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The Nose

Case history: Miss Lotta Snotty. 6 year old girlRecent URTI, very sneezy childPresents with a nose bleed> what probably caused the bleed?> how will you treat it?. HOW TO STOP A NOSE BLEED acute management. Which one is right?..?. EPISTAXIS (NOSE BLEEDS). IN CHILDRENUsually bleed from Little's area (Ant. Bleed)May be associated withURTIRhinitis (e.g. Hay fever)Nose picking Foreign body (foul discharge).

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The Nose

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    1. The Nose Dr Sassa Calthrop-Owen

    2. Case history: Miss Lotta Snotty 6 year old girl Recent URTI, very sneezy child Presents with a nose bleed > what probably caused the bleed? > how will you treat it?

    3. HOW TO STOP A NOSE BLEED acute management Which one is right…..?

    4. EPISTAXIS (NOSE BLEEDS) IN CHILDREN Usually bleed from Little’s area (Ant. Bleed) May be associated with URTI Rhinitis (e.g. Hay fever) Nose picking Foreign body (foul discharge)

    5. Anatomy of the nose

    6. HOW TO STOP A NOSE BLEED acute management Which one is right…..?

    7. HOW TO STOP A NOSE BLEED ACUTE MANAGEMENT Pinch soft part of nose Put head forward NOT back Avoid tissues Avoid nose blowing TOP TIP : get them to lean forward, arms on desk, use both thumbs to apply pressure

    8. What to do when the bleeding has stopped? Examine Little’s area - ? Bleeding vessel Use lignocaine applied with a cotton bud Wait 5 mins Cauterise with a silver nitrate stick NEVER do both sides at one go If no vessel obvious try naseptin for 7 days If keeps bleeding ? Clotting abnormal (e.g. warfarin) Check bloods

    9. NOSE BLEEDS IN ADULTS Anterior bleeds – management same as children Posterior bleeds Tend to occur in later life Drugs Suspect if can’t see a bleeding vessel Worse if BP raised Consider nasal packing if can’t stop it Remember ABC – call for help quickly

    10. The Return of Lotta Snotty 17yrs old, doing A levels, stressed Sneezing out of control eyes watering asthma worse diagnosis? treatment?

    11. RHINITIS = Inflammation of nasal lining Symptoms Nasal obstruction Clear nasal discharge Bouts of sneezing 3 different types Infective (e.g. URTI) Allergic Intrinsic/Vasomotor – or NANI

    12. Rhinitis – comparing allergic and vasomotor Allergic Rhinitis can be seasonal (e.g. hayfever) or perennial Lots of sneezing May be related to house dust mites/animal dander/pollen Allergen testing positive (sometimes) FH, atopy Vasomotor Rhinitis ‘NANI’ Autonomic imbalance Symptoms with change in temp and humidity Samsters Triad Hormonal changes Alcohol, smoking, drugs

    13. WHAT DOES THE PICTURE SHOW? What symptom is being alleviated by doing this? What facial change will be acquired over time?

    14. MANAGEMENT OF RHINITIS Medical Steroid nasal sprays or drops Anti-histamines Allergen avoidance if allergic rhinitis Beware – rhinitis medicamentosa! Surgical - when to refer? Failure of medical therapy or Patient’s request

    15. Anatomy of the nose -and how to use a spray!

    16. Lotta Snotty Strikes Again A few months go by… 2w URTI – resolving initially, now worse Facial pain, fever, cacosmia, post-nasal drip, bloody nasal mucus, cough, unwell diagnosis? treatment?

    17. ACUTE SINUSITIS What are the symptoms? Facial pain over upper nose / cheek (s) Tenderness on palpation Nasal blockage Associated fever Muco-purulent nasal discharge Pain varies with position (e.g. head down = worse) Cacosmia (patient smells something unpleasant) Congestion lightheadedness

    18. Anatomy of the nose -and what are sinuses for anyway?

    19. ACUTE SINUSITIS Cont’d… How would you treat acutely? Menthol and steam inhalation Topical decongestants Pain relief …over 80% viral ‘The art of medicine consists in amusing the patient while nature cures the disease.’ Voltaire …but not always… Antibiotics – aerobic and anaerobic cover

    20. Revenge of Lotta Snotty Gets worse Develops unilateral pain, swelling & redness round her right eye Diplopia, proptosis, blurred vision Very ill!

    21. So….if symptoms severe/systemic/not resolving after about 10d, consider antibiotics; Cover H flu , strep pneumoniae Complications: Orbital cellulitis meningitis, brain abscess, osteomyelitis (Potts Puffy Tumour) cavernous sinus thrombosis If chronic (over 3w) also need to cover anaerobes, G neg & staph; also fungal

    22. CHRONIC SINUSITIS When should you refer for recurrent sinusitis? Failure of medical therapy Large polpys Septal deviation One-sided blood stained nasal discharge ? Neoplasia Refer urgently

    23. Lotta Snotty Uncut Back from uni, returns complaining of chronically blocked nose Anosmia, rhinorrhoea Rhinitis & asthma persist Diagnosis? Treatment?

    24. NASAL BLOCKAGE CAUSES Mucosal swelling URTI (infective rhinitis) Rhinitis (allergic/vasomotor) Polyps Septal deviation Idiopathic Traumatic 3) Nasal collapse On inspiration 4) Nasopharyngeal obstruction enlarged adenoids polyps tumour

    25. THINGS YOU MAY SEE ON NOSE EXAM POLYPS Polyps look grey Polyps are painLESS

    26. Bride of Lotta Snotty So Lotta was cured and lived happily ever after, except she married a man with obstructive sleep apnoea who fell asleep at traffic lights… but that’s another story.

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