Epistaxis: Kisselbach plexus is series of arteries joined to form anterior nasal septum blood supply, 90% of nose bleeds. Most posterior nose bleeds are splenopalatine artery. Causes: trauma, nasal septum, chemical irritants (intranasal steroids, nasal cannula), rhinosinusitis, blood thinners. Some authors think severe acute elevated BP can prolong hemorrhage, though its recommend to not tx BP until hemorrhage controlled. Diagnosis for posterior hemorrhage determined once anterior bleeding treatment has failed.
Direct Pressure: have patient blow out clot to allow topical vasoconstriction to reach mucosa. Instill oxymetazoline or phenylephrine and then hold direct pressure – hold for 10-15 minutes.
Chemical Cauterization: need to have direct visualization of bleeding vessel. Apply silver nitrate sticks just proximal to bleeding source in anterior nasal septum. Needs to be bloodless field. Never do chemical cautery to both sides of septum.
Thrombogenic Foams/Gels: Before packing, consider placing Gelfoam or Surgicel – bioabsorbable, no removal necessary. Floseal is similiar, but is a syringe mixed with thrombin that you inject in to create foam.
Anterior Packing: Balloons (Rapid Rhino) are more comfortable than layered strip gauze/sponges. Soak with water first, then slowly inflate until bleeds stops or patient becomes very uncomfortable. Inflate with air only.
Nasal Tampons/Sponges: expand with hydration, apply abx ointment first, then apply. If it does not expand, instill 5mL NS.
Posterior Packing: can do bilateral packing or do balloon/sponge that is longer in length. Posterior packing is generally only temporary measure while waiting on ENT support. Rhino Rocket has a anterior and posterior balloon that can be inflated. Can also just use a 12-14F foley catheter with 30cc balloon (place until you can see it in the posterior oropharynx, inflate 7cc and retract until lodged in posterior nasopharynx. Add another 5-7cc and then secure to patient’s cheek. Do not inflate the whole way to prevent pressure necrosis.)
Disposition: If any packing placed, send home with staph coverage (Augmentin). ENT f/u in 2-3 days. If posterior packing required, needs admission for further treatment and monitoring.
Nasal Fractures: usually clinical diagnosis. Xrays are terrible. CTs should only be ordered if concerned about other intracranial injury or facial fracture. Periorbital ecchymosis with rest of orbit unremarkable likely related to nasal fx. Tx: If not much swelling, can consider closed reduction at bedside, though likely better for elective closed reduction within 6-10 days (though not much later than this due to possible fibrous connective tissue development). Reduction: anesthesia with infraorbital block, then intranasal mucosa anesthesia, then use surgical elevator to life depressed nasal bone anteriorly and laterally in one motion. Measure how far you should apply elevator by measuring tip of nose laterally to midline of the eye and then apply 1 cm less than that mesurement). Apply external splint afterward and consider nasal packing as well. Children nasal fractures best left to ENT f/u within 4 days.
Nasal Septal Hematoma: can occur with nasal fractures. Need urgent I&D to prevent nasal septal necrosis – leading to saddle deformity. Can also develop abscess. I&D with packing and then need to apply bilateral nasal packing to prevent reaccumulation. Needs 24hr f/u.
Nasal Foreign Bodies: Use vasoconstrictor such as 0.05% oxymetazoline, then consider 2-4% nebulized lidocaine. If able to visualize edges, use alligator or Takahashi forceps.
Sinusitis: 6 sinuses: two maxillary, two frontal and single ethmoid and frontal sinus. Paranasal sinuses not fully develop until 12yo. Acute inflammation leads to obstruction resulting in negative pressure in sinuses. Acute is usually viral. If bacterial, usually H. flu and Strep pneumonaie. Chronic due to anaerobes, GN bacteria, staph, occasional fungi in immunocompromised. Symptoms: nasal congestion, facial pain/pressure, diminshed smell, nasal drainage for < 12 weeks, sinus pressure with bending forward, changing head positions, fever. Chronic or recurrent acute can get CT sinuses to r/o invasive infection or neoplasm. Tx: supportive, nasal saline irrigation + decongestant. Oxymetazoline for 3 days to avoid rebound congestion/edema (rhinitis medicamentosa). Topical steroids can shorten duration as well. Abx can help shorten symptoms if symptoms have been ongoing for > 7 days. If goint the abx route, use amoxicillin or zpack/bactrim in PCN allergy. If received abx already, consider fluoroquinoline or high dose augmentin. If chronic sinusitis, consider ENT consult for functional endoscopic sinus surgery which can relieve obstruction.
Tintinalli, Seventh Edition, Chapter 239: Epistaxis, Nasal Fractures, and Rhinosinusitis