ENT 2 - nose

Question 1

Breathing
Through nose is primary way to breathe

Air-conditioning
Nasal mucosa adjusts temperature and humidity air before entering the lungs

Filtration & purification
Hairs filter + trap larger particles and mucus captures smaller particles (to nasopharynx to swallow)
Secretions also make enzymes kill microorganisms and antibodies (e.g. IgA) are present

Sinus ventilation
Sinuses make mucus to moisturise and protect the nose

Nasal resistance

Vocal resonance
A chamber for producing certain sounds (e.g. M, N NG)

Olfaction (smell)
Olfactory neuroepithelium in ST, olfactory nerves and bulbs control olfaction, signal to brain (e.g. olfactory cortex)

Blood vessels/flow and nasal sections
Controlled by ANS

Question 2

what is olfaction?

Answer 2

Olfaction: works by detection of odor by olfactory receptor neurons (ORNs) in the olfactory epithelium (OE)

Transmits signal through cribiform plate to the Mitral Cells (MC) in the olfactory bulb in the brain

ORNs are supported by Sustentacular Cells (SuC) also in OE

Stem cells (SCs) in OE can replace SuC and ORN cells

Thus, sense of smell could be affected if damage/loss of SuC, ORN or MC

Only SuC have receptors that allow binding and infection by SARS-CoV-2. Evidence suggests that loss of SuC cells leads to anosmia (mechanism not yet fully understood)

Question 3

what are conditions effecting the nose?

Answer 3

1. Rhinitis (allergic** and non-allergic) and rhinorrhea
2. Polyps
3. Bacterial sinusitis
4. Nasal staphylococci

Question 4

what causes nasal congestion?

Answer 4

Nasal Congestion: Many causes including rhinitis, polyps, infections (cold & flu), sinusitis

Question 5

what causes rhinorrhea?

Answer 5

(runny nose): Many causes including infections (e.g. cold & flu), cold temperature, rhinitis

Question 6

drugs acting on the nose
examples

Answer 6

Decongestants – sympathomimetic amines
Ephedrine: intranasal, direct and indirect α- and β-adrenergic agonist (via NA)
Pseudoephedrine: oral/by mouth, direct and indirect α-adrenergic agonist (via NA)
Phenylephrine: oral/by mouth, direct α1-adrenergic agonist
Xylometazoline: intranasal, direct α1 and 2-adrenergic agonist

Decongestants – other
Sodium chloride solution (0.9%) drops or spray: liquefy secretions

Anti-inflammatory glucocorticoids
Fluticasone: intranasal, agonist GR
Beclometasone: intranasal
Mometasone: intranasal, agonist GR

Suppressors of inflammatory mediator release (eyes!)
Sodium cromoglicate (cromolyn): stabilises mast cells

Anti-histamines
Cetirizine: Oral, H1 Receptor antagonist (allergy)
Loratidine: Oral, H1 Receptor inverse agonist (allergy)
Acrivastine: Oral, H1 Receptor antagonist (allergy)
Azelastine: Topical (intranasal), H1 Receptor antagonist (allergic conjunctivitis and rhinitis) – also eyes

Anti-cholinergic (parasympatholytic)
Ipratropium bromide: intranasal, mAChR antagonist, blocks secretions

Question 7

what is the treatment options for allergic conjunctivitis?

Answer 7

Allergic conjunctivitis: Anti-histamine (antazoline only w/xylometazoline, 2-3x/day); mast-cell stabilisers (cromoglicate, lodoxamide, 4x/day); both - azelastine, epinastine, ketotifen, olopatadine (all 2x daily). Diclofenac (NSAID) eye drops can be adjunctive

Question 8

what is the treatment for non-allergic rhinitis?
congestion
rhinorrhea

Answer 8

Non-allergic Rhinitis Treatment (including infective)

Congestion: sympathomimetic decongestants topically (e.g. ephedrine, safest, intranasal up to 4x daily) or pseudoephedrine can be taken orally (3-4x daily)

Rhinorrhea: ipratropium bromide spray (topical, 2-3x daily)

Question 9

allergic rhinitis
1st line drugs

Answer 9

Intranasal antihistamine - Within 15 min - 2x daily

Oral non-sedating antihistamine - Within 1 hr - Once-daily options (some 3x)

Intranasal corticosteroids - Within 12 hrs+ - Once-daily options (some 2x)

Question 10

what is sympathomimetic agents - examples, target and mechanism

Answer 10

Target: Nasal blood flow
example: (e.g. Ephedrine, pseudoephedrine)
moa: vasoconstriction (to limit histamine effects)

Question 11

what is corticosteroids - examples, target and mechanism

Answer 11

target : 2. Anti-inflammatory

(e.g. fluticasone, mometasone)

moa :anti-inflammatory steroid (suppress inflammation)

