The Angry Face Syndrome

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

I must say when I first read the title of this article (full reference below) I thought it was a joke. Apparently, I was just unaware this syndrome exist.

The authors state, “The finding of frontal bossing, deep radix, straight nasal dorsum, and an over projection of the nasal tip constitutes the angry face syndrome.” (photo credit, from article)

The authors note, “When the syndrome components of frontal bossing, a deep radix, and nasal tip projection are present but include a significant nasal dorsal hump (instead of a straight dorsum), the angry face syndrome does not apply. Somehow the dorsal hump negates the message of anger to the observer.”

Their solution is a rhinoplasty

with attention to a major radix augmentation graft and substantial reduction of the nasal tip projection. In addition, as with the illustrative cases described herein (Figures 1, 2, and 3), we also correct other offending features at the same time (eg, dependent nasal tip, boxy tip, poor alar support, alar base width, wide nasal bones).

Their conclusion:

In all of our years of teaching rhinoplasty, we have always maintained that in considering surgery, the patient must understand that nothing in the external world will change because the of the patient's rhinoplasty. The only thing that will change is the way the patient feels about himself or herself, ie, their self-esteem.

Rhinoplasty for the angry face syndrome, however, may be the exception to the rule.

REFERENCE
The Angry Face Syndrome; Pastorek NJ, White WM; Arch Facial Plast Surg 2011;13(2):131-133; doi:10.1001/archfacial.2011.14

Skin Grafting in Lower Third Nasal Reconstruction

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Skin grafts for the lower third nasal defects should not be overlooked as an option.  The article listed below  (first one)reminds us that  skin grafts can give a better cosmetic results than a local flap in certain situations.  

The lower third of the nose is defined by its margins, which include the alar rims inferiorly, the nasolabial grooves laterally, and the alar groove, which forms the junction with the upper two-thirds of the nose.

Classically, the lower third of the nose is composed of six subunits: bilateral ala and soft triangles, the central tip, and columella. (photo credit)

The skin in this area is thick, richly populated with sebaceous glands, often stiff and difficult to rotate and form into local flaps.

Criteria given for selecting lower third nasal defects that can be acceptably treated with full-thickness grafts

include defect location; size smaller than 1 cm; and a partial-thickness defect with underlying dermis, subcutaneous tissue, or perichondrium.

Rather than increasing the small defect to a larger defect (whole subunit size), the authors achieved acceptable cosmetic results using full-thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter.

Any defects larger than 1 cm were reconstructed more successfully with entire subunit reconstructions using more standard reconstruction techniques (local or adjacent flap techniques).  Defects that involve cartilage or deeper are by definition complex nasal defects that will require onlay cartilage grafting for satisfactory reconstruction.  These are not appropriate for skin grafting.

Donor site selection is important to try to match “like with like.”   Best choices include:

The senior author prefers preauricular and more preferably forehead skin for lower third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily texture, and they suffer the same degree of daily sun exposure and actinic damage as the lower third of the nose.

Other donor sites available to the reconstructive surgeon include the nasolabial fold, postauricular skin, and supraclavicular skin.

Poor donor site choices:

Postauricular donor sites suffer very little (if any) daily sun exposure and have much thinner skin than the nasal lobule. Therefore, they are prone to pigmentation changes and do not provide a good contour match for reconstructing the lower third of the nose.

Likewise, the skin of the supraclavicular region contains very few sebaceous elements and is often hyperpigmented before harvest.

 

Any distortion of the alar rim or obliteration of the nasolabial groove is exceedingly noticeable and difficult if not impossible to correct secondarily so care must be taken regardless of technique used in these area.

REFERENCE

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?; Plast Reconstr Surg. 124(3):826-835, September 2009; McCluskey, Paul D.; Constantine, Fadi C.; Thornton, James F.

Nasal Reconstruction, Principles and Techniques: Multimedia; eMedicine article, August 28, 2008; Joseph Fata, MD

Nasal Reconstruction-Beyond Aesthetic Subunits: A 15-Year Review of 1334 Cases;  Plast Reconstr Surg. 2004;114:1405-1416; discussion 1417-1419; Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.

