PANCE Blueprint EENT (6%)

ReelDx Virtual Rounds (Epistaxis)

Kiesselbach's Plexus or Little's Area is the most common site for anterior bleeds

The sphenopalatine artery (Woodruff’s plexus) is generally the source of severe posterior nosebleeds. Direct pressure for 15 minutes, posterior balloon packing is used to treat posterior epistaxis

DX: The majority do not require testing other than direct visualization

• Patients with symptoms or signs of a bleeding disorder and those with severe or recurrent epistaxis should have CBC, PT, and PTT.
• CT may be done if a foreign body, a tumor, or sinusitis is suspected.

TX: Most nosebleeds are anterior and stop with direct pressure

• Apply direct pressure for at least 10-15 minutes, seated and leaning forward
• Short-acting topical decongestants (Afrin, phenylephrine, cocaine)
• Anterior nasal packing 
  • Patients with nasal packing must be treated with antibiotics (cephalosporin) to prevent toxic shock syndrome, and the 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 or coagulation disorder (like vWD)

Teardrop-shaped growths that form in the nose or sinuses

• 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

DX: Diagnosis is clinical

• Patients may complain of chronic congestion and a 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

ReelDx Virtual Rounds (Rhinitis)

Rhinitis is inflammation of the nasal mucosa characterized by sneezing, nasal congestion, runny nose (rhinorrhea), and postnasal drip

• Types include:
  • Allergic rhinitis (IgE-mediated mast cell histamine release, seasonal or perennial)
  • Viral (infectious) rhinitis (common cold)
  • Nonallergic rhinitis (vasomotor, hormonal, medication-induced)
• Allergic rhinitis presents with sneezing, clear rhinorrhea, nasal congestion, itchy eyes/nose, allergic shiners, and often atopic comorbidities (e.g., asthma, eczema)
• Physical exam may reveal pale, boggy nasal turbinates, allergic shiners, and a transverse nasal crease

DX: Diagnosis is clinical; skin testing or serum IgE testing may help confirm allergen sensitivities

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

• Intranasal corticosteroids (first-line for allergic rhinitis)
• Antihistamines (oral or intranasal)
• Decongestants (short-term use only)
  • Intranasal decongestants (e.g. Afrin) should not be used for more than 3-5 days, as they may cause rhinitis medicamentosa
• Allergen avoidance and immunotherapy in selected cases
• Nonallergic rhinitis may be triggered by temperature changes, strong odors, medications, or hormonal shifts
  • Vasomotor rhinitis responds well to intranasal iproptrium bromide
• Complications include sinusitis, sleep disturbance, and impaired quality of life

Allergic shiners

Allergic salute with transverse nasal crease

After URI. Sinus pain/pressure (worse with bending down and leaning forward). Facial tap elicits pain.

• 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 = lasts 12 weeks or longer

DX: Plainview X-ray (waters view) is a good initial screening, CT is the Gold Standard

TX: Indications for antibiotics in rhinosinusitis include the duration of symptoms >10 days without improvement, onset of fever > 102.2 and purulent nasal discharge or facial pain > 3-4 days, and worsening of symptoms after viral URI > 5-6 days that was initially improving

• Amoxicillin-clavulanate 875 mg/125 mg orally twice daily (x 7 days adults and 14 days pediatrics)
• Penicillin-allergic: Doxycycline 100 mg orally twice daily (x 7 days adults and 14 days pediatrics)

**Macrolides (clarithromycin or azithromycin) and trimethoprim-sulfamethoxazole are not recommended for empiric therapy because of high rates of resistance to S. pneumoniae

Risk for resistance or antibiotic failure

• Augmentin 2 g PO BID (x 7 days adults and 14 days pediatrics)
• Levofloxacin 750 mg PO daily once daily x 7 days

Chronic rhinosinusitis (CRS) lasts 12 weeks or longer despite attempts at medical management. 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

Front view illustration and side-by-side CT scans of normal and chronic sinusitis

• Persistent foul-smelling purulent unilateral nasal discharge in a young child without other respiratory symptoms should raise suspicion for a retained nasal foreign body, even without a history of witnessed foreign body insertion.

DX: Diagnosis is clinical

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