ENT - Nasal blockage Flashcards

1
Q

Stephen, a 23-year-old final year medical student who is complaining of a blocked nose.

What questions in the history would you like to ask about his blocked nose?

A

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
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2
Q

What does this image show?

A

Septal deviation

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3
Q

What are some causes of septal deformity?

A
  • Congenital
  • Infective e.g. infective septal haematoma
  • Trauma
  • Inflammatory e.g. granulomatosis Polyangitis Arteritis, sarcoidosis
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4
Q

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

  • Septoplasty
  • Rhinoplasty
  • Nasal splints
  • Adenoidectomy
A

Septoplasty

  • Rhinoplasty = procedure which corrects a deformity of the external nose
  • Nasal splints = plints 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 obstruction but it’s bilateral
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5
Q

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

A
  1. About the procedure:
    • What the procedure is for?
    • What it involves?
    • The intended benefits
  2. Risks or complications - common + serious/major + those specifically relating to pt
  3. Alternatives to the procedure and the pros/cons (must include no treatment)
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6
Q

What are the potential risks / complications of a septoplasty?

A
  • Bleeding & infection
  • Anosmia/Hyposmia
  • Numbness of the nose
  • Numbness of the upper teeth
  • Altered appearance
  • Septal perforation
  • Failure to improve symptoms
  • Further procedure/revision surgery
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7
Q

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

A

RAST testing

(Radioallergosorbent test - identifies any allergies to specific allergens)

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8
Q

What is Cetirizine?

A

2nd gen anti-histamine

  • Uses:
    • allergic rhinitis, dermatitis, urticaria
  • Side effects:
    • headache, dry mouth, sedation GI pain, tachycardia (rare)
  • MoA:
    • Selective H1 antagonist
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9
Q

What does this image show?

A

Nasal Polyps

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10
Q

How are nasal polyps managed?

A
  • 1st line:
    • Topical nasal steroid - drops (for short course in severe cases), sprays (for less severe cases & long-term maintenance)
    • Oral prednisolone - for severe polyps
  • 2nd line:
    • Functional endoscopic sinus surgery - anatomy/physiology are preserved as much as possible, endoscopes + debrider are used to excise as much of the polyps as possible (produce more room for improved medical management)
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11
Q

What are the risks of functional endoscopic sinus surgery you need to disclose?

A
  • 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
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12
Q

What are the diagnostic criteria for rhinosinusitis?

A

Rhinosinusitis criteria (summary):

  1. Nasal blockage / congestion / obstruction - +1 of the following:
    • Facial pain / pressure
    • ↓ or loss of smell
    • Nasal polyps
    • Mucopurulent discharge, primarily from middle meatus
    • CT changes
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13
Q

How long does acute rhinosinusitis last?

How long does rhinosinusitis have to last to be considered chronic?

A
  • Acute rhinosinusitis = lasts < 12 weeks with complete resolution of symptoms
  • Chronic rhinosinusitis = lasts > 12 weeks without complete resolution of symptoms
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14
Q

How is chronic rhinosinusitis managed?

A

Polyps present:

  1. Consider short course of oral prednisolone
  2. Then continue as if poylps weren’t present

No polyps:

  1. Antihistamine + allergen avoidence if proven allergy
  2. Topical nasal steroid OR short-course of topical drop steroid
    • Fluticasone (Flixonase)
    • Beclomethasone (Beconase)
    • Mometasone (Nasonex)
  3. Nasal saline irrigation
  4. Abx - if presence of infection
    • Macrolides e.g. clarithromycin = recommended (in long-term shown to have anti-inflammatory effect)
  5. Functional endoscopic sinus surgery
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15
Q

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 manouvre
A

Valsalva manouvre (used to test Eustachian tube)

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