Diagnosing Tonsils and Adenoid

Examination of the tonsils by looking in the back of your child’s mouth using a light and mirror or a flexible telescope.
Your doctor may recommend a tonsillectomy if your child suffers from frequent bouts of tonsillitis or ear infections, or has breathing problems caused by swollen tonsils.
Xray of the Postnasal space shows enlarged adenoid.

Preop preparation

A tonsillectomy usually requires an overnight stay in hospital. If your child has a cold or infection in the week before the operation, please let your doctor know about it. The operation may need to be postponed until your child has fully recovered.
The operation is done under general anaesthesia. This means your child will be asleep during the procedure. Typically, your child must not eat or drink for about six hours before a general anaesthetic. Often the operation will be planned for the morning, so that your child will only have to miss breakfast.
The surgeon and anaesthetist will usually visit your child before the operation. Please tell them if your child has any allergies, loose teeth or any history of bleeding problems in the family.
You may be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

Operation

Most tonsillectomy operations are done in children under 15. The only effective treatment for recurrent and persistent tonsillitis is to have the tonsils removed. The tonsils will shrink in size as your child grows older, so an operation may not be necessary. Painkillers and antibiotics only provide temporary relief and are not used for long-term treatment. A viral infection won’t respond to antibiotics.
The operation usually takes about 30 minutes. There are several methods available for removing tonsils.

• Traditional Disection method - a special surgical blade is used to cut out the tonsils. Pressure is applied to stop the bleeding, and dissolvable stitches or heat is used to seal the wound.
• Laser Tonsillectomy

Post op period

Your child will be monitored and will need to rest on their side until the effects of the anaesthetic have passed. Your child will be groggy, and may feel or be sick.
Your child may complain of a sore throat, earache and a stiff jaw. Pain relief and antibiotics are usually prescribed for a week .
You should encourage your child to drink and eat as soon as they feel ready, starting with clear fluids such as water or apple juice.
After about 12 hours, a white or yellowish membrane -slough - will appear where the tonsils were. This is nothing to worry about and is not a sign of infection.
Your child will usually be ready to go home the morning after the operation. Before you go home a nurse will give you a date for a follow-up appointment.

Recovering from tonsillectomy

Once home, follow the surgeon’s advice about pain relief. You can give your child painkillers such as paracetamol or ibuprofen syrup .Follow the instructions in the patient information leaflet that comes with the medicine and ask your pharmacist for advice. Do not give aspirin to children under 16.
If your child is prescribed antibiotics it’s important to finish the course.
Get your child to drink plenty of fluids and eat. It’s best to start with soft or liquid foods which are easier to swallow. Giving your child a dose of pain relief half an hour before meals may help make eating more comfortable. Encourage your child to brush their teeth thoroughly, at least twice a day.
Your child should rest for a few days and stay at home to avoid contact with possible infections at school. Also keep your child away from crowded and smoky places, and from people with coughs and colds.
If your child develops any of the following symptoms, please contact your doctor or the hospital immediately if any bleeding from the nose or throat or a high temperature
You can expect your child to make a full and quick recovery once the initial pain has resolved. Complete recovery can take two weeks.

Side effects?

Tonsillectomy is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.
These are the unwanted, but mostly temporary effects of a successful procedure, for example feeling sick as a result of the general anaesthetic. Common side-effects include:
• sore throat, earache and a stiff jaw - these side-effects may last for up to two weeks
• bad breath - this usually improves after two to three weeks
This is when problems occur during or after the operation. Most children are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or infection. Antibiotics are usually prescribed to help prevent infection.
Specific complications of tonsillectomy are rare but include:
• bleeding within 24 hours - your child may need to go back into theatre to have it stopped
• bleeding four to seven days after the operation (secondary haemorrhage) - this can be the result of an infection
• damage to the teeth or jaw - this can be caused by the instruments used to keep the mouth open during surgery
• chest infection and breathing problems - there’s a risk blood and tissue from the operation may get into the throat and down into the lungs

Snoring and sleep apnea in children

Most children snore on occasion, and about 10 percent or more snore on most nights. Snoring is a noise that occurs during sleep when the child is breathing in and there is some blockage of air passing through the back of the mouth. The opening and closing of the air passage causes a vibration of the tissues in the throat.

