Diseases of the Nose, Nasal Trauma, and Epistaxis

1. Acute and Chronic Diseases of the Nose

Acute Rhinitis (Common Cold)

• Nasal congestion, rhinorrhea (initially clear, may become mucopurulent)
• Sneezing, mild fever, malaise
• Onset in winter, associated with dry air that desiccates nasal mucosa

Allergic Rhinitis

• Seasonal (hay fever): triggered by pollens
• Perennial: triggered by year-round allergens

Chronic Rhinitis / Rhinosinusitis

• Chronic hypertrophic rhinitis: persistent mucosal thickening, inferior turbinate hypertrophy, nasal obstruction
• Atrophic rhinitis (ozena): mucosal atrophy, crusting, foul odor (Klebsiella ozaenae), loss of smell
• Chronic rhinosinusitis (CRS): persistent inflammation of nasal and paranasal sinus mucosa; may be with or without nasal polyps

2. Trauma of the Nose

Nasal Fracture

• Swelling, epistaxis, periorbital ecchymosis ("raccoon eyes")
• Nasal deviation, crepitus, nasal obstruction
• Tenderness over nasal bones

1. Rule out septal hematoma (urgent) — look for a unilateral bluish, fluctuant swelling of the nasal septum
2. Rule out CSF rhinorrhea (halo sign, β-2 transferrin)
3. Assess for associated orbital wall or ethmoid fractures
4. Nasal radiographs are NOT routinely needed — they will not alter treatment — Roberts and Hedges' Clinical Procedures in Emergency Medicine

• Immediate reduction (<3 hours from injury) if minimal edema and simple fracture
• Delayed reduction 3–10 days post-injury in children, 6–10 days in adults, once edema resolves but before fracture consolidation
• Fractures >3 weeks old should not be reduced in the ED

3. Epistaxis

Epidemiology and Anatomy

1. Sphenopalatine artery (from external carotid via internal maxillary): supplies turbinates, posterior/inferior septum — most commonly implicated in posterior epistaxis
2. Anterior and posterior ethmoidal arteries (from ophthalmic branch of internal carotid): supply superior mucosa
3. Superior labial branch of facial artery (external carotid): supplies anterior mucosal septum

Causes / Risk Factors

Note on hypertension: Studies have NOT established a direct causal relationship between hypertension and epistaxis. Elevated BP seen with epistaxis is most often a stress response. Antihypertensive treatment is only urgent if there are signs of a true hypertensive emergency. — Roberts and Hedges'

Initial Assessment

• Hemodynamic stability: vital signs, orthostatic symptoms, estimate blood loss
• Start IV access and fluid if significant hemorrhage
• CBC, coagulation studies (only if on anticoagulants, known coagulopathy, or recurrent/prolonged epistaxis)
• Identify bleeding source: anterior vs. posterior (history + nasal speculum exam)
• Topical anesthesia + vasoconstrictor (e.g., oxymetazoline, cocaine 4%, or lidocaine + phenylephrine) before procedures

4. Anterior Tamponade (Anterior Nasal Packing)

Step-by-step Approach

1. Merocel sponge (nasal tampon): Insert dry, along the floor of the nasal cavity parallel to the hard palate. Expand with 5–10 mL of saline. If it has a drawstring, tie around a gauze to prevent posterior displacement.
2. Rapid Rhino device: Soak in sterile water (NOT saline — saline inhibits its hydrocolloid gelling) for 30 seconds. Insert along the floor parallel to the hard palate. Inflate with air only (not saline/water) until the pilot cuff is rounded and firm.
3. Traditional petroleum gauze packing: Layer accordion-style into the nasal cavity from floor to roof using bayonet forceps.

5. Posterior Tamponade (Posterior Nasal Packing)

Posterior Gauze Pack (Classic Method)

1. Anesthetize the nares and posterior pharynx with topical anesthetic.
2. Prepare a rolled gauze with two silk ties (2-0) — one pair to pull through the nose, one to remain oral for removal.
3. Pass a No. 10 red rubber catheter through the bleeding nostril; retrieve it from the oropharynx with forceps.
4. Attach catheter to the silk ties on the gauze pack; retract catheter to carry the pack into the nasopharynx.
5. Guide the pack manually into position. Attach the oral silk tie to the cheek.
6. Place anterior packing in addition.
7. Secure nasal silk ties over a gauze pad/dental roll to maintain posterior pack position.

