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MD2 ENT > Common Conditions of the Nose > Flashcards

Common Conditions of the Nose Flashcards

1
Q

What are the 3 main functions of the nose?

A

Conditioning of inhaled air (warms, humidifies, filters)

Immunity

Olfaction

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2
Q

How does the nose contribute to the immune system?

A

High levels of IgA

Lysozymes

Proteins in mucus

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3
Q

How does the nose warm and humidify the incoming air?

A

Turbinates: erectile tissue which directs airflow (combination of laminar and turbulent airflow)

Epithelium: mostly respiratory (pseudostratified ciliated columnar with goblet cells

Blanket: consisting of more viscid superficial Gel and deeper Sol layer - cilia tips beating in Gel layer to funnel to post-nasal space

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4
Q

What are the sinuses of the face?

A

Frontal

Sphenoid

Maxillary

Anterior ethmoid

Posterior ethmoid

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5
Q

Which sinuses drain to the superior meatus?

A

Sphenoid

Posterior ethmoid

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6
Q

Which sinuses drain to the middle meatus?

A

Frontal

Anterior ethmoid

Maxillary

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7
Q

Which sinuses drain into the meatus?

A

None; only the nasolacrimal duct

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8
Q

List 5 theories explaining the presence of the facial sinuses

A

Modify vocal resonance

Lighten skull

“Airbag” of the brain

Buoyancy in water to keep head afloat

Immunological prechambers

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9
Q

What structures form the upper 1/3 bony pyramid of the nose?

A

Nasal bones attached to frontal bone (superiorly)

Lacrimal bones (supero-lateral)

Ascending process of maxila (infero-lateral)

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10
Q

What structures form the lower 2/3 cartilaginous pyramid of the nose?

A

Upper and lower lateral cartilages

Sesamoid and fibrofatty tissue

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11
Q

What are the two components of the midline nasal septum?

A

Quadrilateral cartilage anteriorly

Bony septum posteriorly

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12
Q

List 9 nasal symptoms to ask about on Hx

A

Nasal blockage

Nasal congestion

Rhinorrhoea

Sneezing

Nasal irritation

Post-nasal drip

Olfaction

Epistaxis

Facial pressure/pain

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13
Q

What anatomical relations of the nose are important to consider when taking a Hx?

A

Orbits and lacrimal system antero-laterally

Skull base superiorly

Oral cavity and teeth inferiorly

Post-nasal space and associated Eustachian opening postero-inferiorly

Cavernous sinus and its contained structures postero-lateral to sphenoid (CN IV, CN III, CN V1, CN V2, ICA, CN VI)

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14
Q

What symptoms of the orbits and lacrimal system may arise due to nasal pathology?

A

Epiphora: due to blockage of nasolacrimal apparatus

Diploplia: due to displacement of axis of globe e.g. by trauma or tumour, opthalmoplegia due to mechanical restriction of extra-ocular muscles

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15
Q

What is lamina papyracea and what is the risk with this condition?

A

Paper thin bone between orbit and nasal cavity

Easily injured

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16
Q

What nasal symptoms may have their origin from the skull base superiorly?

A

CSF rhinorrhoea

Change in smell (e.g. anosmia, cacosmia, parosmia, phantosmia) due to mechanical restriction of airflow to olfactory region or neurological deficit

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17
Q

When might nasal pathology cause CNS symptoms (i.e. change in cerebral function)?

A

With frontal lobe invasion

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18
Q

Ix for CSF rhinorrhoea

A

Double ring-sign on blotting paper

Glucose

B-2 transferrin (gold standard)

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19
Q

What nasal symptoms can occur as a result of post-nasal space and Eustacian tube pathology?

A

Nasal obstruction e.g. due to adenoidal hypertrophy

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20
Q

What middle ear symptoms can be caused by nasal pathologies?

A

Middle ear effusion due to obstruction of Eustachian orifice

Persisting unilateral middle ear effusions require further Ix to exclude post-nasal tumours

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21
Q

What structures are contained within the cavernous sinus?

A

Venous sinus

Optic nerve

Occulomotor nerve

Trochlear nerve

Abducens nerve

ICA and associated sympathetic plexus

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22
Q

What symptoms can be caused by disruption of the cavernous sinus and its associated structures?

