ENT JC096: Common Nasal Conditions And Nasopharyngeal Carcinoma Flashcards
History taking of Nasal conditions
Nose:
1. Congestion / Blockage / Obstruction
- Nasal discharge
- Anterior (blow / sneeze out)
- Posterior (post-nasal drip)
- Nature (yellowish / clear) - Sneezing, Itchiness
- may indicate allergy - Olfactory disturbances / Loss of smell (Anosmia)
- X Loss of taste (seldom disturbed in nasal conditions, usually only anosmia during common cold) - Facial pressure / pain
- Epistaxis
- Anterior / Posterior
Adjacent organs:
1. **Eye itchiness
2. Visual disturbance
3. **Otalgia / Aural fullness (problem with nasopharynx)
4. ***Dental pain
5. Snoring (OSA)
6. Fever
7. Other comorbidities e.g. Asthma, Atopy —> related to Allergic rhinitis
8. Social + Occupational history
9. Drug history
10. Smoking
11. Family history (NPC, allergy)
P/E of Nose
Sit upright
- External nose
- Nasal bridge (upright?)
- External wound / scar - Base of nose (Columella)
- Scar (fine line of incision for rhinoplasty) - Side view of nose
- Nasal bridge (straight / hump / depression)
- Proportion of nose compared to face - Anterior rhinoscopy with Speculum
- extend alar cartilage - Nasoendoscopy
- to go deeper than anterior end of inferior turbinate to nasopharynx
- can also see middle meatus
- Rigid / Flexible (for larynx)
***Causes of Nasal obstruction
DDx:
3 categories:
1. ***Nasal deformity
- Injuries of Nose
- Nasal septal deviation +/- External deviation of nasal bridge
- Crooked nose / Deviated nose / Saddle nose
- ***Mucosal swelling (thickened mucosa)
- Acute infection
- Chronic rhinosinusitis
- Allergic rhinitis
- Non-allergic rhinitis - ***Nasal mass
- Sinonasal tumours (usually unilateral)
—> Inverted papilloma
—> Carcinoma
—> Olfactory neuroblastoma
- NPC
- Nasal deformity: Injuries of Nose
Usually blunt trauma, sometimes penetrating
1. Septal haematoma
- ***emergency ∵ cartilage depends on blood supply from mucosa
—> haematoma lift up mucosa from septal cartilage
—> necrosis of cartilage
- Fracture nasal bone
- deviation of nose / step in nasal bridge
- may have open wound in skin
- swelling / discolouration of skin over nasal bone
- tenderness
- higher mobility of nose
- deformity
- treatment
—> Treat epistaxis, open wound as emergency
—> No treatment (if no deformity / septal haematoma)
—> ***Closed reduction (so nose can heal in a better position) within 7-10 days (∵ nose remain swollen for first few days —> difficult to tell whether nasal bridge is reduced back to normal alignment) - Fracture / dislocation of septum
- Nasal deformity: Nasal septal deviation
- Rarely exactly in midline
- Asymptomatic if minor
Causes:
1. Trauma (birth, long-forgotten / recent injury)
2. Nasal surgery
3. Developmental
Effect of marked deviation:
1. Nasal obstruction
2. Obstruction of normal sinus drainage pathway
3. Epistaxis (∵ turbulent airflow through deviated nasal septum)
Management:
- ***Septoplasty / Septorhinoplasty if symptomatic
(Medical treatment usually ineffective)
- Mucosal swelling
Causes:
1. Acute infection
- URTI
- Nasal vestibulitis
—> infection of skin of nasal vestibule (i.e. nostrils)
—> Staphylococci
—> Topical antibiotic treatment
- Rhinosinusitis
- Chronic rhinosinusitis (with / without Polyposis)
- Allergic rhinitis
- Non-allergic rhiniti
Rhinosinusitis
- both nose + sinus lined by same nasal mucosa —> subject to same disease process
- “rhinosinusitis” more accurate than “sinusitis”
- most rhinosinusitis caused by ***viruses
- Acute / Chronic
Acute bacterial rhinosinusitis
Causes:
1. URTI
2. Dental abscess / extraction (esp. pre-molar / molar teeth —> infection spread upward towards maxillary sinus)
—> ***unilateral usually
3. Trauma
Predisposing factors:
1. Poor drainage
- e.g. septal deviation, turbinate hypertrophy, nasal polyposis
