ENT - Nasal Conditions Flashcards
Epistaxis
Aetiology
Anterior Bleed
Posterior Bleed
Clinical Features
First-Aid Management
1.) Aetiology - bleeding from the nose, often idiopathic (85%) but can also be due to other causes:
- local: trauma, foreign body, rhinosinusitis, polyps, tumour, iatrogenic (e.g on anti-coagulation), cocaine
- systemic: HTN, coagulopathies, vasculopathies
2.) Anterior Bleed - most common (90%)
- originate from Little’s area (Kisselbach’s plexus) which is formed by the anastomosis of 5 arteries:
- anterior and posterior ethmoidal, greater palatine, sphenopalatine, septal branch of superior labial artery
3.) Posterior Bleed - from the posterior nasal cavity
- branches of the sphenopalatine arteries of the nose
- can enter the oropharynx –> coughing up blood
- more common in older patients
4.) Clinical Features - continuous nasal bleeding
- hx: recent trauma, co-morbidities, clotting disorders, facial pain, otalgia, systemic sx,
- facial pain or otalgia may indicate a nasopharyngeal tumour (including angiofibroma)
- if suspecting CSF, can dip the fluid
5.) First-Aid Management
- sit up and forwards: ensure blood passes anteriorly and out through the nares (and not into the pharynx)
- apply constant compression to the nares for >20mins
- use ice on nasal bridge to stimulate vasoconstriction
- spit out any blood in the mouth
- can prescribe Naseptin nasal cream (chlorhexidine and neomycin) to prevent infection (contraindicated in peanut allergies)
Management of Epistaxis
Cautery
Packing
Surgical Intervention
Life-Threatening Epistaxis
1.) Cautery - using silver nitrate or bipolar diathermy
- anterior bleed: done with anterior rhinoscopy
- posterior bleed: done with a rigid endoscope
- only cauterise if the bleeding point can be found
- can control bleeding to help find bleeding points using adrenaline-soaked gauze to soak up any excess blood
- examine the oropharynx to exclude a posterior bleed
2.) Packing - if no bleeding point can be visualised
- anterior packing: insert nasal pack into nasal cavity,
- contralateral nasal pack can be inserted if anterior packing fails to control the bleeding
- posterior packing with a Foley catheter: if epistaxis persists and bleeding is entering the oropharynx
- contralateral pack if this also fails to control bleeding
- need abx: cefalexin, Pen V
- complications: failure, breathing difficulties, infection, pain
3.) Surgical Intervention - if packing fails, surgical ligation or radiological embolisation of blood vessels:
- sphenopalatine, anterior ethmoidal (cannot be embolised as it comes from ICA), ECA (last resort)
4.) Life-Threatening Epistaxis - large volume bleeds, haemodynamic instability, persistent post-intervention
- A-E assessment, IV access, resus w/ blood products
- routine bloods including FBC, clotting, and G+S
- manage any reversible underlying causes (e.g. malignant hypertension, coagulopathies)
Acute (Rhino-)Sinusitis
Aetiology
Pathophysiology of Bacterial Rhinosinusitis
Clinical Features/Diagnosis
1.) Aetiology - symptomatic inflammation of the mucosal lining of the nasal cavity AND paranasal air sinuses
- viral: rhinovirus, influenza, coronavirus
- post-viral: residual mucosal inflammation following a viral infection that produces ongoing symptoms
- risk factors: cigarette smoke, air pollution, ciliary impairment, asthma or atopy, septal deviation, polyps, anxiety/depression, diabetes
2.) Pathophysiology of Bacterial Rhinosinusitis
- primary viral infection leads to reduced ciliary function, oedema, increased secretions
- impeded drainage from sinuses (mainly maxillary) and stagnant secretions becomes ideal for bacteria
- common bacteria: S. pneumoniae, H. influenzae, Moraxella catarrhalis, S aureus
3.) Clinical Features/Diagnosis - 2+ of the following:
- blocked/runny nose (+/- green/yellow discharge)
- recent URT infection, fever
- altered sense of smell
- headache: facial pain behind the nose, forehead and eyes (worse on leaning forwards), often tenderness over the affected sinus
- sudden onset of symptoms for less than 12 wks w/o improvement and worsen after initial improvement
Management of Acute Rhinosinusitis
Initial Management
Red Flag Symptoms
Specialist Management
Complications
1.) Initial Management - depends on days of symptoms:
- <5d or improving: analgesia and nasal decongestants or nasal irrigation w/ saline and steam inhalation
- >10d or worsening after 5d: high dose intranasal corticosteroids for 14 days for those >12 years of age
- systemically unwell: oral abx are indicated, Pen V or Co-amoxiclav (if very unwell)
