40. Diseases of the Nose

Question 1

bony nose on the nasal ridge, the rest is cartilage, some fatty tissue

Answer 1

relevant anatomy

Question 2

inferior turbinate which is what you can see, middle turbinate, superior turbinate

Answer 2

internal structures of the nose

Question 3

internal carotid > opthalmic artery > anterior ethmoidal artery and posterior ethmoidal artery

Answer 3

blood supply to the lateral wall

Question 4

external carotid > maxillary artery > greater palatine artery, lesser palatine artery, and sphenopalatine artery > branches of sphenopalatine artery

Answer 4

blood supply to the lateral wall

Question 5

facial artery > branches of the facial artery

Answer 5

blood supply to the lateral wall

Question 6

very similar to lateral wall supply, kiesselbach’s plexus bracnes of the internal and external carotid

Answer 6

blood supply to the septum

Question 7

upper part of nose/face drains via angular vein intracranially to the cavernous sinus, also drainage via fiacial to jugular vein

Answer 7

venous drainage of the nose

Question 8

upper lip, philtrum, and nose, contains cavernous sinus, oculomotor nerve, trochlear nerve, opthalmic nerve, abducent nerve, maxillary nerve, internal carotid artery, sella turcia, sphenoid sinus, sphenoid bone, nasopharynx, pituitRY GLAND, optic chiasm

Answer 8

danger triangle

Question 9

primarily respiratory epithelium, specialized olfactory area, some squamous epithelium at the nares

Answer 9

nasal mucosa

Question 10

increased secretions, nasal obstruction, bleeding, foul odor, pain, altered sense of smell

Answer 10

symptoms of nasal pathology

Question 11

nasal speculum opens up and down, or nasal endoscopy but needs topical anesthetic, can visualize nasopharynx

Answer 11

examination of the nose

Question 12

palpate all the facial bones so you know it is isolated, no imaging if tender only at the nasal bridge, the nose is aligned, the nareas are patent, and there is no septal hematoma, management of most nasal fraftures is deferred until swelling resolves, for extensive facial trauma CT is the preferred imaging modality

Answer 12

isolated nasal trauma

Question 13

can compress the septum and cause necrosis, can become infected, drainage followed by packing, with ENT follow up, remember image

Answer 13

septal hematoma

Question 14

common complaint, usually not a sign of systemic disease, common causes include trauma, nosepicking, dry mucosa due to dry winters, allergies, less common causes include coagulopathy, thrombocytopenia, and cancer

Answer 14

epistaxis

Question 15

not common 1:150,000 people is about 50/year in the US, primarily adolescent males, can present with massive epistaxis or mass effect, benign but grows aggressively

Answer 15

juvenile nasopharyngeal angiofibroma

Question 16

personal history of bleeding issues, blood in the stool or urine, gum bleeding, anticoagulant medications, family history of bleeding disorders, prior episodes on the same side with what triggers them, if treatment was attempted

Answer 16

epistaxis history

Question 17

management is done stepwise, apply pressure, add topical vasoconstrictor oxymetazoline, cautery only if you can see the source and only do one side of the septum, then tamponade, then surgical management

Answer 17

epistaxis history

Question 18

pressure, topical vasoconstrictor oxymetazoline, cautery if you can see the source, only do one side of the septum, tamponade, surgical management

Answer 18

epistaxis management

Question 19

if unable to control pressure +/- topical vasoconstri ction +/- cautery, proceed with packing, can be vaseline gauze or commercial products, packing remains for 24-48 hours, packing remains for 24-48 hours, oral antibiotics are not uniformly recommended but consider for prevention of sinusitis and toxic shock syndrome, may pack both sides if first doesn’t stop it, if still bleeding suspect posterior bleed

Answer 19

anterior expistaxis

Question 20

when efforts to stop epistasis as already described don’t work you may have a posterior bleed, posterior pack and also anterior pack, will often need inpatient care

Answer 20

posterior epistaxis

Question 21

uncontrolled bleeding or bleeding that recurs when pack is removed may need a surgical or interventional radiology approach

Answer 21

if all else fails

Question 22

don’t touch your nose, don’t put anything in your nose like finger, tissue, or gauze, use a humidifier when sleeping, use saline spray, ENT referral if the patient needed more than anterior packing, assess for causes/sources

Answer 22

epistaxis after care

Question 23

most common in children, can cause purulent drainage, foul odor, bleeding, and pain, acutely parents can see the child put it there, but subacutely can cause unilateral purulent drainage with bad smell, can be removed with parent’s kiss, balloon catheter, forceps, caveats with button batteries, concern for aspiration, check for other orifices, consider sinus infection

Answer 23

nasal foreign body

Question 24

make sure there is only one foreign body, if subacute presentation with purulent discharger, treat with oral antibiotics for presumed sinus infection, consult ENT if injury

Answer 24

nasal foreign body aftercare

Question 25

itchy nose, stuffiness, watery nasal discharge, sneezing, itchy etes, seasonal with pollen or perennial, pale boggy mucosa with swollen turbinates and watery nasal discharge, treat with oral medications like antihistamines, and leukotriene modifiers, topical meds intranasally like antihistamines and steroids, or immunotherapy, avoid allergens

Answer 25

allergic rhinitis

Answer 26

nasal polyps

Question 27

generally bilateral in older patients, related to chronid inflammation or infection, red flags include unilateral polyps which may be malignancy, children or young adults with polyps consider underlying disorders like cystic fibrosis, obstructive complains as well as allergy, fullness, decreased sense of smell, treat with topical steroids, oral steroids if very symptomatic, surgical resetction

Answer 27

nasal polyps

Question 28

overuse of oxymetazoline and or phenylephrine nasal spray, is real

Answer 28

rhinitis medicamentosa

Question 29

deviated septum, perforated septum

Answer 29

other causes of nasal obstruction symptoms

Question 30

acute painful inflammation of the entrance to the nose, usually no complaint of obstruction, erythema may have pustule and or crusting, tendnerness, usually cause by s aureus, treat with topical muciprocin or antistaph antibiotic, venous drainage is relevant

Answer 30

nasal vestibulitis

Question 31

common cold caused by a variety of viruses, accompanying systemic disease and other respiratory symptoms, course is 7-10 days with congestion thick and sometimes discolored toward the middle of the course, treatment is symptomatic, no antibiotics unless there is a sinus infection

Answer 31

acute rhinitis

Question 32

failry common especially as people get older, can lead to loss of enjoyment of food and ultimately malnutrition and depression, obstructive diseases 30% like sinusitis, allergies, polyps, post infetious like 15-30%, with SARS cov-2 most patients who have lost smell recover it spontaneously within a few weeks, trauma 10-30% direct mucosal injury to the CNS anywhere on the pathway, medications, drugs of abuse, aging, CNS disease like alzheimer’s, parkinson’s, multiple sclerosis, stroke, pseudotumor, cerebri, idiopathic, workup is directed by history, may include CT scan to evaluate sinus disease or MRI to evaluate CNS, treatment depends on cause, often no treatment with patience required

Answer 32

olfactory dysfunction

Question 33

olfactory neurons > bulb > nerves > nuclei, cortex, and amygdala

Answer 33

olfactory pathway