Nasal Emergencies
Mr T Rockley (consultant ENT surgeon) and A McLeod
Epistaxis
This is the commonest ENT emergency. Some bleeds can be truly
frightening, both for you and the patient. Be reassuring and ask for
help if you feel out of your depth.
Types of Bleeding
GROUP 1: Juvenile type.
Usually children, recurrent short-lived bleeds, virtually never anaemic
or clotting problems.
Pathology: Prominent retrocolumellar vein on septum
Treatment: First aid - pinch soft part of the nose.
In ENT clinic - AgNO3 stick cautery until it turns white, using
Cophenylcaine either as a spray or on a piece of cotton wool placed in
the anterior part of the nose as local anaesthetic. Give 3
month discretionary appointment. If unco-operative or
unsuccessful, electrocautery GA day case electively.
GROUP 2 Adult type.
Usually elderly arteriopath, single one-off large bleed, the ENT
equivalent of haematemesis/melaena. Requires admission and
often transfusion, risk of circulatory collapse etc.
Pathology: arterial bleed, almost always on the nasal septum butmore
posteriorly on vomeroethmoid region.
Treatment: As with all big bleeds, (1) resuscitation, i.e.
cross-match, IVI, etc. (epistaxis blood is OK for cross-match), also
(2) control the bleeding point.
Equipment needed:
Headlight
Killians (if available) and Thudichums speculae
Suction with Lempert sucker
0.5" plain ribbon gauze half-inch or one-inch ribbon gauze
prepared with BIPP
Mask and gown
Nasal ballon (e.g. Rapid Rhino) and nasal tampon (e.g. merocel)
Cotton wool and Jobson-Horne probes,
Co-phenylcaine local anaesthetic spray
Tilley nasal dressing forceps.
Stages of Treatment:
1. Get all blood clots out of nose - ask patient to blow, or use the
suction.
2. Anaesthetise nose - either spray, pack
loosely with ribbon gauze soaked in cophenylcaine or "paint" it with
JHP/cotton wool.
3. Find the bleeding point - suck up and down
the septum going from front to back until you see the bleeder.
4. If you find it, press on it with
forceps/cotton wool until it stops, then re-anaesthetise the nose at
leisure, cauterise the bleeding point with AgNO3, then pack with BIPP
or Simpson's balloon.
5. If you can't find the bleeder, pack "blind" with Rapid Rhino nasal
baloon or Merocel nasal tampon. Remember that Rapid rhino needs to be
soaked briefly in sterile water (NOT saline) while Merocel should be
inserted straight from the pack with perhaps a small amount of KY jelly
on the end to aid insertion.
In increasing stages of desperation, if they continue to bleed....
6. Pack the other side as well, it might help compress the septum.
7. Use BIPP or Ribbon gauze + vaseline to pack the nasal cavity (see
pic below). A: Gauze is
gripped with Tilley 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 nasal cavity is
filled.
8. Remove your packs, put in Brighton choanal balloons
or Foley catheters, get an assistant to exert traction on them and pack
against it with BIPP. Secure balloons anteriorly.
If at this point you're still not achieving success, call the
consultant on call; he/she will do either
9. Nasal pack under GA
10. Choanal plus nasal pack under GA.
11. Emergency septal surgery if bleeder is behind deflection.
12. Tie off sphenopalatine, maxillary, anterior ethmoid or external
carotid arteries (see pic at bottom of section)
GROUP 3 Bleeding disorders
Renal dialysis, liver failure, low platelets, HHT, haemophilia, etc.
Watch out for HIV or Hepatitis. Use cautery very sparingly if
at all. Pack very gently and avoid trauma to mucosa. Ask
Haematologist for help with platelets or FFP or Factor VIII if
necessary.
GROUP 4 Nasal Tumours
It is exceptionally rare for nasal tumours to present with bleeding.
However, one can occasionally come across the very rare juvenile
angiofibroma. This typically presents in a teenage male with profuse
bleeding and often associated anaemia.
"Strawberry" haemangioma of septum is occasionally encountered, mainly
in elderly people; requires cautery or excision (with Tilley-Henckel
forceps)
Notes:
Investigations - for type 1; FBC, clotting tests etc. not indicated
unless clinicaly evidence of petechiae, history of easy bleeding,
bleeding elsewhere, pallor etc.
Sinus x-ray are not indicated as routine: malignancy of nose and
sinuses causes blood-stained nasal discharge rather than frank
epistaxis.
Note: If you are packing a post-op SMR bleed, always pack bilaterally
as the septum is mobile.
