6. Nose Flashcards
Describe nasal polyps
Fleshy, benign swellings of nasal mucosa, middle meatus most commonly, usually BILATERAL prolapsing into the nasal cavity
S+S =
- Blocked nose and water rhinorrhoea
- Purulent post-nasal drip
- Decreased smell/reduced taste
- Sneezing, snoring
- Mouth breathing
- Headaches
Ix = anterior rhinoscopy or nasal endoscopy
- single unilateral requires biopsy
Mx = topical steroids (betamethasone), followed by fluticasone, endoscopic sinus surgery (ESS) if medical Tx fails
What is the causes and pathophysiology of epistaxis?
Ae = idiopathic (85%), local trauma (nosepicking), facial trauma, dry/cold weather, haemophilia, septal perforation, infection, rhinitis
- Recurrent: angiofibroma, nasopharyngeal tumours, telangectasia, severe HTN, coag disorders
Path = bleeding from Littles area (Kiesselbach’s plexus)
- Anterior or posterior
Outline the management of epistaxis
***plastic apron + gloves
1) resuscitate if needed, tranexamic acid, cannulate (wide bore: Hb, G+S, clotting, LFTs, U+Es, fluids) (obs - HR, RR, sats)
2) Hx = which side, trauma, how much loss, warfarin/aspirin, PMH
3) pt to pinch lower half of nose 20m, breath through mouth, sit forward, spit blood unto bowl
4) ice dorsum of nose
5) prepare to cauterise with silver nitrate - pt blow out clots, gentle suction clots, cotton ball soaked in 1:200,000 adrenaline for 2m or lidocaine spray
6) cautery 2 secs at a time, start from the edge, move in on a circle (avoid if actively bleeding - meds washed away) - refer to ENT is cant see bleeding point
7) If bleeding continues try anterior nasal pack (horizontally, along floor), remove after 24h
8) if bleeding continues try postnasal pack
POSTERIOR = diathermy, arterial endoscopic ligation (sphenopalatine A), embolisation of internal maxillary or facial artery (can cause stroke)
***fluid therapy, blood transfusion, massive haemorrhage protocol, intensive care, naseptin, follow up (if continued bleeding)
Outline acute rhinosinusitis
<12w
Ae = rhinovirus, coronavirus, parainfluenza, RSV, strep pneumonia
S+S = nasal obstruction, congestion, coloured discharge, facial pain/pressure, hyposmia/anosmia, fever, malaise, headache, halitosis, dental pain, fatigue, ear pain
Ix = skin prick tests, RAST, CT before surgery/? malignancy
Self-limiting
<5d Sx Tx = analgesia, nasal saline irrigation, fluid rehydration, topical decongestant
>5d = intranasal corticosteroid (fluticasone), if severe Abx
Outline chronic rhinosinusitis
> 12w
Ae = allergic, CF, occupational, hormonal, granulomatous, infective, anatomical, iatrogenic, cocaine
S+S = blue turbinates, nasal obstruction, congestion, coloured discharge, facial pain/pressure, hyposmia/anosmia, fever, malaise, headache, halitosis, dental pain, fatigue, ear pain
Ix = skin prick tests, RAST, CT before surgery/? malignancy
Mx = allergen avoidance, anti-histamine (allergic pt), intranasal corticosteroids and nasal saline irrigation, if no improvement after 4w consider MC+S and long-term Abx (macrolide 3m)
- CT if poor response to Tx to consider surgery (septoplasty, submucosal diathermy, nasal polypectomy, functional endoscopic sinus surgery FESS
- with polyps: oral steroids, anti-leukotrienes (asthma)
Describe allergic rhinosinusitis
May be seasonal (hay fever) or perennial
- IgE mediated inflam from allergen exposure to nasal mucosa, mast cell degranulation, histamine release
S+S = sneezing, pruritic, nasal discharge, bilateral itchy red eyes, swollen turbinates, pale mucosae
Mx = allergen/irritant avoidance, nasal saline irrigation, antihistamine (loratadine), if moderate/persistent then intranasal corticosteroids sprays
What advice would you give someone following a simple, resolved nosebleed?
Within the first 24h following nosebleed avoid blowing or picking nose, heavy lifting, strenuous exercise, lying flat, drinking alcohol or hot drinks
What are the possible complications of rhinosinusitis
BONY = osteomyelitis, potts puffy tumour
ORBITAL = preseptal cellulitis, orbital cellulitis, abscess, cavernous sinus thrombosis
INTRACRANIAL = abscess, meningitis, superior sagittal snus thrombosis
