 mL of saline in the anterior nasal cavity
to prevent retrograde travel of the posterior balloon and subsequent airway obstruction. An
umbilical clamp or other device can be placed across the stalk of the balloon adjacent to the
nostril to further prevent dislodgement; the clamp should be padded to prevent pressure necrosis
of the nasal skin. Balloon packs generally are left in place for two to five days. As with anterior
packing, tissue necrosis can occur if a posterior pack is inserted improperly or balloons are
overinflated.
If a specialized balloon device is not available, a Foley catheter (10 to 14 French) with a 30-mL
balloon may be used. The catheter is inserted through the bleeding nostril and visualized in the
oropharynx before inflation of the balloon.18 The balloon then is inflated with approximately 10 mL
of saline, and the catheter is withdrawn gently through the nostril, pulling the balloon up and
forward. The balloon should seat in the posterior nasal cavity and tamponade a posterior bleed.
With traction maintained on the catheter, the anterior nasal cavity then is packed as previously
described. Traction is maintained by placing an umbilical clamp on the catheter beyond the
nostrils, which should be padded to prevent soft tissue damage. As with anterior epistaxis, topical
antistaphylococcal antibiotic ointment may be used to prevent toxic shock syndrome. However,
use of oral or intravenous antibiotics for posterior nasal packing most likely is unnecessary.
Nasal balloon
Submucosal resection if bleeding site obscured by deviated septum/polyp
Ligation of ethmoid/sphenopalatine/external carotid arteries if persisten
Angiography and vessel embolisation rarely needed
Monitor Hb, BP, ? crossmatch
Control HTN
Causes
Local
Spontaneous
Trauma
Tumours
Hereditary telangiectasia
HTN
Hemophilia
Leukaemia
Anticoagulant therapy
Thrombocytopenia
Recognise and manage rhinosinusitis.
Rhinitis
Inflammation of the nasal cavity mucosa occurs readily due to high vascularity and abundant
mucus glands.
Sx:
Rhinorrhoea – infective; non-infective; allergic…
Nasal obstruction
Sneezing
Itching
Infective rhinitis/rhinosinusitis Green mucus = neutrophilic
Organisms: Viral: Adeno/rhino
S. aureus
S. pneumoniae ) Capsulated. If occurring together ? IgG2 deficiency
H. influenzae )
M. Catarrhalis
Fungal (immunocompromised)
May spread to paranasal sinuses, middle ear, anterior cranial fossa (through cribriform plate),
lacrimal ducts & conjunctiva.
Take nasal swab for MC&S. Important, as different Rx for several common causes.
Rx.
If >7 days. (Most resolve spontaneously)
Systemic ABx. Oral amoxicillin/augmentin/cefuroxime
S. aureus: Topical ABx – Naseptin (chlorhexidine + neomycin); Bactroban (mupirocin)
TDS for 5 days, then re-swab to confirm eradication.
Rx. Failure suggests rhinosinusitis (pus in the sinuses)
Allergic rhinitis (with ↑ IgE)
Seasonal
-Pollens/fungi
Steroid spray/
Cromoglycate
Antihistamine
Perennial
-House dustmites
-Animal fur
-Feathers…
Steroid spray/
Cromoglycate
Antihistamine
? Avoidance
Steroid sprays do not act immediately. Use prophylactically.
For seasonal rhinitis, start 1 month before pollen season (~May – August)
Don’t exceed 800mg total steroid/day. More than this saturates hepatic 1st pass metabolism
enzymes and may lead to Cushing’s syndrome. (Nb. Must also take account for inhaled steroids
used for asthma…)
RAST (radioallergosorbant test) Tests blood for specific IgE to common allergens. Useful in
determining which allergens to avoid. Eg. Get rid of the cat or keep cat and change bedding!
