- Inflammation of the nasal mucosa lining - Entire nasal cavity affected- bilateral

- Simple acute infective rhinitis (viral- common cold) - Allergic rhinitis- similar symptoms to infective rhinitis

2- Nose (common conditions) Flashcards by Saskia Chapman

Nasal polyps
Background

Fleshy, benign swelling of the nasal mucosa
Usually bilateral: common (>40 years)
Unilateral polyps -> red flag and should raise suspicions of tumour

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causes of nasal polyps

They result from chronic inflammation and are associated with:
- Chronic rhinitis
- Asthma
- Samters triad (nasal polyps, asthma and aspirin allergy)
- CF
- Eosinophilic granulomatosis with polyangiitis (Churg- Strauss)

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presentation of nasal polyps

Polyps look slightly lighter
In this pic: Emerge out of the middle meatus (between middle and inferior turbinate’s)
Pale or yellow in appearance/ fleshy and reddened

Symptoms
- Blocked nose and water rhinorrhoea
- Post-nasal drip
- Drip goes into the pharynx and larynx- irritation and cough
- Decrease smell and reduced taste
- Sinusitis- blockage of the sinus air cavities
- Unilateral poly +/- blood tinged secretion may suggest tumour – cancer

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nasal polyp red flag

Blocked nose and water rhinorrhoea
Post-nasal drip
Drip goes into the pharynx and larynx- irritation and cough
Decrease smell and reduced taste
Sinusitis- blockage of the sinus air cavities
Unilateral poly +/- blood tinged secretion may suggest tumour – cancer

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Management of nasal polyps

Topical or systemic corticosteroids
Possible surgery as last option (functional endoscopic sinus surgery)
–> Intranasal polypectomy
–> Endoscopic nasal polypectomy (when deeper in the nose or sinuses)

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Rhinitis
Background

Inflammation of the nasal mucosa lining
Entire nasal cavity affected- bilateral

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causes of rhinitis

Simple acute infective rhinitis (viral- common cold)
Allergic rhinitis- similar symptoms to infective rhinitis

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presentation of rhinitis

Nasal congestion
Rhinorrhoea – runny nose
Sneezing
Nasal irritation
Postnasal drip

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management of rhinitis

Management
- Topical/ oral nasal antihistamines
- Topical intranasal steroids
- Nasal saline wash

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sinusitis background

Inflammation of the mucous membrane of the paranasal sinuses
- Acute <3 weeks (some sources say <12 weeks)
- chronic >3 months

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paranasal sinuses

Paranasal sinuses are air filled spaces lined with resp mucosa and therefor have cilia and goblets cells – extensions of the nasal cavity
Sinuses drain into nasal cavities via ostia’s into a meatus  most commonly the middle meatus

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pathophysiology of sinusitis

Infection leads to reduced ciliary function, oedema of nasal mucosa and sinus ostia and increased nasal secretions  that cant drain due to ostia blockage
Maxillary most commonly affected due to gravity- ostia is high up
Stagnant secretions- breeding ground for bacterial infection

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causes of sinusitis

usually viral infection (URTI)
- Rhinovirus
- Parainfluenza virus

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which bacteria cause sinusitis

only 3%
- Streptococcus pneumonia
- Haemophilus influenzae

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presentation of sinusitis

Coryzal symptoms- yellow sputum – recent URTI
Facial pain- esp when looking down
Headache
Nasal discharge
Loss of smell
Nasal obstruction
Vertigo if mucus builds up in eustachian tube
Ear pain, tiredness

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management of sinusitis

Analgesia
Intranasal decongestants and nasal saline

If symptoms don’t improve after 10 days
- Intranasal corticosteroids for 14 days if symptoms present for more than 10 days e.g. mometasone
- Oral abx e.g. phenoxymethylpenicillin if severe presentation

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chronic sinusitis

> 3 months

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causes of chronic sinusitis

Allergies esp hay fever and environment allergies
Nasal polyps/ Deviated septum
Resp tract infection

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investigations for chronic sinusitis

Investigations
- Nasal endoscopy
- CT scan

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manageemnt of chronic sinusitis

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Avoid triggers, stop smoking
Nasal irrigation with saline solution to relieve congestion and nasal discharge
Intranasal corticosteroids for up to 3 months e.g. mometasone
Specialist referral if unilateral symptoms
Recurrent otitis media/pneumonia in child

Surgery: functional endoscopic sinus surgery
- Involves using a small endoscope inserted through the nostrils and sinuses
- Removal of anything obstructing the sinuses e.g. swollen mucosa, bone, polyps, deviated septum
- Balloon inflation to dilate sinuses

Nasal Spray Technique

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Steroid nasal sprays are often misused, which means they will not be as effective. A good question to ask is, “do you taste the spray at the back of your throat after using it?” Tasting the spray means it has gone past the nasal mucosa and will not be as effective.
The technique involves:
* Tilting the head slightly forward
* Using the left hand to spray into the right nostril, and vice versa (this directs the spray slightly away from the septum)
* NOT sniffing hard during the spray
* Very gently inhaling through the nose after the spray

TOM TIP: It is worth learning and practising how to explain the use of a steroid nasal spray. You may be asked to explain how to use a steroid nasal spray in your OSCEs. I probably explain the technique several times a month in general practice.

