Nose and sinus disease

Epistaxis

• Local causes – Digital trauma, deviated septum, dry air exposure, rhinosinusitis, neoplasia or chemical irritants e.g. inhaled corticosteroids or chronic nasal oxygen
• Systemic factors – Chronic renal insufficiency, alcoholism, HTN, vascular malformations, warfarin, von Willebrand’s disease or haemophilia or NOAC, antiplatelets
• Anatomy
  • Keisselbach plexus on anterior nasal plexus 90% of bleeds
    • Superior labial branch of facial artery
    • Anterior ethmoidal and terminal branch of sphenopalatine artery
  • Posterior bleeds usually from sphenopalatine artery (branch of internal maxillary off external carotid)

• Identify any causes, laterality
• Must identify anterior vs. posterior
  • 90% anterior
  • Usually posterior if anterior measures fail and cannot visualise bleeding point with good examination
  • Hints at posterior include elderly patients with coagulopathy, significant posterior pharyngeal haemorrhage visualised, haemorrhage from both nares and failed anterior measures
• If haemorrhage poorly controlled or systemic illness  – FBC, G&H, X-match, coags
• Treatment
  • Rapid reduction of BP not advised
  • Correct any coagulopathy depending on patient factors

• Treatment
  • Direct nasal pressure
    • Blow nose to expel clots and spray co-phenylcaine
    • Lean forward and pinch nares for 10-15 minutes breathing through mouth
    • Two tongue depressors taped together can aid this
  • Chemical cauterisation
    • Once two attempts at direct pressure have failed, silver nitrate is next
    • Co-phenylcaine then direct visualiation of bleeding site
    • Place just proximal to bleeding point
    • Need relatively bloodless field as chemical reaction cannot proceed with active haemorrhage due to washout of substrate
    • Once relatively bloodless field achieved, place silver directly on bleeding point briefly
    • Never perform on both sides of septum and subsequent attempts spaced out 4-6 weeks
  • Anterior epistaxis tampons (Merocel)
    • 5 or 10cm lengths
    • Cover with Chlorsig and insert
    • If not expanded within 30 seconds, irrigate with 5mL N/S to aid expansion
  • Anterior epistaxis balloons (Rapid Rhino)
    • Coated with cellulose to aid platelet aggregation
    • Soak in water (or 500mg IV tranexamic acid) then insert and inflate with air until bleeding stops
    • Do not inflate with saline as if bursts, aspiration can result
    • Bilateral packing may improve septal tamponade
  • Posterior rapid rhinos (70% effective)
    • Higher complication rates of pressure necrosis, infection, hypoxia and cardiac dysrhythmias
    • Do not dilate posterior balloon >10mL as risk of pressure necrosis significantly increases
  • 10% of patients require invasive ENT intervention
    • Sphenopalatine artery – Inject around via descending palatine foramen just medial to 2^nd upper molar with 1mL 2% lignocaine + adrenaline
    • Sphenopalatine artery surgical ligation or embolisation (80-90% effective)
• NOPAC study
  • Topical 200mg TXA on dental role applied in ED if bleeding continued despite topical vasoconstrictor and at least 10 minutes or pressure/ice/both
  • No difference in formal packing rates, other treatments, hospital admission, transfusion or recurrent epistaxis

• Disposition
  • If haemorrhage controlled after 1 hour, can discharge home with ENT follow-up within 48 hours ideally
  • If packing removed after 4-6 hours, monitor for at least 1 hour for re-bleeding and then can safely d/c home with ENT f/u
  • Continue warfarin if therapeutic INR
  • Discontinue NSAID’s for 3-4 days
  • If packing removed within 24-48 hours, no antibiotic prophylaxis is necessary
  • Can discharge home with anterior packing in place with advice to return to ENT follow-up within 24-48 hours
  • If posterior packing, admission is strongly advised to monitor for complications

Nasal fractures

• Examination
  • Periorbital ecchymoses without other signs is highly suggestive of nasal bone fracture
  • Profuse epistaxis suggests nasal bone fracture
  • Nasal bone mobility = fracture and is tested by grasping dorsum of nose and attempting to rock pyramid back and forth
  • Anterior rhinoscopy with bloodless field using topical vasoconstrictors and evacuation of clots allows assessment for mucosal lacerations, septal fractures/deviation and septal haematomas
• Diagnosis is clinical and radiological confirmation of isolated nasal bone fractures is not required

Nasal fractures

• Treatment
  • Exclude other traumatic injuries and nasal septal haematoma
  • Nasal fractures with lacerations = open fracture
  • Ideally reduction performed within 2 weeks in adults if required
• Disposition
  • GP in 3-4 days for consideration of reduction if ongoing deformity or nasal obstructionENT consult if CSF rhinorrhoea
  • Discussion with and ENT review in 24 hours if incised nasal septal haematoma
  • ENT in 2-3 days if child due to rapid healing

Nasal septal haematoma

• Haematomas lift the perichondrium (which supplies blood to septal cartilage)
• Needs urgent I&D to prevent ischaemic necrosis of septum
• Necrosis leads to saddle deformity, nasal obstruction and nidus for abscess
• Risk of spread to osteomyelitis, cavernous sinus thrombosis, meningitis and intracranial abscess (dangerous triangle)

Nasal septal haematoma

• Drainage
  • Cotton pledgets soaked in 4% lignocaine for 5 minutes +- subcut local anaesthetic
  • Small horizontal incision superficially through mucosa (ensuring not to incise septum)
  • Evacuate clot with suction or forceps
  • Perform bilateral anterior nasal packing coated in topical chlorsig to prevent reaccumulation and keep septum in midline
• Discharge with oral cephalexin 500mg QID
• ENT follow-up within 24 hours

