PANCE Blueprint EENT (7%)

Sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleed, direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis

TX: Most nosebleeds are anterior and stop with direct pressure

• Apply direct pressure at least 10-15 minutes, seated leaning forward
• Short-acting topical decongestants (Afrin, phenylephrine, cocaine)
• Anterior nasal packing 
  • Patients with nasal packing must be treated with antibiotics (cephalosporin) prevent toxic shock syndrome and patient has to return to take the packing out.
• If there is no packing in the nose, place a small amount of petroleum jelly or antibiotic ointment inside the nostril 2 times a day for 4–5 days
• Posterior balloon packing is used to treat posterior epistaxis. These patients must be admitted to the hospital and prompt consultation with an otolaryngologist is indicated
• Recurrent epistaxis: Must rule out hypertension of hypercoagulable disorder

• Samter's triad:
  1. asthma 
  2. aspirin sensitivity
  3. nasal polyps
• Usually benign, often with allergic rhinitis. Consider Cystic Fibrosis when multiple polyps are seen
• Chronic congestion and decreased sense of smell

TX: Topical nasal corticosteroid (3-month course) is the initial treatment choice. This is effective for small polyps and can reduce the need for surgical intervention.

• Oral steroids (6-day taper) can also help reduce the size
• Surgical removal may be necessary if therapy is unsuccessful or if polyps are large

TX: Avoid any known allergens and use antihistamines, cromolyn sodium, nasal or systemic corticosteroids, nasal saline drops or washes, and immunotherapy

• Intranasal decongestants not to be used more than 3-5 days may cause rhinitis medicamentosa

• Viral: Most common, symptoms < 7 days. Bacterial: Symptoms 7+ days and associated with bilateral purulent nasal discharge.
• Organisms: S. pneumoniae, H. influenzae, M.catarhalis. Chronic: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard
• Chronic = lasts 12 weeks or longer

TX: Indications for antibiotics in rhinosinusitis include the duration of symptoms >10 days without improvement. Treatment five to seven days

• Amoxicillin (500 mg orally three times daily or 875 mg orally twice daily) or amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily)
• Penicillin-allergic: Doxycycline 100 mg orally twice daily or 200 mg orally daily
• Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance of S. pneumoniae
• kids Amoxicillin x 10-14 days

Chronic sinusitis: Therapy is typically given for at least three weeks and may be extended for up to ten weeks in refractory cases

• Amoxicillin-clavulanate: 875 mg twice daily or two 1000 mg extended-release tablets twice daily
• Pen allergic: Clindamycin 300 mg four times daily or 450 mg three times daily

TX: Prior to removal consider using oxymetazoline drops to shrink the mucous membrane