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Probability diagnosis

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Idiopathic: spontaneous from Little’s area

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URTI: common cold/flu/sinusitis

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Rhinitis: allergic and atrophic

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Vestibulitis

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Trauma (incl. nose picking, nose injury)

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Drugs (e.g. anticoagulants, aspirin)

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Serious disorders not to be missed

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Vascular:

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  • hypertension and arteriosclerosis

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Infection:

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  • systemic febrile illness (e.g. malaria)

  • HIV/AIDS

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Cancer/neoplasia:

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  • tumours of nose/sinuses/nasopharynx

  • intracranial tumours

  • leukaemia

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Other:

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  • thrombocytopenia

  • coagulopathy (e.g. haemophilia, liver disease)

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Pitfalls (often missed)

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Exposure to toxic agents

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Vitamin deficiencies: C and K

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Septal granulomas and perforations

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Foreign bodies (esp. in children)

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Cocaine abuse

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Rarities:

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  • hereditary haemorrhagic telangiectasia

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Masquerades checklist

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Drugs: anticoagulants, aspirin, nasal sprays Anaemia: aplastic anaemia

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Key history

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Recent trauma to nose. Significant past history (e.g. hypertension). Drug and alcohol history (e.g. anticoagulants). Bleeding or bruising tendency.

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Key examination

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  • Nasal airways and sinuses

  • Skin for evidence of purpura or ecchymoses

  • Lymph node areas and abdomen for hepatosplenomegaly

  • Vital signs (esp. blood pressure)

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Key investigations

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Probably none. Consider:

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  • FBE

  • clotting studies

  • sinus X-ray

  • INR

  • CT scan (occasionally).

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Diagnostic tips

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  • Recent onset of persistent bleeding in elderly points to carcinoma.

  • Severe epistaxis is often caused by liver disease coagulopathy.

  • Difficult-to-control posterior bleeding is a feature of the hypertensive elderly.

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