NOSE:

A.  Sinusitis

Etiolgy:

1. Caused by Streptococcus pneumoniae, Haemophilus influenze, Branhamella catarrhalis, Staphylococcus aureus and Streptococcus pyogenes.
    
2. Predisposing factors:  Anatomic abnormalities (congenital and acquired, tumor, granulomatous disease, mucosal hypertrophy, foreign body, trauma, etc.), mucosal ciliary dysfunction, bacterial colonization, immunodeficiency.

1. Radiography:  Acute sinusitis in the absence of complications does not warrant an immediate CT scan.
    
2. Any patient with orbital changes, mental status changes, gross physical abnormalities, or suspicion of tumor should undergo CT with IV contrast.  Note:  IV contrast is not used for noncomplicated cases of sinusitis.  Plain film Xray's should not be obtained.  Most otolaryngologists use primarily CT ( yet this "overreads").

1. Treatment of acute sinusitis involves antimicrobial therapy and decongestant therapy for relief of symptoms.
    
2. For uncomplicated cases of sinusitis, first line therapy involves the use of Amoxicillin (up to 90mg/kg/d) for 7-10 days. 
    
3. For treatment failures or multiple courses of prior antibiotics, a second generation cephalosporin, amoxicillin-clavulanate, a  flouroquinolone, or macrolide antibiotic should be employed for at least 10 days, up to 3 weeks.
    
4. Decongestant therapy is aimed at relieving symptoms.
    
5. Nasal saline irrigation, oxymetazoline (for no more than 3 days), a topical nasal steroid, and pain medication may be prescribed
    
6. Recurrent or recalcitrant sinusitis should be referred to an otolaryngologist.
    
7. It is important to recognize the complications of sinusitis. Patients should be evaluated for   periorbital/orbital cellulitis or abscess, cavernous sinus thrombosis, meningitis, intracranial abscess, mucoceles or mucopyoceles. If these complications are suspected, emergent CT and otolaryngology  consult should be obtained.

B.  Epistaxis

Etiology:

1. 90% originate from anterior 1/3 of septal area - Kiesselbach's plexus
    
2. Posterior epistaxis originates from sphenopalatine artery and it's tributaries
    
3. Superior bleeding - from anterior and posterior ethmoidal arteries.
    
4. Local and/or Systemic factors can contribute to epistaxis:
    
1. Local: trauma, FB, toxin, tumor, infection, sudden pressure change, dryness, nose picking (epistaxis digitarum).
    
2. Systemic: HTN, blood dyscrasia, vascular disease, nephritis, ASA, warfarin, hemophilia

1. Pt's Vitals (BP, pulse, mentation) and ABC must be addressed and if  indicated two large bore IVs are inserted and blood drawn (if indicated by hx) for CBC, PT/PTT, T&X.
    
2. Pt is instructed to pinch the nose for 5 min. Pinching can be done with two fingers or, if pt gets tired, take two tongue depressors, tape the end of both and clip the free end on the nose with a dressing applied between the nose and the tongue depressors.
    
3. If above maneuver is not helpful, apply on a tip of a gauze 2% Lidocaine, 4% cocaine or phenelephrine hydrochloride, insert it  into the nose and re-pinch it x 5 min.
    
4. Visualize the area. If bleeding vessel is noted, cauterize it with silver nitrate starting with area around the vessel first. Absorbable packing (gelfoam, surgicel) is then placed. Note!!! Cauterization shouldn't be performed on hemophilic pt. Like any other trauma this may cause more bleeding.
    
5. If blood continues to ooze - a non-absorbable packing (xeroform gauze, Merocel) is then used. These  pts, when DC home, must be prescribed systemic Staph. covering  antbx.
    
6. As mentioned above, if anterior epistaxis is well controlled yet pt still c/o trickling blood into pharynx,  posterior epistaxis is assumed and, in the ER, Foley catheter is placed into the nares, Inject  5-10 ml to  inflate  balloon and pulled back to create pressure and tamponade of the vessel. Clamp the Foley. Cut and discard the rest. Pack with petrolatum gauze around Foley to avoid pressure ulcers. These pts must have STAT  ENT consult and, due to apnea reflex, must be admitted to ICU.
    
7. Pts that are successfully DC from ER, must be instructed to use humidified air,  avoid sneezing/ blowing nose, head-bed  elevation, avoid ASA, avoid Valsalva (stool softeners may be indicated), avoid bending and heavy lifting. FU with ENT must be emphasized.

C.  Nasal Trauma

1. The most common bony injury of the face are the nasal bones. Altercations, MVA's, and falls are the most common mechanisms.
    
2. The patient presents with or  without nasal deformity, epistaxis, nasal obstruction, and pain.
    
3. The bony nasal dorsum is examined for symmetry, crepitus, pain, hematoma, and discoloration. The skin overlying the nasal bones should be examined for lacerations or abrasions.  An examination for other fractures and injuries should be performed.  Ethmoid/Cribriform can be broken due to transmitted forces and give CSF leak (see "Maxilofacial" section).
    
4. The cartilagenous septum should be examined for signs of a hematoma (the septum appears swollen, tense, may be pale or bluish in color).
    
5. Xray or CT is not necessary. CT is only performed if other fractures of the facial bones are suspected.  Xray images do not change the treatment of nasal fractures and are often over and under-read.
    
6. Treatment consists of:
    
1. The standards of ABC's.
    
2. Skin abrasions are treated with a topical antibiotic ointment.  Lacerations are closed in two layers (5-0 or 6-0 nonabsorbable sutures are removed in 3-4 days).
    
3. If a septal hematoma is present, the inferior margin is incised (after injection with 1% lidocaine), the hematoma evacuated, and a small piece of iodoform gauze is placed to act as a drain.  The nasal cavity is then packed with nonabsorbable packing and the patient is started on antibiotics.  Epistaxis is controlled with silver nitrate for identifiable bleeding vessels, or packing for diffuse bleeding.  Uncontrollable epistaxis may require reduction of any fracture for control of bleeding.  The nasal fracture itself may be reduced either immediately, or up to 2 weeks after the fracture by the otolaryngologist.  Ice packs for 24 hours, decongestants, and analgesics may be administered.

D.  Furunculosis/Cellulitis

1. Staphylococcus aureus is the typical infectious agent.  Trauma from picking, scratching, shaving, or hair pulling may result in a secondary infection.
    
2. Symptoms:  a painful, tense, raised, erythematous lesion.  May occur in any area of hair bearing skin.  Most commonly occurs in the nasal vestibule.  May progress to a spreading superficial cellulitis in addition to an abscess.
    
3. The main concern is the prevention of further complications such as cavernous sinus thrombosis.
    
4. Treatment consists of penicillinase resistant antibiotics, warm compresses, head of bed elevation, pain medication, and incision and drainage for any pointing abscess.  Topical antibiotic ointment may also be applied.

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