Nose Procedures (Skills)

Anterior Naris

The opening outside of the nose into the nasal cavity

Turbinates

Folds in the nasal cavity that humidfry the air coming in

Superior / Middle / Inferior

What makes the floor of the nose

Hard Palate

What makes the roof the of the nose

Cribriform Plate

Chona

The opening between the nasal cavity and the pharynx

Vestibule

The cavity just after the anterior nares

What arteries flow through the nasal cavity

Anterior ethmoid

Posterior ethmoid

Sphenopalatine

Greater palatine

Superior labial

Kiesselbach plexus

A network of arteries in the anterior nasal cavity that communicates with most arteries in the nose

What artery of the nasal cavity is not communicating with Kiesselbach

Posterior ethmoid

What are the peak ages of epistaxis

< 10 years old

70-79 years old

Causes of Pediatric Epistaxis

Trauma (Digital / Injury / Foreign Body)

Inflammation / Crusting

Causes for Elderly Epistaxis

Atraumatic

Winter

Medications / Comorbidities

Local Causes of Epistaxis

Digital manipulation (#1)

Deviated nasal septum

Foreign body

Trauma

Inhaled corticosteroid use

Inhaled cocaine use

Dry air exposure: environmental and nasal oxygen

Rhinosinusitis

Environmental inhalants

Barotrauma

Nasal polyps

Nasal malignancies

What are the systemic causes of epistaxis

Inherited

Hereditary hemorrhagic telangiectasia (Osler Weber Rendu disease)

Acquired

Iatrogenically

What are the inherited causes of epistaxis

vonWillebrand disease

Hemophilia

What are the acquired causes of epistaxis

Disorders of platelet numbers/function

Hematologic malignancies

Chronic renal insufficiency

Chronic alcohol use

Hypertension

What are the iatrogenically causes of epistaxis

Aspirin, NSAIDS, other anticoagulants

Herbal medications – garlic, gingko, ginseng

What are the methods for controlling epistaxis

Nasal compression

Oxymetazoline / Phenylephrine nasal spray

Nasal cautery

Nasal packing

Embolization

Surgical Artery Ligation

Who embolizes for epistaxis

IR

Who does artery ligation for epistaxis

Otolaryngologist

What artery is usually ligated for epistaxis

Sphenopalatine

What supplies are needed for nose procedures

Otoscope or headlight

Lidocaine with epinephrine 1-4%

Cotton pledgets

Oxymetazoline (Afrin)

Phenylephrine (Neo-synephrine)

Suction collection system (Yankauer or Frazier)

Nasal packing

Silver nitrate sticks

Normal saline/saline bullets

Saline-based lubricant or antibiotic ointment

Nasal speculum

Bayonet forceps

Hemostat clamp

Kidney emesis basin

Tongue depressors

PPE

What are the steps of epistaxis control

Ensure stable airway

Obtain history – trauma, medications, systemic illness

PPE – both you and patient

Have patient blow nose

Mild Bleed = 2 sprays or Pledgets

Identify site of bleeding (See source = Cauterize)

Significant Bleed = Hold compression

Consider packing

What are the sprays used for epistaxis control

Oxymetazoline (afrin)

Phenyephrine (Neo-synephrine)

What are the pledgelets used for epistaxis control

Lidocaine with Epinephrine (1-4%)

Cocaine 4%

What agent is used for cauterizing for epistaxis control

silver nitrate

How long should you hold compression for epistaxis

At least 5 min

How do you hold compression for epistaxis

Anterior cartilaginous aspect of nose – not nasal bone

Head tilted forward

Thumb and middle finger

What are the steps of nasal cautery

Identify source of bleeding

Anesthetize the nasal mucosa with cotton pledgets or cotton balls

After visualizing the (anterior) bleeding site, silver nitrate sticks may be placed just proximal to the bleeding source on the anterior nasal septum