2. Poor immunity
Causative organisms:
1. **Streptococcus pneumoniae
2. **Haemophilus influenzae
3. ***Moraxella catarrhalis
4. Anaerobic organisms (dental source)
Symptoms:
- Symptoms of viral URTI >10 days / worsening after 5-7 days (double sickening)
- **Nasal obstruction
- **Nasal discharge (anterior / post-nasal drip)
- ***Facial pain (∵ collection of fluid, discharge within sinus —> distension)
- Reduction of smell (Anosmia)
- Fever
Signs:
- Facial tenderness
- Edema, mucopurulent discharge in middle meatus / nasopharynx
Treatment:
1. Analgesics
2. Antibiotics (not needed if viral origin)
3. **Intranasal steroid spray
4. **Short-term (<7 days) nasal decongestant (e.g. Oxymetazoline, Ephedrine)
5. ***Nasal douching with saline
Complications:
1. **Orbital cellulitis, abscess
2. **Cavernous sinus thrombosis (spread posteriorly along venous drainage)
3. ***Intracranial infection (sphenoid, ethmoid sinus spread upwards)
- Meningitis, Encephalitis, Abscess
Chronic rhinosinusitis
Clinical features (~ to Acute bacterial rhinosinusitis):
- Purulent nasal + post-nasal discharge
- Nasal obstruction
- Facial discomfort
- Headache
- Halitosis (bad breath ∵ purulent drainage into mouth)
- ***Absent fever
Nasal polyposis:
Associated diseases:
1. Asthma (Samter’s triad: Aspirin sensitivity + Asthma + Nasal polyposis)
2. Allergic fungal sinusitis
3. Cystic fibrosis
Polyposis vs Inferior turbinate on endoscopy:
Nasal polyp:
- **Pale, greyish
- Translucent
- **Insensitive to touch
Inferior turbinate:
- Sensitive to touch
- Attached to lateral nasal wall
Management:
1. **Intranasal steroid (1st line)
2. **Nasal saline irrigation (1st line)
3. Short-term antibiotic (for superimposed infection)
4. Long-term antibiotic (reserved for refractory disease not responding to Intranasal steroid)
- **Anti-inflammatory effect (rather than antimicrobial effect)
- Macrolide, Doxycycline
5. Antihistamine (for atopy / co-existing allergic rhinitis)
6. **Surgery: Endoscopic sinus surgery
Samter’s triad
- Aspirin sensitivity
- Asthma
- Nasal polyposis
Aka Aspirin exacerbated respiratory disease
Pathophysiology:
Arachidonic acid
1. —(COX, inhibited by Aspirin)—> Prostaglandin / Thromboxane
2. —> Leukotriene —> Asthma + ***Nasal polyposis
Mucocele
- Epithelial-lined sac that contains mucus
—> Drainage of paranasal sinus is blocked
—> Expand + erode bone - Most common in ***fronto-ethmoidal region
Complications:
- ***Orbital displacement + Proptosis
Management:
- ***Surgical marsupialisation (open the mucocele for drainage)
Allergic rhinitis
- Type 1 hypersensitivity reaction
- Aeroallergens —> IgE production
Allergic rhinitis and its impact of Asthma (ARIA) guideline:
- Unified allergic airway
- Asthma and Allergic rhinitis: share common epidemiology, pathophysiology, treatment
- Treatment of allergic rhinitis —> Improve asthma control
Symptoms:
Early:
- Sneezing
- Itching
- Rhinorrhoea
- Nasal obstruction
Late:
- Nasal congestion
- ***Hyperresponsiveness to allergens, irritants, atmospheric changes
Common allergen in HK:
- House dust mites
- Cockroach
- Furry pet
- Pollen
- Mould
- Multi-allergen
History taking of Allergic rhinitis
- Other atopy
- **Asthma (氣管), **Eczema (皮膚), ***Allergic conjunctivitis (眼) - Possible triggers
- Seasonal (pollens)
- Pets - Frequency + Severity of symptoms
- Intermittent vs Persistent - Associated problems
- **Sinusitis
- **Otitis media
- Sleep disturbance
Management of Allergic rhinitis
- Allergen avoidance
- Pharmacotherapy
- **Oral Antihistamine
- **Intranasal Steroid
- ***Leukotriene receptor antagonist (esp. in patients with asthma)
- Nasal douching with saline
- Short term systemic steroid, Decongestant (if refractory + severe symptoms) - Immunotherapy
- Surgery
How to check which substance patient allergic to?