Inflatable Balloon Packs (Preferred — Easier, Better Tolerated)

• Insert 12-Fr Foley catheter through the bleeding naris into the nasopharynx
• Inflate balloon halfway with 5–7 mL saline, then pull forward to seat against the posterior choana
• Finish inflating, then place anterior packing to prevent forward migration

• Posterior balloon inflated first to tamponade the nasopharynx
• Anterior balloon then inflated to compress the nasal cavity
• Easier to use than gauze, less distressing to patients

6. Septal Hematoma

• Bilateral nasal obstruction (blood collects on both sides of the cartilage)
• Purple/dusky, fluctuant, "grape-like" swellings on the septum
• Significant nasal pain (unlike simple deviation)
• Saddle-nose deformity if left untreated (avascular necrosis of cartilage)

• Avascular necrosis of septal cartilage → saddle-nose deformity
• Secondary infection → septal abscess
• Septal perforation, nasal valve collapse

• Quilting sutures or nasal packing (bilateral)
• Incising a piece of mucosa before packing to provide drainage
• If it reaccumulates: repeat drainage

7. Septal Abscess

• Secondary infection of a septal hematoma (most common)
• Nasogastric tube injury to septum
• Furunculosis
• Direct extension from sphenoiditis
• Dental infection
• Iatrogenic (post-septoplasty)

• Severe nasal pain and tenderness
• Fever, malaise
• Widened septum with bilateral dusky/erythematous, fluctuant swellings
• Complete nasal obstruction
• Erythema of the nasal vestibule

• Saddle-nose deformity (cartilage necrosis)
• Nasal valve collapse
• Facial cellulitis / preseptal cellulitis
• Cavernous sinus thrombosis (via facial vein/pterygoid plexus)
• Orbital extension / orbital cellulitis
• Intracranial extension: epidural abscess, meningitis, intracranial abscess
• Sepsis

1. Prompt surgical incision and drainage (operative)
2. IV antibiotics — empiric coverage for S. aureus (including MRSA consideration) and gram-negative organisms; guided by intraoperative cultures
3. Bilateral drainage with nasal packing after I&D
4. Close monitoring for intracranial/orbital complications

Summary Table

Acute and Chronic Diseases of the Paranasal Sinuses — Conservative and Surgical Treatment — Rhinogenic Complications

1. Anatomy and Pathophysiology Overview

2. Classification

3. Acute Rhinosinusitis (ARS)

Etiology

• Viral (most common): Rhinovirus, influenza, parainfluenza — CT changes present in uncomplicated viral URI, but these resolve spontaneously
• Bacterial (superimposed, ~2% of viral URIs):
  • Streptococcus pneumoniae (most common, ~31%)
  • Haemophilus influenzae (~21%)
  • Moraxella catarrhalis (especially children)
  • Staphylococcus aureus (including MRSA)
  • Anaerobes (in odontogenic sinusitis)
• Fungal: Rare in immunocompetent; acute invasive fungal sinusitis in immunocompromised (see complications)

Risk Factors

• Viral URI, allergic rhinitis (most important)
• Anatomic: septal deviation, turbinate hypertrophy, nasal polyps, adenoid hypertrophy, foreign body
• Immunodeficiency, cystic fibrosis, primary ciliary dyskinesia (Kartagener syndrome)
• Dental disease (odontogenic sinusitis → maxillary sinus)
• Cigarette smoking, cocaine use, GERD
• Barotrauma (swimming, diving, flying)

Clinical Features

• Persistent symptoms ≥10 days without improvement ("double worsening" — initial improvement then recurrence)
• Severe onset: fever ≥39°C + purulent nasal discharge + facial pain for ≥3–4 consecutive days
• Facial pain/pressure/fullness, especially unilateral and maxillary
• Purulent anterior or posterior nasal discharge
• Nasal obstruction/congestion
• Hyposmia/anosmia