If there are bleeding points on both sides of the septum directly
opposite each other, only cauterise the worse side, otherwise there is
a risk of septal perforation
The
arteries of the post nasal space
Kiesselbach's plexus is also known as Little's area
Septal haematoma
Septal haematoma is often missed, and if not treated promptly has
disastrous effects on the nose: the septal cartilage rapidly disappears
and later nasal collapse is inevitable. Be very suspicious of
nasal trauma with complete obstruction; there might be a
subperichondrial haematoma of the septum. It appears on
examination as a swelling of the nasal septum.
This can be confused with a simple deviation of the nasal septum.
You can confirm that it is indeed a septal haematoma by spraying the
nose with Co-phenylcaine, and then probing the swelling with a
Jobson-Horne probe.
A haematoma will feel soft and boggy whereas cartilage will feel
firm. Alternatively, you can try aspiration with
a 5 ml syringe and a green needle.
If you suspect septal haematoma, tell your consultant
on call, who will do formal drainage.
Broken nose
This is one of the commonest fractures in clinical practice. Treatment
should be guided by several principles:
X-rays to confirm the fracture are unnecessary.
This fracture heals much quicker than other fractures, so if any
treatment is required, it has to happen within two weeks.
If the nose is broken but not at all displaced, no treatment is
necessary. Just advise the patient not to play any sport for
six weeks.
Sometimes, if there is a lot of oedema, you can't tell if it is
displaced or not. In such cases, make an appointment for ENT
clinic for 3-5 days after the initial injury.
If the nose is displaced, ie pushed to one side or flattened, then
treatment is required and must take place within two weeks.
Refer to next ENT clinic.
If there is a break in the skin, making it a compound fracture, suture
or steristrip the skin straight away and then treat the bony injury
separately.
Don't forget: if the nose has been broken, look for other less
obvious facial injuries eg fractured orbital margin or
cheekbone. And if the nose is very blocked, check the patient
hasn't got a septal haematoma which requires emergency drainage
in its own right.
Straightening the nose:
If the nose is displaced to one side, it can be straightened under
local anaesthetic. Spray the nasal cavity with Co-phenylcaine
local anaesthetic, and infiltrate the bony dorsum with lignocaine /
adrenaline using a dental syringe. Insert the needle in the
midline of the nasal dorsum, level with the eyes, and infiltrate to
either side.
Wait 15 minutes and then, with the patient lying
supine on the couch, manipulate the deviated nose straight. If
the reduction seems unstable ( ie if you can wobble it from side to
side just with two fingers ), some form of splintage is required.( eg
Plaster of Paris )
If the patient is young or squeamish, arrange GA day case manipulation.
If the bones are depressed, a GA is probably going to be
required.
Acute sinusitis
This is usually managed in general practice, but can sometimes appear
in the Emergency Department.
Acute sinusitis is a complication of an upper respiratory tract
infection. The sinuses are hollow spaces in the bones of the
face, and they open into the nose via very narrow channels. If
those channels get blocked by mucosal swelling, infection can get
trapped in the sinuses.
Clinical features:
The patient has a persistent dull ache in the forehead (frontal
sinusitis), between the eyes (ethmoid sinusitis), or upper jaw / teeth
(maxillary sinusitis). The pain is usually described as a
"pressure" or "fulness" pain, worse if they lean forward. There are
also symptoms of nasal congestion or pus draining from the
nose. They may be pyrexial. There isn't any
visible facial swelling, but endoscopy of the nose reveals the pus
draining from the sinuses into the nasal cavity. Tenderness of
the sinuses is a useless physical sign; don't bother with
it.
Treatment: Analgesia, antibiotics and topical nasal
decongestants.
The likely organism is from the upper respiratory tract, ie strep,
haemophilus or staph. Co-amoxiclav is the ideal antibiotic. If the
patient is allergic to penicillin, try
clarithromycin instead.
Don't forget; the problem isn't just infection, it is poor sinus
drainage as well. So, you also need to prescribe a topical
mucosal decongestant for the nose eg Otrivine spray.
Foreign bodies in the nose
Do not try to remove a foreign body from a child's nose unless you
think you can get it first go; children will not co-operate for a
second attempt if they've been hurt the first time.
Useful instruments are headlight, wax hook, crocodile
forceps. An experienced nurse to hold the patient is
very helpful; the correct grip needs to be demonstrated.
Nasal foreign bodies are not emergencies (unless painful, or button
batteries) and can be referred to next available ENT clinic.
The typical sign of a foreign body in the nose is a unilateral smelly
nasal discharge in a pre-school child, perhaps with excoriation around
the nostril.
