ENT Case 3 - Nasal Blockage

Question 1

What questions should you ask in a history of blocked nose?

Answer 1

Nasal Symptom Questions:

• Is it one or both sides that feel blocked?
  
  • Which side feels blocked?
  • Is either/both sides ever clear?
• Duration of blocked feeling?
• Intermittent or constant?
• Hx of trauma?
• Previous nasal surgery?
• Any medications?
  
  • e.g. nasal sprays, decongestants (designed for short term used, if used for > 2-weeks and then stopped –> can cause rebound congestion)
• Other conditions e.g. asthma, eczema i.e. atopic picture
• Other nasal symptoms:
  
  • sneezing
  • rhinorrhoea
  • facial pain
  • postnasal drip
  • epistaxis

Question 2

What are some causes of septal deviation?

Answer 2

• Congenital
• Infective (eg. infective septal haematoma)
• Trauma
• Inflammatory (eg. granulomatosis Polyangitis Arteritis, Sarcoidosis)

Question 3

Which of the following would be the most appropriate management for septal deviation?

• Septoplasty
• Rhinoplasty
• Nasal splints
• Adenoidectomy

Answer 3

SEPTOPLASTY

• Rhinoplasty = procedure which corrects a deformity of the external nose
• Nasal splints = splints that are sometimes inserted at the end of a rhinoplasty or septorhinoplasty to hold the tissues in their new position)
• Adenoidectomy = adenoids tend to regress after age 7/8, if they are large they can cause bilateral obstruction

Question 4

What are the key components of consenting a patient for a procedure?

Answer 4

• About the procedure:
  
  • What the procedure is for
  • What it involves
  • Intended benefits of the procedure
• Risks / complications
  
  • Common and serious / rare
• Alternatives to the procedure and the pros and cons (must include no treatment)

Question 5

What are the potential complications of septoplasty?

Answer 5

• Bleeding and infection
• Anosmia / hyposmia
• Numbness of the nsoe
• Numbness of the upper teeth
• Altered appearance
• Septal perforation
• Failure to improve symptoms
• Further procedure / surgery required

Question 6

What blood test should be ordered in a history of chronic rhinosinusitis, that is worse in the summer?

Answer 6

RAST testing

Radioallergosorbent test - identifies any allergies to specific allergens

Question 7

What is Cetirizine?

Answer 7

2nd gen anti-histamine

Uses:

• Allergic rhinitis
• Dermatitis
• Urticaria

Side effects:

• Headache
• Dry mouth
• Sedation
• GI pain
• Tachycardia (rare)

Mechanism of action:
- Selective H1 antagonist

Question 8

How are nasal polyps managed?

Answer 8

1st line:

• Topical nasal steroid
  - Drops - for short courses in severe cases
  - Sprays - for less severe cases and long term maintenance
• Oral prednisolone
  - For severe polyps

2nd line:

• Functional endoscopic sinus surgery
  - Used to create more room for medical management to work effectively

Question 9

What are the risk of functional endoscopic surgery?

Answer 9

• Bleeding
• Infection
• Recurrence
• Hyposmia / anosmia
• Synechiae - adhesions in nasal cavity
• Orbital injury - due to proxmity to operative field
• Blindness - optic nerve is close + rarely an ethmoidal air cell can be wrapped around the optic nerve (this is called an Onodi cell)
• Epiphoria (watery eye) - if nasolacrimal duct is damaged
• Meningitis - if dura breached
• CSF leak - if skull base and dura are breached

Question 10

What are the diagnostic criteria for rhinosinusitis?

Answer 10

Nasal blockage / congestion / obstruction

+ 1 of the following:

• Facial pain / pressure
• Hyposmia / Anosmia
• Nasal polyps
• Mucopurulent discharge (primarily from the middle meatus)
• CT changes

Question 11

How long does acute rhinosinusitis last?

How long does it have to last before it is considered chronic?

Answer 11

• Acute rhinosinusitis = < 12 weeks with complete resolution of symptoms
• Chronic rhinosinusitis = > 12 weeks without complete resolution of symptoms

Question 12

How is chronic rhinosinusitis managed?

Answer 12

Polyps present:

• Consider short course of oral prednisolone
• Then continue as if poylps weren’t present

No polyps:

• Antihistamine + allergen avoidance if proven allergy
• Topical nasal steroid OR short-course of topical drop steroid
  
  • Fluticasone (Flixonase)
  • Beclomethasone (Beconase)
  • Mometasone (Nasonex)
• Nasal saline irrigation
• Abx - if presence of infection
  
  • Macrolides e.g. clarithromycin = recommended (in long-term shown to have anti-inflammatory effect)
• Functional endoscopic sinus surgery

Question 13

Which of the following is not used to assess nasal patency?

• Nasal misting on the back of a metal spatula
• Acoustic rhinometry
• Nasal inspiratory peak flow
• Valsalva manoeuvre

Answer 13

Valsalva manouvre (used to test Eustachian tube)

Acoustic rhinometry - not used in clinic, but in research to measure patency