Use suction to help visualize the source of the bleeding

Apply silver nitrate directly to the bleeding site

Why don’t we use electrocautery for nasal bleeds

risk of septal perforation

How long do we wait between attempts of cauterization on the same side

4-6 weeks

What agent is used for antestheize for nasal cautery

1:1 mixture

0.05% oxymetazoline + 1-4% lidocaine (± Epi)

Indication for Nasal Packing

Persistent epistaxis

Contraindications for Nasal Packing

Nasal bone fracture or cribriform plate fracture

Uncontrolled airway (Shock and AMS)

Hemodynamic instability

What should be done if we think a patient has nasal bone fracture or cribriform plate fracture

Consult ENT

Where does anterior epistaxis came from

Kiesselbach plexus

What is the common disposition for anterior bleeding in the nise

Pack and discharge home if medically stable

What is the common disposition for posterior bleeding in the nise

MUST occlude choanal arch with packing

Often hospitalized

Where does posterior bleeding occur in the nose

Sphenopalatine artery

Steps to Anterior Packing

Position patient in 45-90 degree angle

Prepare all instruments and supplies

Don proper PPE for yourself

Drape patient with gown

Pretreat with topical anesthesia and vasoconstrictor

Lubricate packing

Insert packing by sliding along the floor of nasal cavity until completely in place

Inflate balloon or use saline to promote inflation of sponge

If continued bleeding, have patient pinch nose

check posterior pharynx for bleeding

Steps to Posterior Packing of the Nose

Position patient in 45-90 degree angle

Prepare all instruments and supplies

Drape patient with gown

Pretreat with topical anesthesia and vasoconstrictor

Lubricate balloon

Insert packing by sliding along the floor of nasal cavity until completely in place

Partially inflate posterior balloon slowly (1-3 cc)

Retract device until resistance encountered – balloon in choanal arch

Partially inflate anterior balloon slowly (5-6 cc)

Monitor bleeding and then slowly inflate with additional air or saline until balloon is completely inflated or bleeding controlled.

Consult ENT

Monitor vital signs

How long are nasal packing left int

2-3 days

Where are nasal packing removed

ED

ENT outpatient

What is the post-procedure care for nasal packing

Follow up in 2-3 days

Consider Abx prophylaxis for TSS and infection

Patient Education

What is the patient educaiton for post-nasal packing

Return to ED with continued bleeding

Discuss methods to stop bleeding at home (compression, oxymetazoline)

Humidification, saline based lubrication,

avoid nose picking

Follow-up with PCP/cardiology if anticoagulants have been stopped

Complications from Nasal Packing

Infection (sinus or systemic) and toxic shock syndrome

Septal perforation

Airway compromise

Nasal packing becomes dislodged or leak

Recurrent bleeding

Pressure necrosis

Severe pain

Anxiety

Hypoxia

Cardiac dysrhythmias

What complications of nasal packing are specific to posterior packing

Hypoxia

Cardiac dysrhythmias

Management of Recurrent Epistaxis

Refer to ENT for rhinoscopy

Indications for Nasal Foreign Body Removal

– Any time there is a foreign body in the nose

Contraindication for Nasal Foreign Body Removal

Unable to protect airway

Supplies for Nasal FB removal

Oxymetazoline or phenylephrine and 1-4% lidocaine

Headlight

Instruments – nasal speculum, alligator forceps, curette, Frazier suction, Katz extractor

Steps to Nasal FB removal

Patient should be seated at 45 – 90-degree angle

Assess type of foreign body and come up with plan

Patient should occlude unaffected nostril and blow out

Prepare nose with oxymetazoline and lidocaine (+/-) depending on object

Remove item with instrument, suction

When do we refer nasal FB to ENT

Patient uncooperative

Unsuccessful attempt at removal x 2

FB unable to be visualized

When should the patient call the office post- nasal FB removal

fever,

unilateral purulent nasal drainage,

persistent nasal obstruction,

epistaxis

nasal pain

How many attempts are given to remove nasal FB

2