2- Nose (common conditions) Flashcards
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
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)
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
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
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)
Rhinitis
Background
- Inflammation of the nasal mucosa lining
- Entire nasal cavity affected- bilateral
causes of rhinitis
- Simple acute infective rhinitis (viral- common cold)
- Allergic rhinitis- similar symptoms to infective rhinitis
presentation of rhinitis
- Nasal congestion
- Rhinorrhoea – runny nose
- Sneezing
- Nasal irritation
- Postnasal drip
management of rhinitis
Management
- Topical/ oral nasal antihistamines
- Topical intranasal steroids
- Nasal saline wash
sinusitis background
Inflammation of the mucous membrane of the paranasal sinuses
- Acute <3 weeks (some sources say <12 weeks)
- chronic >3 months
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
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
causes of sinusitis
usually viral infection (URTI)
- Rhinovirus
- Parainfluenza virus
which bacteria cause sinusitis
only 3%
- Streptococcus pneumonia
- Haemophilus influenzae
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
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
chronic sinusitis
> 3 months
causes of chronic sinusitis
- Allergies esp hay fever and environment allergies
- Nasal polyps/ Deviated septum
- Resp tract infection
investigations for chronic sinusitis
Investigations
- Nasal endoscopy
- CT scan
manageemnt of chronic sinusitis
- 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
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
around 50% of all facial fractures
causes of nasal fractures
trauma to nose
presentation of nose fracture
- 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