Acne Hypertrophica or Rhinophyma

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Flipping through the 1908 textbook A Text-Book of Minor Surgery by Edward Milton Foote, MD the photos accompanying the acne hypertrophica section caught my eye. Allow me to share that section of the book with you.

Acne Hypertrophica

This is an overgrowth of the nose, which is generally considered to be one of the forms of acne rosacea, but is here included with the tumors to which it belongs clinically, for the appearance of the lesion and the treatment warrant this classification.

This is a disease of middle life, or later, marked by a great overgrowth of the sebaceous follicles, with thier ducts, as well as of blood-vessels and fatty tissue. The skin itself is not greatly thickened, and may even be thinned, apparently the result of over-stretching it. The tumor as a whole is soft and flabby, of dark red color, due to the venous congestion. It is not necessarily the result of alcoholism, and many of these patients are unjustly accused of intemperate habits.

Lesser degrees of hypertrophic acne of the nose are frequently found. Such an extreme overgrowth as is shown in Figs 42 and 43 is decidedly exceptional, although even more marked instances are occasionally seen.

Although this overgrowth is benign in character, the excess tissue should be removed, as this can be accomplished without much risk, and the feelings of the patient will thereby be spared many mortifying remarks.

Today we tend to call this problem rhinophyma which is a descriptive term derived from the Greek "rhis" meaning nose and "phyma" meaning growth.

Treatment:

This consists in the removal of wedge-shaped pieces of the growth, so that the normal contour of the nose may be restored. The spongy tissue is very insensitive, so that a small amount of eucain or cocain is sufficient. Hemorrhage is free, but may be controlled by pressure and ligatures. Although these patients are usually plethoric and stand very well the loss of blood, it may be advisable to remove only a potion of the growth at one sitting. This plan has the further advantage of enabling the surgeon to observe the effect of a partial removal of the tumor before completing the task. Removal may be effected in such a way that pedicled flaps are utilized to cover the raw spaces. Their vitality is low, and unless the pedicle is very broad, they are likely to slough. Therefore it is advisable not to undermine them too extensively. The results of this plastic surgery are very satisfactory (Figs 44 and 45). In some cases, if the quality of the skin is too poor, it is better to shave off all of the tissue down to the cartilage and to cover the wound with skin grafts.

Medical treatment through the years has included avoidance of stimulation factors (ie alcohol), appropriate cleanliness, and treatment of secondary infection and inflammation with antibiotics and steroids. In the 1920’s, treatment of the condition included X-ray and radium. Unfortunately, this was found to lead to a greater incidence of skin cancer and thyroid tumors 20 years later.

Surgical treatment has greatly benefited from the addition of lasers. Between 1908 and now, not only were scalpel used to “debulk” the tissue, but so have cryosurgical techniques, chemical peels, dermabrasion, the Shaw knife (a thermally heated scalpel), the Bovie, hot wire loops, and lasers.

The removal of the tissue is often referred to as “decortication.” The goal is to remove the tissue in layers and to avoid injury to the underlying cartilage. If 2-3 mm of skin tissue is left above the cartilage level, the nose regains its shape and there should remain enough sebaceous glands elements for re-epithelialize of the nose. A major advantage of the laser is the near bloodless field.

There is a beautiful example of the results obtained by use of the laser for treatment of rhinophyma here.

REFERENCES

Rhinophyma (Grand Rounds presentation at Baylor College of Medicine) by Randall S. Zane, MD; October 29, 1992
Diagnosis and Treatment of Rosacea; MedScape Article, May 21, 2002; Aaron F. Cohen, MD, Jeffrey D. Tiemstra, MD

Treatment of Nasal Fxs – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Nasal fractures are extremely common.  Deciding which technique to use for a given nasal fracture can be challenging.  The recent article (full reference below) in the Arch Facial Plastic  Surgery does a very nice job of condensing down the treatment of nasal fractures into a logical approach.

