DISORDERS OF THE NOSE AND PARANASAL SINUSES Flashcards
What is the differential diagnosis list for someone who presents with a blocked nose?
Physiological - Nasal cycle
Congenital - e.g. choanal deformity
Traumatic - e.g. septal deformity
Infective rhinitis
Allergic rhinitis
Non-allergic rhinitis
Nasal polyps
Adenoidal hypertrophy in children
Malignancy of nose, sinus or postnasal space
What is the normal nasal cycle?
The often unnoticeable alternating partial congestion and decongestion of the nasal cavities. This has benefits both in breathing and smelling.
What is choanal atresia?
A congenital nasal defect, which occurs when there is failure of the bucconasal membrane to rupture and therefore the nasal cavities remain separate from the nasopharynx.
Is choanal atresia normally unilateral or bilateral?
Unilateral and as a result might not present until later in life. If a patient is born with bilateral choanal atresia then the newborn will have severe respiratory difficulties. Remember that newborns are obligate nose breathers.
Is choanal atresia more common in males or females?
Twice as common in females as males.
What other congenital abnormalities are associated with choanal atresia?
CHARGE association:
Coloboma
Hearing deficit
choanal Atresia (particularly bilateral)
Retardation of growth
Genital defects (in males)
Endocardial defects
What are the clinical features of choanal atresia?
Breathing difficulty
Cyanosis within hours of birth
Obstruction is relieved by crying as the baby begins to breathe through mouth
Obstruction is worsened by attempts at feeding
Other congenital abnormalities
How do you diagnose choanal atresia?
Failure to pass a naso-endoscope or Foley catheter through the nose into the nasopharynx confirms the diagnosis.
CT scanning will help in determining the extent of the anatomical abnormality.
How do you manage a patient born with choanal atresia?
Airway control - oropharyngeal airway. However this is temporary as feeding is prevented. Devices such as the McGovern nipple allow feeding and airway maintenance.
Surgical management - The atretic plate may be removed as soon as is possible. Fibreoptic endoscopy has made early intervention in neonates much easier.
What is a nasal dermoid cyst?
A dermoid cyst is a teratoma of a cystic nature that contains an array of developmentally mature, solid tissues. It frequently consists of skin, hair follicles, and sweat glands. In the nose, they usually form a midline mass on the dorsum of the nose which presents in childhood.
How do you manage someone with a nasal dermoid cyst?
MRI is performed to rule out cranial extension prior to surgical excision. Cranial extensions include gliomas or encephalocoeles both of which can also come down into the nose and hence look like a dermoid cyst.
When someone presents with a history consistent with a nasal bone fracture, what is it important to exclude as a complication?
Septal injuries and septal haematoma
How do you manage a displaced nasal bone fracture?
Usual strategy is to manipulate the bones back into place under anaesthetic (MUA). It is most effective if done in the first two weeks since injury.
What are the complications of a nasal septal haematoma?
Septal necrosis and abscess formation can lead to collapse of support for the tip of the nose and an ugly saddle deformity.
What symptoms would alert you to the presence of a nasal septal haematoma?
Severe bilateral nasal blockage. This is rare following more simple injuries.
Also pain that worsens rather than decreases over the following few days may indicate the formation of a septal abscess.
What might you see on examination of a nose with a suspected septal haematoma?
A cherry red fluctuant swelling of the anterior part of the septum - usually bilateral - which is soft when pressed with a cotton bud.
How do manage a patient with a nasal septal haematoma?
This is an ENT emergency to avoid necrosis.
The haematoma needs to be drained via an intranasal incision under local anaesthetic. Afterwards the nose is packed to prevent reaccumulation of the blood.
Prophylactic antibiotics are also given orally.
What are local (to the nose) causes of epistaxis (nose bleed)?
Nose picking
External trauma
Infection
Drying of the mucosa
Effects of ageing on blood vessels
Septal perforation
Tumours
What are the systemic causes of epistaxis (nose bleed)?
Platelet factors - thrombocytopenia
Clotting abnormalities - eg haemophilia, von Willebrand’s disease, liver disease
Medication - anti-platelet, anti-coagulant
Hereditary haemorrhagic telangiectasia
High blood pressure
What is the single most common cause of epistaxis?
Idiopathic
Why does the nose have such a prolific vascular supply?
Rapid humidification and warming of inspired air
What are the four main arteries whose branches make up Little’s area in the nose?
LEGS:
superior Labial artery (from the facial artery)
anterior Ethmoidal artery (from the ophthalmic artery)
Greater palatine artery (from the maxillary artery)
Sphenopalatine artery (terminal branch of the maxillary artery)
What is another name for Little’s area in the nose?
