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Nose: epistaxis 77
OSCE Counselling cases
OSCE COUNSELLING CASE 2.1 –
What advice should you give to an
adult male who is coming into hospital
and has had his nose packed?
The patient should be advised that he will be in hospital between 2 and 3 days. The packing will be in
place for 1 to 2 days and may be painful when removed. The patient should also be advised that there
might be some fresh bleeding and clots when the packs come out. It is important to stress that a few
simple investigations will be done to check the clotting status and this may require treatment as well.
OSCE COUNSELLING CASE 2.2 –
A single mother has a child aged
3 years with profuse intermittent
nosebleeds, which occur at night
It is important to stress that the bleeding always looks a lot worse than the actual amount lost. A simple
analogy – that a cup of coffee or a glass of wine looks more when spilt – will often sufce. It is also
worthwhile stressing that children often rub the blood on their face while they are having nosebleeds.
Counsel the mother that it is perfectly easy to stop most nosebleeds by sitting the child up, asking him
to breathe through the mouth and squeezing the cartilaginous part of the nasal septum between the
thumb and forengers for 10 minutes (see Figure2.2). Treatment can entail cautery or Naseptin cream,
although episodes of bleeding that are uncontrollable with conservative measures require cautery to
arrest haemorrhage.
REVISION PANEL
Both adults and children bleed primarily from the anterior septum – Little’s area.
Elderly patients can bleed from the posterior nasal cavity.
Diagnosis includes identifying the bleeding point and excluding other local and systemic
conditions.
Epistaxis can typically be controlled with squeezing the anterior external nose.
If epistaxis does not stop with local pressure, nasal cautery is usually effective. Occasionally nasal
packing and artery ligation are required to arrest the haemorrhage.
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78 Ear, nose and throat (ENT)
UNILATERAL NASAL DISCHARGE
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What are the important ndings on examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.3 –
Child with unilateral discharge
A child aged 2 years presents with a 1-week history of unilateral nasal discharge.
CASE 2.4 –
Adult with head injury
A 24-year-old man who had a head injury a month previously with slight concussion has a loss of sense
of smell and a unilateral clear discharge from the left side of the nose.
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Unilateral nasal discharge 79
OSCE Counselling cases
OSCE COUNSELLING CASE 2.3 –
The child with unilateral discharge
How would you counsel the mother of a child who is concerned that the cause of unilateral symptoms
could be tumour?
OSCE COUNSELLING CASE 2.4 –
The adult with a cerebrospinal uid
(CSF) leak
A patient who has had an endo-nasal repair of a cerebrospinal uid (CSF) leak wonders if there are any
particular post-operative instructions.
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80 Ear, nose and throat (ENT)
Key concepts
Unilateral mucoid nasal discharge in a child is usually caused by a foreign body.
Unilateral nasal discharge should be investigated.
Unilateral clear nasal discharge is CSF until proved otherwise.
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Unilateral nasal discharge 81
Answers
Clinical cases
CASE 2.3 –
Child with unilateral discharge
A1: What is the likely differential diagnosis?
A foreign body
A2: What additional features in the history would you like to elicit?
Ask the parent if the child put anything into his nose. Remember that other children may have put an
object into the child’s nose.
A3: What are the important ndings on examination?
Examination often reveals unilateral purulent nasal discharge. Depending on the child’s age and the
cooperation of both child and parent, this can sometimes be suctioned revealing the foreign body. This
can often be removed in the outpatient department, although it is critical that you do not cause the
child too much distress. If the child is uncooperative, then removal under general anaesthetic should be
arranged.
A4: What investigations would be most helpful and why?
No investigations are required for mucoid or purulent discharge. The child should be examined in the
operating theatre.
A5: What are the treatment options?
If the foreign body cannot be removed in the outpatient department, the child should be put on the
next available operating list and the nose examined under general anaesthesia to exclude a foreign
body. The foreign body is usually easily found and removed. The discharge may take a few days to
settle, particularly if there is some granulation tissue in the nose. Florid granulations may be removed at
the same time. If no foreign body is found the child may have unilateral sinusitis and a washout of the
maxillary sinuses can be undertaken at the same time.
CASE 2.4 –
Adult with head injury
A1: What is the likely differential diagnosis?