Sinusitis and rhinosinusitis

• Acute <4 weeks; subacute 4-12 weeks and chronic >12 weeks
• Any acute inflammation of rhinitis results in obstruction of sinus ostia, with accumulation of secretions, reabsorption of air, negative pressure in sinuses and clinical symptoms
• Clinical features
  • Acute viral rhinosinusitis = 2 or more of:
    • Blockage/congestion of nose
    • Facial pain or pressure
    • Diminished sense of smell
    • Anterior or posterior nasal discharge
    • +- tooth pain, fever, sinus pressure leaning forward

Acute rhinosinusitis

• Includes acute viral rhinosinusitis, acute bacterial rhinosinusitis and post-viral ARS
• Post-viral ARS
  • Increase in symptoms after 5 days or persistence >10 days
• Acute bacterial rhinosinusitis
  • <2% of acute viral rhinosinusitis is complicated by bacterial infection yet >85% receive antibiotics in primary care
  • H. influenzae and S. pneumoniae
  • At least 3 of:
    • Discoloured, purulent nasal discharge
    • Severe, localized pain
    • Fever >38
    • ESR/CRP elevation
    • Double sickening (better then worse)

rhinosinusitis

• Examination
  • Pain and tenderness over sinuses with percussion
  • Mucosal nasal swelling
  • Redness/swelling to face
  • Foreign bodies in nose
  • Perform neurological examination and check for ENT + teeth extension of disease
• Diagnosis
  • Clinical
  • CT helpful if toxic or to evaluate for intracranial extension
• DDx
  • Migraine, craniofacial neoplasm, foreign body retention and dental caries

rhinosinusitis

• Treatment
  • Acute uncomplicated
    • Supportive, nasal saline irrigation, nasal decongestants (3 days max), topical corticosteroids shorten duration of illness
    • Should continue treatment for 7-14 days
    • Antibiotics have small treatment effect if symptoms >7 days and purulent nasal secretions
      • NNT = 18 to shorten time to resolution while NNH = 8 for adverse effect
    • Amoxicillin 500mg QID for 5 days (longer duration not helpful)
    • If received antibiotics within last 4-6 weeks, consider cipro or augmentin

rhinosinusitis

• Complications
  • Extension to meninges, cavernous sinus thrombosis, intracranial abscess
  • 75% of cases of orbital cellulitis are attributable to sinus disease
  • Frontal sinusitis can lead to osteomyelitis of frontal bone with Pott’s puffy tumor (doughy swelling) +- subdural or extradural empyema

Acute rhinosinusitis

• Red flags (when to return):
  • Unilateral symptoms
  • Bleeding
  • Cacosmia (perceived malodorous smell)
  • Signs of meningitis
  • Altered neurology
  • Frontal swelling
  • Any orbital involvement
    • Diplopia
    • Reduced VA
    • Painful ophthalmoplegia
    • Periorbital oedema and erythema
    • Globe displacement

Chronic rhinosinusitis

• Chronic rhinosinusitis usually anaerobic, gram-negative, S. aureus or fungi in immunocompromised
  • Ix for allergy, CF, nasal polyposis or immunocompromise
  • Non-contrast CT of sinuses can evaluate for invasion of surrounding structures or neoplasms
  • Bacterial cultures may be helpful at this stage with ENT follow-up
• CRS with nasal polyposis
  • Topical steroids + nasal irrigation for 8 weeks + PO prednisone 25mg mane for 5 days then 12.5mg mane for 5 days
  • Erythromycin 250mg QID for 8 weeks enhances mucociliary fx, reduces inflammation and may reduce polyp size
• CRS without nasal polyposis
  • Topical steroids and nasal irrigation trial for 8 weeks
• Consider antihistamines if allergic component suspected
  • Subacute, chronic or recurrent

Mucormycosis

• Group of fungal infection syndromes that occur in immunocompromised hosts
• Genera: Mucorales – Ubiquitous in nature
• Most commonly Rhizopus, Mucor, Rhizomucor
• Fragile in the lab and difficult to culture
• Rhizopus have an enzyme called ketone reductase, allowing them to thrive in high glucose, acidic environments
  • DKA a significant risk factor accordingly
• Desferrioxamine also increases the risk of mucormycosis, as chelated iron (feroxamine) is a siderophore for Rhizopus, increasing iron uptake to the fungus and stimulating growth and tissue invasion
• Iron overload itself may also pose a risk factor for infection
• Invasion of the vasculature is the hallmark of infection with infarction and necrosis
• Rhino-orbital-cerebral mucormycosis
  • Acute sinusitis with fever, nasal congestion/discharge, headache and sinus pain
  • Spreads to contiguous structures such as palate, orbit and brain, usually rapidly over days
  • Hallmarks are palatine eschars, destruction of the turbinates, perinasal swelling and erythema/cyanosis of facial skin
  • The escar may be visible within the nose, on the palate or around the orbit
  • Orbital involvement may yield proptosis, periorbital oedema and visual disturbance
  • Facial numbness may occur due to invasion around the sensory branches of the CN V
  • May spread to cavernous sinus and cerebrum
• Pulmonary mucormycosis
  • Rapidly progressive pneumonia that often presents with haemoptysis
• Treatment
  • Surgical debridement and antifungals
  • IV amphotericin B

Last Updated on August 28, 2023 by Andrew Crofton