Diagnostic approach to nasal disease

Question 1

Stridor

Answer 1

Harsh inspiratory noise
Disease of larynx or proximal trachea
Caused by air turbulence as it passes through narrow space
Worsen with hot humid weather or exercise

Question 2

reverse sneezing

Answer 2

Reflex response to irrationof nasopharyngeal mucosa
Associate with caudal nasal, nasopharynx or sinus disease
usually self limiting

Question 3

Orthoptera

Answer 3

Breathing with head and neck extended
Sternal recumbency

Question 4

nasal d/c char

Answer 4

Volume, frequency, consistency, location and change with chronicity

Question 5

PE findings

Answer 5

Resp rate, effort, sound
Nasal dc
Sneezing
Ocular dc
Regional lymphadenopathy
Nasal or oral ulceration
Dental disease
Palate abnormalities
Palate the nasal/facial bones for pain,symmetry
Assess airflow from nostril using glass slide
Fundic exam
Neurologic exam

Question 6

Dz localization

Answer 6

Nasal cavity: nasal dc, sneezing, stertor
Nasopharynx: stertor, snoring, mild nasal dc, reverse sneezing
Pharynx: coughing, gagging, repeated attempts to swallow, dysphagia
Larynx: exercise intolerance, voice changes stridor, resp distress, coughing, gagging

Question 7

unilateral d/c

Answer 7

neoplasia, FB, dental dz, fungal dz

Question 8

Hemorrhagic d/c

Answer 8

Hemorrhagic dischargeneoplasia, fungal, trauma, acute foreign body, coagulopathy, hypertension

Question 9

Bilateral d/c

Answer 9

viral disease, immune mediated, allergic, systemic illness

Question 10

Sedated oral exam

Answer 10

Indicated for patients with stridor, change in vocalization , dysphagia
Propofol
Assessment of oropharynx, larynx and laryngeal function
dopram-if needed to stimulate respirations

Question 11

When to use nasal/skull rads

Answer 11

Dental disease, laryngeal tumors, metallic foreign bodies
utility is low!

Question 12

advanced imaging

Answer 12

Preferred
Eval nasal cavity, nasopharynx, and frontal sinuses
disease localization and severity
Etiology dx poss.
should be performed prior to rhinoscopy/bx
costly

Question 13

rhinoscopy

Answer 13

P with nasal or nasopharyngeal dz
After imaging
General anesthesia req
Evaluate nasal cavity, choanae, nasopharynx-visual appearance and turbinate atrophy
FB ID and removal
ID fungal plaques, nasal mites and nasal tumors
impression smear for cytology
bx for histo and poss culture

Question 14

rhinoscopy procedure

Answer 14

sternal recumbency
mouth gag
well inflated endotracheal cuff
pharynx packed with gauze

Question 15

Flexible rhinoscope

Answer 15

2.5-5mm external diameter size
Tip passed just beyond caudal edge of soft palate
retroflex 180 degress to view nasopharygnx and caudal choanae

Question 16

rostral rhinoscopy

Answer 16

2-3 mm rigid fiber optic scope
Bleeding occurs
Constant saline infusion, suction and intermittent flushing

Question 17

rhinoscopic biopsy

Answer 17

Pinch biopsy: Samples are often nondiagnostic
Core biopsy: allow for larger, deeper bx, perform blindly

Question 18

nasal culture

Answer 18

Not useful
Samples for bacterial culture: deep biopsy culture, deep nasal swab
difficult to interpret
Primary bacterial rhinitis is rare
Fungal cultures are done commonly

Question 19

nasal flush

Answer 19

place catheter in proximal nasal cavity and occlude the nares around the catheter
For visualization, diagnostic, and therapeutic
Gauze sponges in oropharynx to prevent aspiration

Question 20

stertor

Answer 20

noisy airway breathing/snoring
obstruction of nasal passages, choanae or nasopharnyx

Question 21

DDx for p c upper airway dz

Answer 21

Infectious, anomaly, laryngeal paralysis, trauma, brachycephalic syndrome, granulom/abscess, immune mediated, allergic, polyp, neoplasia, foreign body, dental disease, systemic disease

Question 22

dx work up

Answer 22

minimum data base, thoracic rads (not that helpful), FNA of regional LNs, impression smears of nasal dc (cryptococcus), BP, coag, blood test for infectious disease

Question 23

exam with general anesthesia

Answer 23

needed to evaluate the nasal cavity, nasopharynx and to perform advanced imaging
perform thorough oral exam prior to intubation: palpate palate, exam nasopharynx with spay hook, otoscope for most proximal nasal turbinates