Allergic Rhinosinusitis, Nasal Polyps & Epistaxis

Question 1

What is allergic rhinosinusitis?

Answer 1

It is an IgE mediated inflammation of the nasal mucosa and paranasla sinuses.

Question 2

What are the airborne triggers for allergic rhinosinusitis

Answer 2

1) Pollen
2) Dust/dust mites
3) Mold
4) Animal dander

NB:- There is also a genetic predisposition

Question 3

How many turbinates are in the lateral wall of the nose and name them.

Answer 3

There are 3 turbinates on the lateral wall and they are;
Superior turbinate
Middle turbinate
Inferior turbinate

NB:- Each of the turbinates have a meatus located at the base.

Question 4

In the anatomy of the nose, which region is responsible for olfaction?

Answer 4

Upper 1/3rd contains the olfactory neuroepithelium

Question 5

In the anatomy of the nose, which region is responsible for respiration?

Answer 5

Lower 2/3rd contains respiratory epithelium

Question 6

What is the kiesselbach’s plexus and what are the 4 arteries that make it up?

Answer 6

The kiesselbach’s plexus is a plexus of arteries that lies in the septum. It consists of; SAGS
1) Sphenopalatine artery
2) Anterior ethymoidal artery
3) Greater palatine artery
4) Superior labial artery

Question 7

List the 4 paranasal sinuses

Answer 7

FEMS
1) Frontal sinus
2) Ethmoid sinus
3) Maxillary sinus
4) Sphenoid sinus

Question 8

What are the features of early phase reaction?

Answer 8

Increased mucus production
Runny nose
Wheezing
Itchy red eyes
Nasal itch
Sneezing

Question 9

What are the features of late phase reaction?

Answer 9

Nasal congestion
Mucosal inflammation
Runny nose

Question 10

Briefly describe the pathophysiology of nasal polyps

Answer 10

Exposure to allergens will cause Inflammatory reaction that leading to increased inflammatory response. The increased inflammatory response causes sinus obstruction which will eventually lead to stasis. The stasis causes bacterial colonization and worsening edema that will eventually causemucosal prolapse

Question 11

What are the clinical features of rhinosinusitis?

Answer 11

ROSIE
Rhinorrhea +_ post natal drip
Nasal Obstruction
Sneezing
Nasal Itching
Eye symptoms

Question 12

What are the clinical signs seen on general examination in allergic rhinosinusitis

Answer 12

Allergic shiners
Dennie-Morgan lines
Allergic salute

Question 13

What are the clinical signs seen on nasal examination in allergic rhinosinusitis

Answer 13

Reduced patency
Engorged turbinates
Rhinorrhoea
Nasal polyps

NB:- Eye examination reveals vernal conjuctivitis

Question 14

What are the confirmatory tests for allergic rhinosinusitis

Answer 14

In-vivo: Skin-prick tests
In-vitro: PRIST, RAST

Other tests that are used in assessing allergic rhinosinusitis include
1) X-ray of paranasal sinuses (ocipitomental, ocipitofrontal & lateral views)
2) FBC; to help rule out Non allergic rhinitis with eosinophilic syndrome (NARES)
3) CT of paranasal sinuses

Question 15

What are the treatment options for allergic rhinosinusitis?

Answer 15

Non-pharmacological
1) Allergen avoidance
2) Home remedies (steam inhalation which helps to decongest by activating the cilia in the nostrils to aid movement of mucous, sinus irrigation with warm saline)

Pharmacological
1) Anti-histamines (Chlorphenamine eg piriton, Loratidine, Cetrizine
2) Decongestants (xylometazoline which is a local decongestant, pseudoephedrine which is systemic )
3) Mast cells stabilizers
4) Leukotriene antagonists
5) Steroids

Operative
1. ENDOSCOPIC ASSISTED
- Functional endoscopic sinus surgery
- Endoscopic sinus surgery

2. OPEN PROCEDURES
   
   • Intranasal polypectomy
   • Transnasal ethmoidectomy
   • Caldwell-Luc (Anterior antrostomy)

Question 16

What is Epistaxis

Answer 16

This is the bleeding of nasal or nasopharyngeal origin. It is an Otorhinolaryngological emergency.

Question 17

What is the etiology of epistaxis

Answer 17

LOCAL
Trauma
Infections
Foreign bodies
Cocaine use
Picking your nose
Sino-nasal neoplasms
Atmospheric changes
Deviated nasal septum

SYSTEMIC
1) Blood dyscrasias
2) Vascular anomalies
3) CLD (clotting factors not produced)
4) CKD (urea accumulation causes bone marrow suppression thus leading to thrombocytopenia)
5) Drugs eg Aspirin
6) Hypertension
7) Vicarious menstruation

IDIOPATHIC

Question 18

How do you classify epistaxis?

Answer 18

BASED ON SITE
1) Anterior or Posterior
2) Unilateral or Bilateral

BASED ON PREDISPOSITION
1) Spontaneous or Provoked

Question 19

How do you manage a patient in the ER with epistaxis?

Answer 19

• It is an ENT emergency that demands urgent response and resuscitation
• I’ll do the ABCDE of resuscitation
• I’ll place the patient in TROTTERS position and keep a bowl under the nose for estimation of blood loss
• Normally, bleeding should stop within 3-10 mins, if it doesn’t it means that the chances of trotters position stopping the bleeding is slim
• Cauterization either with Electrocauterization (diathermy) or Chemical cauterization (using silver nitrate, copper sulphate or phenol)
• If it fails, I will pack the nostril(s) with gauze loaded with petroleum jelly or Bismuth Iodoform Paraffin Paste (BIPP). This is for anterior bleeds. If there is still vomiting blood from the mouth when the nostrils are packed, it means the bleeding is mostly posterior and for that you’ll need a foley’s catheter passed through the nostrils and inflated with air and pulled back.
• If bleeding continues, call the ENT surgeon.

NB:- If bleeding stores for a while and continues again after packing —> it is an anterior bleed that involves large blood vessel.

Question 20

Discuss the drainage of the paranasal sinuses.

Answer 20

1) Nasolacrimal duct drains through the inferior meatus

2) Maxillary sinus, frontal sinus, anterior ethmoidal sinus drains into the middle meatus

3) Posterior ethmoidal sinus drains into the superior meatus

4) Sphenoid sinus drains into the sphenoethmoidal recess

Question 21

Which plexus is found at the back of the lateral wall of the nose?

Answer 21

Woodruff’s plexus

Question 22

What is the classification of allergic rhinitis based on time pattern?

Answer 22

1) Perineal
2) Seasonal

Question 23

What is the classification of allergic rhinitis based on severity?

Answer 23

1) Mild:- Does not affect quality of life

2) Moderate - Severe:- Affects quality of life eg sleep, work, school

3) Intermittent:- Symptoms <4 days a wk and or <4 consecutive wks in a year

4) Persistent:- Symptoms >4 days in a wk and or >4 consecutive wks in a year.

NB:- 1 & 2 are used to describe the severity while 3 & 4 are used to describe the frequency