A

Visual loss

Visual disturbance

Diploplia

Horner’s

Retro-orbital pain

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23
Q

What is Samter’s triad?

A

Cliical triad including aspirin intolerance, asthma and nasal polyps

24
Q

What specific features of Hx are important in a presentation with nasal symptoms?

A

Smoking

Drug Hx (many drugs cause rhinitis)

Aspirin intolerance

Asthma

Allergic Hx

Age: polyps in children = ?CF

25
Q

What is rhinitis and what are the 7 causative groups?

A

Inflammation of nasal mucosa, causative groups include:

Allergic

Infectious

Occupational

Drug-induced

Hormonal

Others (irritants, food, emotion)

Idiopathic

26
Q

What is allergic mucosa and how is it classified?

A

Inflammation of nasal mucosa due to allergen exposure with an associated IgE response

Intermittent: <4 days/week or <4 weeks

Persistent: >4 days/week AND >4 weeks

Also classified by severity/social impact (mild, moderate/severe)

27
Q

What are the symptoms of allergic rhinitis?

A

Clear rhinorrhoea (anterior or posterior)

Nasal blockage +/- itching of the nose (often alternating between nares)

Sneezing

28
Q

How is allergic rhinitis managed?

A

Mild intermittent: oral or local non-sedative H1-blocker, intranasal decongestant (<10 days) or oral decongestant, allergen and irritant avoidance

Moderate severe intermittent or mild persistent: add in intra-nasal steroid and local cromone

Mild to moderate severe persistent: immunotherapy

29
Q

What is rhinitis medicamentosa?

A

Inflammation of the nasal mucosa secondary to prolonged alpha agonist topical medications

30
Q

What are the symptoms of rhinitis medicamentosa?

A

Clear rhinorrhoea

Marked nasal congestion and obstruction which is progressively less well controlled by the topical medication

31
Q

What is rhinosinusitis?

A

Acute or chronic inflammation of nasal mucosa due to infectious agent (typically viral or bacterial but may be fungal), +/- polyps

Termed rhinosinusitis because it’s continuous with the sinus mucosa

32
Q

What are the symptoms of rhinosinusitis and what is their typical duration?

A

Clear or purulent rhinorrhoea

Nasal congestion/obstruction

Sneezing

Nasal irritation

Epiphora

Duration usually <2 weeks

33
Q

What are the typical symptoms of a common cold? What is the usual causative organism? How long does it last? What about for an acute non-viral cold?

A

Symptoms: rhinorrhoea, blockage, itching

Organism: mostly rhinovirus, rarely (0.5-2%) associated bacterial infection

Duration: symptoms <10 days

Acute non-viral: symptoms worsen after 5 days, last >10 days but still <12 weeks

34
Q

John, previously fit and well 32 year old male, attends ED after slipping over his son’s toy and hitting his nose onto the mantelpiece yesterday

Nil LOC, alert, cooperative

Next step?

A

ABC

Hx: ask about epistaxis, nasal blockage, nasal deformity and features of a skull base fracture

35
Q

John, previously fit and well 32 year old male, attends ED after slipping over his son’s toy and hitting his nose onto the mantelpiece yesterday

Nil LOC, alert, cooperative

John reports an initial episode of epistaxis that settled after a few mins, and has noted that his nose is bent more to the right

He was fine initially but then developed gradual bilateral obstruction

Likely Dx?

A

Nasal fracture

36
Q

What are the characteristics of anterior epistaxis?

A

Usually noticed initially through nares

Most commonly due to damage to the anterior septum (Little’s area/Kiesselbach’s plexus; represents confluence of multiple vessels)

Controlled by direct pressure

37
Q

What are the characteristics of posterior epistaxis?

A

More likely felt dripping down back of nose

Usually from sphenopalatine artery

May need nasal packing as cannot apply simple first aid direct pressure

38
Q

Why might bleeds from nasal fractures persist?

A

Due to fracture stenting vessel; in this case, treatment of epistaxis may necessitate fracture reduction if bleeding not controlled by packing/pressure

39
Q

Role of imaging in Dx of nasal fracture?

