Epistaxis and Allergic Rhinitis Overview

Epistaxis (Nosebleeds)

• Patient Presentation: 56-year-old male with recurrent nosebleeds primarily from the right nostril for the past week. Bleeding is mild to moderate, lasting 10-15 minutes, and stops with pressure. Last episode occurred while brushing teeth. Reports nasal dryness and occasional crusting. No trauma, recent upper respiratory infections, sinus congestion, or fever. Patient is otherwise well.
• Past Medical History (PMH): Uncontrolled hypertension, seasonal allergic rhinitis
• Social History: Construction manager, smoker of 1 pack per day for 20 years
• Physical Exam (PE): Visible crusting in anterior septum; prominent vascularization noted in Kiesselbach's plexus.

Allergic Rhinitis (Hay Fever)

• Patient Presentation: 28-year-old female with three-month history of nasal congestion, sneezing, and itchy eyes. Symptoms worsen in the morning and when exposed to dust or visiting her grandmother's house (cat). Intermittent clear nasal discharge and frequent throat clearing. Relief with antihistamines - no fever, chills or respiratory infections.
• Past Medical History (PMH): Mild asthma controlled with PRN albuterol inhaler, seasonal allergies.
• Physical Exam (PE): Pale nasal mucosa with clear rhinorrhea and turbinate edema, cobblestoning of the posterior pharynx.
• Plan: Allergen avoidance, intranasal saline sprays, and intranasal corticosteroids (fluticasone). Do not use antihistamine nasal sprays, oral/nasal decongestants, or start immunotherapy during pregnancy.

Non-Allergic Rhinitis

• Patient Presentation: 45-year-old female with one-year history of persistent nasal congestion and clear rhinorrhea. Symptoms are daily, non-seasonal, and not triggered by specific allergens. Exacerbated by strong odors and temperature changes. Little relief from over-the-counter antihistamines. No fever, chills, and no respiratory infections.
• Past Medical History (PMH): Controlled GERD.
• Physical Exam (PE): Nasal mucosa mild edema; no erythema or discharge.
• Plan: Topical intranasal glucocorticoids, topical antihistamines, or combined use most effective. Nasal saline irrigation is another option.

Rhinitis Medicamentosa

• Patient Presentation: 38-year-old male with three-month history of persistent nasal congestion worsened by using an over-the-counter nasal decongestant (Afrin). Now requires the spray multiple times a day for relief. Nasal congestion worsens when attempting to discontinue use. No fever, chills, or discharge.
• Plan: Withdraw use of intranasal decongestants, and use intranasal glucocorticoids if needed.

Acute Rhinosinusitis (Common Cold)

• Patient Presentation: 32-year-old male with a 10-day history of nasal congestion, facial pressure, and thick nasal discharge. Symptoms started after a common cold. Yellow-green discharge and occasional post-nasal drip. Mild headache and decreased sense of smell, but no fever or chills.
• Plan: Likely bacterial (S. pneumoniae, H. influenzae, or M. catarrhalis), assess for complications or need for antibiotics.

Chronic Rhinosinusitis

• Patient Presentation: 45-year-old female with six-month history of persistent nasal congestion, facial pressure, and postnasal drip, thick clear-to-mucoid discharge. Complaints of diminished smell and worsening of facial pressure with bending forward. No fever, chills, or acute worsening.
• Plan: ENT/allergy referral, intranasal saline or corticosteroids, oral corticosteroids for 10-15 days, antibiotics/antileukotriene agents (if needed).

Invasive Fungal Rhinosinusitis

• Patient Presentation: 57-year-old male with a one-week history of worsening facial pain, nasal congestion, and headache accompanied by fever, chills, and malaise. Black necrotic tissue observed on the nasal septum and turbinate. Decreased sensation, and blurry vision in the eye. History of poorly controlled diabetes.
• Plan: Immediate hospital admission, ENT referral, IV antifungals (voriconazole or amphotericin B), and surgery.

Foreign Body in Nose

• Patient Presentation: 4-year-old male with three-day history of foul-smelling yellow-green nasal discharge from the right nostril. Reports no pain or trauma, but an itchy nose. Mother recalls small toys being present.
• Plan: Attempt to remove foreign body in the nose. Consider nasal decongestant and topical anesthetic initially; possible conscious sedation for more difficult retrievals.

Nasal Trauma

• Patient Presentation: 32-year-old male with nasal pain, swelling, and breathing difficulty after a basketball game. No major bleeding noted but some mild spotting. No loss of consciousness or neck pain.
• Plan: Nasal packing for septal hematomas, bilateral I&D, fluid culture, antibiotics (cephalexin, clindamycin) x 3-5 days. Closed reduction of fracture if necessary.

Polyp of Nasopharyngeal & Paranasal Sinus

• Malignant Polyps: Squamous cell carcinoma (SCC) is most common. Early symptoms resemble rhinosinusitis (unilateral nasal obstruction, discharge, pain, or epistaxis). Poor prognosis for advanced tumors.
• Benign Polyps: Often associated with allergic rhinitis. Pale, edematous, mucosal-covered masses. Possible chronic nasal obstruction. Topical intranasal steroids or surgery may be necessary for large polyps. Benign inverted papilloma (BIP) is primarily caused by human papillomavirus (HPV). Malignant potential; excision usually recommended.

This quiz covers the clinical presentation and management of epistaxis and allergic rhinitis, with case studies highlighting patient symptoms and backgrounds. Understand key factors such as previous medical history and environmental triggers. Test your knowledge on the differences and similarities between these two conditions.