Question 12

what is cromolyn sodium - examples, target and mechanism

Answer 12

Suppression of mediator release

[Omalizumab – allergic asthma]

inhibit histamine release
monoclonal antibody (mAB) prevents IgE interaction

Question 13

what is h1 receptor antagonist - examples, target and mechanism

Answer 13

4. Mediator receptor blockade

(e.g. azelastine)
Leukotriene antagonists (inhibits leukotriene Receptor - )
(e.g. montelukast)

block vasodilation
block inflammation

Question 14

what is the mode of action of Nasal congestion

Answer 14

Intranasal ephedrine or systemic pseudoephedrine used as nasal decongestants

Indirect and direct sympathomimetics as substrates for uptake system

Indirect - taken up via NET into neuron then into vesicle via VMAT leading to NA release to act on adrenergic receptors of postsynaptic neuron
+
Direct – act directly on adrenergic receptors

Vasoconstriction to reduce mucosal blood flow and oedema

Question 15

what is polyps
cause
symptom
treatment

Answer 15

Non-cancerous, soft growths inside the nose (or sinuses)

Cause
Linked with chronic inflammation (e.g. asthma, infections, disorders but sometimes unknown cause)

Symptoms
Nasal congestion, rhinorrhea, nasal drip, loss of smell/taste, nosebleeds, snoring – symptoms will be persistent

Treatment
Corticosteroid nasal drops/spray to shrink
(e.g. fluticasone, mometasone,
budesonide)
May use Sodium chloride wash
Oral steroids short-term if necessary
Surgery possible to remove

Question 16

what is acute sinusitis?
causes
symptoms
diagnosis
treatment

Answer 16

Causes
Usually viral (acute – e.g. rhinovirus) and following URTI, some cases bacterial
Both usually self-limiting - usually lasts 2-3 weeks [Chronic >12 weeks]
Inflammation leads to build up of mucus, can lead to further infection

Symptoms
Blocked nose, nasal discharge, facial pain/pressure, sinus headache, loss/reduced sense smell, may have cough, symptoms >10 days, fever >38oC, purulent/discoloured discharge, severe pain, worsening of initial symptoms [more indicative of bacterial]

Diagnosis
Based on signs/symptoms, can examine for face pain and use otoscope or nasal speculum to examine nose (e.g. inflammation), discharge

Treatment
Depends on duration of symptoms and severity
Pain can be managed with analgesia (paracetamol, ibuprofen)
Nasal saline or nasal decongestants can be used but limited evidence to support
High-dose nasal corticosteroids an option if >10 days symptoms
Antibiotics may also be an option if >10 days symptoms

If systemically unwell, symptoms more serious or high-risk complications:
Immediate antibiotics, 1st line: phenoxymethylpenicillin, 5d, QDS (adult 500mg)*
Refer to hospital if required (e.g. severe systemic infection)

Systemic illness, severe, co-amoxiclav TDS, 5 days, adults 500/125mg – see NICE guidance for all doses (including children)

Doxycycline/clarithromycin alternatives to penicillin (or erythromycin in pregnancy)

If symptoms <10 days – no antibiotics, self-care

Self-care (pain management: paracetamol, ibuprofen)

If >10 days with no improvement: consider high-dose intranasal corticosteroid (14d – 12yrs+ only, off-label), typically no antibiotics or back-up prescription (depends risk of bacterial infection)

Question 17

when is antibiotics used for in sinusitis?

Answer 17

symptoms not improved after more than 10 days

Consider no antibiotic or back-up antibiotic prescription (likelihood bacterial)

Consider high-dose nasal corticosteroid for 14 days

Question 18

what is the treatment of staphylocci ?

Answer 18

If required (e.g. admission to hospital, HCPs – would swab to test):

Chlorhexidine and neomycin (broad-spectrum antiseptic + aminoglycoside antibiotic) cream 4x daily, 10 days

Mupirocin (agent that inhibits bacterial protein and RNA synthesis) nasal ointment used for the eradication of nasal carriage, including methicillin-resistant Staphylococcus aureus (MRSA) . Used as 2% ointment, 2-3 times per day, 5 days

Question 19

what are the components in nose anatomy

Answer 19

• frontal sinus
  -sphenoid sinus
  -upper lip
  -nasal vestibule

Question 20

Throat anatomy & physiology

Answer 20

Throat: Pharynx & Larynx
Pharynx (see diagram)
Larynx (including epiglottis)
Vocal chords
Epiglottis prevents food from entering trachea
Trachea (windpipe, connects larynx to lungs)
Oesophagus (connects pharynx to stomach)

Question 21

what are the common throat condition?
and mouth conditions

Answer 21

Main throat condition is sore throat: pharyngitis and tonsilitis

In mouth have:
Oral ulceration and inflammation
Fungal and viral infection such as thrush or herpes
Dry mouth

Question 22

what are drugs which act on the throat?

