The nose

Published on 23/06/2015 by admin

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14.2 The nose

Stuart Lewena, Gervase Chaney

Rhinitis and sinusitis

1 Acute rhinitis is common and largely due to viral infections.

2 Mucopurulent discharge does not mean bacterial infection.

3 Antibiotics might be indicated in prolonged cases of nasal discharge (> 10–14 days duration), indicating possible sinusitis.

4 Constant nasal discharge may be due to perennial allergic rhinitis.

Epistaxis

1 Epistaxis is common and largely responds to simple first aid – compression of the nose.

2 Severe cases are uncommon, but are a medical emergency, requiring nasal packing and urgent ENT referral.

3 Underlying bleeding tendency should be excluded in cases with a family history of bleeding tendency or those with severe recurrent epistaxis.

Nasal trauma

1 Nasal trauma is common.

2 Most injuries will require little or no intervention. However, a careful examination to exclude septal haematoma is essential.

3 Septal haematoma requires urgent ENT referral.

4 Acute assessment can be difficult and a review, once the swelling has settled, is required to manage any deformity.

Rhinitis and sinusitis

Introduction

Viral upper respiratory tract infections causing rhinitis and inflammation of the upper respiratory tract are a frequent cause of febrile illness presentations amongst children to emergency departments. Children will commonly experience three to eight of these infections per year, even more if attending day care. After exclusion of more significant illness, education and symptomatic treatment is all that is required. Despite recommendations against such practice, many children will have been prescribed antibiotics. Bacterial sinusitis has been estimated as complicating only 0.5–5% of upper respiratory tract infections. Most of these will resolve without antibiotic treatment.

History

The common cold usually commences with a throat irritation and clear, thin nasal discharge and progresses to a thick, mucopurulent discharge after a few days. This does not indicate bacterial infection. Sneezing, nasal obstruction, systemic features such as malaise and low-grade fever, and cough are common. Generally the duration is about 7 days.

Persistence of mucopurulent nasal discharge without improvement for longer than 10–14 days, or more severe acute symptoms, such as high fever, headache, facial pain and/or swelling are more indicative of bacterial sinusitis.

Persistent clear nasal discharge is more likely due to perennial allergic rhinitis. This may be associated with sneeze, and itchy eyes and/or nose. Unilateral nasal discharge, particularly offensive, is suggestive of a nasal foreign body.

Examination

In rhinosinusitis, nasal discharge is the usual finding. This may be clear or mucopurulent and, as already discussed, is not indicative of cause. A red throat is a common association. In allergic rhinitis, the nasal mucosa will be pale and swollen. Facial swelling, such as orbital/periorbital and/or facial tenderness may occur in sinusitis.

Investigations

Investigations are not indicated for the common cold. Sinusitis is also a clinical diagnosis. Radiological investigations for acute sinusitis are difficult to interpret, as similar findings may be found in the common cold or even asymptomatic children. Also, the sinuses of young children are poorly developed, with frontal and sphenoid sinuses not appearing till 5–6 years of age. Radiological investigations should be reserved for those cases with suspected complications of orbital/intracranial extension, or possibly in recurrent cases.

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