Diagnostic approach to nasal disease Flashcards
Stridor
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
reverse sneezing
Reflex response to irrationof nasopharyngeal mucosa
Associate with caudal nasal, nasopharynx or sinus disease
usually self limiting
Orthoptera
Breathing with head and neck extended
Sternal recumbency
nasal d/c char
Volume, frequency, consistency, location and change with chronicity
PE findings
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
Dz localization
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
unilateral d/c
neoplasia, FB, dental dz, fungal dz
Hemorrhagic d/c
Hemorrhagic dischargeneoplasia, fungal, trauma, acute foreign body, coagulopathy, hypertension
Bilateral d/c
viral disease, immune mediated, allergic, systemic illness
Sedated oral exam
Indicated for patients with stridor, change in vocalization , dysphagia
Propofol
Assessment of oropharynx, larynx and laryngeal function
dopram-if needed to stimulate respirations
When to use nasal/skull rads
Dental disease, laryngeal tumors, metallic foreign bodies
utility is low!
advanced imaging
Preferred
Eval nasal cavity, nasopharynx, and frontal sinuses
disease localization and severity
Etiology dx poss.
should be performed prior to rhinoscopy/bx
costly
rhinoscopy
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
rhinoscopy procedure
sternal recumbency
mouth gag
well inflated endotracheal cuff
pharynx packed with gauze
Flexible rhinoscope
2.5-5mm external diameter size
Tip passed just beyond caudal edge of soft palate
retroflex 180 degress to view nasopharygnx and caudal choanae
rostral rhinoscopy
2-3 mm rigid fiber optic scope
Bleeding occurs
Constant saline infusion, suction and intermittent flushing
rhinoscopic biopsy
Pinch biopsy: Samples are often nondiagnostic
Core biopsy: allow for larger, deeper bx, perform blindly
nasal culture
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
nasal flush
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
stertor
noisy airway breathing/snoring
obstruction of nasal passages, choanae or nasopharnyx
DDx for p c upper airway dz
Infectious, anomaly, laryngeal paralysis, trauma, brachycephalic syndrome, granulom/abscess, immune mediated, allergic, polyp, neoplasia, foreign body, dental disease, systemic disease
dx work up
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
exam with general anesthesia
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
