E.N.T. Dr Katie Bleksley GPST1

Aims To cover common conditions of the nose presenting to General Practice

Objectives Gain a working knowledge of the presentation and management of : Foreign Bodies Epistaxis Nasal Fractures Vestibulitis Rhinitis Sinusitis Nasal polyps

Foreign Bodies in the Nose

Foreign Bodies in the Nose Features Nasal discharge Respiratory Symptoms (Less commonly) Management Try blowing Under Optimal Conditions try removal Refer ENT

Epistaxis

Epistaxis Causes Trivial Lethal Spontaneous Infection Minor trauma (usually Little’s area) Hypertension Bleeding disorders / Anticoagulation

Epistaxis Sites of Bleeding Caution – inspect back of the throat Anterior - Little’s area (front of nasal septum) Posterior – Often underestimated Caution – inspect back of the throat

Epistaxis Hx HPC: Which nostril? Assess severity: Duration (>15-20 mins)? Frequency Precipitant? SR: (pre)syncope. Bleeding elsewhere PMH: HTN, bleeding tendency DH: anticoag/ antiplt, SH: EtOH FH: bleeding tendency

Epistaxis examination Nose: Be guided by Hx Little’s area Might be tricky to see Don’t forget to check BP

Epistaxis Conservative Rx: >15-20 mins / (pre)syncope go to hosp: Pressure Sit with head forwards Ice pack Ice cubes Anterior Bleed >15-20 mins / (pre)syncope go to hosp:

Advice after nose bleed (Immediately after cauterisation avoid hot food/drinks.) Avoid vasodilation: heat, exercise, EtOH, hot drinks Avoid HTN No nose picking/blowing/scratching

Nasal fractures Features Soft tissue swelling – can mask fractures Bridge depressed/deviated Septal deviation Palpation – painful, crepitus, ‘give’

Nasal fractures Septal haematoma (boggy) CSF leak Young children Associated HI / facial or jaw injuries

Nasal fractures

Nasal fractures Management X-Rays not indicated Drain septal haematoma ENT review at the time if obvious deviation or at 7-10days

Vestibulitis

Vestibulitis Causes Management ‘Eczema’ Infection Foreign body FB removal Antibiotic / Steroid ointment

Nasal discharge: rhinitis/sinusitis Unilat discharge in adult – malig Unilat discharge in child - FB

Rhinitis / Hayfever Presentation: Hx: Sneezing, watery rhinorrhoea, post nasal drip, nasal blockage, itchy eyes, nose, palate and throat. (nocturnal) cough Hx: precipitant? Pollen, features, HDM, moulds, animals Perenial vs seasonal

Rhinitis Rx Saline nasal douche and dec allergen exposure Inhale steam +/- menthol Antihistamines loratadine 10mg od Decongestants Ephedrine 1 drop tds to each nostril (for 5d) Steroid nasal drops: beclomethasone 2 tds (adults only, max 1 mo) Teach technique Short term, then switch to the spray Or start spray 2-3 wks before pollen season starts If resistent to Rx refer to ENT (RAST/skin prick/surgery)

Acute sinusitis Presentation: Purulent discharge Facial pain /discomfort Usually assd with URTI (10% due to tooth infections)

Acute Sinusitis Rx Warm face packs Decongestants Steroid nasal spray Spray / oral Max 5-7days Steroid nasal spray Antibiotics?? No/little evidence that they affect the natural course (2 ½ weeks) Consider if: significant comorbidities >7days systemically unwell /signs of complications Doxycycline /Amoxil 7-14 days (Amoxil and metro if dental origin) Recurrent sinusitis, manage in the same way, Refer to ENT if Sxs interfering with life.

Nasal Polyps

Nasal Polyps Assd with asthma and rhinitis and sinusitis Presentation: blockage, watery discharge, PND, change in voice, loss of smell/taste. O/E: smooth pale insensate, usually bilat, Rx: steroid nasal drops –beclomethasone 0.1% bd (max 1 month) until polyps shrink, then nasal spray for maintenance. If medical Rx fails refer ENT for surgery. Unilat unusal irreg polyp (esp if ulcerated/bleeding)? malig

Summary We have covered: Nasal FB removal Epistaxis assessment, management and RF modification Nasal Fracture management and red flags Vestibulitis Rhinitis Sinusitis Nasal polyps

Questions ?