Majority of the children that snore have obstructive sleep apnea syndrome (OSAS).
How do you know if your child is just a normal snorer or if he has obstructive sleep apnea? Children who snore and do not have OSAS should be otherwise well, without daytime sleepiness and they should have normal sleep patterns. In contrast to normal primary snoring, children with OSAS usually have disrupted sleep with short ‘pauses, snorts, or gasps’ in their sleep.

Other signs or symptoms might include:
• large tonsils and/or adenoids with frequent mouth breathing, hyponasal speech and nasal obstruction
• poor weight gain or being overweight
• high blood pressure
• Snore loudly and on a regular basis
• Have pauses, gasps and snorts and actually stop breathing. The snorts and gasps may waken them and disrupt their sleep.
• Be restless or sleep in abnormal positions with their head in unusual positions
• Sweat heavily during sleep
• During the day, children may have headaches, especially in the morning
• Have behavioral, school and social problems
• Be difficult to wake up
• Be irritable, agitated, aggressive and cranky
• Be so sleepy during the day that they actually fall asleep or daydream
• Speak with a nasal voice and breathe regularly through the mouth

Once it is determined that your child has obstructive sleep apnea syndrome, it will be time to discuss treatment options, which usually include removing enlarged adenoids and tonsils -adenotonsillectomy.
Other treatments might include treating a child’s allergies and helping overweight children lose weight.

Remember to be especially suspicious that your child may have OSA if he regularly snores and has apnea, daytime sleepiness, and/or school and behavioral problems.

Causes

They commonly occur in more general diseases such as asthma and cystic fibrosis.
Late onset asthma rather than childhood asthma is associated with nasal polyps. Of the patients with polyps 20% to 40% will have coexisting asthma. Although nasal allergy is present in some cases, more than two thirds of the patients show no evidence of systemic allergic disease. However, 90% of nasal polyps have eosinophilia- Absolute Eosinphil count will be high. These polyps tend to recur more than in other conditions. Nasal polyps are rare in children between the ages of two and 10 years. If found in children cystic fibrosis should be excluded.

Symptoms

Nasal polyps are common in both sexes.One-sided nasal polyps are rare and associated with a range of conditions and need further investigations both in adults and children eg.Antrochoanal polyp, Ringerts pappilloma
Polyps look like small grapes and can appear singly or in clusters in the nasal cavity. The can cause:
• Blocked nose
• Runny nose and/or sneezing are seen in about half of patients
• A poor sense of smell (Anosmia or Hyposmia) and taste which may not always return after treating the polyps
• Chronic Catarrh

Treatment

D N Endoscopy, where a small illuminated endoscope is used to see up the nose will exclude any infection or any unusual feature.

Medical treatment

Nasal polyps are known to shrink when nasal sprays or drops containing nasal steroids are used. Stronger steroids in drop form can be used but should only be used with care and limited to short courses because some is absorbed into the body.
Polyps respond and shrink using drops or sprays in up to 80% of people. New nasal steroid sprays can be taken to control symptoms for many years as very little is absorbed into the body and they can work well, but many take up to six weeks of treatment before their full effect can be felt.
Steroids in tablet form(Methyl Prednisolone, Defla cort) can provide good relief of symptoms but the effects are short-lived and they are used sparingly because of concerns about side effects. If medicines don’t work then surgery is needed.
Injection of Methyl Prednisolone 80 mg IM once in a month for 3 months can be tried.

Surgical treatment

Nasal Polypectomy. Nasal polyps blocking the nose can be removed surgically and this often helps the patient to breathe better. In three out of four patients the polyps come back after an average period of four years.
FESS.Functional endoscopic sinus surgery is the standard procedure to get the ethmoids opened and better removal of polyps.

“O God, the almighty divine healer, bless me with the art of healing. Strengthen me with your Holy Spirit. Let the knowledge acquired be bright and illuminant, and second to none. Let there be physical, mental and spiritual peace for every one I touch”

Atrophic rhinitis (Ozena) is a rare chronic inflammatory disease that affects the lining of the nasal cavity. This condition is characterized by a wasting away or an atrophy of the bony ridges and the mucus membranes inside of the nasal cavity. It is characterized by progressive nasal mucosal atrophy, nasal crusting, fetor, and enlargement of the nasal space with paradoxical nasal congestion.
The nasal cavities are roomy with lot of crusts which is foul smelling.
Exact cause unknown, but Endocrine, nutritional deficieancy, autoimmune causes, infective etiology are blamed.