A

No indication for imaging to confirm a nasal fracture unless you are suspecting other facial fractures, skull boase disruption, or there are central signs

40
Q

List 6 clinical features which may raise your suspicion of a basal skull fracture?

A

Mechanism of injury

CSF rhinorrhoea/otorrhoea

Raccoon eyes

Battle’s sign

Haemotympanum

Subconjunctival haemorrhage with no posterior margin

41
Q

How should an uncomplicated nasal fracture be managed?

A

Manage any epistaxis, etc

Provide referral to ENT in 5/7 time once swelling has subsided, in order to make a decision about manipulation under GA

42
Q

What is the major complication of septal haematoma?

A

Progression to septal abscess, resulting in cartilage destruction and saddle nose deformity

43
Q

Dx?

A
44
Q

Jane, a 15 year old student, presents with 2 year Hx of clear rhinorrhoea, sneezing and daily bilateral, alternating nasal congestion; symptoms are worse in dusty environments

PHx: asthma

O/E: image attached

Likely Dx?

A

Allergic rhinitis (swelling in nostril is not a nasal polyp but an enlarged inferior turbinate)

45
Q

Dx?

A

Nasal polyp (more translucent, non-tender, cf enlarged turbinate)

46
Q

Confirming Dx of allergic rhinitis?

A

Skin prick tests

47
Q

How can allergic rhinitis be further managed if alternating nasal obstruction is the main issue for the patient?

A

Consider ENT referral for turbinate reduction procedure

48
Q

A few months later, Jane (our allergic rhinitis patient), re-attends with 1/52 of purulent rhinorrhoea, persistent nasal obstruction and 2/7 Hx bilateral cheek and inter-orbital pain worsened by leaning forward

O/E: image attached

Dx?

Mx?

A

Dx: acute rhinosinusitis

Mx: oral Abx, nasal decongestants (e.g. pseudoephridine, xylometazoline, oxymetazoline) to reduce mucosal oedema and open sinus ostea to ventilate sinuses, saline nasal douche to improve mucociliary clearance and mechanically clear purulent secretions

49
Q

What pathogens are most commonly responsible for acute rhinosinusitis?

A

Upper respiratory pathogens, e.g. pneumococcus, Haemophilus influenzae, Moraxella catarrhalis

50
Q

Jane presents with acute rhinosinusitis which is managed routinely

She has an initial improvement but then develops R eye pain and swelling, double vision and opthalmoplegia

Cause of symptoms?

Why is this an emergency?

Mx?

A

Suggest orbital spread of infection; sinugenic causes are the most likely aetiology for orbital infections

Emergency because increased intra-orbital pressures may compromise vision due to optic nerve compression; red/green colour vision disturrbance is an ominous initial sign that should mandate immediate Mx

Mx: immediate ENT referral for admission, IV Abx, high res CT of paranasal sinuses and brain, and ?drainage if abscess

51
Q

Derek, 57 year old carpenter, presents with 3/52 of purulent rhinorrhoea on a background of a 3 year Hx of post-nasal drip, facial pressure and nasal congestion

O.E: image attached (can see some mucopus but not much else)

Dx?

What are the effect of lifestyle factors on this Dx?

Mx?

A

Chronic rhinosinusitis

Smoking can make control harder, occupational exposure to hardwoods increases risk of developing adenocarcinoma

Mx: nasal steroid spray (mainstay of therapy), saline nasal douche, Abx (because purulent)

52
Q

What organisms are typically responsible for CRS?

A

Similar to acute sinusitis but additionally S. aureus and anaerobes

53
Q

What action is required in the event that CRS does not resolve with conventional therapy?

A

ENT review: CT, endoscopy in clinic (look for co-existent polyps), consider FESS

54
Q

FESS: what is it and what is the aim?

A

Functional Endoscopic Sinus Surgery: opens narrow passages (esp osteo-meatal complex, OMC)

Aim: to open (ventilate) sinuses and return them to their premorbid “functioning” state, also allows medical therapy to enter

55
Q

What does the CT demonstrate?

A

Arrows show blocked OMC on left, patent on right

MD2 ENT (10 decks)

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