Epistaxis Overview and Management

Epistaxis (Nosebleeds)

• Most nosebleeds are idiopathic, highest incidence in individuals under 10 and over 40.
• Local triggers include nasal trauma, rhinitis, low humidity, nasal septal deviation, alcohol use, and chemical irritants (e.g., cocaine).
• Systemic conditions that can cause nosebleeds include genetic or acquired coagulation disorders, hematologic cancers, and anticoagulation medication.

Anterior Nosebleeds

• Usually unilateral and involve moderate, continuous bleeding.
• Small clots may be present, depending on the bleeding amount.
• Bleeding may be spontaneous or follow nasal trauma.

Posterior Nosebleeds

• Can occur bilaterally and involve severe bleeding, often difficult to treat.
• Bleeding into the pharynx is a sign of a posterior nosebleed.

Epistaxis Management

• Assess ABCs and CBC.
• Apply direct pressure to the anterior portion of the nose for 15 minutes.
• Have the patient sit upright and lean forward to reduce venous pressure and swallowing of blood.
• May apply short-acting topical nasal decongestants (e.g., phenylephrine 0.125% to 1%).
• Consider nasal packing.
• Posterior nosebleeds require specialist consultation.

Rhinitis

• Rhinitis is a nasal sinus cavity inflammation triggered by exposures that prompt the body to remove foreign objects.
• Allergic rhinitis causes a heterogeneous, inflammatory response affecting paranasal and sinus mucosa, characterized by sneezing, rhinorrhea, mucosal swelling, obstruction, conjunctivitis, and nasal-ocular and pharyngeal itching, in response to allergens.
• Membranes typically have a pale, violaceous color and edematous appearance.
• Other causes of rhinitis include infectious, anatomic, pharmacological, food/drink related, rhinitis medicamentosa, and other medical conditions such as pregnancy, hypothyroidism, cocaine use, and atrophic change.

Rhinitis Diagnosis and Management

• Diagnostics are based on clinical findings; cytologic studies (Wright Stain) and allergy referrals (RAST testing).
• Management includes antihistamines, oral decongestants, intranasal steroids and environmental avoidance; thorough medication review is essential as many medications can trigger rhinitis.

Sinusitis

• Acute sinusitis resolves within 2-3 weeks of treatment; bacterial, viral, fungal, or allergic causes.
• Abrupt onset, nasal congestion, purulent nasal discharge, headaches worsened by bending forward, fever, and fatigue are common.
• A full HEENT and dermatologic exam are performed for diagnostics.
• Nasal congestion, facial/dental pain, postnasal drip, headache, fever and yellow or green nasal discharge are common symptoms.
• Sensations of pain in the teeth and forehead are often worse in the morning.
• Frontal and maxillary sinus pain on palpation also are common symptoms and prodromal common cold, allergic or idiopathic rhinitis may be also present.

Sinusitis - Subacute & Chronic

• Subacute sinusitis resolves within 4 to 12 weeks, while chronic sinusitis lasts over 12 weeks.
• Prolonged sinus infection (greater than 12 weeks), resisting treatment or with recurrent acute infections is characteristic.
• Frequent exacerbations, often caused by gram-negative or anaerobic microorganisms are common in chronic cases.
• Nasal congestion, discharge, a cough lasting more than 30 days, and dull headaches are frequently observed.
• CT scans are used for recalcitrant cases. MRI with/without contrast, might be required for suspected masses.

Sinusitis Management

• Symptomatic treatment for rhinorrhea, sneezing, and coughing (viral rhinosinusitis).
• Pharmacotherapy includes first-generation antihistamines, NSAIDs, decongestants or cough suppressant.
• Antibiotics may be prescribed for symptomatic durations lasting over 10 days and/or purulent discharges. Antibiotic choices should be individualized based on community resistance.

Smell and Taste Disturbances

• Anosmia (loss of sense of smell), Parosmia (smell distortion) and Hyposmia (diminished sense of smell) can be caused by aging, tobacco, toxins, medications, malignant neoplasms, nasal inflammation, infection, malnutrition, head or facial trauma, Parkinson's disease, Alzheimer's disease, multiple sclerosis, diabetes, or inflammatory autoimmune disease.
• Hypogeusia (diminished taste), ageusia (absent taste), and dysgeusia (persistent or unpleasant taste) can also result from similar underlying conditions, as well as endocrinologic dysfunction, anesthesia, malignant neoplasms, head or neck irradiation, and surgical procedures.

Smell and Taste Disturbances - Diagnostics & Management

• Exam and diagnostics include HEENT exam, cranial nerve exam, University of Pennsylvania Smell Identification Test, Sniffin' Sticks, CBC, electrolytes, BUN, creatinine, LFTs, TSH, ANA, ESR, SSA, LA/SSB, vitamin levels, metal concentrations, MRI, and CT scanning.
• Treatment focuses on addressing underlying conditions like rhinitis, sinusitis, infections, gastroesophageal reflux disease, or anemia.
• Medications triggering the problem may be discontinued. Intranasal glucocorticoids often are effective.
• Additional treatments include antihistamines, leukotriene inhibitors, proton pump inhibitors (for GERD-related throat pain), and tricyclic antidepressants. Referral to a specialist might be necessary for ineffective interventions.

Tumors and Polyps of the Nose

• Malignant tumors (e.g., carcinomas, lymphomas, sarcomas, melanomas, squamous cell carcinoma) can develop in the nose, nasopharynx, and paranasal sinuses.
• Benign tumors, like Juvenile angiofibroma and inverted papilloma, are common types.
• Symptoms vary but may include nasal obstruction, discharge, facial swelling, bleeding (epistaxis), headache and/or visual/olfactory changes. Early symptoms often remain asymptomatic.
• Diagnostics for tumors usually include a full HEENT and nasopharynx exam, sinus X-rays, CT scans, MRI, and potentially endoscopic evaluations/biopsies.
• Management for malignant tumors often involves chemotherapy or radiotherapy. For nasal polyps, nasal topical steroids, intranasal capsaicin, surgical excision, or referral to otorhinolaryngology may be needed .