Pathology

The ciliary epithelium is replaced by stratified squamous epithelium, atrophy of mucous glands.The turbinates also atrophy.

Symptoms

The symptoms include nasal crusting, discharge, and a bad odor

Examination of the nasal passage shows greenish discharge. Septal perforation may co exist.

Treatment

Nasal irrigation with alkaline solution(1 litre boiled and cold water add 1 tsp salt, sugar and soda bicarb) or normal saline.
25%glucose in glycerin nasal drops
Local antibiotic ointment, drops
Systemic antibiotics with anerobic cover.

Surgery

The aim of surgery is either to narrow the nasal cavity or in special cases to close the nostril. Closure of the nostril (Young’s operation), is achieved by raising a circular skin flaps. Raising the skin flap is difficult, the suture line may break down and an excessive scar tissue may form resulting in vestibular stenosis.

Modified Young’s operation aim at partial closure of nostrils one at a time.

Prognosis

There is a tendency to recover spontaneosly.

Sleep apnea is a common disorder in which you have one or more pauses in breathing or shallow breaths while you sleep.
Breathing pauses can last from a few seconds to minutes. They often occur 5 to 30 times or more an hour. Typically, normal breathing then starts again, sometimes with a loud snort or choking sound.
This results in poor sleep quality that makes you tired during the day. Sleep apnea is one of the leading causes of excessive daytime sleepiness.
The most common type of sleep apnea is obstructive sleep apnea. This most often means that the airway has collapsed or is blocked during sleep. The blockage may cause shallow breathing or breathing pauses. Enlarged tonsils with redundant uvula and soft palate is the usual cause of OSA.
Tonsillectomy before LAUP or UPP will give a better result in these type of patients.

The tonsillectomy can be an important component of surgery for OSA, especially if the tonsils are at all enlarged. The removal of redundant tissue by tonsillectomy increases the caliber of the throat thereby reducing blockage to breathing. In a mature adult, pain following tonsillectomy can be unpleasant, but is reasonably well controlled with prescription medication. The UPPP and tonsillectomy remain a very important part of surgery to expand the upper breathing passage for treatment of OSA

The uvulo-palato-pharyngoplasty (UPPP) and tonsillectomy are often performed as a part of Obstructive Sleep Apnea surgery. The UPPP procedure shortens and stiffens the soft palate by partial removal of the uvula and reduction of the edge of the soft palate. Most patients who snore, but do not have apnea should enjoy a dramatic decrease in loudness of snoring after UPPP.

Fish bone in the throat

If you have swallowed a fish bone there will be pain and dysphagia. And also will be drooling of saliva. Attempted removal by putting finger might have caused further damage.
Chicken bone, bottle tops, bay leaf, pills, battery and coin are the other common foreign bodies stuck in the throat and commonly seen in the ENT clinics.

On examination

If symptoms are mild, test the patient’s ability to swallow, first using a small cup of water and then small piece of bread. See what symptoms are reproduced, or if the bread eliminates the foreign body sensation.
With the patient sitting in a chair, inspect the oropharynx with a tongue depressor, looking for foreign bodies or abrasions

Inspect the hypopharynx with a good light or headlamp mirror, paying special attention to the base of the tongue, tonsils and vallecula, where foreign bodies are likely to lodge. Maximize your visibility and minimize gagging by holding the patient’s tongue out (use a washcloth or 4×4″ gauze for traction and take care not to lacerate the frenulum of the tongue on the lower incisors) and have the patient raise his soft palate by panting. This may be accomplished without topical anesthesia, but if the patient is skeptical or tends to gag, you may anesthetize the soft palate and posterior pharynx with a spray (10% lidocaine spray) or by having the patient gargle with Xylocaine viscous.

A small fish bone is frequently difficult to see. It may be overlooked entirely except for the tip, or it may look like a strand of mucus. If the object can be seen directly, carefully grasp and remove it with Tilley forceps .Objects in the base of the tongue or the hypopharynx require a mirror or indirect laryngoscope for visualization.

Fiber optic nasopharyngoscopy is preferred when available.

Further treatment is probably not required, but you should instruct the patient to seek follow-up if pain worsens, fever develops, breathing or swallowing is difficult, or if the foreign body sensation has not totally resolved in 2 days.