Pathology
Occurs frequently as part of atopy: Hereditary ↑ IgE = asthma, eczema & allergic rhinitis
Type 1 hypersensitivity reaction – biphasic response (like asthma)
Primary response mediators
Mast cell degranulation products
Rx. Antihistamine
Secondary response mediators
Eosinophils
Neutrophils, basophils, monocytes…
Rx. Steroids
Non-allergic rhinitis
Eosinophil +ive
Eosinophil -ive
Associated with
intrinsic (nonallergic) asthma &
nasal polyposis
Vasomotor rhinitis
Due to autonomic
imbalance
Ipratropium
Steroid spray
+ Antihistamine
Typically in 40s-50s (around the menopause – male & female!) Thought to be due to ↓ in sex
steroids, resulting in mucosal hyper-reactivity.
Treating rhinitis improves asthma. Give becotide and beconase (not >800mg/day total)
Β blockers
Betahistine
NSAIDS
ASA
pollution
Heat/cold
Allergens
Asthma
Exercise/emotion
Reflux
Rhinitis
Nasal obstruction:
- Polyps
- Deviated septum
- Sinusitis
-Infective
-Non-allergic
-Allergic
Childhood asthma/rhinitis = 90% allergic
Adult asthma = 40% allergic
Adult rhinitis = 30% allergic
Rx for non-infective rhinitis
Aim is to create a clear nasal passageway
1. Local steroid: Mometasone spray (nasonex)/ Fluticasone drops (flixonase) + antihistamine:
Levocabastine spray or cromoglycate spray.
2. Short term betamethasone spray
3. Systemic steroids if not controlled with <800mg topical. (10-20 days prednisolone)
4. Surgery: Cauterize/trim turbinates; Polypectomy; septoplasty; submucosal resection
what are these surgeries??
Drops should be applied in a head-down position to prevent swallowing.
Vasoconstrictors eg. Ephedrine may be used in short term whilst waiting for steroids to act. No
more than 5 days at a time. May use in 1 nostril for 5 days, then switch. Avoid overuse or leads to
rebounds vasodilation.
Other causes of rhinitis
Atrophic rhinitis: ?due to excessive turbinate trimming/chronic Klebsiella infection. Foul smelling
crusts
Rhintis medicamentosa: Reflex nasal vasodilation due to inappropriate use of vasoconstrictor
drops.
Primary mucociliary dyskinesia
Nasal polyps
Associated with allergic and non-allergic rhinitis, chronic rhinosinusitis, asthma, primary ciliary
dyskinesia, cystic fibrosis. Investigate children for these.
Unknown pathology. Possibly inflammatory. Usually bilateral and cause obstruction
Multiple polyps much more common in adults. Rarely occur in <10s (think CF)
Yellow-grey or pink. Smooth and moist. Pedunculated. May be confused with the inferior
turbinate. Beware!
Consist of loose oedematous stroma with lymphocytic and eosinophilic infiltration covered by
respiratory epithelium.
Symptoms
None if small
Nasal airway obstruction: Mouth breathing, snoring
Rhinorrhea
Postnasal drainage
Dull headache
Hyposmia/ anosmia
Differential
Encephalocoele, glioma, rhabdomyosarcoma, lymphoma, nasal carcinoma
Examination
Anterior rhinoscopy
Rigid/flexible nasendoscopy (best way to view nasal cavity and nasal polyps)
Otoscopy: extensive polyposis causing eustachian tube dysfunction can cause fluid and infection
in the middle ear space
CN exam
CT and MRI scans can help diagnose the polyp or polyps; define the extent of the lesion in the
nasal cavities, sinuses, and beyond; and narrow the differential diagnosis of an unusual polyp or
clinical presentation.
Treatment
Oral and topical nasal steroids
Antibiotics for bacterial superinfections
Treat allergic rhinitis
Surgery
Simple polypectomy is effective initially to relieve nasal symptoms, especially for isolated polyps
or small numbers of polyps. High recurrence in benign multiple nasal polyposis.
Endoscopic sinus surgery removes the polyps and also opens the clefts in the middle meatus,
where they most often form, which helps decrease the recurrence rate.
Biopsy or remove lesions that are not benign polyps depending on clinical suspicion
Recognise deviation of the nasal septum.
The septum provides dorsal support and helps to maintain the position of the columnella and
nasal tip. It also separates the nasal passages and serves as shock absorption for the floor of the
frontal fossa.