nasal fracture background

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around 50% of all facial fractures

causes of nasal fractures

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trauma to nose

presentation of nose fracture

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deformity to the nose
swelling
skin laceration
ecchymosis
epistaxis
CSF rhinorrhea

investigations for nasal fracture

- No place for X-ray - CT preferred imaging modality – would only be needed with more serious injuries needing facial and skull X-ray

management of nasal fractures

Can be seen semi electively (within 7-10 days of injury) to be assessed for nasal deformity or obstruction - Non-displaced fractures can be managed conservatively - If displaced- manipulation under either local or general anesthetic, if not it may need surgery 12 months after the operation - Must also exclude complications like septal haematoma which would need draining - If aesthetic results unsatisfactory -> rhinoplasty or septoplasty - Refer to ENT if required

septal haematoma background

- Potential complication from nasal injury - very important not to miss - always look up the nose

causes of septal ahematoma

- Buckling(bending) of cartilage due to trauma

Pathophysiology of nasal haematoma

- Tears/shears blood vessel - Accumulation of blood - Strips perichondrium away from cartilage (nasal septum) - Causes submucosal blood vessels to tear and blood to accumulate within this sapce - Starving cartilage of blood supply - Cartilage dies-> fibrosis and affects shape - Infection can be an issue

diagnosis of nasal haematoma

- Must look up the nostrils for swelling - Visible on anterior rhinoscopy as boggy red/purple sweeling from the nasal septum -> Using a jobson horn probe, gently palpate the mucosa, as a haematoma will be fluctuant, which helps to differentiate from a deviated septum

Management of nasal haematoma

**Incision and drainage** and a **tamponade** placed to stick perichondrium back onto cartilage

Complications of nasal haematoma

- If you don’t treat septal haematoma- **Saddle nose deformity** due to avascular necrosis - Nasal septal abscesses

deviated nasal septum background

- A deviated septum occurs when the thin wall (nasal septum) between your nasal passages is displaced to one side. In many people, the nasal septum is off-center — or deviated — making one nasal passage smaller

causes of deviated nasal septum

- Present at birth - Injury to the nose

presentation of deviated nasal septum

- Difficulty breathing - Crusting + bleeding - Recurrent sinus infections - May also have no symptoms

Investigations for deviated nasal septum

CT scan and nasal endoscopy

Management of deviated nasal septum

- Nasal sprays including decongestants, antihistamine and corticosteroids - Surgery: may need a septoplasty operation to correct the septum deviation if causing significant problems

nose bleeds 'epistaxis' background

can be due to anterior or posterior bleed in the nasal cavity

anterior bleed of the nose

Kiesselbachs plexus (branches of the **maxillary artery**) (‘littles area’) – *most common* - Area of the nasal mucosa at the front of the nasal cavity that contains amin blood vessels - E.g. picking nose

Posterior bleed

Sphenopalatine artery (10%) - small proportion - more serious and difficult to reach - often bleeding from both nostrils and vomiting blood - Older patients

causes of nose bleeds

Causes * Nose picking * Colds * Sinusitis * Vigorous nose-blowing * Trauma * Changes in the weather * Coagulation disorders (e.g., thrombocytopenia or Von Willebrand disease) * Anticoagulant medication (e.g., aspirin, DOACs or warfarin) * Snorting cocaine * Tumours (e.g., squamous cell carcinoma)

Presentation of nose bleeds

- Blood leaking from nose - When a patient swallows blood during nosebleed -> vomit blood - Usually unilateral - Bleeding from both nostrils indicates bleeding posteriorly (sphenopalatine artery) in the nose --> Higher risk of aspiration of blood

management of simple nose bleed

- Sit up tilt head forward (not backwards- aspiration) - Squeeze soft part of nostrils for 10-15 minutes - Spit out any blood in the mouth rather than swallowing

what is considered a significant nose bleed

if last >10-15 mins bleeding from both nostrils haemodynamically unstable

management of significant nose bleed

Hospital admission 1) Examination - Inspection with thudichum - If too much blood to visualise septum -> adrenaline soaked gauze ->vasoconstriction 2) Nasal packing using nasal tampons or inflatable packs - Anterior packing initially - Posterior packing with a Foley catheter 3) Nasal cautery using silver nitrate sticks 4) Surgery- ligated surgically of embolised radiologically

maangement after an acute nosebleeds

Naseptin nasal cream (chlorhexidine or neomycin) 4 x daily for 10 days to reduce crusting, inflammation and infection

Management of recurrent nose bleeds

After nosebleed avoid * Blowing or picking the nose. * Heavy lifting. * Strenuous exercise. * Lying flat. * Drinking alcohol or hot drinks.

Investigations for recurrent nose bleeds

- Full blood count (thrombocytopenia) - Clotting panel - If worried about cancer refer to ENT on 2 week wait

management of recurrent nose bleeds

- Naseptin applied to nostrils 4 x day for 10 days -> reduce crusting and vestibulitis ***Beware of allergy to neomycin, peanut or soya***** - Nasal cautery (more uncomfortable) with silver nitrate

2- Nose (common conditions) Flashcards

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