X-ray neck

If you and your patient are not satisfied, you may proceed to a soft tissue lateral x ray of the neck. This will probably not show radiolucent or small foreign bodies, such as fish bones, or aluminum pop tops, but may point out other pathology, such as a retropharyngeal abscess, or severe cervical spondylosis, which might account for symptoms .Lateral soft-tissue x rays, can be very misleading because ligaments and cartilage in the neck calcify at various rates and patterns. The foreign body you see on a plain x ray may simply be normal calcification of thyroid cartilage.

Barium swallow-Contrast study

You may also want to proceed to a barium swallow, if available, to demonstrate with fluoroscopy any problems with swallowing motility, or perhaps coat and thus visualize a radiolucent foreign body. Remember that endoscopy is technically difficult after barium has coated the mucosa and possibly obscured a foreign body. It may be preferable to use a water-soluble contrast (e.g., Gastrographin) but even under the best of circumstances, contrast studies are of limited value.

Endoscopy

Rigid laryngoscopy, esophagoscopy, and bronchoscopy under general anesthesia for the few cases where your suspicion of a perforating foreign body remains high (e.g., when the patient has moderate to severe pain, is febrile or toxic, cannot swallow, is spitting blood, or has respiratory involvement.

Antibiotic cover

If X rays are negative and careful inspection does not reveal a foreign body, and the patient is afebrile with only mild discomfort, the patient may be sent home and observed.A short course of broad spectrum antibiotic is prescribed.

Reassure him that a scratch on the mucosa can produce a sensation that the foreign body is still there, but that if the symptoms worsen the next day or fail to resolve within two days he may need further endoscopy.
All patients who complain of a foreign body of the throat should be taken seriously. Even relatively smooth or rounded objects that remain impacted in the esophagus have the potential for serious problems, and a fish bone can perforate the esophagus in only a few days.

Impacted batteries represent a true emergency and require rapid intervention and removal because leaking alkali produces liquefactive necrosis. A pill, composed of irritating medicine (e.g., tetracycline) swallowed without adequate liquid, may stick to the mucosa of the pharynx or esophagus and cause an irritating ulcer. Bay leaves, invisible on x rays and laryngoscopy, have lodged in the esophagus at the cricopharyngeus and produced severe symptoms until removed via rigid endoscope.

The sensation of a lump in the throat (Globus Pharyngis), unrelated to swallowing food or drink, which is related to crico- pharyngeal spasm and anxiety. The initial workup is the same as with any foreign body sensation in the throat.

The adenoids are small pads of tissue found behind the back of the nose above the throat. They cannot be seen by looking in the mouth. Adenoids can become very large and block the eustachian tubes (the tubes from the middle ears to the back of the nose) and cause ear infections. Large adenoids can also block the nasal airway causing your child to breathe through his mouth and snore at night. Adenoids can become infected and carry germs (bacteria).

Your body can still fight germs without your adenoids. We only take them out if they are doing more harm than good.

Why take them out?

• Blocked-up nose: Very large adenoids can block the nasal passages. This causes snoring and keeps your child from being able to breathe through his nose. Severe blocking may lead to more serious problems (such as sleep apnea). Removing the adenoids lets the child breathe normally through the nose.
• Recurring ear infections: Very large adenoids can block the eustachian tubes and lead to ear infections or the failure of ear infections to clear. If a child has surgery to place Grommet tubes in the eardrums at the same time the adenoids are taken out, it can help prevent recurring ear infections.

What are the alternatives if the adenoids not removed?

Your adenoids get smaller as you grow older, so you may find that nose and ear problems get better with time. Surgery will make these problems get better more quickly, but it has a small risk. You should discuss with your surgeon whether to wait and see, or have surgery now.

For some children, using a steroid nasal spray will help reduce congestion in the nose and adenoids, and may be helpful to try before deciding on surgery. Antibiotics are of little help and only produce temporary relief from infected nasal discharge. They have side effects and may promote bacteria that are resistant to antibiotics.

Have a second opinion

If you would like to have a second opinion about the treatment, you can ask your specialist. He or she will not mind arranging this for you.

Adenoid surgery-How it is done

Arrange for a week off school. Let us know if your child has a sore throat or a cold in the week before their operation - it may be safer to put it off for a few weeks. We often give a short course of antibiotics before the operation.