• Tenderness over affected sinus (maxillary, frontal, ethmoid)
• Purulent discharge in middle meatus (on nasal endoscopy)
• Erythematous, edematous nasal mucosa

• Pain (facial pressure, headache)
• Obstruction (nasal blockage)
• Discharge (purulent)
• Smell (decreased olfaction)

Conservative (Medical) Treatment of ARS

• Nasal saline irrigation: isotonic or hypertonic saline — reduces mucosal edema, clears secretions, improves mucociliary function
• Intranasal corticosteroids (e.g., mometasone, fluticasone): reduce mucosal edema, facilitate ostial drainage; modest benefit in ARS
• Topical nasal decongestants (oxymetazoline): maximum 3–5 days to avoid rebound rhinitis medicamentosa
• Analgesics (NSAIDs/paracetamol) for pain
• Steam inhalation, adequate hydration

• Indicated when symptoms persist ≥10 days, are severe, or worsen after initial improvement
• First-line: Amoxicillin-clavulanate (preferred over amoxicillin alone given prevalence of β-lactamase-producing organisms)
• PCN allergy: Doxycycline, or respiratory fluoroquinolone (levofloxacin, moxifloxacin)
• Duration: 5–7 days for uncomplicated ARS
• Reserve broad-spectrum agents for treatment failures, severe disease, or immunocompromised patients

Most acute sinusitis resolves without antibiotics. Overprescription drives resistance. Antibiotics hasten recovery by only ~0.5–1 day in mild-to-moderate cases. — Textbook of Family Medicine 9e

4. Chronic Rhinosinusitis (CRS)

Definition and Classification

• CRS without nasal polyps (CRSsNP): Predominantly neutrophilic; more associated with anatomic obstruction, infection, and smoking
• CRS with nasal polyps (CRSwNP): Predominantly eosinophilic, Th2-driven; associated with allergy, asthma, and aspirin sensitivity (Samter's triad)

Medical (Conservative) Treatment of CRS

1. Intranasal corticosteroids — cornerstone; reduce polyp size, mucosal edema; must be continued long-term
2. Nasal saline irrigation — twice daily; essential adjunct
3. Systemic corticosteroids — short courses for acute exacerbations, polyposis, or presurgical optimization
4. Antibiotics — for acute exacerbations; longer courses (3–6 weeks, macrolides such as clarithromycin or azithromycin at anti-inflammatory doses) may be used for CRS without polyps
5. Antihistamines / leukotriene antagonists — for allergic component
6. Antifungal therapy — limited evidence; reserved for allergic fungal sinusitis (voriconazole, amphotericin B for invasive disease)
7. Biologic agents (dupilumab, mepolizumab, omalizumab) — for refractory CRSwNP with type 2 inflammation

Imaging

• CT of paranasal sinuses (without contrast): gold standard for preoperative planning and staging chronic disease. Lund-Mackay score quantifies disease extent.
• Add IV contrast when complications are suspected (orbital/intracranial spread)
• MRI — superior for distinguishing soft tissue, identifying intracranial or orbital extension, and characterizing fungal disease

5. Surgical Treatment

A. Functional Endoscopic Sinus Surgery (FESS)

"The primary objective of FESS is to restore paranasal sinus function by reestablishing the physiologic pattern of ventilation and mucociliary clearance." — Cummings Otolaryngology

• Performed through the nostrils with rigid nasal endoscopes (0°, 30°, 70°)
• Targets the ostiomeatal unit: uncinectomy, middle meatal antrostomy, anterior ethmoidectomy
• Diseased mucosa is preserved when possible; bone is removed to open drainage pathways
• Extent of surgery (partial → extended ethmoidectomy → sphenoidotomy → frontal sinusotomy [Draf I/IIa/IIb/III]) is tailored to disease extent
• Balloon catheter dilation (BCD/balloon sinuplasty): less invasive alternative for isolated maxillary/anterior ethmoid disease without polyps; preserves mucosa

B. Maxillotomy (Caldwell-Luc Operation)

• Extensive maxillary sinus disease not accessible endoscopically (e.g., antrochoanal polyps, fungal balls)
• Benign or malignant tumors of the maxillary sinus
• Foreign bodies
• Oro-antral fistula
• Failed FESS with residual maxillary disease
• Access for orbital floor repair (blowout fracture)
• Recurrent acute sinusitis with irreversible mucosal disease

