21 - Nose Flashcards
What bones make up the nose?
- Ethmoid
- Vomer
What is the blood supply to the nose?
All comes from internal and external carotid arteries
Little’s Area (Kiesselbach’s) (SEPTAL): LEGS
L - Septal branch of the superior labial artery
E - Anterior and Posterior Ethmoidals
G - Greater Palentine
S - Sphenopalentine
What are some of the causes of epistaxis?
- Idiopathic
- Traumatic e.g nose picking
- Iatrogenic e.g anticoagulants
- Foreign body
- Inflammatory e.g polyps, rhinitis
- Malignancy
- Cocaine use
- Coagulopathies
- HTN
- Hereditary haemorraghic telengectasia
What are some important questions to ask in a history when a patient presents with epistaxis?
- Side, duration, approximate blood loss
- Previous episodes and treatment?
- Risk factors:
- Recent trauma e.g pituitary surgery BEWARE
- Recent URTI
- HTN
- Anticoagulants
- Smoker?
- Cocaine?
- PMHx e.g coagulopathies
How should you treat epistaxis - is it an emergency?
All epistaxis should be deemed an emergency and as severe until proven otherwise.
e.g Posterior bleed may not be externally bleeding but could be swallowing a lot of blood
When is epistaxis classed as life-threatening and what is the management for this?
- Large volume bleeds
- Haemodynamically unstable
- Not stopping with interventions
Mx: A to E, Airway trained personnel present, adequate IV access, resuscitation with blood products
What is the management of epistaxis in general (non-life threatening)?
STEPWISE TREATMENT - MONITOR OBS AND RESUS AS NEEDED
General:
- Sit up and head forward
- Spit out any blood in mouth
- Pinch soft part or put nasal clip on anterior nose for 20 minutes for continuous compression
- Ice on nose for vasoconstriction
- Look for source of bleeding on septum with thudicum and in patients mouth (ant or pos?)
- Send off for bloods e.g FBC, G+S, Clotting and reverse and coagulopathies
SEE IMAGE FOR FURTHER MANAGEMENT
What advice should you give to patients post-cautery?
- Avoid hot showers
- Don’t bend, lift or strain
- No food or hot drinks
- Avoid picking nose
- Send sneezes through mouth
- Come back to A and E if bleeding again for >20minutes
Why should you not use silver nitrate if actively bleeding to cauterise and why shouldn’t you cauterise both sides?
- Bleeding will wash the chemical away and can burn lips
- Risk of perforation
What are some of the risks with posterior packing and surgical embolisation for the treatment of epistaxis?
Posterior Packing:
- Aspiration of Foley catheter
- Packing induced OSA (nasopulmonary reflex - watch resp rate)
Embolisation:
- Risk of stroke
- Never embolise anterior ethmoidal as comes off of ICA
After treating a nose bleed what can you prescribe a patient?
Naseptin (chlorhexadine and neomycin) for 10 days to prevent crusting
Avoid in peanut and soy allergy
What are some examples of anterior packing devices and why should you avoid them if possible?
- Rapid Rhino and Nasal tampons
- Means they have to have an admission
What pathologies could cause recurrent epistaxis?
Always consider leukaemia
What are some important questions to ask with nasal trauma?
- Mechanism of injury (impact, force, direction)
- Pain?
- Nasal deviation?
- Obstruction?
- Epistaxis?
How do you manage a nasal laceration?
- Clean wound
- Consider if need tetanus prophylaxis based on mechanism of injury
- Oppose edges of skin with steri-strips or sutures for primary intention healing
- If cannot get skin to oppose, refer to plastics as may need to heal by secondary intention
After nasal trauma what are two complications you need to assess for?
- Septal haematoma (risk of AVN if left)
- Rhinorrhea (CSF leak from basilar skull fracture)
- Anosmia
How does a septal haematoma present?
On anterior rhinoscopy a boggy red/purple swelling from the nasal septum
Use a Jobson-Horne probe to see if fluctuant as this distinguishes it from a septal deviation
How is a septal haematoma treated and why does it need to be treated?
- Incision and drainage under general anaesthetic
- Risk of avascular necrosis as septum gets its blood supply from overlying perichondrium
- Avascular necrosis of septum can lead to saddle nose deformity, septal perforation and infection/abscess formation
What is the risk with a nasal septum abscess?
Ascending cavernous sinus infection and the associated intracranial or ocular complications
How may a nasal fracture present and what investigations should you do?
- New nasal deformity with swelling and black eyes
- Look for septal haematoma and treat promptly if so
- Treat any epistaxis
- No X-ray needed, if suspect other facial fractures then can do CT
- If uncomplicated nasal fracture (no septal haematoma) can send home and see in clinic after 7-10 days
When a patient with a nasal fracture comes to ENT clinic 7-10 days later, what are you assessing for? (seen 7-10 days later to allow swelling to settle)
Nasal deformity – objective assessment for any bony or septal deviation, patient’s perception of the appearance of their nose
Nasal obstruction – ask how the patient is symptomatically, air flow can be assessed by holding a metal tongue depressor below the nose and observing misting during nasal breathing
How is a nasal fracture treated if there are symptoms?
