Nose bleed

The following points in the history are important for the management of a patient with a nose bleed:

age of patient

number of bleeding episodes

sensation of blood in the throat

amount of blood/duration of bleeding

previous history of epistaxis, trauma, nasal surgery

family history of bleeding disorder

anticoagulant, NSAID, aspirin, cocaine use

other significant medical conditions, e.g. IHD, COPD, hypertension, coagulopathy.

When examining the patient try to locate the side of the bleeding, look at the linearity of the nose (if asymmetrical, is this due to recent trauma?); check the appearance of the septum and Little’s area. The latter is the area of the septum seen through the nostrils when the nasal tip is tilted upwards (Fig. 11.1). Blood vessels in Little’s area are prone to bleeding. Check the throat for blood running down the nasopharynx. Ensure you get a set of vital signs and examine the cardiovascular system looking for any indication of shock.

Fig. 11.1 Little’s area of the nasal septum (reproduced with permission of Mr Kim Ah-See, ENT Consultant, Aberdeen).

The treatment of epistaxis is dependent on the site of the bleeding and the experience of the healthcare professional.

If bleeding has stopped by the time of presentation or ceases with the simple first aid measures (TIP) and the vital signs are normal no further treatment is necessary. If it is a recurrent bleed antibiotic nasal cream should be prescribed. Recurrent nose bleeds in children tend to be caused by digital trauma to Little’s area. In adults remember to check blood pressure. If elevated, ask them to attend the GP for further management.

If the bleeding fails to respond to simple first aid measures packing should be applied to the nasal cavity from which the bleed is suspected to have originated. The simplest pack and the easiest to insert is the nasal tampon (Fig. 11.2). However, the nose can be packed with ribbon gauze if available and the healthcare professional is competent at the procedure. Nasal tampons are supplied small and flat but expand and take on the contours of the cavity when they are hydrated with either blood or saline. The leading edge of the nasal tampon should be lubricated prior to insertion. It should then be inserted in a horizontal plane into the nasal cavity. If the nasal tampon does not expand with the blood in the nose, saline should be dripped onto the external end of the nasal tampon until it expands and causes compression. The thread of the tampon should be secured with tape and a nasal sling may be applied to soak up any excess blood.

Fig. 11.2 Nasal tampon (reproduced with permission of BASICS Scotland).

If anterior packing fails to stop the bleeding after 15 minutes a posterior bleed should be suspected (approx. 5% of bleeds). These require packing using a long nasal tampon, an epistaxis balloon or a Foley catheter with an anterior pack depending on what is available (Fig. 11.3). Long (posterior) nasal tampons are inserted in the same way as an anterior tampon. Some epistaxis balloons have an anterior and posterior balloon. The balloon is lubricated with saline and inserted, again in a horizontal plane. The posterior balloon is inflated to the recommended volume, gentle traction is applied to position the balloon in the posterior nasal space and then the anterior balloon is inflated to the recommended volume. Foley catheters and single balloon epistaxis catheters are inserted in the same way but do not have an anterior balloon and therefore an anterior pack is necessary. The Foley catheter must be secured with care taken to prevent pressure necrosis of the nasal tissues. All patients with a posterior bleed require admission (Box 11.3). If a large volume of blood has been lost, oxygen, venous access and fluid resuscitation may be necessary.

Fig. 11.3 Posterior and anterior nasal tampons, deflated and inflated double balloon epistaxis catheters and single posterior space epistaxis balloon catheter (reproduced with permission of BASICS Scotland).

Box 11.3 Patients with a nose bleed – who needs to go to hospital?

All patients with a posterior pack must be admitted to hospital. They require analgesia and close monitoring particularly of vital signs and O₂ saturations

All patients with a personal history of bleeding disorder must be admitted to hospital

Patients with a history of recent nasal surgery should be discussed with the appropriate surgical team

Patients taking anticoagulants may be treated in the community if a recent INR is known and over-anticoagulation is not suspected

Patients with an anterior pack and significant other medical illness such as angina or COPD should be considered for admission for close monitoring depending on severity of co-morbid conditions. By packing the patient’s nose we cause respiratory compromise that may lead to exacerbations of pre-existing illnesses

Epistaxis precipitated by trauma and where a facial or nasal fracture cannot be excluded should be referred to hospital

Sore throat

Several features need to be elicited when dealing with patients with sore throats:

duration?

previous episodes or recent surgery?

response to previous treatments?

one side or both?

associated features or other symptoms (associated symptoms may lead to a particular diagnosis)?

ability to swallow food, liquid, saliva?

halitosis?

drugs which may cause agranulocytosis, candidal overgrowth or Stevens–Johnson syndrome?

occupational exposure to physical irritants?

