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Yr4: Neurology & Special Senses > ENT: Nasal Problems > Flashcards

ENT: Nasal Problems Flashcards

1
Q

What is sinusitis?

What is difference between acute and chronic sinusitis?

A
  • Inflammation of paranasal sinuses in face (often accompanied by inflammation of nasal cavity- termed rhinosinusitis)
  • Acute is <12/52, chronic is >12/52
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2
Q

State some potential causes of sinusitis

A
  • Infection (particularly viral URTI)
  • Allergies (e.g. hay fever)
  • Obstruction of drainage (e.g. polyps, foreign body, trauma)
  • Smoking
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3
Q

Describe typical presentation of sinusitis

A

Symptoms

  • Nasal congestion
  • Nasal discharge
  • Facial pain/pressure
  • Facial swelling over affected area
  • Anosmia

Examination

  • Tenderness to palpation of affected areas
  • Inflammation & oedema of nasal mucosa
  • Discharge
  • Fever
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4
Q

What investigations may be done for pts with persistent sinusitis symptoms despite treatment?

A

Investigations not needed in most cases however in those with persistent symptoms despite treatment may consider:

  • Nasal endoscopy
  • CT scan sinuses
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5
Q

Discuss the management of acute sinusitis

A
  • If had symptoms <10 days, advise that most cases resolve in 2-3 weeks
    • Plenty of fluids
    • Simple analgesia
    • Avoid allergic triggers
    • Avoid smoking
    • Clean nose with salt water
    • De-congestant sprays (if pt wants)
  • If symptoms don’t improve after 10 days:
    • High dose nasal steroid spray for 14 days (e.g. mometasone)
    • Delayed abx prescription for phenoxymethylpenicillin to be used if worsening or still no improvement in 7 days
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6
Q

Discuss the management of chronic sinusitis

A
  • Avoid triggers: allergens, stop smoking
  • Saline nasal irrigation
  • Pharmacological:
    • Steroid nasal sprays or drops (e.g. mometasone)
    • If allergic, try nasal or oral antihistamines first, then nasal steroids, PO steroids can be used in short term for important life events
  • Functional endoscopic sinus surgery (see separate FC for more info)
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7
Q

Explain how to use a nasal spray correctly

A
  • Tilt head slightly forwards
  • Use left hand to spray into right nostril and vice versa (like an X)
  • Place nozzle just inside nostril and point slightly outwards
  • Don’t sniff hard during the spray
  • Exhale out of mouth then gently inhale through nose after using the spray
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8
Q

Explain what is involved in functional endoscopic sinus surgery

A
  • Insert endoscope through nostrils & sinuses
  • Instruments used to remove or correct any obstructions to sinuses (e.g. swollen muscosa, bone, polyps or a deviated septum [this would be called septoplasty])
  • Balloons can also be inflated to dilate opening of sinuses
  • Need CT scan prior to assess structures
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9
Q

What are nasal polyps?

Describe their appearance

A
  • Growths of nasal mucosa that occur in nasal cavity or sinuses; they can slowly grow & obstruct nasal passage
  • Pale grey/yellow growths on mucosal wall (can visualise using nasal speculum, otoscope or nasal endoscopy)
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10
Q

Polyps are usually bilateral, unilateral polyps are……?

A

A red flag for nasal malignancy and require referral to ENT

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11
Q

Nasal polyps are associated with several conditions; state some

A
  • Chronic rhinitis, sinusitis or rhinosinusitis
  • Asthma
  • Samter’s triad (nasal polyps, asthma & aspirin sensitivity)
  • Cystic fibrosis
  • Churg-Strauss syndrome (eosinophilic granulomatosis with polyangiitis)
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12
Q

State some symptoms a pt may experience due to nasal polyps

A
  • Chronic rhinosinusitis
  • Anosmia
  • Difficulty breathing through the nose
  • Snoring
  • Nasal discharge
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13
Q

Discuss the management of polyps

A
  • Intranasal topical steroid spray or drops
  • Surgery:
    • Intranasal polypectomy (if polyps are visible close to nostrils)
    • Endoscopic nasal polypectomy (if polyps are further in nose or in sinuses)
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14
Q

What is a nasal septal haematoma?