- Manipulation under anaesthesia: local or general anaesthetic within 2-3 weeks before bones set
- If still issues after this can have rhinoplasty (changing shape of nasal bones) and septoplasty (nasal septum alteration)
Why can rhinorrhea occur after nasal trauma and how can you test it to see if it is CSF?
- Fracture through cribriform plate
- Test the fluid for high levels of beta-2 transferrin
How is a CSF leak following nasal trauma managed?
Conservative: most will resolve spontaneously after 2 weeks with some bed rest and head elevation of 10-15 degrees. Avoid coughing and sneezing
Surgical: not often needed
What are some ways of getting a foreign body out of a child’s nose?
- Ask them to blow their nose
- Parental kiss (blow into mouth whilst occluding other nostril)
- Crocodile forceps
- If battery needs to be removed ASAP
What are some causes of septal perforation?
- Septal surgery
- Trauma (nose picking, foreign body, septal haematoma)
- Inhalants (nasal steroid/decongestant sprays, cocaine abuse)
- Infection (TB; syphilis; HIV)
- Inflammation/malignancies
What is the management for a septal perforation?
- Saline nasal irrigation
- Closure with septal prosthesis
When doing surgery on the sinuses, what are some structures that can be damaged?
- Lamina papyracea (medial wall of orbit)
- Anterior cranial fossa
- Internal carotid artery
Where do each of the paranasal sinuses in the head drain into?
Hiatus Semilunaris is important drainage for most of the sinuses
Thinking about the anatomy of the paranasal sinuses, what could be some complications of rhinosinusitis?
Orbit: periorbital sinusitis could spread to the orbit and be sight threatening
Intracranial Spread: from frontal sinus could spread to cause meningitis or intracranial abscess formation
What are the different classifications of rhinosinusitis?
Acute
- Lasts <12 weeks. Complete resolution of symptoms
- Split into viral and non-viral
Chronic
- Lasts >12 weeks without complete resolution of symptoms
- Split into CRS with polyps or without polyps
What is the definition and clinical features of rhinosinusitis?
Inflamation of the mucoses of the nose and paranasal sinuses characterised by two or more symptoms one of which must be:
- Nasal blockage/obstruction/congestion
- Discoloured nasal discharge (anterior or posterior nasal drip)
- Facial pain or pressure
- Altered or loss of sense of smell
AND EITHER
- Endoscopic signs of polyps, mucopurulent discharge or oedema in middle meatus OR
- CT signs of mucosal changes in the sinuses
What are some of the organisms that tend to cause acute rhinosinusitis and how can you tell which organism is likely causing the sinusitis?
Viral usually resolves within 5 days, bacterial if more than 5 days
- Viral: rhinovirus, influenza virus
- Bacterial: S.Pneumoniae, Haemophilus Influenzae, Moraxhella Catarrhalise
- Allergic
What are some risk factors for developing acute rhinosinusitis?
- Cigarette smoke (active or passive)
- Air pollution
- Anatomical variations, e.g septal deviation, nasal polyps, or sinus hypoplasia
- Anxiety or depression
- Asthma
- Diabetes
What are some differentials for acute rhinosinusitis?
- Viral URTI
- Allergic rhinitis: patient has history of atopy, unlikely to have anosmia and mucopurulent discharge
- Facial pain syndromes e.g migraine: no nasal symptoms
What are some investigations you can do to diagnose rhinosinusitis?
- Clinical symptoms enough to diagnose
- CT if complications
- Skin prick testing if recurrent and suspect allergic cause
How is acute sinusitis managed?
Symptoms up to 5 days: Analgesia and Nasal Decongestants
Symptoms over 5 days and not improving: Topical Nasal Steroids and Oral Antibiotics
Refer to ENT: if any red flags or if not improving after 7-14 days
What are some red flag symptoms with acute rhniosinusitis that would make you refer to ENT?
- Eye signs: periorbital swelling or erythema, displaced globe, visual changes, ophthalmoplegia
- Severe unilateral headache, bilateral frontal headache, or frontal swelling
- Neurological signs or reduced conscious level
If a patient is reffered to ENT with sinusitis what can they do that cannot be done in primary care?
Ix: Flexible Nasoendoscopy, CT
Mx: admission for IV abx, oral steroids and consider surgery
What are some complications of acute rhinosinusitis?
- Preseptal cellulitis, orbital cellulitis, or abscesses
- Osteomyelitis
- Pott’s puffy tumour (osteomyelitis of the frontal sinus result in a soft boggy swelling over forehead)
- Intracranial abscesses
- Venous sinus thrombosis
What are some of the risk factors for chronic rhinosinusitis?
- Atopy
- Cilliary impairment e.g CF
- Aspirin sensitivity
- Smoking
- Immunosuppressants
- Anatomical variants e.g septal deviation
- Trauma
- Foreign body
- Swimming and diving
Chronic rhinosinusitis has the same symptoms as acute. What difference is there between acute and chronic rhinosinusitis on examination?
In chronic, rhinoscopy will reveal generalised mucosal swelling, mucopurulent discharge, and/or polyps
Polyp is overgrowth of swollen mucosa that has prolapsed from sinus into nose
What are the differential diagnoses for chronic rhinosinusitis?
