Approach to Sinusitis / Nose Bleeds

Differential diagnosis

• Infective
  • Upper respiratory tract infection
  • Lower respiratory tract infection
  • Sinusitis
  • Human immunodeficiency virus infection
  • Syphilis – catarrhal rhinitis
• Allergic rhinitis
• Inflammatory
  • Nasal polyps
  • Eosinophilic vasomotor rhinitis
  • Wegner’s granulomatosis
  • Churg-Strauss syndrome
• Neoplastic
  • Nasopharyngeal carcinoma
  • Lymphoma (malignant granuloma)
• Traumatic
  • Foreign body
  • Fracture of nasal bones
  • Inhalation of toxic fumes
• Hereditary haemorrhagic telangiectasia

History

• Characterize the nasal discharge
  • Is the blood coming from your nose, or only when you cough?
  • How long has this been going on for?
  • Have you noticed that anything in particular makes it worse?
  • How long does each episode last?
  • Have you had this problem before?
• Infective
  • Have you had a cold or sore throat recently?
  • Did you have a problem with recurrent colds when you were younger?
  • Do you find that your nose is always blocked?
  • Is there any pain in your face?
• Allergic
  • Do you have eczema?
  • Do you have asthma?
  • Does anyone in your family have eczema, asthma or problem with runny noses?
• Inflammatory
  • Have you recently taken aspirin (vasomotor rhinitis)?
  • Have you noticed any fevers?
  • Do you have any joint pain?
  • Is there any numbness or weakness in your hands or feet?
  • Have you noticed any blood in your urine?
• Neoplastic
  • Have you lost any weight?
  • Is the discharge always blood-stained?
  • Have you noticed any swellings in your neck?
  • Have you noticed any difficulty in pronouncing words?
  • Have you noticed any double vision?
• Have you had any injuries to your nose or face recently?
• Sexual history (HIV, syphilis)
  • Are you sexually active?
  • How many partners do you have?
  • Are your partners male or female?
  • Do you use any illicit drugs?
• Do you smoke?

Examination

• General appearance (cachectic suggests underlying malignancy)
• Sinus tenderness
• Nose
  • Nasal polyps
  • Dried blood
• Inflammatory
  • Joint pains
  • Ulcers in the nasal cavity
  • Ulcers of the mouth
  • Anterior uveitis
• Respiratory
  • Listen for crackles (alveolar haemorrhage vs pulmonary fibrosis)
• Neurological (nasopharyngeal carcinoma)
  • Extra-ocular movements
  • Elevation of the soft palate
  • Trapezius, sternocleidomastoid strength
  • Tongue deviation

Investigations

• Blood tests
  • Full blood count
    • Anaemia of chronic disease in malignancy
    • Leukocytosis in infection
  • ANCA if inflammatory granulomatous disease suspected
• Chest radiograph to look for infective process
• Nasal swab
• Skull x-ray if trauma
• Magnetic resonance imaging if neurological deficit

Management

• Patient education
• Avoidance of allergens
• Nasal decongestant
• Immunosuppression for granulomatous disease
  • Screening for other complications – renal, neurological, pulmonary
• Referral to ENT for nasendoscopy and biopsy if NPC suspected