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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3113_Библиотеки_им_академика_М_И_Перельмана
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348 SYMPTOM SORTER
Ready reckoner
Viral croup Epiglottitis Laryngitis Obstruction Laryngeal paralysis
Very sudden onset No Ye s No Ye s No
Continuous stridor Possible Ye s No Yes Ye s
Toxic and feverish Possible Ye s No No No
Drooling saliva No Ye s No No No
Very sore throat No Ye s No Possible No
Possible investigations
ere are no investigations likely to be performed in primary care. e following might be
performed in hospital: FBC (WCC raised in infection), lateral X-ray of pharynx (enlarged
epiglottis in epiglottitis), CXR (may show foreign body, distal collapse or external compression
of larynx or trachea) and laryngoscopy (for direct visualisation of the larynx).
TOP TIPS
In practice, the rst step is to exclude those conditions requiring immediate admission
(epiglottitis or inhaled foreign body), leaving a probable diagnosis of vira l croup. Management
then depends on the child ’s general condition – in particular, the level of respiratory distress.
Children with viral croup may have marked stridor and some recession when crying. It is
reasonable to observe such children at home provided these signs disappear when the child
is settled.
When managing a child at home, make absolutely sure that the parents understand the signs
of deterioration. If in doubt, arrange review.
e toxic child with low-pitched stridor (oen not marked), severe sore throat or diculty
in swallowing, and respiratory distress has epiglottitis until proved otherwise. Admit
immediately and do not examine the throat (this can provoke respiratory obstruction).
Restlessness, rising pulse and respiratory rate, increasing intercostal recession, fatigue and
drowsiness are ominous signs – admit urgently regardless of precise diagnosis.
Consider an inhaled foreign body if the onset is very sudden and there are no other symptoms
or signs of respiratory infection.
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349
NOSE
Blocked nose 350
Nosebleed 353
Runny/discharging nose 356
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350
BLOCKED NOSE
The GP overview
is extremely common symptom is very familiar to all GPs. e most frequent cause, the
common cold, is not included here, since nasal obstruction in itself is not usually the presenting
symptom. e majority of causes of nasal obstruction are benign, but care should be taken to
consider referral in those few cases that do not respond promptly to simple treatment.
Differential diagnosis
COMMON
vasomotor rhinitis
allergic rhinitis (seasonal and perennial)
nasal polyps
adenoidal hypertrophy (in children)
nasal septal deviation (may aect 20% of adults)
OCCASIONAL
overuse of over-the-counter nasal decongestants (rhinitis medicamentosa)
chronic sinusitis
papilloma
trauma (including septal haematoma)
foreign body (especially toddlers)
RARE
iatrogenic (e.g. doxazosin)
carcinoma of nose and sinuses: squamous cell, adenocarcinoma
other rare nasal tumours (e.g. melanoma, teratoma)
unilateral choanal atresia
broangioma of puberty
https://t.me/med1917
BLOCKED NOSE 351
Ready reckoner
Vasomotor rhinitis Allergic rhinitis Adenoids Polyps Septal deviation
Sudden onset Ye s Ye s No No No
Discharge Ye s Ye s Possible Possible No
Sneezing Possible Yes No Possible No
Unilateral No No Possible Possible Ye s
Previous trauma No No No No Ye s
Possible investigations
LI KE LY: None.
POSSIBLE: Sinus X-rays, allergy tests.
SMALL PRINT: FBC, adenoid X-ray, CT scan.
Sinus X-rays may be helpful in conrming chronic sinusitis.
Allergy tests may identify sensitivities to particular allergens.
FBC: Eosinophilia in allergic rhinitis (though rarely required for diagnosis).
Adenoid X-ray: Will conrm adenoidal hypertrophy.
CT scan denes size and extent of nasopharyngeal carcinoma and sinus pathology.
TOP TIPS
Nasal obstruction is usually the cause rather than the result of recurrent sinusitis. Dealing
with the underlying problem may well relieve the sinusitis.
Nasal allergy and polyps oen coexist. It is worth trying medical treatment to relieve the
symptoms before referring for polypectomy.
Very sudden nasal blockage with profuse watery rhinorrhoea is likely to be caused by
vasomotor rhinitis.
If adenoidal nasal obstruction is present with possible hearing or speech diculties, or
possible sleep apnoea, refer with a view to adenoidectomy.
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352 SYMPTOM SORTER
Unilateral bloodstained discharge in an older patient with nasal blockage is sinister and
suggests malignancy.
So swelling on either side of the septum following trauma suggests septal haematoma. is
should be evacuated to reduce the risk of cartilage necrosis and infection.
Check what over-the-counter nasal sprays the patient has been using, remembering the
possibility of rhinitis medicamentosa.
A toddler with a unilateral nasal blockage and foul-smelling discharge is likely to have a
nasal foreign body.
NOTES:
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353
NOSEBLEED
The GP overview
is is commonest in the very young and the very old. It may present routinely as a recurrent
problem, or in the acute situation when the patient cannot control the bleeding. e latter cases
usually result in trivial haemorrhage by clinical standards, but may create a disproportionate
amount of alarm. Occasionally, a prolonged nosebleed can cause signicant hypovolaemia,
especially in the elderly.