1. Incision in the upper buccal sulcus (gingivobuccal fold) above the upper premolars
2. Subperiosteal elevation of the mucoperiosteum over the anterior maxillary wall (canine fossa)
3. Osteotomy through the anterior wall of the maxillary sinus (canine fossa trepination)
4. Complete inspection, curettage, and removal of diseased mucosa from the sinus
5. Creation of a nasoantral window (inferior meatus antrostomy) for drainage
6. Wound closure

C. Frontotomy (Frontal Sinus Surgery)

• Draf I: Removal of cells below the frontal ostium (agger nasi drainage); minimal
• Draf IIa: Opening of the frontal ostium between the middle turbinate and lamina papyracea (standard FESS frontal sinusotomy)
• Draf IIb: Opening from nasal septum to lamina papyracea (more extensive, ipsilateral)
• Draf III (Modified Lothrop / "Mega-antrostomy"): Combined bilateral frontal sinus drainage through a single common opening by removing the frontal sinus floor and superior nasal septum; definitive endoscopic procedure for refractory frontal sinusitis

1. External frontoethmoidectomy (Lynch-Howarth procedure): Incision along the medial canthus; removal of ethmoid air cells and frontal floor; creation of naso-frontal communication. Risk of stenosis/re-obstruction.
2. Osteoplastic flap with obliteration: Bicoronal or eyebrow incision; anterior wall of the frontal sinus is reflected as a bone flap; the sinus is completely exenterated and obliterated with fat (abdominal fat graft). Used for irreversible disease, mucoceles, or intracranial complications.
3. Trephination: Small drill-hole above the medial eyebrow to drain acute frontal sinusitis or pyocele urgently ("external frontal sinus drainage").

6. Rhinogenic Orbital Complications

Chandler Classification (1970) — Orbital Complications of Sinusitis

Microbiology

Diagnosis

• CT sinuses and orbits with IV contrast: mandatory when postseptal involvement is suspected
• Indications for urgent CT: central signs, inability to assess vision, gross proptosis, ophthalmoplegia, deteriorating visual acuity/color vision, bilateral edema, no improvement at 24 h, swinging pyrexia >36 h
• Relative afferent pupillary defect (RAPD): early sign of optic nerve compromise → urgent surgical intervention

Treatment

7. Rhinogenic Intracranial Complications

"Almost 50% of patients with intracranial complications initially present with periorbital cellulitis or frontal swelling — intracranial involvement must always be actively excluded." — Cummings Otolaryngology

Types of Intracranial Complications

Pott's Puffy Tumor

Management: IV antibiotics + external drainage (trephination/needle aspiration or open drainage) with or without sinus surgery. CT/MRI mandatory to exclude intracranial involvement. — Cummings Otolaryngology

Acute Invasive Fungal Sinusitis (Special Case)

1. Immediate frozen section biopsy
2. Emergency surgical debridement to bleeding tissue (operating room)
3. Antifungal therapy (amphotericin B for mucormycosis; voriconazole for Aspergillus)
4. Reverse immunosuppression (aggressive glycemic control, reduce immunosuppressants)
5. Infectious disease consultation

Imaging of Intracranial Complications

• CT with IV contrast: first-line; identifies bone erosion, abscess collections, hydrocephalus
• MRI with gadolinium: superior for intracranial soft-tissue detail, dural sinus thrombosis (MRV), early cerebritis, meningitis enhancement

Summary

Acute RS     → viral/bacterial → medical Rx (saline, steroids, antibiotics PRN)
Chronic RS   → OMU obstruction → AMT → FESS (first-line surgery)
                                     → Caldwell-Luc (maxillary, open access)
                                     → Frontotomy/Draf III (frontal, refractory)

Complications:
  Orbital: Chandler I→V (preseptal → cellulitis → subperiosteal abscess → orbital abscess → CST)
  Intracranial: meningitis → epidural abscess → subdural empyema → brain abscess → sinus thrombosis
  Frontal bone: Pott's puffy tumor
  Immunocompromised: acute invasive fungal sinusitis (emergency debridement)