Answer 22

Anti-inflammatory: Topical corticosteroids: hydrocortisone and betamethasone;
Topical NSAIDs: benzydamine, flurbiprofen (lozenges)

Anaesthetics: Topical lidocaine, benzocaine

Antibiotics: Phenoxymethylpenicillin, clarithromycin, erythromycin

Analgesia: Paracetamol, ibuprofen, choline salicylate

Anti-fungals: Topical nystatin, miconazole; Systemic fluconazole, amphotericin

Anti-virals: Topical acyclovir, systemic valaciclovir

Anti-septics: Chlorhexidine

Question 23

what is acute sore throat?
causes
symptoms
diagnosis
treatment

Answer 23

Pharyngitis or tonsilitis are inflammation of the pharynx or tonsils

Cause: Often viral, can be bacterial or other causes
Strep throat by airborne drops or contact

Other signs and symptoms:
Sore throat, fever (common), may have headache,
nausea, vomiting, abdominal pain

Diagnosis:
Examination and signs/symptoms. FeverPAIN and
CENTOR criteria scores can be used as guide (next slide)

Treatment:
IF needed and bacterial infection,
for GAS – phenoxymethylpenicillin, 500mg QDS 5-10 days
If penicillin allergy: clarithromycin (erythromycin if allergy/pregnancy)
Can relieve symptoms: painkillers (paracetamol), fluids, medicated lozenges*

Question 24

what is the Clinical scoring tools forStrep. throat

Answer 24

FeverPAIN Scoring:
1 point for each of: Fever, Purulence, Attend within 3 days or less of symptom onset, Severely Inflamed tonsils, No cough or coryza,. Maximum score: 5

CENTOR Scoring:
1 point for each of: Tonsiliar exudate, tender anterior cervical lymphadenopathy or lymphadenitis, history fever (>38oC), no cough. Maximum score: 4

The higher the score, the greater the likelihood of isolating Streptococcus

FeverPAIN 4-5 or Centor 3-4, person more likely to benefit from antibiotic – this helps guide treatment choice and offer of antibiotics

If systematically unwell, at high risk of complications or signs of more serious condition, offered immediate antibiotics (referral to hospital for severe cases)

Question 25

when are antibiotics given for sore throat?

Answer 25

Typically self-limiting, but where no prescription for Abx is given, if symptoms worsen, don’t improve (7 days) or become very unwell, seek medical help

With back-up prescriptions, not needed now but use if symptoms don’t improve (3-5 days)

In all cases if symptoms worsen or the person becomes very unwell, medical help should be sought

FeverPAIN score 0 or 1, CENTOR 0, 1 or 2 = no antibiotic

FeverPAIN score 2 or 3 = Consider no antibiotic or back-up antibiotic prescription

FeverPAIN score 4 or 5, CENTOR score 3 or 4 = Consider immediate antibiotic or back-up antibiotic prescription

Question 26

what are self care measures for acute sore throat?

Answer 26

For all: self-care advice. Can manage pain with paracetamol or ibuprofen. Drink plenty fluids. Some evidence medicated lozenges help pain in adults.

Question 27

what are selfcare measures for sinusitis?

Answer 27

For all: self-care advice. Can manage pain with paracetamol or ibuprofen

Question 28

what are possible drugs which acts on the nose and examples

Answer 28

Decongestants – sympathomimetic amines
Ephedrine: intranasal, direct and indirect α- and β-adrenergic agonist (via NA)
Pseudoephedrine: oral/by mouth, direct and indirect α-adrenergic agonist (via NA)
Phenylephrine: oral/by mouth, direct α1-adrenergic agonist
Xylometazoline: intranasal, direct α1 and 2-adrenergic agonist

Decongestants – other
Sodium chloride solution (0.9%) drops or spray: liquefy secretions

Anti-inflammatory glucocorticoids
Fluticasone: intranasal, agonist GR
Beclometasone: intranasal
Mometasone: intranasal, agonist GR

Suppressors of inflammatory mediator release (eyes!)
Sodium cromoglicate (cromolyn): stabilises mast cells

Anti-histamines
Cetirizine: Oral, H1 Receptor antagonist (allergy)
Loratidine: Oral, H1 Receptor inverse agonist (allergy)
Acrivastine: Oral, H1 Receptor antagonist (allergy)
Azelastine: Topical (intranasal), H1 Receptor antagonist (allergic conjunctivitis and rhinitis) – also eyes

Anti-cholinergic (parasympatholytic)
Ipratropium bromide: intranasal, mAChR antagonist, blocks secretions