14 - Nose and Paranasal Sinuses

Question 1

What are the functions of the nose and nasal cavity?

Answer 1

Question 2

What is the external nose and nasal cavity made up of?

Answer 2

External: Nasal bone right at the top with frontal process of maxilla contributing, rest is made of cartilage

Nasal cavity: see pic

Question 3

What are the different regions of the nose?

Answer 3

• Vestibule lined with sebaceous, sweat glands and hair
• All lined with mucous membrane

Question 4

Why is the lateral wall of the nose irregular?

Answer 4

• Slow down airflow and increase surface area than air passes over
• 3 conchae and 3 meatuses, with paranasal air sinuses opening into the nasal cavity in the middle meatus
• Formed by respiratory mucosa over bony plates

Question 5

What is the nasal septum made up of?

Answer 5

• Septal cartilage
• Vomer
• Ethmoid bone

Question 6

What is being shown here and how does it occur?

Answer 6

- Bilateral septal haematoma

• Punch or injury to nose can buckle septum and shear blood vessels
• Blood accumulates sub-pericondrium stripping cartilage of blood supply

Question 7

What complication can occur if you don’t treat a septal haematoma?

Answer 7

- Avascular necrosis of cartilaginous septum leading to saddle-nose deformity

• Can develop infection in haematoma leading to abscess, increasing change of necrosis
• Also examine for septal haematomas if nasal injury presented

Question 8

Answer 8

Trigeminal

Question 9

What are the symptoms a patient would present with that would make you think of nasal polyps?

Answer 9

• Blocked nose and rhinorrhoea
• Post-nasal drip or tickly cough
• Decreased smell or taste

Usually bilateral, common over 40, pale or yellow in appearance and usually under middle turbinate

Question 10

What are some red flags for nasal cancer?

Answer 10

• Unilateral polyp
• Blood tinged secretion

Question 11

What are the symptoms and causes of rhinitis?

Answer 11

Inflammation of nasal mucosal lining

Question 12

Why is there a rich blood supply to the nose?

Answer 12

• To warm and humidify inspired air but mucosa easily damaged so epistaxis
• Arterial supply from opthalmic and maxillary
• Venous drainage to pterygoid venous plexus, cavernous sinus and facial vein

Question 13

Where are the main areas for nose bleeds and how do you treat them?

Answer 13

- Kiesselbach’s plexus (anterior septum): pinch node and lean forward

• Posterior from sphenopalatine (branch of maxillary) artery requires nasal packing as cannot tamponade

Question 14

What is the function of the paranasal sinuses?

Answer 14

• Extensions of nasal cavity so lined with respiratory mucosa
• Humidify and wamr air and reduce weight of skull
• Drain into nasal cavity via ostia in a meatus
• URTI can cause sinusitis

Question 15

What is the sensory innervation to the paranasal sinuses?

Answer 15

• Nasal cavity, sinuses and nose all branches of trigeminal nerve
• Olfactory nerve in roof of nose

Question 16

What are the symptoms of acute sinusitis and how do you treat it?

Answer 16

• Often secondary to viral infection causing inflammation of mucosa
• Acute is viral (1-2 weeks) but longer may be bacterial so give antibiotics

Question 17

Which sinus is most affected by acute bacterial sinusitis and why?

Answer 17

- Maxillary as ostia high up

• If URTI then reduced ciliary function, oedema or nasal mucosa and increased nasal secretions so sinus drainage impeded
• Stagnant secretions in sinus are breeding ground for bacterial infection

Question 18

What are the commonest bacteria leading to acute bacterial sinusitis?

Answer 18

- S. Pneumoniae

• H.Influenzae
• Moraxella Cattarhalis

Question 19

What nasal disorders need to be referred to ENT?

Answer 19

• Foreign body
• Septal haematoma

Question 20

Apart from URTI’s, what can cause sinusitis?

Answer 20

Dental infections in maxillary sinus

Question 21

What are some complications of sinusitis?

Answer 21

• If in ethmoidal air cells can spread to orbit and lead to orbital cellulitis
• Sight threatening as can involved optic nerve and can track back intracranially

Question 22

If a patient has epistaxis and you maintain pressure on the soft part of the nose and this doesn’t stop the bleeding, what should you do next?

Answer 22

1. Cautery
2. Anterior packing if doesn’t work
3. Posterior packing

Question 23

Answer 23

Question 24

A 16 year old boy whilst playing rugby was punched over the right ear during a scrum. After the game he noticed his ear was painful, red and a prominent bulge had arisen in the upper auricle.

At home he decided to take some painkillers and let it settle. The next day the swelling had not disappeared, so he made an appointment to see his GP. The doctor diagnoses a perichondrial haematoma and refers him to the ENT department.

Answer 24

Bleed between perichondrium and cartilage

Question 25

Label the following blood vessels in the nose and where they came from.

Answer 25

Most commonly in old and young