- Recurrent acute rhinosinusitis
- Foreign body
- Malignancy: blood stained discharge, unilateral polyps/symptoms/eye signs
What investigations should you do if you suspect chronic rhinosinusitis?
- Need to do anterior rhinoscopy and nasendoscopy to look for polyps!!!
- Skin prick tests if allergy suspected
- CT sinuses if surgery planned
When do you need to refer someone with chronic rhinosinusitis to ENT urgently?
- Unilateral polyps
- Blood stained discharge
- Eye symptoms
Need to be biopsies for histological diagnosis!
How is chronic rhinosinusitis managed?
Calculate Visual Analogue Score (VAS)
Mild (VAS<3)
- Nasal saline douching
- Topical steroid sprays
- Allergen avoidance
Moderate to Severe (VAS>3)
- Long term antibiotics
- Oral steroids
- Antihistamines
- Topical steroid sprays
- Refer for CT of sinuses and if refractory refer for surgery (FESS)
What is functional endoscopic sinus surgery and what are the complications with this?
- Need a CT beforehand
- Remove any polyps that have formed and open up the sinuses
- Reduces obstruction, drain any collections of mucus, and allow topical treatments to reach all areas to prevent recurrence
- Complications: bleeding, infection, recurrence, injury to orbit, CSF leak
What are some complications of chronic rhinosinusitis?
Mucocele
- Usually in frontal sinus so lump on forehead
- Can erode bone and invade local structures e.g orbit and brain
How can you explain to a patient how to use a steroid spray?
- Tilt the head slightly forward
- Use the left hand to spray into the right nostril, and vice versa (sprays slightly away from the septum)
- DO NOT snif hard during the spray
- Very gently inhale through nose after spray
What are some causes of exacerbations of allergic rhinitis?
IgE mediated type 1 hypersensitivity
- Pollen
- Mould
- House dust mites
- Animals
What is the pathophysiology of allergic rhinitis?
Allergic reaction leads to synthesis and release of prostaglandin D and leukotrienes and mast cell degranulation to release histamine
This increases capillary permeability so congestion, oedema, rhinorrhoea, sneezing and irritation
How is allergic rhinitis classified?
Allergic Rhinitis according to its Impact on Asthma (ARIA)
Duration of Symptoms:
- Intermittent: symptoms <4 days a week and <4 weeks
- Persistent: symptoms >4 days a week and >4 weeks
Severity of Symptoms:
- Mild: normal daily activities and sleep
- Moderate to severe: impairment of daily activities and sleep
How is allergic rhinitis investigated and managed?
Ix
- Skin prick tests
- RAST blood test if above not possible
Mx
Conservative: allergen avoidance, nasal douching with saline
Medical: antihistamines, topical nasal steroids (mometasone), LTRA antagonists
Immunotherapy
How does peri-orbital cellulitis present and where does it arise from?
Presentation: pain, loss of colour vision, oedema of eyelids, proptosis, reduced eye movements
Comes from direct spread of pus from the ethmoid sinus or from thrombophlebitis of mucosal vessels in any of the sinuses
Why is peri-orbital cellulitis an emergency?
Sight threatening
- Risk of blindness as there is tension and septic necrosis of optic nerve
How is peri-orbital cellulitis managed in general?
DO A CT SCAN TO SEE EXTENT OF DISEASE
- IV antibiotics
- Nasal decongestants
- Urgent surgical drainage if abscess
What are nasal polyps
Nasal polyps are growths of the nasal mucosa that can occur in the nasal cavity or sinuses. They are often associated with inflammation, particularly with chronic rhinitis. They grow slowly and gradually obstruct the nasal passage.
Polyps are usually bilateral. Unilateral nasal polyps are a red flag and should raise suspicions of tumours.
TOM TIP: If you remember one thing about nasal polyps, remember that unilateral polyps are concerning for malignancy and require a specialist referral for assessment.
What are nasal polyps associated with?
Nasal polyps are associated with several conditions:
- Chronic rhinitis or sinusitis
- Asthma
- Samter’s triad (nasal polyps, asthma and aspirin intolerance/allergy)
- Cystic fibrosis
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
How do nasal polyps present
Nasal polyps may be found on examination in patients presenting with:
- Chronic rhinosinusitis
- Difficulty breathing through the nose
- Snoring
- Nasal discharge
- Loss of sense of smell (anosmia)
You can examine the nose with a nasal speculum, which holds the nostrils open. Alternatively, you can use an otoscope with a large speculum attached. A specialist can perform nasal endoscopy to visualise the nasal cavity in detail to assess any polyps.
Nasal polyps appear as round pale grey/yellow growths on the mucosal wall.
How do you manage nasal polyps?
Unilateral polyps should be referred for specialist assessment to exclude malignancy.
Medical management involves intranasal topical steroid drops or spray.
Surgical management is used where medical treatment fails. This involves removing the polyps:
- Intranasal polypectomy is used where the polyps are visible close to the nostrils
- Endoscopic nasal polypectomy is used where the polyps are further in the nose or the sinuses
