ENT (nose) Flashcards
What is epistaxis?
Nosebleeds
Where is the most common source of bleeding in nosebleeds?
Kiesselbach’s plexus which is in Little’s area. This is at the front of the nasal cavity and contains a lot of blood vessels that are prone to bleeding.
What can trigger nosebleeds?
Nose picking
Colds
Sinusitis
Vigorous nose blowing
Trauma
Changes in weather
Coagulation disorders - e.g. thrombocytopenia, HHT
Anticoag medications - e.g. aspirin, DOACs, warfarin
Foreign body - e.g. something up the nose, snorting drugs
Tumours
What may bilateral epistaxis suggest?
That the bleeding is posterior to the nose - most commonly from the sphenopalatine artery
Which artery most commonly causes posterior, more severe nosebleeds?
Sphenopalatine artery
How are nosebleeds managed?
Sit up, tilt head forwards, squeeze soft part of nostrils for 10-15 mins. If still doesn't stop then - anterior packing - cautery with silver nitrate - posterior packing Then consider surgical ligation.
What are nasal polyps?
Growths of the nasal mucosa that occur in the nasal cavity or sinuses. They grow slowly and gradually cause obstruction.
What are nasal polyps often associated with?
Chronic rhinitis or sinusitis
Asthma
Cystic fibrosis
How may nasal polyps present?
Chronic rhino-sinusitis Difficulty breathing through the nose Snoring Nasal discharge Loss of sense of smell (anosmia)
What is anosmia?
Loss of sense of smell
How are nasal polyps managed?
Nasal douching
Intranasal topical steroid sprays
Surgery - polypectomy or FESS (functional endoscopic sinus surgery - to improve drainage of sinuses)
If unilateral refer to exclude malignancy
What is sinusitis?
Inflammation of the paranasal sinuses in the face.
What is the difference between acute and chronic sinusitis?
Acute < 12 weeks
Chronic >12 weeks
Chronic > 12 weeks
Name the different paranasal air sinuses
Frontal
Ethmoidal
Sphenoid
Maxillary
What are paranasal air sinuses?
Hollow spaces within the bones around the nasal cavity.
What is the physiology behind sinusitis?
The paranasal air sinuses produce mucous which drains into the nasal cavities via holes called ostia. When these ostia get blocked the mucous builds up causing sinusitis.
What can cause sinusitis?
Infection - particularly following upper respiratory tract infections
Allergies
Obstruction of drainage - due to foreign body, polyps or trauma
Smoking
How does acute sinusitis present?
Recent upper resp infection Nasal congestion Nasal discharge Facial pain, pressure, swelling Headaches Loss of smell
How does acute sinusitis present?
Recent upper resp infection Nasal congestion Nasal discharge Facial pain, pressure, swelling, tenderness Headaches Loss of smell Fever
How is acute sinusitis managed?
Most acute are viral - self limiting.
If not improving by 10 days then
- high dose corticosteroid nasal spray for 14 days - e.g. mometasone 200mg bid (twice a day)
- antibiotics - most commonly phenoxymethylpenicillin 500mg qid (4 times a day) for 5 days.
If patient has systemic infection or sepsis then admit to hospital.
How is chronic sinusitis managed?
Advice - avoid triggers, stop smoking, good dental hygiene
Saline nasal irrigation
Intranasal corticosteroids - e.g. mometasone/ fluticasone for up to 3 mnths
Refer to specialist - Functional endoscopic sinus surgery
Describe the correct nasal spray technique
- Tilt head slightly forwards
- Use opposite hand to nostril (left hand to spray up right nostril ) so the spray is away from the septum
- Don’t sniff hard during the spray
- Gently inhale through the nose after the spray
Describe the correct nasal spray technique
- Tilt head slightly forwards
- Use opposite hand to nostril (left hand to spray up right nostril ) so the spray is away from the septum
- Don’t sniff hard during the spray
- Gently inhale through the nose after the spray
What is allergic rhinitis?
IgE mediated type 1 hypersensitivity reaction which cases an inflammatory response in the nasal mucosa
What are some common causes of allergic rhinitis?
