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15.4 Nose/Paranasal Sinuses Conditions

Table of Contents

15.4.1 Acute Rhinitis

It is a viral inflammatory condition in the nasal mucous membrane, usually part of a more wide-spread infection of the upper respiratory tract.

Non-Pharmacological Treatment

  • Bed rest& warm drinks

Pharmacological Treatment

A: Ephedrine nasal drops (1% for adults and 0.5% for children) 1–2 drops into each nostril 6 hourly for not more than 5 days

Note: Oral drugs to reduce swelling of the mucous membrane, antihistamines and antibiotics are not indicated

15.4.2 Allergic Rhinitis

It is an irritation of the nasal mucosa by an allergen in a previously sensitized individual. Common allergens include house dust (mite’s feaces), pollens, cockroach antigen, animal dander, moulds (in-door)

Diagnostic Criteria

  • Itchy nostrils, throat, eyes
  • Watery nasal discharge
  • Nasal congestion
  • Sneezing

Investigations:

  • Anterior rhinoscopy – watery nasal discharge, nasal congestion

Pharmacological Treatment:

Avoidance of an allergen (if possible)

A: Cetrizine (PO) 10mg daily for adults until when symptoms have improved.

Children aged 2–6 years: 5mg daily until when symptoms have improved

AND

C: Beclomethasone (two puffs each nostril once daily) until symptoms have improved

15.4.3 Adenoid Hypertrophy

It is hypertrophy of the lymphoid tissues in the nasopharynx; presenting with mouth breathing, snoring and otitis media with effusion. It is reported mainly in children.

Investigations: Nasopharynx lateral view X-ray.

Pharmacological Treatment:

A: Cetrizine (PO) 10mg nocte for 2 weeks. Children: 5mg nocte for 2 weeks

AND

B: Normal saline (Sodium chloride 0.9%) nasal spray/drops 4 hourly for 2 weeks

AND

A: Phenoxymethylpenicillin (PO) 500mg 8 hourly for 7 days. Children up to 5 years: 6 mg/kg 6 hourly for 10 days

OR

C: Azithromycin (PO) 500mg once daily for 3 days. Children: 10mg/kg once daily for 3 days

OR

B: Amoxicillin+Clavulanic acid (PO)

Adults: 625mg (500mg amoxicillin+125mg Clavulanic acid) 8 hourly for 7 days

Children: 375mg (250mg amoxicillin+ 125 Clavulanic acid) 12 hourly for 7 days;

AND

A: Paracetamol (PO) 1gm 8 hourly until fever is controlled:

Children 10 mg/kg body weight 8 hourly until fever is controlled

15.4.4 Acute Rhinosinusitis

It is the inflammation of the mucosal lining of the nose and paranasal sinuses of not more than 12 weeks duration. In sinusitis of dental origin, anaerobic bacteria are often found.

Acute Purulent Rhinosinusitis

Bacterial infection with pus accumulation in one or more of the paranasal sinuses

Diagnostic Criteria

  • Anterior rhinoscopy – watery/purulent nasal discharge occasionally foul smelling
  • Nasal congestion
  • Plain paranasal sinuses X ray (Water’s, Caldwell views)
  • Mucosal thickening; air fluid levels

Pharmacological Treatment:

A: Phenoxymethylpenicillin (PO) 500mg 8 hourly for 7 days. Children up to 5 years: 6 mg/kg 6 hourly for 10 days

OR

A: Azithromycin (PO) 500mg once daily for 3 days. Children: 10mg/kg once daily for 3 days

OR

B: Amoxicillin+Clavulanic acid (PO)

Adults: 625mg (500mg amoxicillin+125mg Clavulanic acid) 8 hourly for 7 days Children: 375mg (250mg amoxicillin,+125 Clavulanic acid) 12 hourly for 7 days;

Note: Treatment periods shorter than ten days increase the risk of treatment failure

Referral: To ENT Specialists

  • Children with ethmoiditis presenting as an acute periorbital inflammation or orbital cellulitis must be hospitalized immediately
  • Adults with pronounced symptoms despite treatment
  • If sinusitis of dental origin is suspected
  • Recurrent sinusitis (>3 attacks in a year) or chronic sinusitis (duration of illness of >12 weeks)

15.4.5 Nose Bleeding (Epistaxis)

Nose bleeding is a condition which is common in adults. It may be due to a local cause in the nasal cavity (e.g. trauma, tumor, foreign body, septal varisces, or septal deviation); or a systemic cause (e.g. blood disorders, vascular disorders, renal failure, hepatic failure, or use of anticoagulants (warfarin, heparin). Most cases of epistaxis are minor; do not require hospitalization. Patients with significant nose bleeding do require hospitalization.

Non-Pharmacological Treatment

  • Stabilize the patient: put an open intravenous line, do blood grouping and cross matching
  • Put the patient in a sitting position and advise the patient to pinch the soft part of the nose gently for 5 minutes
  • Put on a gown, glasses, head light and sterile gloves and evacuate clots.Do a thorough head and neck examination
  • Cauterize septal varisces (if any) using a silverex stick
  • Do an anterior nasal packing by introducing into the nasal cavity as far posterior as possible sterile Vaseline gauzes (or iodine soaked gauzes if not available) using a dissecting forcep (if bayonet forcep is not available)
  • Put rolled dry gauze on the collumela and plaster it

If the patient is still bleeding

  • Do a posterior nasal packing using a Foley’s catheter introduced through the nasal cavity into the oropharynx, balloon it with normal saline up to 10–15cc while pulling it outward to impinge on the posterior nasal choana, then do anterior nasal packing as above
  • Put dry gauze on the nose to prevent necrosis of the collumela and fix the catheter on the nose with an umbilical clamp
  • Almost all of the nasal bleedings will be controlled by this way

Note: Remove the packs after 72 hours

Pharmacological Treatment (to prevent rhinosinusitis)

A: Phenoxymethylpenicillin (PO) 500mg every 8 hours for 7 days. Children up to 5 years: 6 mg/kg 6 hourly for 10 days

OR

A: Azithromycin (PO) 500mg once daily for 3 days. Children: 10mg/kg once daily for 3 days

OR

C: Amoxicillin/Clavulanic acid (PO)
Adults: 625mg (500mg amoxicillin+125mg Clavulanic acid) 8 hourly for 7 days
Children: 375mg (250mg amoxicillin+125 Clavulanic acid) 12 hourly for 7 days;

PLUS

A: Paracetamol (PO) 1gm 8hourly until fever is controlled

Children 10 mg/kg body weight 8 hourly until fever is controlled

NOTE: Putting an ice cube on the forehead, extending the neck or placing a cotton bud soaked with adrenaline in the vestibule will not help

Referral: refer the patient to the next facility with adequate expertise and facilities if:

  • he patient is still bleeding repack and refer immediately
  • Failure to manage the underlying cause, refer the patient

15.4.6 Foreign Bodies in the Nose

This situation usually occurs in children.

Non-pharmacological treatment:

  • Restrain the child before removal using a cerumen hook, if the child cannot be restrained sedation is advised

NOTE: A unilateral foul smelling nasal discharge in a child is due to a foreign body until proven otherwise

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