They start with the classification of nasal fractures (photo credit)

• Type I, “simple straight” --  unilateral or bilateral displaced fracture without resulting midline deviation.
• Type II, “simple deviated” – unilateral or bilateral displaced fracture with resulting midline deviation.
• Type III, “comminution of nasal bones”  -- bilateral nasal bone comminution and crooked septum with preservation of midline septal support; septum does not interfere with bony reduction
• Type IV, “severely deviated nasal and septal fractures”  -- unilateral or bilateral nasal fractures with severe deviation or disruption of nasal midline, secondary to either severe septal fracture of septal dislocation.  May be associated with comminution of the nasal bones and septum, which interfere with reduction of fractures.
• Type V, “complex nasal and septal fracture” – severe injuries including lacerations and soft tissue trauma, acute saddling of nose, open compound injuries, and avulsion of tissue.

The treatment of nasal fractures has classically been divided into open reduction (OR) and closed reduction (CR). 

Closed reduction involves manipulation of the nasal bones without incisions and has been the time-honored method of fracture reduction for thousands of years. It generally produces acceptable cosmetic and functional results, but its detractors point out that 14% to 50% of patients have deformities after CR.

Open reduction techniques for nasal fractures may include a range of techniques including septoplasty, osteotomies, and full septorhinoplasty.
Interesting, the study authors state,

There was no statistical difference between the results of an open repair and closed repair in terms of revision rate, patient satisfaction scores, or surgeon evaluation scores. Furthermore, our expert raters failed to find a difference in outcome based on the type of repair. Based on this data, it would seem that our patients did not perceive any difference in outcome, ie, patients were just as likely to be happy with the results of a closed repair as they were with open repair. These results contrast with those of many studies in which the surgeon's assessment shows a clear bias toward one technique or another.

The authors supplied this wonderful algorithm for treatment of nasal fractures (photo credit)



REFERENCE
The Treatment of Nasal Fractures: A Changing Paradigm; Arch Facial Plast Surg. 2009;11(5):296-302; Michael P. Ondik; Lindsay Lipinski; Seper Dezfoli; Fred G. Fedok

Prevention and Management of Complications of Rhinoplasty – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

This article is a CME (continuing medical education) article.  As such it is a review of complications of rhinoplasty.  It is a good review and worth reading.

Complications of rhinoplasty can be classified into hemorrhagic, infectious, traumatic, functional, or aesthetic problems.  Here is a  summary of the article.

Hemorrhagic Complications

Postoperative bleeding is one of the most common
complications following nasal surgery. 

Epistaxis  --  The most common causes of mild epistaxis are bleeding from the incision sites and traumatized
mucosa.

For mild to moderate epistaxis being with

• 60-degree head elevation
• gentle nostril pressure for 15 minutes
• application of topical decongestant nasal sprays such as oxymetazoline or phenylephrine.

If bleeding persists

• Remove the septal splints and gently suction the nasal passages remove blood clots and crusts.
• Cauterize focal areas of bleeding with silver nitrate or place a light hemostatic packing made of methylcellulose over the bleeding surface.

Continued bleeding may require a formal nasal pack, either in the form of gauze or a commercially available nasal tampon.
Bleeding that persists despite anterior packing may signify
a posterior bleed from a branch of the sphenopalatine
artery.  If so, a posterior pack may be required. 

• Patients should be observed for airway compromise while a posterior pack is in place.
• Antibiotics should be administered while packing is in place to reduce the risk of toxic shock syndrome.

Serious bleeding occurs in less than 1 percent of patients, but warrants operative exploration when conservative measures fail.

Septal Hematoma -- is a potentially serious complication of rhinoplasty.  These patients may present with symptoms of nasal obstruction, pain, rhinorrhea, or fever.   The typical finding on physical examination is an ecchymotic nasal septal mass.

Untreated septal hematoma may lead to cartilage necrosis with subsequent loss of dorsal support and a saddle-nose deformity.

Management

• early recognition with prompt evacuation of the hematoma, either via needle aspiration or incision and drainage.
• Antimicrobial therapy should be initiated if a secondary nasal septal abscess is suspected.

Infectious Complications

Postoperative infections following rhinoplasty can range in severity from mild cellulitis of the soft tissue envelope to life-threatening systemic illness resulting from cavernous sinus thrombosis or toxic shock syndrome.

Local wound infections (such as cellulitis) -- treat with systemic antibiotics and close observation.

Abscesses require prompt surgical drainage in addition to antibiotic therapy. Common sites of abscess formation following
rhinoplasty include the nasal dorsum, nasal tip, and septum.

