Acute Nose Disorders



The nose being highly vascular with communications with intracranial venous sinuses, it is highly prone for emergencies due to trauma, infections and allergy.


Foreign Body Nasal Cavity Inferior Turbinate Maxillary Sinusitis Cavernous Sinus Thrombosis 
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The nose being highly vascular with communications with intracranial venous sinuses, it is highly prone for emergencies due to trauma, infections and allergy.

Applied Anatomy

  • The nasal cavity is a triangular space and the anterior nares are at the antero-inferior corner. There is a tendency to assume the nose to be a pair of tubes. The posterior end of the nasal cavity – the choana – is wider; hence, an FB in the nose is predisposed to slipping backwards.

  • The choana houses the adenoids, which is big in paediatric age group and is a cause for mouth breathing, epistaxis and ear pain [1].

  • The antero-inferior aspect of the nasal septum is the Little’s area – the junction of many blood vessels and the Kiesselbach’s plexus, the commonest source of epistaxis.

  • The inferior turbinate is often mistaken for a nasal polyp or foreign body.

  • The inferior turbinate on either lateral wall is erectile tissues. They have reversible engorgement capability and function as protectors of the respiratory system, by filtering and holding large particles in the inspired air. They also control the flow of air and moisturise the inspired air.

  • The dangerous area of the face is a triangle with the angles of mouth including the upper lip at the base and the apex at the root of nose [1]. Venous drainage from this region is communicating through the ophthalmic vein with the intracranial venous sinuses by veins which have no valves. Bacterial infections of this region can lead to cavernous sinus thrombosis.


  • Epistaxis is one of the commonest emergencies in ENT encountered by the emergency physician; this could range from trivial bleeding due to nose picking to being an expression of malignancy in the nose or nasopharynx (Table 22.1).
    Table 22.1

    Aetiology for epistaxis




    Nasal block





    Bleeding diathesis

    Chronic sinusitis/neoplastic

    Septal granulation

    Tumour benign/malignant

  • Irrespective of the aetiology, the management is by standard techniques and protocols.


  • Keep the patient seated and provide a bowl to hold under the nose or to spit blood from the mouth.

  • Establish IV access.

  • Examine and attempt to locate bleeding point which is often not possible, because of active bleeding. Further, there may not be a visible pathology like granulation or aberration. The bleeding point could be hidden posteriorly.

  • Pinch the nose (Hippocrates technique) – Both alae nasi are apposed against the nasal septum with index finger and thumb firmly for at least 5 min, while breathing is continued through the mouth. If available, ice cubes wrapped in cloth should be applied over the nose.

Anterior Nasal Packing

  • Thudicum’s nasal speculum and nasal dressing forceps are ideal for this procedure.

  • Seat the patient on a bed and stand by the side.

  • Use a good source of illumination, for evaluation.

  • Ensure universal precautions – mask, gloves and eyewear.

  • Have suction (with fine-tipped Frazier nozzle) available at the bedside.

  • Apply a cotton pledget, soaked with oxymetazoline or phenylephrine (nasal decongestants), and apply pressure. Alternatively, the medication can be sprayed into the nostril.

  • Roller gauze soaked in a combination of povidone-iodine, lignocaine and Inj. Adrenaline solution (2 % and 1:100,000, respectively) is ideal.

  • Packing should commence from the posterior inferior end of the nostril, from the floor of the nose until the nostril is completely packed.

  • The anterior tip of the roller pack should be accessible for later removal.

  • Packing should be bilateral. The patient should be asked to breathe through the mouth.

  • Maintain the pack for a maximum of 24 h.

  • If available, commercial nasal packs could be utilised.

  • If prior to packing, a bleeding point is identified over the Little’s area, cauterisation with endoscopic bipolar cautery; trichloroacetic acid in 10 % dilution or 75 % silver nitrate may be utilised. Silver nitrate leaves behind black discoloration of the skin [2].

  • While using materials for cautery, care should be taken not to touch healthy mucosa.

Postnasal Packing

  • In case of bleeding from the posterior aspect of the nasal cavity, posterior nasal packing is necessary [3].

  • Temporary postnasal tamponade can be achieved by the following technique:

  • A pair of Foley’s catheters is passed, one into each of the nostrils, until the balloon tip is visualised against the pharyngeal wall.

  • Inflate the bulb with 5–15 ml normal saline.

  • Retract the catheter gently, until it hitches snugly against the posterior nasal cavity.

  • Apply a padded umbilical clamp across catheter, to prevent the balloon from dislodging.

  • Proceed with anterior nasal clamping, as described earlier.

  • Postnasal packing requires hospitalisation and antibiotic coverage and the pack is to be retained for about 24–48 h.

  • Rarely, embolisation of blood vessels requires to be done.


  1. 1.

    Commence empirical antibiotic therapy. The incidence of maxillary sinusitis as a sequel is significant.

  2. 2.

    Admit for 12–24 h for observation of ongoing bleeding [4].

  3. 3.
    Instruct the patient the following:
    1. (a)

      Avoid nasal manipulation or nose blowing.

    2. (b)

      Sneeze with mouth open.

    3. (c)

      Avoid vasodilating actions – physical exertion, spicy foods and alcohol consumption.

    4. (d)

      Prevent mucosal drying by applying saline nasal sprays several times per day.

    5. (e)

      Return for review and removal of tamponade after 24 h.


Foreign Body (FB) in the Nose

  • Commonly a paediatric emergency, FB can be of three types:
    • Miscellaneous objects – plastic or rubber components of toys, buttons, eraser rubber, sponge, etc.