When examining the throat look at the appearance of the tonsils and surrounding tissue. If swelling is present, is it bilateral or unilateral? Is there pus or exudate present on the tonsils (tonsillitis or glandular fever)? If the patient has had recent tonsillar surgery does the tonsillar bed look sloughy, infected or bleeding? Is there peritonsilar redness or swelling (peritonsilar cellulitis)? Look at the appearance of the pharynx – does it look red (pharyngitis), are there any white spots (candida) or ulcerated areas? Can the patient swallow or are they drooling saliva? Is trismus (spasm of the pterygoid muscles preventing opening of the mouth) present (quinsy)? Does the patient have features of systemic toxicity or lymph nodes?

Pharyngitis/tonsillitis/glandular fever/candida

Most sore throats (90–95%) are viral in nature and require only symptomatic treatment with fluids and an antipyretic analgesic. Mild cases of bacterial tonsillitis, commonly from streptococci, will also respond to this conservative treatment. However, if the patient has significant fever, nausea and vomiting and no signs of a viral URTI (upper respiratory tract infection) the use of antibiotics can be argued. The choice of antibiotic should be penicillin V or erythromycin initially for 10 days. Shorter treatment durations have been associated with recurrent and early relapse of the infection.

There is no test available to differentiate glandular fever from tonsillitis at initial emergency presentation. Therefore the initial treatment is the same as for tonsillitis. Amoxicillin based antibiotics should be avoided if glandular fever is suspected as it can cause a generalised macular rash. If the patient is unable to swallow fluids or their own saliva hospital admission for assessment and intravenous antibiotics will be necessary.

Candidal sore throats can be suspected on history and confirmed on examination by the presence of white plaques adherent to the mucosa of the palate and gums (Fig. 11.4). Treatment is with a topical antifungal such as nystatin. If the patient is immunocompromised then systemic antifungals may be necessary.

Fig. 11.4 Candidal infection of throat (reproduced with permission of the BMJ Publishing Group from Emerg Med J 2005 22:128–139).

Peritonsillar cellulitis and quinsy

Both of these conditions are complications of bacterial tonsillitis and should be suspected in someone whose sore throat gets substantially worse and who becomes more unwell than is usual with an uncomplicated tonsillitis. Peritonsillar cellulitis is the presuppurative stage of quinsy – a localised collection of pus above the tonsil. A patient with either condition will complain of a severe unilateral sore throat and difficulty swallowing. The patient may also complain of ipsilateral (on the same side) ear pain and pain on movement of the neck. Examination of the throat will reveal a very swollen, red area above and to the side of the inflamed tonsil. The uvula (the tissue that hangs down from the roof of the mouth at the back of the palate) may be pushed to one side. Enlarged cervical lymph nodes are the cause of the neck pain. If peritonsillar cellulitis is the diagnosis there will be relatively little trismus. If trismus is a feature, quinsy should be suspected. There may be a change to the quality of the voice. Treatment may require drainage, intravenous antibiotics and fluids. Suspected cases need to be referred to hospital for assessment and treatment (Box 11.4).

Box 11.4 Patients with a sore throat – who needs to go to hospital?

Patients with severe tonsillitis with systemic upset and inability to swallow should be admitted for IV antibiotics and fluid. Pain on swallowing, on its own, is not an indication for hospital admission

Patients with quinsy should be admitted to hospital for incision and drainage

Patients with suspected Stevens–Johnson syndrome should be admitted to hospital

Stevens–Johnson syndrome

This is a rare multisystem illness with widespread vesiculobullous lesions and erosions of the mucous membranes associated with erythema multiforme of the skin (Fig. 11.5). The highest incidence is in the 20–40-year age group; it is twice as common in males and is more common in spring and autumn. Infection (especially Mycoplasma and herpes simplex), drugs (especially antibiotics and anticonvulsants) and malignancies are common precipitating factors; 50% of cases have no identifiable aetiology. Suspected cases should be referred to hospital for assessment as many will require ITU or HDU care.

Fig. 11.5 Stevens–Johnson syndrome (reproduced with permission of the BMJ Publishing Group from Emerg Med J 2005 22:128–139).

