1. E.N.T.
Dr Katie Bleksley GPST1

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

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

4. Foreign Bodies in the Nose

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

6. Epistaxis

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

8. 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

9. 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

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

11. 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:

12. 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

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

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

15. Nasal fractures

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

17. Vestibulitis

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

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

20. 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

21. 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)

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

23. 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 days (Amoxil and metro if dental origin)
Recurrent sinusitis, manage in the same way, Refer to ENT if Sxs interfering with life.

24. Nasal Polyps

25. 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

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

27. Questions ?