Kiesselbach’s plexus
How do you manage a patient with epistaxis in the acute setting?
As with any emergency, the ABCDE approach must be taken.
Pressure is applied to the anterior part of the nose (the soft area), while the patient is told to lean forward to avoid swallowing blood. Ice packs may also be used to help stem blood flow to the nose.
If bleeding continues and there is an obvious bleeding point, then cautery may be used. If there is no obvious bleeding point then the nose should be packed.
How do we cauterise a vessel in the nose in the management of epistaxis?
Either using silver nitrate or using diathermy
What types of nasal packs can be used in the management of epistaxis?
Anterior packs:
Ribbon gauze soaked in iodoform paste (BIPP packing)
Sponge tampons (Merocel)
Rapid rhinos (inflatable and deflatable)
Posterior packs:
Gauze packs
Foley catheter
Apart from packing someone’s nose, what else must you do for a patient whose epistaxis had to be controlled in this way?
Patients who required nasal packing should be admitted to hospital and given oxygen face masks.
Packs should be left in for 24 hours. If any longer than this is needed then prophylactic antibiotics should be considered to prevent staphylococcal toxic shock.
You must also look for a cause if none has been found (eg thrombocytopenia)
If cautery and nasal packing have been unable to arrest epistaxis, what should be done for the patient?
Endoscopic ligation of the sphenopalantine arteries within the nose plus sometimes clipping the ethmoidal arteries via a medial orbital incision. In extreme circumstances, radiographic embolisation may be required to arrest the epistaxis.
What is rhinosinusitis?
Inflammation affecting the mucosal surfaces of the nose and paranasal sinuses.
What are the symptoms of rhinosinusitis?
Nasal blockage
Rhinorrhoea (mucous fluid in the nasal cavity)
Hyposmia / anosmia (reduction in / loss of smell)
Facial pain (often worse bending forwards)
What is the difference between acute and chronic rhinosinusitis?
Time difference, which may also indicate the cause:
Less than 12 weeks - acute infective
More than 12 weeks - chronic
What is the time difference between viral and bacterial rhinosinusitis?
Less than 10 days - viral
More than 10 days but less than 12 weeks - bacterial
What are the common causative organisms of a bacterial rhinosinusitis?
Streptococcus pneumonia
Haemophilus influenzae
Moraxella catarrhalis
Where do the majority of facial sinuses drain to?
Ostiomeatal complex
On examination of someone with rhinosinusitis with an endoscope, what might you see?
Pus in the ostiomeatal complex
How do you manage someone with bacterial rhinosinusitis?
Antibiotics - amoxicillin, co-amoxiclav or cephalosporins
Topical decongestant - ephedrine drops or xylometazoline spray
If this doesn’t work, surgical intervention may be needed
What are the complications of acute bacterial rhinosinusitis?
Orbital complications - especially in children. Ranging from periorbital cellulitis to cavernous sinus thrombosis. May result in vision loss or even death if not treated appropriately.
Osteomyelitis of the frontal bone - Potts puffy tumour
Intracranial complications - meningitis, subdural and extradural empyema, encephalitis, brain abscess.
What are the symptoms of chronic rhinosinusitis?
Nasal blockage
Rhinorrhoea
Anosmia
Facial pain
All lasting more than 12 weeks
What are the different types of chronic rhinosinusitis?
CRS with polyps
CRS without polyps
Wegener’s granulomatosis
Sarcoidosis
What are nasal polyps?
Multiple oedematous outgrowths of mucosa with a profuse eosinophilic reaction.
What is Samter’s triad?
Chronic rhinosinusitis with polyps
Asthma
Allergy to aspirin
Are nasal polyps in children a common presentation?
No. When they are seen a generalised mucociliary clearance disorder such as Kartagener’s syndrome or cystic fibrosis must be excluded.
Which sinuses do nasal polyps usually originate from?
Ethmoid sinuses
Are inflammatory nasal polyps usually uni- or bi-lateral?
Usually bilateral. Unilateral polyps should raise the question of neoplasia and should prompt ENT referral
What mode of imaging is most commonly used to more closely examine nasal polyposis before surgical intervention?
CT
How does you manage inflammatory nasal polyps?
- Steroid spray - fluticasone or mometasone
- Steroid nasal drops - Fluticasone or Betamethasone
- Oral steroids - Prednisolone
- Surgery
What signs and symptoms might lead you to suspect neoplasia of the nose or sinuses?
Unilateral nasal blockage
Bloody discharge
Facial pain
Numbness in the infraorbital region
Loosening of teeth
What are the different types of malignant sinonasal tumours?
Adenocarcinomas
Squamous cell carcinomas
Melanomas
Olfactory neuroblastomas
Lymphomas