Hayfever - tree pollen or grass
House dust mites
Pets
Other allergens
How does allergic rhinitis present?
Running, blocked and itchy nose
Sneezing
Itchy, red and swollen eyes
Often in someone with a family history of atopy.
How is allergic rhinitis managed?
Avoid triggers
Nasal saline irrigation
Nasal corticosteroid sprays - e.g. fluticasone
Nasal antihistamines
Oral antihistamines e.g. non sedating - loratadine, sedating - promethazine
What is a septal haematoma?
When blood collects between the lining and cartilage of the nasal septum
What causes a septal haematoma?
Trauma - fracture, recent surgery etc.
How are septal haematomas managed?
Urgent drainage to prevent permanent deformity
What can occur if a nasal septal haematoma is not treated?
Saddle nose deformity (the cartilage in-between the nostrils can become necrotic as it gets it blood supply from the overlying tissue)
Infection
Abscess
How may a nasal septal haematoma present?
Often after trauma. - congestion / blockage - difficulty breathing - bruising - swelling - overall change in shape of nose - headache Visible buldge on examination up the nose
What are the symptoms of a deviated nasal septum?
- obstruction
- difficulty breathing
- nosebleeds
- facial pain
- noisy breathing/ snoring during sleep
- preference for sleeping on one side due to narrowing of one nostril
What can cause a deviated nasal septum?
Congenital - present at birth
Trauma - mainly in childhood
Trauma
How is a deviated nasal septum managed?
Management of symptoms with decongestants, antihistamines and nasal steroid sprays.
Surgical repair - sepatoplasty to straighten the nasal septum. May also need rhinoplasty to reshape the nose.
If a child presents with a nasal fracture what must be thought about?
safeguarding
What antibiotic is given for acute bacterial sinusitis if the patient is allergic to penicillin?
Doxycycline 200 mg on first day and then 100mg once daily for 4 days
OR
Clarithromycin 500mg bid (2x daily) for 5 days
What antibiotics are given for acute sinusitis that lasts > 10 days?
Phenoxymethypenicillin (penicillin 5) - 500mg 4x daily for 5 days
When is someone with chronic sinusitis referred to a specialist?
Unilateral symptoms
Persistent symptoms after 3 months of treatment
Nasal polyps
Recurrent episodes of otitis media or pneumonia
Unusual opportunistic infections
What are some adverse reactions to intranasal corticosteroids?
Dryness, irritation and nosebleeds
Also dryness and irritation of the throat
Describe the nasal spray technique
- blow the nose to clear it
- close off one nostril and put the nozzle in the other
- tilt head forwards slightly
- breathe in slowly as you squeeze the mist into the nose - avoid sniffing
- breathe out through the mouth
- repeat for the other nostril if necessary
What should be monitored when a child has prolonged treatment with corticosteroids?
Growth - as can suppress growth.
What drug treatments should be given to someone presenting with mild rhinitis symptoms?
Intranasal antihistamine such as azelastine - one spray twice daily
or oral antihistamines such as loratadine - 10mg once daily
What add on drug treatments can be given to someone with moderate to severe allergic rhinitis?
On top of intranasal or oral antihistamines
- add intranasal steroids
- Intranasal corticosteroids - e.g. fluticasone to be used during exposure.
What is the function of the nose?
- sense of smell
- warms and humidifies air
- aids breathing
- immune defence
- vocal resonance
How should allergic rhinitis be managed?
Nasal saline irrigation
Avoid triggers
Intranasal or oral antihistamines
Intranasal or oral steroids if severe
Where do the paranasal air sinuses drain?
Sphenoid sinus = spheno-ethmoidal recess
Posterior ethmoid cells = superioor meatus
All other sinuses = middle meatus
Where does the nasolacrimal duct drain into?
The inferior meatus
What are some complications of rhinosinusitis?
Chronic infection.
Periorbital infection (orbital cellulitis)#
Intracranial involvement - meningitis / encephalitis / brain abscess
What are complications of sinus surgery?
- infection
- bleeding
- pain
- damage to the orbit
- anterior skull base injury - can lead to a CSF leak