Non-ENT causes of sore throat

Angina can present with pain in the throat or jaw related to physical exertion. Consider this in middle aged and older patients, with or without a previous history of ischaemic heart disease, with a normal throat examination and no other ENT symptoms. Patients with suspected angina should have an ECG and be given sublingual nitrate (see Chapter 3).

Gastro-oesophageal reflux disease can present with a sore throat and persistent cough. Examination often reveals pharyngitis. Consider this in older, overweight individuals with a persistent sore throat with or without a history of dyspepsia.

Tobacco usage – heavy smokers may develop a chronic pharyngitis with pain.

Occupational irritants – fumes from some chemicals can cause a chronic pharyngitis.

Figure 11.6 shows the sore throat treatment algorithm.

Fig. 11.6 Sore throat treatment algorithm.

Sore ears/discharging ears

Painful ears are a common complaint, particularly in young children. The pain may originate from the ear itself or be referred from another site. There are some important features to establish about the pain to help make the diagnosis:

is there a discharge?

associated symptoms, e.g. coryza, symptoms of systemic toxicity?

one ear or both?

previous episodes, previous surgery or recent ear syringing?

do you use cotton buds?

recent swimming, diving or flying?

is there any associated hearing loss?

When examining the ear look for the presence of scars; for deformity of the pinna; at the appearance of external auditory canals; at the appearance of tympanic membranes. Feel for lymph nodes. Does tugging on the pinna or pressure on the tragus cause discomfort (otitis externa/furunculosis) – look behind the pinna at the skin over the mastoid process for swelling or redness; feel for tenderness (mastoiditis).

Otitis externa/furunculosis

Otitis externa

is an inflammation (usually infective) of the external auditory canal, which can spread to the pinna, periauricular soft tissues, or even the temporal bone. It is common in patients with eczematous ear canal skin and in those who produce trauma with cotton buds. Streptococci, staphylococci, pseudomonas and fungi are the usual infecting organisms. Pressure on the tragus or gentle tugging on the pinna (Fig. 11.7) will cause discomfort. In the early stages the canal is tender and red and there may be a slight watery discharge. As the condition progresses there may be oedema of the canal and accumulation of debris. Treatment is with topical antibiotic and steroid combination drops and simple analgesia. Any associated cellulitis should be treated with systemic antibiotics.

Fig. 11.7 Tugging on the pinna in an upward and backward direction to try and elicit discomfort caused by external auditory canal problems (reproduced with permission of BASICS Scotland).

Furunculosis

is an infection of a hair follicle. When this occurs in the outer ear canal it causes severe throbbing pain. Examination of the ear canal may reveal a red lump with or without pus. The abscess may rupture itself or may in severe cases require incision and drainage. Simple analgesia is the only initial treatment necessary with advice to see the GP if not improving within 48 hours.

Otitis media

Acute otitis media (AOM) is usually a short-term inflammation of the middle ear and is principally characterised by earache, irritability and ear tugging in children. Loss of hearing may also occur due to effusion in the middle ear. It is often preceded by upper respiratory symptoms, including cough and rhinorrhoea. Systemic symptoms can also be present depending on the severity of the illness. Otoscopic appearances typical of AOM include bulging tympanic membrane with loss of landmarks, changes in membrane colour (typically red or yellow) and perforated tympanic membrane with discharge of pus.

The cause of acute otitis media may be viral or bacterial in origin. Viruses are present in about 40–75% of infections and often precede or co-exist with bacterial infections. The main bacteria responsible are Streptococcus pneumoniae (40%), Haemophilus influenzae (25%) and Moraxella cattarhalis (10%). Effusion is a common complication of AOM but severe complications including mastoiditis are exceedingly rare. Mastoiditis has been found to occur in less than 1 in 1000 children with untreated AOM.

AOM is usually a self-limiting condition. About 80% of AOM will resolve within 3 days without antibiotic treatment. Although there is no definitive consensus on the optimum treatment of AOM in children, the available evidence suggests that antibiotic treatment should not be offered routinely. The mainstay of treatment is analgesia. Both paracetamol and ibuprofen are adequate analgesics. Parents should be reassured and involved in discussions of the pros and cons of antibiotic treatment. A ‘wait and see’ approach may be a good compromise for some people. A prescription for antibiotics can be issued on the day of consultation but not be redeemed unless the condition has not resolved after 72 hours. This has been found to be effective and feasible in two studies.^1,2 Although antibiotics should not be routinely prescribed, the following indications may support their selective use:

child under 2 years

bilateral AOM

systemic symptoms including high temperature and vomiting

local signs (such as tympanic perforation and discharge of pus) that suggest the infection is severe.

