Nose

Question 1

nasal trauma

Question 2

peri orbital cellulitis definition

Answer 2

an infection of the periorbital soft tissue characterised by erythema and oedema

Question 3

peri orbital cellulitis epidemiology

Answer 3

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

Question 4

types of peri orbital cellulitis

Answer 4

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

Question 5

why children peri orbital cellulitis

Answer 5

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

Question 6

causes peri orbital cellulitis

Answer 6

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

Question 7

organisms peri orbital cellulitis

Answer 7

Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Staphylococcus aureus, group A streptococcus, and upper respiratory tract anaerobes. Staphylococcus aureus is usually the most common pathogen.

Question 8

clinical features peri orbital cellulitis

Answer 8

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

Question 9

signs orbital cellulitis

Answer 9

Proptosis
Ophthalmoplegia
Decreased visual acuity
Loss of red colour vision – first sign of optic neuropathy
Chemosis
Painful diplopia

Question 10

peri orbital cellulitis classification

Answer 10

chandler classification
pre
post
subperiosteal abscess
intra orbital abscess
cavernous sinus thrombosis

Question 11

examination peri orbital cellulitis

Answer 11

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

Question 12

ddx peri orbital cellulitis

Answer 12

Vesicles of herpes zoster ophthalmicus
Erythematous irritation of contact dermatitis
Raised, dry plaques of atopic dermatitis

Question 13

tx peri orbital cellulitis

Answer 13

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

Question 14

complications periorbital cellulitis

Answer 14

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

Question 15

most common cause of epistaxis in children

Answer 15

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)

Question 16

<2 children epistaxis

Answer 16

rare
referred to ENT for investigation

Question 17

pathophysiology epistaxis

Answer 17

most comes from little’s area - confluence of vessels originating from ICA and external carotid arteries

Question 18

recurrent epistaxis

Answer 18

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

Question 19

risk factors epistaxis

Answer 19

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)

Question 20

examination epistaxis

Answer 20

see source on anterior septum of affected side
see evidence of septal haematoma

Question 21

septal haematoma tx

Answer 21

urgent review by ENT and drainage to avoid permanent disfigurement

Question 22

ddx epistaxis

Answer 22

foreign body - ruled out in unilateral offensive nasal discharge

Question 23

investigations epistaxis

Answer 23

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

Question 24

initial management epistaxis

Answer 24

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

Question 25

primary acre/A and E management epistaxis

Answer 25

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

Question 26

definitive management epistaxis

Answer 26

pts should be discharged with naseptin ointment BD for 2 weeks
- must check for peanut allergy so must be checked

Question 27

reoccurrence risks

Answer 27

-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

Question 28

red flags epistaxis

Answer 28

-Persistent unilateral bleeding

-Weight loss

-Visual disturbance

-Facial pain