Differential diagnosis
COMMON
spontaneous (from Little’s area; may be aggravated by nose-picking and sneezing)
nasal infection and ulceration
dr ugs (e.g. anticoagulants)
allergic rhinitis (and atrophic rhinitis)
hypertension (oen with atherosclerosis)
OCCASIONAL
nasal sprays (e.g. corticosteroids)
septal granulomas and perforations
severe liver disease
tumours of nose and/or sinuses
abnormal anatomy: septal deviation
trauma: nasal fracture
RARE
leukaemia
thrombocytopenia
coagulopathy: haemophilia, Christmas and von Willebrand’s diseases
vitamin deciencies: C and K
hereditary haemorrhagic telangiectasia
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354 SYMPTOM SORTER
Ready reckoner
Spontaneous Hypertension Infection Drugs Rhinitis
Recurrent Possible Ye s Possible Ye s Yes
Generalised bruising No No No Ye s No
Discharge or crusting No No Ye s No No
Nasal congestion No No Possible No Ye s
Soreness/pain in nose Possible No Ye s No No
Possible investigations
LI KE LY: None (INR if on warfarin).
POSSIBLE: FBC, clotting studies.
SMALL PRINT: LFT, sinus X-ray, CT scan.
FBC: To check for thrombocytopenia or other signs of blood dyscrasia.
LFT: Severe (e.g. alcoholic) liver disease causes clotting problems.
Raised INR may reect severe liver disease or warfarin overdose.
Further clotting studies: If disorders such as haemophilia or von Willebrand’s disease are
suspected.
Sinus X-ray/CT scanning (usually secondary care): If tumour a possibility.
TOP TIPS
Emergency calls for children with acute epistaxis can usually be dealt with by clear, calm
and authoritative advice on the telephone. First-aid measures should also be advised in the
elderly, but hospital referral may prove necessary, as the bleeding can be considerable and
more dicult to stop.
When children are presented in the surgery, establish any parental concerns. e main
problem is oen a fear of a blood disorder such as leukaemia rather than the inconvenience
of the symptom itself.
In young or middle-aged adults with recurrent bleeding and ulceration, consider cocaine
abuse.
Adults with recurrent epistaxis may well expect their blood pressure to be taken; either go
ahead and take it, or, if the cause is obviously not hypertension, explain why there is no need.
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NOSEBLEED 355
Severe nosebleed unresponsive to standard rst-aid measures is best dealt with in hospital –
especially in the elderly. Refer urgently to ENT or A&E.
If recurrent nosebleeds with purpuric bruising, check FBC and coagulation screen urgently.
Beware of recent onset of persistent unilateral bloodstained discharge and obstruction in the
middle-aged and elderly. Carcinoma of the nose, nasopharynx or sinus is possible.
Patients on warfarin should have an urgent INR and review of their dosage requirements.
NOTES:
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356
RUNNY/DISCHARGING
NOSE
The GP overview
ough not usually viewed as a signicant symptom, this is very bothersome to those that suer
it. Many of the pathologies overlap with the causes of the ‘Blocked nose’ – please refer to this
chapter too, as appropriate. e cause is rarely sinister, but referral for further assessment may
be necessary if it persists in spite of treatment.
Differential diagnosis
COMMON
URTI including common cold
allergic rhinitis (seasonal or perennial)
vasomotor rhinitis
sinusitis
infected nasal mucosal lesion (herpes simplex, impetigo)
OCCASIONAL
polyps
rhinitis medicamentosa
cocaine abuse
cluster headaches (though these will usually present with the pain)
chemical irritation (smoke, fumes)
nasal foreign body (usually seen in toddlers or children)
drug side eects (e.g. α-blockers, calcium channel blockers)
RARE
malignancy
CSF rhinorrhoea following head injury
barotrauma (‘sinus squeeze’)
Corynebacterium diphtheriae infection
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RUNNY/DISCHARGING NOSE 357
Ready reckoner
URTI Allergic rhinitis Vasomotor
rhinitis
Acute sinusitis Mucosal
infection
Long history No Possible Possible No No
Sneezing Ye s Ye s Possible Possible Possible
Facial pain Possible No No Ye s No
Fever Possible No No Ye s No
Purulent discharge Possible No No Ye s Possible
Possible investigations
Usually none. Sinus X-rays, CT scan and allergy tests likely to be ordered by specialist aer
referral rather than in primary care.
TOP TIPS
Use an auriscope with the largest available speculum to look into the nasal cavity – tell
patients to hold their breath or the lens will steam up.
Intermittently runny nose associated with a nasal obstruction that is dependent on position,
e.g. disappears when lying down, suggests a single nasal polyp.
Patients who describe their runny nose as ‘just like turning on a tap’ probably have vasomotor
rhinitis.
Remember to enquire about non-prescribed medication. Cocaine abuse, or the use of OTC
sympathomimetic drops may be very relevant in making a diagnosis; and the response to any
OTC treatments such as intranasal steroids might help guide diagnosis and further treatment.
https://t.me/med1917
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