A

Collection of blood (haematoma) between septal cartilage & overlying perichondrium

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15
Q

Describe the typical presentation of nasal septal haematoma

A
  • Hx of relatively minor trauma
  • Nasal obstruction (most common symptom)
  • Pain
  • Rhinorrhoea
  • Bilateral, red swelling arising from nasal septum (differentiate between deviated septum and septal haematoma by feeling; septal haematoma will be boggy but deviation will be firm)
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16
Q

Discuss the management of nasal septal haematomas

A

Immediate referral to ENT for:

  • Surgical drainage
  • +/- nasal packing to prevent reaccumulation
  • +/- IV antibiotics
17
Q

What is the main complication of nasal septal haematomas that we are concerned about?

A
  • Saddle nose deformity due to ischaemia of cartilage resulting in cartilage necrosis
  • ******Rarely, a septal abscess can spread intracranially via the venous drainage of the mid-face, leading to cavernous sinus thrombosis*
18
Q

What would your management be if a pt presents to ED with suspected nasal fracture (you have ruled out septal haematoma)?

A

Patients with isolated nasal injuries can be managed as outpatients as the nose is too swollen immediately after trauma. It can only be effectively assessed five to seven days later, once the swelling has subsided. Patients discharged from A&E with nasal trauma should be booked into the ENT emergency clinic seven to ten days afterwards for manipulation and further treatment.

NB - Plain radiographs of the nose are not useful in the assessment of isolated nasal bone fractures and should not be done. This is not the case for mid-face fractures.

19
Q

Where do nosebleeds usually originate from? Include specific blood vessels that supply this area

A

Kiesselbach’s plexus in Little’s area

20
Q

State some potential risk factors/triggers for nosebleeds

A
  • Nose picking
  • Colds
  • Sinusitis
  • Vigorous nose-blowing
  • Trauma
  • Changes in the weather
  • Coagulation disorders (e.g., thrombocytopenia or Von Willebrand disease)
  • Anticoagulant medication (e.g., aspirin, DOACs or warfarin)
  • Snorting cocaine
  • Tumours (e.g., squamous cell carcinoma)
21
Q

Other than a bleeding nose, how else may pts with a nose bleed present?

A

Vomiting blood if swallowed the blood

22
Q

Nosebleeds are usually unilateral; what may be indicated by bilateral bleeding?

A
  • Bilateral may indicate bleeding in posterior part of nose
  • Posterior bleeding has higher risk of aspiration
23
Q

Discuss the management of nosebleeds

A

Usually resolve without medical assistance and simple advice can be given:

  • Sit up and tilt head forwards over a bowl/sink
  • Squeeze soft part of nose/nostrils for 20 minutes
  • Spit any blood out of the mouth rather than swallowing

If bleeding doesn’t stop after 10-15 minutes, bleeding is severe, bleeding is bilateral or pt is haemodynamically unstable then pt needs to go to hospital to be seen by ENT:

  • First line= cauterisation (spray nose with LA, identify bleeding point and apply silver nitrate stick for 3-10 secs before becomes grey-white. ONLY cauterise one side of septum as risk of perforation. Dab area clean and apply Nasseptin)
  • If cautery not suitable (i.e. can’t see the bleed, pt can’t tolerate)= packing (spray nose with LA spray, pack pts nose, examine mouth for any continued bleeding, can consider packing other nostril as it increases pressure on septum and the bleeding vessel)
  • If above fails, may require sphenopalatine ligation in theatre

After treating nosebleed, prescribe Naseptin cream (chlorhexidine & neomycin) 4x daily for 10 days to reduce crusting, inflammation and infection. CONTRAINDICATED IN PEANUT OR SOY ALLERGY.

NOTE about admission: m**ost units in the UK admit packed patients, unless the packs are dissolvable and the patient is very well. Packs tend to stay in for 24-48 hours but shouldn’t remain for much longer. Admit pts who have bleed from posterior or unknown source, haemodynamically unstable

24
Q

What kind of cancer is nasopharyngeal carcinoma?

What virus is it associated with?

State some features of nasopharyngeal cancer

Management

A
  • Squamous cell carcinoma
  • EBV infection
  • Presentation:
    • Otalgia
    • Unilateral serous otitis media (blocks Eustachian tube)
    • Nasal obstruction, discharge or epistaxis
    • Cranial nerve palsies (III-VI)
  • Management:
    • Radiotherapy is first line

Yr4: Neurology & Special Senses (28 decks)

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