Your child will be put to asleep for the operation. We will take out the adenoids through his or her mouth, and then stop the bleeding before he or she is woken up.

In some hospitals, adenoid surgery is done as a day case, so that the patient can go home on the same day as the operation. Some surgeons may prefer to keep children in hospital for one night. Either way, we will only let him or her go home when he or she is eating and drinking and feels well enough.

Most children need about a week off school. They should rest at home away from crowds and smoky places. Stay away from people with coughs and colds.

How long will it take to recover?

Most children are back to normal within 24 hours after surgery. Some children take a few days to recover. More snoring or nasal congestion is normal and is caused by temporary swelling in the back of the nose. Bad breath is also normal and is caused by the scabs that form after surgery. The snoring, congestion, and bad breath should be gone within 10 to 14 days after surgery.

Post operative Instructions after Adenoid Surgery

1. Pain Medicines

Most children have little pain after the operation. Most of the pain will be toward the back of the neck. Your child may have a sore throat for a few days. Give regular doses of pain medicine Like Paracetamol, syrup 4 to 5 times a day for a week. . You can also have your child suck on ice chips or chew gum.

A fever between 99°F (37.5°C) and 101°F (38.4°C) is normal for a few days after surgery and can be treated with Paracetamol. DO NOT USE ASPIRIN because this increase the chance of bleeding.

2. Antibiotics and decongestants are continued for another 5 days.

3. Diet

Begin giving your child cool, clear liquids as soon as she wants to drink. Gradually add foods that your child feels like eating until the diet is back to normal.
Your child may feel sick to her stomach, vomit, feel tired and cranky. This should get better within a few hours..

4. Activity

It is best for your child to rest at home for the first 3 to 4 days after surgery. Normal activities can start as soon as your child feels up to it. There is no rule for the right time to go back to school, but a guideline is 5 to 7 days. Your child should not play rough or play contact sports until 14 days after the surgery.

Possible complications

Adenoid surgery is very safe, but every operation has small risks. The most serious problem is bleeding, which may need a second operation to stop it. However, bleeding after adenoidectomy is very uncommon. It is very important to let us know well before the operation if anyone in the family has a bleeding problem.
During the operation, there is a very small chance that any loose tooth (milk tooth) may be removed to prevent aspiration.

Some children feel sick after the operation. This settles quickly.

A small number of children find that their voice sounds different after the surgery. It may sound like they are talking through their nose a little. This usually settles by itself within a few weeks.

The child’s throat may be a little sore. Prepare normal food. Eating food will help your child’s throat to heal. Chewing gum may also help the pain.

Your child may have sore ears. This is normal. It happens because your throat and ears have the same nerves. It does not mean your child has an ear infection.

Give painkillers as needed for the first few days. Do not use more than it says on the label. Do not give your child aspirin - it could make your child bleed. (Aspirin is not safe to give to children under the age of 16 years at any time, unless prescribed by a doctor).

Functional Endoscopic Sinus Surgery

FESS is a treatment procedures carried out with the help of rigid nasal endoscopes. Most patients having FESS will only need diagnostic procedures, not a surgical operation. I began FESS operation from 1987 when I started working at the Bahrain Defence Force hospital. One way FESS differs from traditional sinus surgery is that a thin rigid optical telescope, called an endoscope, is used in the nose to view the nasal cavity and sinuses. The endoscope allows for better visualization and magnification of diseased or problem areas. This endoscopic exam, along with CT scans, may reveal a problem that was not evident before.

It has revolutionized the surgical treatment of chronic sinusitis. FESS generally eliminates the need for an external incision.

Preop CT Scan of the sinuses

A CT scan is a must before doing FESS. Plain X-ray has no value in defining sinus pathology.MRI scans are less useful than CT for most sinus problems, but MRI may be needed in some rare cases of sinus tumors.

How is the operation done?

Most FESS operations are done under general anesthetic in the operating theatre. Hypotensive anesthesia is a bonus. There is no external cut; the surgery is done through the nostrils.

A powerful headlight and angled telescopes to see around corners are used. Using specially designed fine bone -cutting instruments, and powered suction debriders when appropriate, the sinus openings will be enlarged and anything blocking the sinuses, such as swollen mucosa or polyps, will be removed.

Other procedures such as Septoplasty and LASER vaporization of inferior turbinates are often done at the same time as FESS. If you need stitches, they will be internal and self-dissolving. At the end of the operation it is usual to have a pack (merocel) in each nostril to soak up any blood. This is kept in for a day.