Cavernous sinus thrombosis,  meningitis, or a brain abscess may result without adequate treatment of a septal abscess.

Toxic shock syndrome is an acute, multisystem disease.  It has been described after nasal surgery with the use of both nasal packing and intranasal splints.   Symptoms occur early and can include nausea or vomiting, rash, fever, tachycardia, and hypotension.  Treatment requires the immediate removal of the offending object (packing or splint), intensive care unit admission, intravenous antibiotics, and supportive care.

Traumatic Complications

L-Strut Fractures  -- 
When L-strut fractures occur, they should be repaired immediately to prevent significant deformity.  If it isn’t, the  cartilaginous septal segment will tend to rock posteriorly, resulting in a loss of dorsal support and a saddle-nose deformity.

Depending on the location of the fracture, it may be stabilized with either spread grafts or a combination of spreader grafts and
Kirschner wires.

Intracranial Injury and Cerebrospinal Fluid Leak Intracranial injury and cerebrospinal fluid leaks are a major complication after rhinoplasty.  They can happen with the cribiform plate it violated by surgical instruments or from excessive bony septum manipulation.  Either can result in a cerebrospinal fluid leak and potential intracranial injury or infection.

Symptoms of a cerebrospinal fluid leak include clear rhinorrhea and positional headache. The diagnosis may be confirmed by testing the fluid for the presence of 2-transferrin, a protein highly specific for cerebrospinal fluid. A

Treatment requires hospitalization, bed rest, and prompt otolaryngologic and neurosurgical evaluations.

Epiphora  --  after rhinoplasty is most commonly occurs due to compression of the lacrimal system by the soft-tissue edema.  It normally resolves after 1 to 2 weeks.

Functional Complications

Septal Perforation -- are most often caused by opposing tears in the elevated septal mucoperichondrial flaps with no  intervening septal cartilage.   They may also result from decreased blood flow to those same flaps from an unrecognized septal hematoma or tissue necrosis from septal stitches.

Symptoms of a nasal septal perforation include crusting, bleeding,
whistling, and nasal airway obstruction due to disruption
of the normal laminar airflow through the nasal passages.

Treatment includes

• Local hygiene with nasal saline irrigation
• Obturation with a Silastic septal button
• For small perforations, local advancement flaps with an interposed connective tissue autograft or an allograft can be
  used to close the perforation.

Intranasal Adhesions  -- (synechiae ) result from cicatrical healing of opposed, abraded mucosal surfaces.

Patients may present with nasal obstruction. Intranasal examination will reveal a “bridge” of mucosa from the septum to the inferior turbinate, middle turbinate, or lateral nasal wall.

Treatment requires division and placement of a barrier between the incised surfaces, such as a Silastic splint, until the surfaces undergo complete re-epithelialization.

Postoperative Septal Deviation  -- whether new or uncorrected, following septorhinoplasty is a source of frustration for both the patient and the surgeon.  Any significant septal deviation that persists and causes cosmetic or functional impairment may require revision surgery.

Rhinitis – Atrophic rhinitis is due to atrophy of the nasal mucosa usually due to overresection of intranasal structures such as the middle or inferior turbinate.

Patients often present with subsequent symptoms of dryness, crusting, and nasal obstruction.  These patients will get relief with nasal saline.

Patients may also report a spontaneous clear watery nasal discharge.   This phenomenon is most likely due to  a variant of vasomotor rhinitis caused by abnormal parasympathetic tone to
the intranasal mucosa.  These patients are often effectively treated with topical anticholinergic preparations, such as 0.03% ipratropium bromide  which act locally to decrease the watery rhinorrhea.  The recommended dosing regimen is two sprays in each nostril two to three times a day as needed.

Continued symptoms of watery nasal discharge despite appropriate topical therapy should raise the concern for an occult cerebrospinal fluid leak.

Aesthetic Complications

Tip and Dorsal Deformities
Postoperative deformities of the osseocartilaginous framework may be caused by overresection or underresection of the osseocartilaginous framework, incorrectly performed osteotomies, incorrect shaping of grafts and their edges, and migration of grafts due to insufficient or inaccurate fixation.

