ENT - Common conditions of the nose

Question 1

describe the functions of the nose

Answer 1

•Conditioning of inhaled air
–Warms
–Humidifies
–Filtration

•Immunity
–High levels of IgA, lysozymes, proteins in mucus
•Olfaction
•?Cosmesis

Question 2

Describe sinuses

• definition
• (5) locations
• function of different locations

Answer 2

• Paired air-filled cavities within the facial bones that have openings into the nasal cavity

1. Frontal
2. Maxillary
3. Anterior ethmoid
   (1, 2, 3) Have drainage pathways that converge to the MIDDLE meatus
4. Posterior ethmoid
5. Sphenoid
   (4, 5) Drain to SUPERIOR meatus

C.f. Nasolacrimal duct drains into INFERIOR meatus

Question 3

How does nose condition air (warming & humidification)?

Answer 3

1. Turbinates:
   - erectile tissue, nasal cycle
   - direct airflow: combination of laminar & turbulent airflow
2. Epithelium
   - mostly respiratory (pseudo-stratified ciliated columnar with goblet cells)
3. Blanket
   - consist of more viscid superficial gel & deeper sol layer
   - cilia tips beating in gel layer to funnel to post nasal space

Question 4

Purpose of paranasal sinuses (5) theories

Answer 4

• Modify vocal resonance
• Lighten skull
• The ‘airbag’ of the brain
• Buoyancy in water to keep the head afloat
• Immunological prechambers

Question 5

Describe external nasal structure

• upper 1/3
• lower 2/3

Answer 5

Upper 1/3 - bony pyramid formed by
•nasal bones attached to frontal bone (superior),
•lacrimal bones (supero-lateral)
•ascending process of maxilla (infero-lateral)

Lower 2/3s – cartilaginous pyramid
•Upper and lower lateral cartilages
•Sesamoid and fibrofatty tissue

Question 6

List (9) nasal symptoms

Answer 6

• Nasal blockage
• Nasal congestion
• Rhinorrhoea
• Sneezing
• Nasal irritation
• Post nasal drip
• Olfaction
• Epistaxis
• Facial pressure/pain

Question 7

How are the nose & paranasal sinuses related to other structures around?

Answer 7

• The orbits and lacrimal system antero-laterally
• The skull base superiorly
• The oral cavity and teeth inferiorly
• The post-nasal space and associated Eustachian opening postero-inferiorly
• The cavernous sinus and its contained structures postero-lateral to the sphenoid

Question 8

What structures (7) are contained within the cavernous sinus posterolateral to the sphenoid?

Hence what symptoms (5) do they cause if damaged?

Answer 8

• Venous sinus
• Optic nerve
• Occulomotor nerve
• Trochlear nerve
• Trigeminal nerve
• Abducens nerve
• Internal Carotid Artery and associated sympathetic plexus

Symptoms:
•Visual loss
•Visual disturbance
•Diploplia
•Horner’s
•Retro-orbital pain

Question 9

What is Samter’s triad?

Answer 9

Aspirin intolerance
Asthma
Nasal polyps

It is Aspirin-induced asthma

Question 10

What is rhinitis? List its (7) classes of causes

Answer 10

Inflammation of the nasal mucosa.

Can be classified into many causative groups
•Allergic
•Infectious
•Occupational
•Drug induced
•Hormonal
•Others….irritants, food, emotion
•Idiopathic

Question 11

What is an allergic rhinitis?

• definition of intermittent & persistent
• classification of severity impact
• symptoms

Answer 11

Inflammation of the nasal mucosa due to allergen exposure with an associated IgE response
•Intermittent = 4 days/wk and > 4 weeks

Also classified to severity/social impact
•Mild, Moderate/Severe

Symptoms:
•Clear rhinorhoea (anterior or posterior)
•Nasal blockage +/- itching of the nose. Often alternating between nares
•Sneezing

Question 12

Rx of allergic rhinitis

Answer 12

MIld/intermittent:

• oral/local non sedative H1 blocker (anti-histamine)
• allergen & irritant avoidance
• intra-nasal decongestant

Moderate/severe intermittent:
above plus:
- intranasal steroid
- local cromone

Mild persistent/moderate severe persistent
above plus: immunotherapy or turbinate reduction procedure

Question 13

What is rhinitis medicamentosa?

