Disorders of the Nose

Question 1

Definition of rhinosinusitis (6)

Answer 1

inflammation of nose+paranasal air sinuses+2 of:
-congestion/discharge
-decreased smell
-facial pain/pressure
-cough
-endoscopic signs of polyps/mucous+/-pus discharge from sinuses
-CT shows mucous w/i sinuses
(chronic rhinosinusitis defined as >3mo)

Question 2

Rx of rhinosinusitis (3)

Answer 2

mild(<5d):analgesia+phenylephrine

worse after 5d: topical steroids

severe(temperature+severe pain):topical corticosteroids+amoxicillin

Question 3

Main causes of nasal congestion in children (5)

Answer 3

rhinitis

choanal atresia (congenital blockage of back of nasal passage)

large adenoids

foreign body

tumour

Question 4

Main causes of nasal congestion in adults (4)

Answer 4

deflected nasal septum

topical vasoconstrictors

granulomatous disease

TCAs

Question 5

Features and Sx of allergic rhinosinusitis (5)

Answer 5

IgE mediated

can be seasonal of perennial

Sx:

• sneezing
• rhinorrhoea
• pruritus

Question 6

Rx options for allergic rhinosinusitis (6)

Answer 6

antihistamines 1st line:

• citirazine
• loratidine

nasal steroids e.g. beclometosone 2nd line-can develop tachyphylaxis

may require course of oral corticosteroids

oral decongestants e.g. pseudoephidrine

nasal alpha agonists e.g. sodium cromoglycate,
oxymetazoline

leukotriene receptor anatgonist e.g. zafirlukast

Question 7

Other causes of chronic rhinorrhoea/rhinitis (18)

Answer 7

allergies
foreign bodies
CSF
old-age
fungal infections
HIV
bacteria
CF 
kartagener's
RA atrophic
pregnancy 
COCP
Beta blockers
NSAIDs
decongestant overuse
Ab deficiency
non-allergic rhinitis w. eosinophilia
atrophic

Question 8

Features and associations of nasal polyps (8)

Answer 8

ciliary columnar epithelium

assoc. w.:
- allergic/non-allergic sinusitis
- chronic ethmoid sinusitis
- CF
- aspirin hypersensitivity
- asthma
- kartagener’s
- Churg-Strauss

Question 9

Symptoms of nasal polyps (9)

Answer 9

watery anterior rhinorrhoea

anosmia/taste disturbance

purulent post-nasal drip

snoring

change in voice

nasal obstruction

sinusitis

headaches

mouth breathing

Question 10

appearance of nasal polyps (3)

Answer 10

pale

immobile

insensitive to gentle palpation

Question 11

Rx of nasal polyps (2)

Answer 11

nasal steroid drops (beclometasone)

endoscopic polypectomy-do CT before if unusual anatomy.

Question 12

Symptoms of sinusitis (7)

Answer 12

pain:

• cheek(maxillary), between eyes (ethmoid)
• facial fullness
• worse leaning forward

discharge

anosmia

obstruction/congestion

systemic symptoms

Question 13

DDx for sinusitis (6)

Answer 13

migraine

TMJ dysfunction

GCA

Cervical spine disease

neuralgias

VZV

Question 14

Causes of sinusitis (6)

Answer 14

most after viral infection

direct spread

odd anatomy

mechanical ventilation/NGT

systemic e.g. kartagener’s, immunodeficiency
biofilms

Question 15

common organisms involved in sinusitis (4)

Answer 15

rhinovirus main one

staph aureus following viral URTI

pseudomonas

strep pneumoniae

Question 16

Ix for sinusitis

Answer 16

ESR/CRP more reliable than CT

Question 17

Rx of sinusitis (3)

Answer 17

decongestant+paracetemol 1st line

if prolonged then amoxicillin (+steroids for Sx)

if chronic/recurrent:

• endoscopic surgery to remove sinus mucosa
• fluticasone nasal spray after helps

Question 18

Complications of sinusitis (6)

Answer 18

orbital cellulitis

post-nasal drip

osteomyelitis

subperiosteal abscess

intracranial infection

mucocele>infected procele

Question 19

assoc. and presentation of adenocarcinoma of the maxillary sinus (4)

Answer 19

assoc. w. wood inhalation

presents w. unilateral blocked nose, bleeding and paraesthesia on cheek.

Question 20

Features and Ix for sinus fungal balls

Answer 20

sinusitis which fails to respond to Abx

CT shows round opacity w. mixed density

Question 21

Features of sinus polyps

Answer 21

swelling coming from sinus seen on CT scan

often in ethmoid sinus

Question 22

Mx of nasal fractures (3)

Answer 22

may not require intervention if undisplaced

if displaced, will need reduction under GA w. post-op splintage w/i 10-14d

if reduction unsuccessful, may require septorhinoplasty

(temporal bone fracture may transect VIIth and VIIIth nerves)

Question 23

Causes and Ix for CSF rhinorrhoea (3)

Answer 23

ethmoid trauma-think fractured cribriform plate

if not trauma then tumour

Ix:
-electrophoresis to detect B2-transferrin in CSF.

Question 24

Feature and causes of septal perforation

Answer 24

whistling noise when breathing out

relapsing polychondritis

sniffing salts/cocaine

malignancies e.g. rodent ulcer

nasal steroid/decongestant

chronic inflammatory/granulomatous disease

Question 25

Features, presentation and Rx of septal haematoma (4)

Answer 25

blood between peri-chondrium and septal cartilage

presents w. asymmetrical septum and bluish-reddish fluctuance

can become infected so needs immediate drainage.

Question 26

complications of nasal surgery(3)

Answer 26

bleeding

CSF leak

altered sensation on lips/gums/incisors

Question 27

Causes of epistaxis (9)

Answer 27

trauma

infection

HTN (usually prolongs)

dyscrasias

hereditary: vWf, haemophilia, Osler-Weber-Rendu

increased alcohol intake

septal perforation

neoplasm

septal haematoma

Question 28

Types of epistaxis (2)

Answer 28

anterior: almost always little’s area
posterior: may require more invasive Ix e.g. under GA

Question 29

Kiesselbach’s Plexus

Answer 29

LEGS:

• labial (superior)
• ethmoidals (ant+post)
• greater palatine
• sphenopalatine

Question 30

Initial emergency Mx of epistaxis (3)

Answer 30

ABCDE resus

Hx: which side? trauma? quantity of blood? DHx?PMHx?

Ice dorsum of nose.

Question 31

Further emergency Mx of anterior epistaxis (5)

Answer 31

pinch nose+lean forward

encourage blowing out clots

look inside and spray lidocaine and phenylephrine

cauterise bleeding points w. silver nitrate from out to in, NB. don’t cauterise both sides of septum and avoid in clotting disorders

anterior nasal packing-can go home unlike posterior packing

Question 32

Further emergency Mx of posterior epistaxis (6)

Answer 32

apply pressure for 15 mins but if blood loss increasing then continue to next step

posterior packing

inject local anaesthetic and insert foley catheter

brighton balloon

Give Abx to prevent Eustachian tube infection

may require ligation of sphenopalatine and maxillary arteries

Question 33

Features of posterior epistaxis (4)

Answer 33

pressure not helping

bilateral

no obvious anterior source

blood in nasopharynx.