Persistent tip or dorsal deformities are generally not treated until at least 1 year after the previous rhinoplasty.

Supratip (“Pollybeak”) Deformity -- is a postoperative complication of rhinoplasty in which the nasal supratip assumes a convex shape in relation to the nasal dorsum. The deformity results either from inadequate resection of the lower dorsal septum and upper lateral cartilages or, paradoxically, from overresection of these supratip structures with subsequent scar tissue formation in the resulting dead space.

Patients who develop supratip fullness should be instructed to apply compressive tape onto the supratip area nightly. This is generally effective in treating transient postoperative swelling.  Taping should be discontinued when a permanent depression is obtained.

Steroid injections can improve excessive swelling and reduce scar tissue in the supratip area.  The injections can be used in patients who continue to supratip fullness despite compressive taping.  Triamcinolone acetate,  1 to 2 mg, is injected below the
dermis in the supratip area.  The injections may be repeated at 2-month intervals until an aesthetically pleasing supratip contour is obtained.

Side effects of the steroid injections should be remembered.  The most frequent is dermal atrophy, which may lead to a contraction
deformity of the skin. Other side effects include telangiectasias, depressions, color changes, and eventual visibility of the underlying cartilages or contour imperfections, which may be enhanced by the resulting decrease of skin thickness.

Corrective surgical procedures should not be performed until
at least 1 year after the initial procedure. 

The basic principles include judicious removal of the offending cartilage or scar tissue, adjustment of the osseocartilaginous framework so that the differential between the midvault and the tip is adequate, elimination of dead space by establishing direct contact between the underlying framework and the skin, and application of a dressing with selective compression over the supratip area.

Soft-Tissue Complications
Postrhinoplasty Nasal Cysts  -- are a rare complication
of rhinoplasty. The most common site of occurrence for both types of cysts is the nasal dorsum.  Both may require complete excision.

• Lipogranulomas or “paraffinomas” are foreign-body inclusion cysts that are thought to arise from the use of petroleum-based
  ointments in conjunction with nasal packing.
• Mucous cysts are a second type of nasal cyst that can arise after rhinoplasty. They are thought to arise from ectopic or displaced mucosa and ointment extravasation into osteotomy sites.

Contact Dermatitis and Skin Necrosis --

Contact dermatitis may result from irritation of the skin by the topical adhesives, tape, or dorsal splint. It usually resolves without any permanent sequelae.

Treatment of contact dermatitis

• removal of the offending agent
• application of topical and potentially systemic steroids,
  depending on the severity of the reaction.

Superficial skin necrosis or epidermolysis can occur secondary to excessive compression of the skin by the taping and dressing.  More problematic is partial-thickness or full-thickness skin necrosis that can occurs when the blood supply of the soft-tissue envelope is severely embarrassed. 
Treatment of minor skin necrosis should initially be conservative.

• Daily wound care, allow the wound to close by secondary intention
• Protection from the sun
• After maturation of the scar, dermabrasion, filler substances, skin care, and laser treatment may be helpful.

Telangiectasias -- are small superficial vessels of the skin visible to the human eye and usually measure 0.1 to 1.0 mm in diameter.  Argon and pulsed dye lasers have proven to
be an effective means of treatment.

REFERENCE

Prevention and Management of Rhinoplasty Complications;  Plastic and Reconstructive Surgery:Volume 122(2)August 2008pp 60e-67e; Cochran, C Spencer M.D.; Landecker, Alan M.D.

Nose Bleeds

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

I am one of those people who have periodic nose bleeds from dry mucosa (and the trauma of blowing my nose – allergies and/or colds).  I have had them since childhood.  There have never been any polyps or other issues noted on the couple of exams I have had.  So I learned long ago how to deal with mine.  I thought I would review some basic information with you.

The technically correct medical term for nose bleeds is epistaxis.  It is classified on the basis of the primary bleeding site

Anterior (90% of nose bleeds) 

• The most common source  if bleeding is from the Kiesselbach plexus which is an anastomotic (think multiple roads coming together) network of vessels on the anterior portion of the nasal septum. (photo credit)
• May also be due to bleeding anterior to the inferior turbinate.