The chief worry is a CSF leak. This is the diagnosis of exclusion because sinusitis may occur.
A2: What additional features in the history would you like to elicit?
Ask if there have been any other episodes of discharge before the head injury. If so this changes the
probable diagnosis and makes rhinosinusitis more likely. Although spontaneous CSF leaks do occur, they
are relatively rare. Ask the standard history for the nose episodes of blockage, running and sneezing.
Adults rarely put foreign bodies up their nose unless they have a learning disability or an active
psychiatric problem.
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82 Ear, nose and throat (ENT)
A3: What are the important ndings on examination?
Anterior rhinoscopy (examination of the anterior nose with a headlight and speculum) and nasal
endoscopy occasionally reveal an origin of the CSF leak, a critical feature when planning surgical repair.
A4: What investigations would be most helpful and why?
Collect the uid to measure Tau protein (β2β-transferrin present in CSF but not nasal secretions).
Computed tomography (CT) of the paranasal sinuses and magnetic resonance imaging (MRI) of the
anterior cranial fossa should be undertaken. The treatment is simple: the CSF leak should be closed
surgically. Treatment with prophylactic antibiotics is controversial and best discussed with a local
neurosurgical unit.
A5: What are the treatment options?
Spontaneous cessation of traumatic CSF leaks often occurs within the rst 2 weeks. After this period
the chance of closure decreases, associated with an increase in the risk of ascending meningitis, and
hence surgical closure is recommended. Once the location of the leak has been identied through
a combination of endoscopic and CT ndings, operative closure can be planned, and this is typically
undertaken via an endoscopic nasal approach.
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Unilateral nasal discharge 83
OSCE Counselling cases
OSCE COUNSELLING CASE 2.3 –
The child with unilateral discharge
Nasal tumours in childhood are extremely rare and tend to present with bleeding or blockage. The
common causes of unilateral nasal blockage are foreign body or sinusitis. It is therefore possible to be
reassuring. Additionally, once the patient has been examined, a foreign body can be quickly determined
and treated.
OSCE COUNSELLING CASE 2.4 –
The adult with a CSF leak
The patient needs to avoid any preventable rises in CSF pressure as this may displace the repair causing
the leak to recommence. Hence, if the patient needs to sneeze, he or she is advised to do this with his
or her mouth open (and hand covering this); the patient should avoid straining during defecation and in
some cases this may entail prescribing laxatives. Patients should not lift heavy objects for a minimum of
a week.
REVISION PANEL
Unilateral nasal discharge always indicates an underlying pathology; the age of the patient often
predicts the cause.
Children are likely to have a foreign body causing unilateral discharge, and examination under
anaesthesia is needed if an obvious cause cannot be seen in clinic.
Clinicians should have a high index of suspicion of a CSF leak if a patient presents with a clear
nasal discharge post head injury.
The diagnosis of a CSF leak requires conrmation of CSF (Tau protein) and localization of the leak
(endoscopic examination + CT ± MRI).
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84 Ear, nose and throat (ENT)
NASAL OBSTRUCTION
Questions
Clinical cases
For each of the clinical case scenarios given
Q1: What is the likely differential diagnosis?
Q2: What additional features in the history would you like to elicit?
Q3: What should one look for in the examination?
Q4: What investigations would be most helpful and why?
Q5: What are the treatment options?
CASE 2.5 –
Child with nasal obstruction and snoring
A child aged 7 presents with blocked nose and snoring at night. The mother asks that the adenoids be
removed to improve the symptoms.
CASE 2.6 –
Adolescent with nasal trauma
A 17-year-old teenager had trauma to his nose 6 months previously and comes to the clinic with his
father. He requests surgery to sort out his nasal obstruction.
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Nasal obstruction 85
OSCE Counselling cases
OSCE COUNSELLING CASE 2.5 –
A mother asks whether their cat should
be removed if this causes allergic
rhinitis
OSCE COUNSELLING CASE 2.6 –
What advice should you give to a boy
who wants to continue playing football
and judo when he has repeated injuries
to his nose?
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86 Ear, nose and throat (ENT)
Key concepts
Bilateral nasal discharge is often the result of allergy rather than an adenoid problem.
Treat allergy medically.
Treat septal deformity by surgery when contact sport has ceased.
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