- Symptoms

Answer 13

Inflammation of the nasal mucosa secondary to prolonged alpha agonist topical medications

Symptoms:

• Clear rhinorhoea
• Marked nasal congestion, obstruction which is progressively less well controlled by the topical medication

Question 14

Describe infectious rhinitis

Answer 14

• Inflammation of nasal mucosa
• Due to infectious agent àviral/bacterial/fungal
• Termed rhinosinusitis (As nasal mucosa continuous with sinus mucosa)

Question 15

Describe rhinosinusitis

• definition
• duration
• Symptoms

Answer 15

• Inflammation of the nasal mucosa due to infective cause (typically viral or bacterial)
• Duration: usually

Question 16

Compare anterior & posterior epistaxis

Answer 16

Anterior:
•Noticed initially through nares
•Most commonly anterior septum (Little’s area/Kiesselbach’s plexus)
•Represents confluence of multiple vessels
•Controlled by direct pressure

Posterior:
•More likely felt dripping back of nose
•Usually from sphenopalatine artery
•May need nasal packing as cannot apply simple first aid direct pressure

N.B: Bleeds from nasal fractures may persist owing to fracture stenting vessel -> Treatment may require fracture reduction if bleeding not controlled by packing/pressure

Question 17

What signs (6) raise suspicion for a skull base fracture?

Answer 17

• Mechanism of injury
• CSF rhinorrheoa/otorrheoa
• Racoon eyes
• Battles sign
• Haemotympanum
• Subconjuntival haemorrhage with no posterior margin

Question 18

What can happen if you leave a septal haematoma without treatment?

Answer 18

Can progress to a septal abscess -> cartilage destruction -> saddle nose deformity.

Hence needs an immediate ENT referral to drain the haematoma & possible nasal bone manipulation

Question 19

Compare the appearance of a nasal polyp to an enlarged nasal turbinate

Answer 19

Polyps tend to be more translucent and non-tender

Question 20

How would you manage rhinosinusitis?

• symptoms
• Rx

Answer 20

Symptoms

• purulent rhinorrheoa
• Persistent nasal obstruction
• bilateral cheek and inter-orbital pain pain worsened by leaning forward

Rx:
•Oral antibiotics: Likely upper respiratory pathogens (Strep. Pneum., H. Infl, M. Catarrhalis)
• Nasal Decongestants: reduce mucosal oedema & open sinus ostea to ventilate sinuses
•Saline nasal douche: Improves mucocilliary clearance
•Mechanically clear purulent secretions

Question 21

What do you suspect if a pt develops right eye pain, swelling, double vision, opthalmoplegia from a previous rhinosinusitis? Why is this an emergency?

Answer 21

orbital spread of infection

Sinugenic causes are the most likely aetiology for orbital infections

Emergency because:
•Increased intra-orbital pressures may compromise vision due to optic nerve compression
•Red/green colour vision disturbance is an ominous initial sign that should mandate immediate management

Question 22

Rx of orbital spread of rhinosinusitis infection

Answer 22

Immediate ENT referral
•Admission
•i.v. antibiotics
•High res CT paranasal sinuses & brain
•?drainage if abscess

Question 23

• Derek, 57 yr smoker, carpenter
• 3 year history
• Post nasal drip, facial pressure, nasal congestion, but past 3/52 purulent rhinorrheoa

What do you think is going on?

Answer 23

Chronic rhinosinusitis (CRS)

(but note smoking can make control harder and beware occupation as exposure to hardwoods increases risk of developing adenocarcinoma)

Question 24

Rx of chronic rhinosinusitis

Answer 24

• Nasal steroid spray: the mainstay of therapy
• Saline nasal douche
• Antibiotics as purulent
• Similar organisms to acute sinusitis but additionally S. Aureus, anaerobes

Question 25

What is FESS in ENT?

Answer 25

FESS: functional endoscopic sinus surgery

Aim – to open (ventilate) sinuses and return them to their premorbid ‘functioning’ state. Also, allows medical therapy to enter