Sx
Uni/bilateral nasal airway obstruction & obstructive sleep apnoea
Most cases are traumatic
Recurrent sinus infection due to impaired sinus ventilation
Recurrent serous otitis media
May impair the ability to equalise the middle ear in divers/on planes
2 main deformities:
1. The caudal end of the septum is dislocated laterally, narrowing one nostril, and is displaced
obliquely so that it also obstructs the opposite side.
2. The septum may develop a unilateral convexity. Often associated with a spur. The inferior
turbinate may grow to fill in the gap on the concave side , which may feel more obstructed to the
patient.
Examine using nasal speculum/flexible nasendoscope for polyps/sinus disease after
decongestant and local anaesthetic given.
Septal deviation, obstructing the right nasal cavity (left) and anterior dislocation of the septal
cartilage, obstructing the left nasal vestibule, (right) in the same patient.
Treatment
Only treat if symptomatic
Treat concurrent rhinitis/remove polyps
Surgery: Submucosal resection: For mid-septal deformities with normally placed caudal septum.
The nose is packed with gauze, which is removed after a few days. Straws within the packing
allow nasal breathing.
Complications
Post-operative haemorrhage
Septal haematoma (must drain)
Septal perforation
External deformity (saddle-nose)
Anosmia (Very rare)
Recognise sinusitis
Sinus drainage
Maxillary – maxillary ostia of the middle meatus (this is high up.)
The sinus can’t drain with the head erect unless it is full.
For this reason, it is the most commonly infected.
Infection is often associated with obstruction of the ostia
Molar teeth lie in the floor of the maxillary sinus.
Molar removal may be problematic eg. if the root is fractured in the process a piece may be
driven into the sinus when the patient bites.
A communication may be created between the oral cavity and maxillary sinus and provide a route
for infection.
Ethmoidal – Anterior and middle cells drain into the
middle meatus. Posterior drain into the superior
meatus
If nasal drainage is blocked, infections of the ethmoid
sinuses may break through the fragile medial wall of
the orbit. Severe infections may lead to blindness
because some posterior cells lie close to the optic
canal (contains optic nerve and ophthalmic artery).
May also affect the dural sheath of the optic nerve,
leading to optic neuritis
Predisposing factors for sinusitis
Anatomical abnormality around the ostial opening in
the middle turbinate
Oedema, allergy or polyp formation around the ostia
(functional blockage)
Occurs secondary to: Common cold, influenza,
measles, whooping cough, following dental
extraction/dental abscess
Following entry of infected material: diving, fractures,
gunshot wounds
Acute: S. pneumonia, H.IB, M. Catarrhalis, S.
aureus
Chronic: Anerobic - bacteroides
Following dental extraction: Anerobes
Immunocompromised: Fungal - Candida, Aspergillus, phycomycetes
Sx
URTI or recent dental extraction/infection
Throbbing pain over maxillary antrum. Retro-/supra- orbital if ethmoid or frontal sinus.
Worse on bending, coughing and walking
Headache
Nasal obstruction. Unilateral if unilateral sinusitis present
Purulent rhinorrhoea. Viral rhinitis not resolving after 7-10 days suggests sinus infection
Cheek swelling is RARE and usually indicates a dental problem.
Signs
Tenderness to palpation over maxillary antrum
Purulent mucus in middle meatus seen with nasal speculum and directed light
Dental caries
Oro-antral fistula
X-ray: fluid level in the antrum (40% false negative rate)
CT if ? diagnosis
Rx.
Nasal swab
Oxymetazoline: Topical decongestant. Stimulates α-adrenergic receptors causing
vasoconstriction. 0.05% solution max 2-3 sprays 3xs/day. May become dependent so NO
LONGER than 3 days or get rebound phenomena.
If severe/persisting >7 days oral amoxicillin or doxycycline or erythromycin
Amoxicillin: 250mg/8hrs. Child <10: 125mg/8hrs. Double dose if severe
Analgesia & warm facial compresses.
Occasionally chronic sinusitis needs an antral washout (via nose) if failure to resolve
Complications
Osteomyelitis, orbital cellulites, intracranial extension and septic cavernous sinus thrombosis
Refer to ENT surgeon