Nasal problems

Question 1

Broken nose.

a) Signs
b) Home management
c) When should patients seek urgent medical attention?
d) When should patients seek routine medical attention?
e) Treatment

Answer 1

a) - Pain, swelling, redness, black eyes, profuse nosebleed; crunching/cracking sound, difficulty breathing through the nose
- Deformity (eg. septal deviation)

b) Ice to reduce swelling, painkillers, treat nosebleeds, keep head upright at night;
Avoid picking/blowing nose, avoid contact sports for 6 weeks, avoid wearing glasses until swelling has reduced

c) - Signs of basilar skull fracture - CSF rhinorrhoea/ otorrhoea, Battle sign, Racoon eyes
- Signs of severe head injury/raised ICP
- Septal haematoma
- Infected/ foreign body (eg. glass)

d) If after 3 days: swelling not reduced, nose appears crooked, still bleeding, painkillers not helping, breathing through nose remains difficult

e) (If there is septal deviation)
- Manipulation - usually under local anaesthetic: done between 7-14 days post-injury
- If this fails, may require MUA, or septorhinoplasty

Question 2

Epistaxis.

a) Blood supply to nose
b) Most haemorrhages occur where?
c) Causes
d) Presentation - one/both nostrils, into throat
e) Initial management
f) Further management (if initial measures fail)

Answer 2

a) ICA branches (anterior and posterior ethmoid arteries) and ECA branches (sphenopalatine, internal maxillary)
b) Little’s area (Kiesselbach’s plexus) in the nasal septum; older patients- posterior haemorrhage more likely, more profuse and risk of airway compromise

c) - Idiopathic,
- Nasal trauma: nose-picking, blowing nose, foreign bodies, dry mucosa (eg. secondary to oxygen therapy or cold), head injury
- Platelet disorders: low platelets, vWF, heparin/aspirin or, anticoagulation
- Wegener’s granulomatosis
- Cocaine use
- Nasopharyngeal tumour (eg. angiofibroma)

d) - Anterior haemorrhage: usually one nostril
- Posterior haemorrhage: may be both nostrils, or running into throat

e) - A-E assessment: need for suctioning/adjuncts/ O2?, IV access, monitor HR and BP, take bloods (FBC, UEs, group/save, X-match, clotting), bleeding or bruising elsewhere?, rashes?
- Sit patient upright
- Ask them to squeeze fleshy part of nose for 20 mins
- Breathe through mouth, spit any blood/saliva into bowl
- Ice to suck on/cold packs on forehead
- If on warfarin - Vit K and Beriplex
- Consider giving TxA

f) - Cauterisation - chemical (silver nitrate) or electrical via anterior rhinoscopy visualisation (only for visible anterior bleeding vessels)
- If cautery unavailable/ unsuccessful or posterior bleed - nasal packs (for 2 - 3 days)
- If these fail - call ENT surgeons for sphenopalatine artery ligation or embolisation

Question 3

Septal haematoma.

a) Suspect in who?
b) Why does it require prompt treatment?
c) Management

Answer 3

a) Anyone with facial/nasal trauma, who presents with: bilateral nasal blockage and/or pain

b) Can cause:
- septal necrosis,
- secondary bacterial infection and abscess
- intracranial extension

c) - Incision and drainage of haematoma
- Swab for MC/S and antibiotics

Question 4

Epistaxis: history

a) HPC
b) Ass sx
c) PMHx
d) DHx
e) FHx
f) SHx

Answer 4

a) - Site - determine if blood is running out of the nose and one nostril (usually anterior) or if blood is running into the throat or from both nostrils (usually posterior).
- Onset: ask about trauma (including nose picking)
- Timing: duration

b) - Enquire about any facial pain or otalgia - these may be presenting signs of a nasopharyngeal tumour
- In young male patients ask about nasal obstruction, headache, rhinorrhoea and anosmia - signs of juvenile nasopharyngeal angiofibroma
- Signs of anaemia/ significant blood loss

c) - HTN
- Bleeding disorder
- previous nasal surgery

d) - clopidogrel, warfarin, DOACs, aspirin.
e) - Note family of clotting disorders

f) - Smoking
- Cocaine use