The recommended antibiotics for uncomplicated AOM are shown in Table 11.2.

Table 11.2 Recommended antibiotics for uncomplicated AOM

Antibiotic treatment	AOM first line	AOM second line (treatment failure)
No penicillin allergy	Amoxicillin	Co-amoxiclav
Penicillin allergy	Azithromycin Erythromycin Clarithromycin	Azithromycin if erythromycin used first-line OR seek specialist advice from local microbiologist

There is currently no consensus on the optimal length of treatment with antibiotics for acute otitis media; however the available evidence (Box 11.5) suggests that a 5-day course of antibiotics is usually adequate with the exception of azithromycin where 3 days use is sufficient because of its unique pharmacokinetics. The treatment of AOM with antihistamines and decongestants is not recommended.

Box 11.5 Evidence for the treatment of otitis media

The 2004 SIGN guideline on otitis media³ found that 17 children need to be given antibiotics for one child to benefit from resolution of symptoms

A Cochrane review⁴ gave the NNT as approximately 15

Another systematic review⁵ including more studies of younger children suggests the NNT is 8

The clinical impact of antibiotic treatment in children under 2 years of age may be greater than in older children⁶ but the frequency of adverse effects seen with antibiotics used to treat AOM may be as high as the NNT required to produce a clinical benefit^7,8

Non-ENT causes of ear pain

If there is nothing to find on physical examination of the ear the pain may be referred. There are no causes which need out-of-hours treatment but the patient requires simple analgesia and should be told to see their own GP for further assessment.

Figure 11.8 shows the sore ear treatment algorithm.

Fig. 11.8 Sore ear treatment algorithm.

Foreign body

Foreign bodies in the nose and ear are common in children. A foreign body in the nose, unless impacted, may be inhaled and cause airway compromise. The best way of removal from the nose is to encourage the patient to blow it out themselves, although this can be very difficult in children. An alternative is to cause pressure behind the object to dislodge it. This can be done either by the parent blowing into the child’s mouth whilst occluding the unaffected nostril or by using a bag valve mask to produce the pressure. The swift puff of air forces the foreign body down the nostril. If this does not work and there is a risk of inhalation further assistance should be sought. Foreign bodies in ears are not such a potential problem and routine attendance to GP or A&E is sufficient advice.

Difficult/noisy breathing

See Table 11.3

Epiglottitis

This is a life-threatening condition caused by Haemophilus influenzae infection of the epiglottis. It is now much less common since the advent of Hib vaccination but can occur in those who have not been immunised. Though usually seen in 3–7-year-olds it can occur in adults. The onset of symptoms is rapid with high fever and sore throat being the earliest features. The patient can then develop stridor (a harsh, high-pitched, musical sound produced by turbulent airflow through a partially obstructed airway) and the voice may be muffled or absent. Tachycardia, tachypnoea, swallowing difficulties and drooling may then ensue. The patient will appear toxic, apprehensive and pale. Often they sit upright, leaning forward with neck extended, mouth open and jaw thrust forward – in an attempt to maximise the diameter of the airway. There is usually no cough. Cyanosis, shock, loss of consciousness and complete airway obstruction will ensue unless intervention by a senior ENT surgeon is instigated immediately. Do not attempt to examine the throat. Refer immediately to a hospital with ENT facilities and warn of suspected diagnosis. Give oxygen but do not cause distress and allow the patient to maintain their upright posture. Be prepared to manage the airway en route if necessary. Continue to reassess ABCs during transfer.

Croup

Laryngotracheobronchitis is usually a viral infection. It may be mild or severe and the child can quickly develop respiratory distress. Occurring mainly between the ages of 6 months and 3 years you should suspect if there is pyrexia, a painful barking cough and stridor. All children under the age of 1 year should be admitted to hospital. If there are features of severe respiratory distress (Box 11.6) the child should be admitted to hospital irrespective of age.

Box 11.6 Features of severe respiratory distress

Cyanosis

Agitation

Extreme dyspnoea

SpO₂ <93% in air

Marked use of accessory muscles with marked intercostal and subcostal recession and fatigue

Steroid treatment should be initiated if not admitting the child. A single dose of soluble prednisolone 20 mg or alternative can be given. The child should be reassessed 2–4 h later to ensure the stridor is not worsening. If there is severe airway obstruction nebulised epinephrine (5 ml of 1:10 000 or 1 ml of 1:1000 diluted to 5 ml with saline) can be given and rapid transport arranged. Severe respiratory distress can come on quickly and the healthcare professional should be prepared to intubate and ventilate in the case of respiratory arrest.