The goal of FESS is to open the sinuses more widely. Normally the openings to the sinuses are long narrow bony channels covered with mucosa or the lining of the sinuses. If this lining swells from inflammation, the sinuses can become blocked and an infection can develop. FESS removes some of these thin bony partitions and creates larger openings into the sinuses. After FESS, patients can still develop inflammation from allergies or viruses, but hopefully when the sinus lining swells, the sinus will still remain open. This will permit easier treatment of subsequent exacerbations with more rapid resolution and less severe infections.
The ethmoid sinuses are usually opened. This permits direct visualization of the maxillary, frontal, and sphenoid sinuses and diseased or obstructive tissue can be removed if necessary

Indications for FESS

Polyps-allergic nasal polyps, sinusitis-maxillary, ethmoid, frontal risks?
Nasal and sinus operations are very safe procedures in modern medical practice. But no operation is totally risk free. A general anesthetic carries a minimal risk, with consultant anesthetists using modern drugs and monitoring equipment. There is a low risk of bleeding, either during or up to two weeks after the operation.

Other treatment options?
Long term medication with antibiotics, antihistamines, and steroids helps many people with nasal and sinus problems. Operations are normally only considered when these treatments have already been tried and failed.

Other surgical operations for rhino sinusitis now outdated-

• Sinus wash-Antral lavage
• Intranasal antrostomy
• Caldwell-Luc operation (sub labial antrostomy)
• External fronto-ethmoidectomy

Before the operation

Remember to bring any medicines with you to hospital. You will not be allowed anything to eat for about six hours before operation. The six hour rule does not apply to medicines - these should be taken as usual. When you come into hospital, you will be seen by the nurse who will ask various questions about your general health and attach an identity bracelet to your wrist. Similar questions will be asked by the Resident Medical Officer, and possibly by the anesthetist. You will be examined and checks made to ensure you are fit for anesthetic. If you have any worries or questions, this is a good time to ask.

After the operation

After the operation, you will wake up in the recovery area, where a nurse will look after you. There will probably be a pack in your nose which means you will have to breathe through your mouth. There may be blood in the mouth or nose. This is quite normal and will stop after a while. When you are sufficiently awake, you will return to the ward. You will stay in bed for several hours. Your throat will feel sore; your nose will be blocked. Spit out any blood or secretions; if swallowed it will make you feel sick. The nurse will attend you frequently to check your pulse and breathing. If you are in any discomfort, please let the nurse know as she can you an injection to help relieve it. You will be allowed to drink as soon as the nurse is happy with your condition. You will be advised not to have too much initially as it might make you sick. Food is started as soon as you are able.

At home
Expect to feel as if you have a bad cold or ‘flu for the first 1 - 2 weeks. This is because the lining of your nose will swell up following the trauma of surgery, like the swelling which occurs in viral infections of the nasal lining following a cold. You may well notice large amounts of dark red, brown or green sticky material coming from the back of your nose into the throat, or when you blow your nose, for up to three months after the operation. This is normal and nothing to worry about.

Things to do

• Take all medicines as prescribed, especially antibiotics or nose drops.
• Attend your follow-up appointments - Important treatment will be given.
• Steam inhalations - at least three times daily for two weeks.
• If Otrivine nose drops have also been prescribed, use them before the inhalations.

Things to avoid (for two weeks)

• Smoking, or any smoky, dirty or dusty atmosphere
• Heavy physical work, including fitness training
• Blowing the nose hard (gentle blowing is acceptable but try a steam inhalation first)
• Close contact with people suffering from cold or flu (avoid large crowds for this reason)

Nosebleeds
A minor degree of bleeding - a few spots on a handkerchief, some bloodstained discharge from the nose - is normal and nothing to worry about. You may get a few large dark red or brown clots coming from the nose, or going back into the throat, in the first 1 - 2 weeks; again this is normal and nothing to worry about. If you get a profuse amount of bright red blood, this is not normal. You should

• Sit down in a chair, pinch the nose and breathe through the mouth.
• If there is someone else around, ask them to put some ice in a plastic bag, and hold it over the bridge of your nose.
• If it doesn’t stop within five minutes you should contact us advice.
• In a more urgent situation, you may call the ENT doctor