- referral to ENT: no improvement after 7-14 days of treatment or the presence of red-flag symptoms
2.) Red Flag Symptoms
- orbital signs: periorbital swelling or erythema, displaced globe, visual changes, ophthalmoplegia
- headache: severe unilateral headache, bilateral frontal headache, or frontal swelling
- neuro: neurological signs or reduced consciousness
3.) Specialist Management
- nasal endoscopy: abnormal anatomy or pathology
- nasal discharge cultures: atypical infections
- CT-paranasal sinuses: extent of the disease, identify complications or anatomical abnormalities
- severe infections or complications: oral steroids, intravenous antibiotics, consider surgery
4.) Complications
- (peri-)orbital cellulitis or abscesses
- intracranial abscess: headache, fever, focal neurology
- cavernous sinus thrombosis: unilateral facial oedema, photophobia, proptosis, CN (3/4/5/6)
- osteomyelitis: can lead to penetration into the skull vault leading to meningitis and encephalitis
- Pott’s puffy tumour: osteomyelitis of the frontal sinus causing a sub-periosteal abscess resulting in a soft boggy swelling over the overlying tissue on the forehead
Chronic Rhinosinusitis
Risk Factors
Clinical Features
Nasal Endoscopy
Management
1.) Risk Factors
- allergy/atopy, immunosuppression, aspirin sensitivity
- ciliary impairment: CF, primary ciliary dyskinesia
- pollutants: smoking, dust, fumes, air pollution
- anatomical: septal deviation, nasal polyps
- hormonal: pregnancy, hypothyroidism
- trauma (surgery, fracture), foreign body, swimming
2.) Clinical Features - >12wks of 2+ sx present:
- headache: facial pain behind the nose, forehead and eyes, often tenderness over the affected sinus
- blocked/runny nose (+/- green/yellow discharge)
- an altered sense of smell
3.) Nasal Endoscopy - required to make a diagnosis, it should show at least one of the following features:
- mucosal swelling, mucopurulent discharge
- mucosal occlusion of the middle meatus
- nasal polyps (often around the middle meatus)
4.) Management - depends on the severity of sx which is assessed using the Visual Analogue Score (VAS)
- mild (0-3) w/o significant mucosal disease: nasal saline douching and topical steroid spray or drops (helps reduce recurrence)
- mod-severe (>3) w/ significant mucosal disease: long-term abx w/ topical steroids and a CT of the sinuses
- surgical intervention (FESS): considered for refractory cases, topical treatments continued after surgery
- functional endoscopic sinus surgery: polypectomy to reduce obstruction and drain any collections of mucus
Septal Haematoma
Pathophysiology
Clinical Features
Management
Complications
1.) Pathophysiology - due to trauma causing separation of overlying perichondrium from the septal cartilage
- this shears blood vessels so blood accumulates in this space (sub-perichondral haematoma)
- this deprives underlying cartilage of its blood supply
2.) Clinical Features - seen on anterior rhinoscopy
- boggy red/purple swelling from the nasal septum
- fluctuant on palpation with a Jobson Horne probe which helps to differentiate from a deviated septum
3.) Management - urgent referral to ENT
- incision and drainage under a general anaesthetic
- IV antibiotics
4.) Complications - untreated causes avascular necrosis of the septal cartilage which leads to:
- septal abscess: infection develops in haematoma which can cause intracranial or ocular complications
- saddle-nose deformity: saddling of the nasal dorsum
Nasal Fractures
Clinical Features
Investigations
Management
Complications of Nasal Trauma
1.) Clinical Features
- swelling: usually too swollen initially to be examined
- nasal deformity: assess for bony or septal deviation, patient’s perception of the appearance of their nose
- nasal obstruction: can assess by observing misting during nasal breathing using a metal tongue depressor
- septal haematoma: manage accordingly
2.) Investigations
- X-rays are not used in an isolated nasal injury
- CT is preferred if suspecting co-existing fractures
3.) Management
- refer to ENT semi-electively (7-10d post-injury) to assess for deformity, obstruction, or haematoma
- MUA: should take place within 14-21 days of injury
- rhinoplasty: if the aesthetic result is unsatisfactory
- septoplasty: nasal septum alteration
4.) Complications of Nasal Trauma
- CSF rhinorrhoea: fracture through cribriform plate, should stop within 2wks if not may require surgery
- acute anosmia: nasal passages blocked with blood
- post-traumatic anosmia: damage to olfactory structures and is unlikely to resolve
- septal haematoma