Vertigo⁹

Vertigo, an illusion of movement, is the cardinal symptom of vestibular dysfunction. Vertigo is typically rotational, but it can be an illusion of tilting to one side or swaying. It is common for acute vertigo to cause a feeling of imbalance during standing or walking. Patients want to lie still and avoid movement. Acute vertigo is accompanied by nausea, vomiting, and autonomic distress of varying degrees of severity. The difficulty is separating the peripheral (otogenic) causes from a central cause (Table 11.4). Peripheral conditions causing vertigo can include external auditory canal obstruction, middle ear infection or trauma, Meniere’s disease and vestibular neuronitis. Central problems presenting with vertigo are usually more serious than the peripheral ones and can include cerebellar infarct or haemorrhage, intracranial space-occupying lesions and demyelinating disease.

Table 11.4 Differentiating between peripheral and central vestibular disorder

May be:

May be unable to walk without falling

Meniere’s syndrome

Patients with Meniere’s syndrome occasionally present with an isolated episode of severe vertigo that lasts for hours and is followed by a sensation of unsteadiness and dizziness for days. Typically, however, the vertigo is preceded or accompanied by reduced hearing, tinnitus that changes in pitch in association with the episode and a sense of fullness or blocking of the ear. Over time, the attacks of Meniere’s syndrome recur, and fluctuations in hearing and episodes of tinnitus may be followed by a residual, low-frequency, sensorineural hearing loss. Fluctuating hearing levels associated with recurrent episodes of vertigo are central to the diagnosis of Meniere’s syndrome. Examination of the ear may show deafness but ENT examination is otherwise normal and CNS examination is normal.

Vestibular neuronitis

Vestibular neuronitis is a clinical syndrome characterised by the acute onset of rotatory vertigo, which is associated with spontaneous nystagmus, postural imbalance and nausea without accompanying cochlear or neurological symptoms. It typically begins over a period of a few hours, peaks in the first day, and then improves within days. Disabling vertigo usually resolves within a week, but it may be followed by a sensation of unsteadiness or transient episodes of dizziness. Complete recovery from the symptoms usually occurs within weeks to months.

Benign paroxysmal positional vertigo

This is the commonest cause of vertigo. The classic symptoms include vertigo that appears with a few seconds latency when changing position of the head in space. The vertigo fades in 30–60 seconds. The dizziness is combined with a nystagmus beating in the direction of the affected canal. The condition is caused by debris in the semicircular canals.

Cerebrovascular event

Cerebellar TIAs or CVAs can present with vertigo. Symptoms are usually sudden onset and associated with nystagmus, ataxia and subtle co-ordination problems. Other neurological manifestations may or may not be present. Co-ordination can be assessed using the finger–nose test, hand tapping and heel–shin test. Hearing loss and tinnitus tend not to be features and examination of the ear is normal. Patients with an acute cerebellar stroke are often unable to walk without falling. Current recommendations are that all patients with suspected TIA or CVA are admitted to hospital for further investigation and treatment. However, unless the vertigo is particularly disabling or there are social reasons admission can be delayed if there is diagnostic uncertainty. If a decision is made not to admit, the patient will require to see a GP within 24 hours.

Other central causes usually present insidiously.

Sinusitis

Sinusitis can be viral or bacterial. Sinusitis presents with facial pain, blocked nose, mucopurulent nasal discharge and anosmia (loss of sense of smell). Referred pain may be present in teeth and ears. Evidence-based treatment consists of simple analgesia/NSAID, reduction of congestion and antibiotic treatment – usually amoxicillin as first line.¹⁰

Dental abscess

Patients with a dental abscess often present with a unilateral swollen throbbing face. Treatment should be provided by a dental practitioner ASAP. However, advice regarding analgesia may be given.

Non-ENT causes of facial pain

Shingles may present with unilateral facial pain before the onset of blisters. Blisters associated with shingles are always unilateral. Patients should be advised to take simple analgesia and contact their own GP within 72 hours of the onset of any blisters (see Chapter 12). Trigeminal neuralgia can present with paroxysms of severe unilateral pain in the trigeminal nerve distribution lasting only seconds, separated by pain-free periods. The pain is often described as severe electric shocks. Contraction of the facial and masticatory muscles during an episode may occur. It should be treated with simple analgesia in the first instance and advice to see their GP.