- ***Skin prick test
- In-vitro **specific IgE blood test
- **Radioallergosorbent test (RAST)
If identified allergens —> can consider Immunotherapy:
- **SC allergen
- **Sublingual allergen
Non-allergic rhinitis
Causes (many):
- Idiopathic: temperature, humidity, pressure (vasomotor rhinitis, intrinsic)
- Drug-induced
- Food-induced
- Hormonal
- Irritants
- Occupational (chemical exposure)
- NARES: non-allergic rhinitis with eosinophilia syndrome
- Atrophic rhinitis
- Emotional
- GERD
- Autonomic
Drug-induced rhinitis
- Anti-HT
- β-blockers
- CCB - Sedatives
- Anti-depressants
- OC pills
Etc.
Rhinitis medicamentosa (Rebound congestion):
- **reactive vasodilation of nasal mucosa
- acquired sensitivity of nasal lining after prolonged use of topical sympathomimetic agents (e.g. Oxymetazoline)
- short-term relief —> turn into chronic obstruction
- management:
—> Avoid prolonged use
—> **Intranasal steroid (to reverse process)
—> Surgery (e.g. turbinate reduction / turbinectomy)
***Neoplasm in Nose / Paranasal sinus
Rare
Red flags:
1. **Unilateral obstruction
2. Epistaxis
3. Bleeding
4. **Cacosmia (foul smell sensation)
5. Proptosis, Diplopia, Epiphora (excessive tearing)
6. Neurological symptoms
**Sinonasal tumours (5 types):
1. Epithelial
- benign: **Inverted papilloma, Antrochoanal polyp
- malignant: ***Carcinoma, Malignant melanoma (behave differently to skin melanoma)
- Mesenchymal
- benign: ***Juvenile nasopharyngeal angiofibroma (vascular tumour, do not attempt biopsy as may result in life-threatening bleeding)
- malignant: Sarcoma - Neural
- benign: Meningioma
- malignant: ***Olfactory neuroblastoma - Lymphoreticular (i.e. lymphatic tissue)
- malignant: Non-Hodgkin’s lymphoma - Odontogenic (i.e. teeth)
- benign: Ameloblastoma (but locally invasive)
Inverted papilloma
Cause: ***HPV
- Inverted mucosal surface into stroma of papilloma
- ***Benign, locally aggressive (can erode bone)
- Unilateral
- ***Lateral nasal wall
- 2-10% risk of malignant transformation (if untreated)
- Management: Surgery
Carcinoma of Nose
Risk factors:
1. Smoking
2. Hard-wood exposure for adenocarcinoma
***Types:
1. SCC
2. Adenocarcinoma
3. Sinonasal undifferentiated (anaplastic) carcinoma
4. Adenoid cystic carcinoma
Olfactory neuroblastoma
- **Olfactory epithelium (originate from **olfactory nerve)
- Late presentation (∵ tumour originate from superior position —> asymptomatic until large to cause epistaxis) with intracranial extension
Management:
- Craniofacial / Cranionasal resection + Adjuvant chemotherapy
Investigations and Management of Sinonasal tumours
Investigations:
1. Biopsy from tumour
2. CT
3. MRI
Management:
1. ***Surgery
- Endoscopic approach
- Open approach
- Craniofacial / Cranionasal resection + reconstruction
- Adjuvant chemotherapy, RT
Nasopharyngeal carcinoma
- 10th most common cancer in HK
- Gradual ↓ in incidence (still common in HK)
- M:F = 2.5:1
Pathology (WHO classification):
1. Non-keratinising
- Differentiated
- **Undifferentiated (>95% cases in endemic area, **EBV virus infection)
2. Keratinising squamous
3. Basaloid squamous
Risk factors:
1. EBV infection
2. Host genetics (Family history)
3. Environmental factors
- **Active + passive tobacco smoking
- Alcohol
- **Preserved foods (e.g. salted fish)
- Poor oral hygiene
Population screening (not in HK):
1. ***Anti-EBV IgA Ab
- Early antigen (EA-IgA)
- Viral capsid antigen (VCA-IgA)
- Nuclear antigen 1 (EBNA1-IgA)
—> Low sensitivity + Low specificity for screening in asymptomatic people
- ***Blood serology EBV DNA
- more common, more recently
- expensive test
- higher sensitivity + specificity
Investigations + Treatment of NPC
Investigations:
1. **Nasoendoscopy + Biopsy
2. USG neck +/- FNAC of LN
3. **MRI with contrast (preferred ∵ better soft tissue delineation)
4. PET/CT (18F-FDG) (for staging)
Treatment:
- Early stage: Intensity-modulated **RT
- Late stage: Concurrent **chemotherapy + RT
- Residual disease / recurrence: ***Surgery (e.g. open maxillary swing / endoscopic / robotic nasopharyngectomy)
—> chemotherapy, 2nd dose RT, immunotherapy (reserved for those unsuitable for surgery)
