Approach to Sinusitis & Nose Bleeds

Approach to Sinusitis & Nose Bleeds 2018-01-30T16:37:04+08:00

Differential diagnosis

  • Infective
    • Upper respiratory tract infection
    • Lower respiratory tract infection
    • Sinusitis
    • Human immunodeficiency virus infection
    • Syphilis – catarrhal rhinitis
  • Allergic rhinitis
  • Inflammatory
    • Nasal polyps
    • Eosinophilic vasomotor rhinitis
    • Wegner’s granulomatosis
    • Churg-Strauss syndrome
  • Neoplastic
    • Nasopharyngeal carcinoma
    • Lymphoma (malignant granuloma)
  • Traumatic
    • Foreign body
    • Fracture of nasal bones
    • Inhalation of toxic fumes
  • Hereditary haemorrhagic telangiectasia

History

  • Characterize the nasal discharge
    • Is the blood coming from your nose, or only when you cough?
    • How long has this been going on for?
    • Have you noticed that anything in particular makes it worse?
    • How long does each episode last?
    • Have you had this problem before?
  • Infective
    • Have you had a cold or sore throat recently?
    • Did you have a problem with recurrent colds when you were younger?
    • Do you find that your nose is always blocked?
    • Is there any pain in your face?
  • Allergic
    • Do you have eczema?
    • Do you have asthma?
    • Does anyone in your family have eczema, asthma or problem with runny noses?
  • Inflammatory
    • Have you recently taken aspirin (vasomotor rhinitis)?
    • Have you noticed any fevers?
    • Do you have any joint pain?
    • Is there any numbness or weakness in your hands or feet?
    • Have you noticed any blood in your urine?
  • Neoplastic
    • Have you lost any weight?
    • Is the discharge always blood-stained?
    • Have you noticed any swellings in your neck?
    • Have you noticed any difficulty in pronouncing words?
    • Have you noticed any double vision?
  • Have you had any injuries to your nose or face recently?
  • Sexual history (HIV, syphilis)
    • Are you sexually active?
    • How many partners do you have?
    • Are your partners male or female?
    • Do you use any illicit drugs?
  • Do you smoke?

Examination

  • General appearance (cachectic suggests underlying malignancy)
  • Sinus tenderness
  • Nose
    • Nasal polyps
    • Dried blood
  • Inflammatory
    • Joint pains
    • Ulcers in the nasal cavity
    • Ulcers of the mouth
    • Anterior uveitis
  • Respiratory
    • Listen for crackles (alveolar haemorrhage vs pulmonary fibrosis)
  • Neurological (nasopharyngeal carcinoma)
    • Extra-ocular movements
    • Elevation of the soft palate
    • Trapezius, sternocleidomastoid strength
    • Tongue deviation

Investigations

  • Blood tests
    • Full blood count
      • Anaemia of chronic disease in malignancy
      • Leukocytosis in infection
    • ANCA if inflammatory granulomatous disease suspected
  • Chest radiograph to look for infective process
  • Nasal swab
  • Skull x-ray if trauma
  • Magnetic resonance imaging if neurological deficit

Management

  • Patient education
  • Avoidance of allergens
  • Nasal decongestant
  • Immunosuppression for granulomatous disease
    • Screening for other complications – renal, neurological, pulmonary
  • Referral to ENT for nasendoscopy and biopsy if NPC suspected

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