Otorhinolaryngology (ENT)
Epistaxis, Nasal Polyps and Sinusitis
Epistaxis, nasal polyps and sinusitis for MBBS ENT: Little's area bleeding, ethmoidal and antrochoanal polyps, Samter triad, acute and chronic sinusitis, mapped to NMC codes EN4.
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Epistaxis, Nasal Polyps and Sinusitis
Epistaxis, nasal polyps and sinusitis for MBBS ENT: Little's area bleeding, ethmoidal and antrochoanal polyps, Samter triad, acute and chronic sinusitis, mapped to NMC codes EN4.
This chapter brings together three common nasal problems. It covers epistaxis and its control, the types of nasal polyps and their associations, and acute and chronic sinusitis with their management and complications, emphasising the red flags that separate benign disease from tumour.
High-yield: Epistaxis, Nasal Polyps and Sinusitis
- Most nosebleeds are anterior and arise from Little's area (Kiesselbach's plexus) on the anterior nasal septum.
- Posterior epistaxis, often from the sphenopalatine artery, is heavier, commoner in older hypertensive patients and harder to control.
- First aid for epistaxis is to sit forward, pinch the soft part of the nose and apply pressure for several minutes.
- Persistent anterior bleeding can be controlled by cautery or anterior nasal packing; posterior bleeds may need posterior packing or balloon.
- Recurrent unilateral epistaxis with nasal obstruction in an adolescent boy should raise suspicion of juvenile nasopharyngeal angiofibroma.
- Ethmoidal (inflammatory) polyps are usually bilateral, pale, insensitive and mobile, and are associated with allergy and asthma.
- An antrochoanal polyp is usually a single polyp arising from the maxillary sinus, commoner in young people and typically unilateral.
- Samter triad is nasal polyps, asthma and aspirin sensitivity.
- Acute sinusitis presents with facial pain, purulent nasal discharge and blocked nose, often following a viral cold.
- Maxillary sinusitis is the commonest sinus infection because the sinus drains against gravity through an ostium high on its medial wall.
- Chronic rhinosinusitis is diagnosed when symptoms persist beyond twelve weeks and is confirmed on nasal endoscopy or CT of the sinuses.
- Functional endoscopic sinus surgery restores ventilation and drainage of the sinuses in chronic disease that fails medical treatment.
- Complications of sinusitis include orbital cellulitis, orbital abscess and, rarely, intracranial spread.
- A unilateral nasal polyp in an adult should be biopsied to exclude a tumour before assuming it is benign.
Epistaxis and polyps, key contrasts
- **Anterior epistaxis:** Little's area on the septum. Common in children. Controlled by pressure or cautery.
- **Posterior epistaxis:** Sphenopalatine artery. Older hypertensive patients. May need posterior packing.
- **Ethmoidal polyps:** Bilateral, multiple, associated with allergy and asthma.
- **Antrochoanal polyp:** Single, unilateral, from the maxillary sinus, commoner in the young.
NMC competencies in this chapter
- **EN4.25:** Epistaxis: causes, first aid and management
- **EN4.30:** Nasal polyps: types, features and management
- **EN4.33:** Acute and chronic sinusitis and its complications
Frequently Asked Questions
Where does most nasal bleeding come from?
From Little's area on the anterior nasal septum, where several arteries anastomose as Kiesselbach's plexus. This is the site of most anterior nosebleeds.
How do I do first aid for a nosebleed?
Sit the patient forward, pinch the soft part of the nose firmly and hold pressure for several minutes. Leaning back is avoided so blood is not swallowed or aspirated.
What is Samter triad?
The combination of nasal polyps, asthma and aspirin sensitivity. Recognising it warns you that aspirin and similar drugs may worsen the airway disease.
Why must a unilateral nasal polyp be investigated?
A single unilateral polyp in an adult can hide a tumour or an antrochoanal polyp, so it should be examined and biopsied rather than assumed to be benign inflammatory disease.
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