    • Biological materials – vegetable seeds, rubber sponge, etc.

    • Chemical contents – capsules, tablets, chalk pieces, button cells, etc.

Clinical Features

  • Known history of insertion of FB.

  • Bleeding from the nose.

  • Nasal discharge and block on one side – Unilateral nasal discharge in children is almost always a FB unless proven otherwise.

  • Obtain history of attempted removal, since there could be:
    • Trauma to mucosa and the presence of blood clots obscuring the view of the FB

    • The FB would have relocated posteriorly and impacted.

    • The child has undergone unpleasant experience and hence would be uncooperative.

  • Neglected vegetable FBs are often foul smelling due to stagnation and bacterial activity. They tend to develop granulation around them and would bleed on touch.

FB Removal

  • Most of the FBs can be removed in the ED. Holding the child in proper position is important (Fig.  24.3).

  • Reassure the child and explain the possibility of the FB getting pushed backwards into the oropharynx and being swallowed.

  • Prepare for GA in case the FB is not able to be removed by this technique.

  • Nasal endoscope is a useful tool in unusual foreign body.


  • A long instrument blunt and curved at the tip is ideal. The nasal suction with curved tip, or a curved artery forceps, could be utilised. The instrument has to be passed upwards and backwards to get behind the FB and once behind adequate force can be used as traction to pull the FB.

  • Similarly, a size 6 F Foley’s catheter, smeared with lignocaine jelly, passed beyond the FB, inflated to fill the nasal cavity adequately and pulled forwards to bring the FB forwards, is a safe and effective alternative [5].

  • Always look for more than one FB.

  • After the procedure, pack the nasal cavity with a gauze roll, soaked with lignocaine to control persistent ooze, if present.

Septal Haematoma

  • Septal haematoma is clearly visualised on examination, as a smooth bulge of the septum.

  • There can be a history of trivial trauma or painful furuncle of the nose.

  • Management is drainage by incision anteriorly and suction of the haematoma. The 2 mm incision is made vertically over the anterior part of the septal bulge; minimal dilatation of the opening done with a mosquito artery forceps and a thin nasal suction is used to suck out the serous fluid/altered blood/purulent collection [6].

  • Bilateral anterior nasal packing with roller gauze is to be performed and retained for 48 h.

CSF Rhinorrhoea

  • The patient presents with clear watery nasal discharge on bending down.

  • There may be a history of head injury that can be even trivial or history of nasal surgery.

  • Associated symptoms can be headache, fever with chills and rigours indicating probable intracranial infections.

  • There need not be a finding of rhinitis, unless there is associated sinus disease.

Filter Paper Test

  • With the patient bending forwards, collect a few drops of the fluid on a blotting paper. If the drops are due to CSF leak, the filter paper would exhibit the double-ring sign – a central circle of blood and an outer clear ring of CSF [7].

  • Collect the fluid directly in a sterile container, and subject it to biochemical analysis. The enzyme B2Tr is produced by neuraminidase activity of the brain and is present in CSF, perilymph and ocular aqueous humour but not in sinonasal mucous secretions and tears.

  • Immunoelectrophoretic assay of beta-trace protein has been reported to have high specificity and sensitivity for CSF detection.

  • Contrast enhanced CT scan to look for any lesion in the brain and the nasal cavity and to locate the leak. The leak is better demonstrated in contrast enhanced CT by injecting contrast in the spinal fluid.

  • Management: Most of CSF leaks close spontaneously within 7–10 days.

  • Conservative management includes absolute bed rest, medication to reduce intracranial pressure such as mannitol and broad spectrum antibiotic, if indicated.

  • There is no role for empirical antibiotic therapy in CSF leak. If signs of meningitis such as fever with rigours are observed, and there is no other cause for fever, CSF analysis to detect the pathogen and antibiotic sensitivity should be carried out.

  • Surgical management is by endoscopic CSF leak repair.

Management of epistaxis


  1. 1.
    Korathanakhun P, Petpichetchian W, Sathirapanya P, Geater SL. Cerebral venous thrombosis: comparing characteristics of infective and non-infective aetiologies: a 12-year retrospective study. Postgrad Med J. 2015;91(1082):670–4.Google Scholar
  2. 2.
    Douglas R, Wormald PJ. Update on epistaxis. Curr Opin Otolaryngol Head Neck Surg. 2007;15(3):180–3.CrossRefPubMedGoogle Scholar
  3. 3.
    Viehweg TL, Roberson JB, Hudson JW. Epistaxis: diagnosis and treatment. J Oral Maxillofac Surg. 2006;64(3):511–8.CrossRefPubMedGoogle Scholar
  4. 4.
    Leong SC, Roe RJ, Karkanevatos A. No frills management of epistaxis. Emerg Med J. 2005;22(7):470–2.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785–92.CrossRefPubMedGoogle Scholar
  6. 6.
    Sayn I, Yazc ZM, Bozkurt E, Kayhan FT. Nasal septal hematoma and abscess in children. J Craniofac Surg. 2011;22(6):17–9.CrossRefGoogle Scholar
  7. 7.
    Burns BJ. Images in emergency medicine. Traumatic cerebrospinal fluid leak. Ann Emerg Med. 2008;51(6):704. 706.CrossRefPubMedGoogle Scholar

Copyright information

© Springer India 2016

Authors and Affiliations

  1. 1.ENT Surgical ClinicPondicherryIndia
  2. 2.Head, Department of Emergency MedicinePushpagiri Medical College HospitalTiruvallaIndia

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