Posterior

• Bleeding will originate from branches of the sphenopalatine artery in the posterior nasal cavity or nasopharynx.
• This is much more serious and usually require admission to the hospital and management by an otolaryngologist.

CAUSES of NASAL BLEEDING (epistaxis)
Most cases have no easily identifiable cause.
Local trauma (ie, nose picking, blowing too vigorously, foreign bodies) is the most common cause.  Other local causes include:

• facial trauma or surgery
• nasal or sinus infections
• allergies
• nasal polyps
• prolonged inhalation of dry air (climate or too warm house)
• tumors

Systemic causes include

• Blood disorders (hemophilia, leukemia, polycythemia vera, thrombocytopenia, von Willebrand’s disease, etc)
• Acquired platelet dysfunctions (related to use of aspirin, NSAIDs, dipyridamole, etc
• Anticoagulation therapy (ie warfarin, enoxaparin, etc)
• Hypertension is rarely (if ever) a direct cause of epistaxis.  Therapy should be focused on controlling bleeding before blood pressure reduction.
• Vascular abnormalities that contribute to epistaxis may include the following:

1. Arteriovenous Malformations
2. Hereditary Hemorrhagic Telangiectasis
3. Sclerotic Vessels
4. Neoplasm (tumor)
5. Septal abnormality (ie perforation or deviation)
6. Endometriosis

WHAT TO DO at HOME
As with all bleeding the first thing to do is remain calm, then apply pressure.   How do you apply pressure correctly?

• Sit up straight.
• Lean your head forward rather than back.  This way you won’t swallow the blood which can irritate your stomach and make you nauseated.
• Pinch the nostrils together with your thumb and index finger for 5-10 minutes. Pinch them tightly and don’t let go early.  Yes, it will be uncomfortable if you have enough pressure.  (photo credit)
• Repeat for another 5-10 minutes, if the bleeding hasn’t stopped.  You may not have held consistent pressure the first time.

Things that can help prevent a nose bleed or re-bleed:

• Avoid local trauma.  No nose picking.  Try not to blow your or sneeze for 24-48 hrs after the nose bleed.
• Minimize exposure to dry air.  This can be a problem if you live in Arizona or in a heated home in the winter.  Adding moisture to the air with a humidifier or vaporizer will help.
• Using salt water nasal spray can help.   This can be used with abandon, no limits.
• Using vaseline occasionally to help keep the lining of your nose moisturized.  Don’t overdo this.

WHEN it’s appropriate to go to the hospital

• You are still bleeding after REALLY pinching the nose for 10 minutes.
• You are having repeated episodes of nosebleeds over a 12-36 hour period.
• You feel dizzy or light-headed or like you are going to pass out.
• Your doctor instructs you to go to a hospital's emergency department.

WHEN it’s appropriate to call your doctor

• Repeated episodes of nosebleeds.  You may need to see a specialist to make sure there are no polyps, etc in your nose.

• Additional bleeding from places other than the nose, such as in the urine or stool.  You may have a blood abnormality or other health issue.

• Bruising easily and are not on a blood-thinner.  This may be a sign of another health issue.

• If you are on any blood-thinning medications, including aspirin or warfarin (Coumadin).  Your doctor should know about your bleeding, as they may wish to change your dosage if you bleed too often or it is difficult to stop.

• If you have any underlying disease that may affect your blood clotting, such as liver disease, kidney disease, or hemophilia (inability of blood to clot)

• If you recently had chemotherapy.  Again your doctor should now, so they can check and make sure you aren’t having other issues.

For anyone interested in more information, may I recommend the following articles.

REFERENCES
Epistaxis by Jeffrey A Evans, MD and Todd Rothenhaus, MD; eMedicine Article; Nov 28, 2007
Epistaxis by Quoc A Nguyen, MD; eMedicine Article; Nov 29, 2007
Nasal Pack, Anterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 10, 2008
Nasal Pack, Posterior Epistaxis by Eric Goralnick MD and Rick Kulkarni MD; eMedicine Article, Oct 3, 2008
Current Approaches to the Management of Epistaxis;  JAAPA May 2003;16:52-64; Richard M Bishow, MPAS, PA-C
Nosebleeds; eMedicineHealth Article