ENT- nose

Question 1

How are foreign bodies in the nose managed?

Answer 1

Parental kiss- parent blows fast into child’s mouth while occluding good nostril
Wax hook/ Jobson probe/suction as tolerated
May need GA
Batteries need urgent removal, everything else can wait

Question 2

What are the predisposing factors for epistaxis?

Answer 2

Trauma / foreign body- URTI- Systemic disorders eg hereditary haemorrhagic telangiectasia

Question 3

What is the management for epistaxis?

Answer 3

First aid: pressure (soft fleshy part), ice, lean forwards
Vestibulitis in children common: use naseptin (check peanut allergy)
Silver nitrate cautery (LA)
Bipolar cautery (GA)

Question 4

What should be checked in a fractured nose?

Answer 4

Head injury: LOC, nausea/vomiting, amnesia
Facial fractures: diplopia, malocclusion (misalignment of dental arches), facial numbness
Nasal symptoms: obstruction, epistaxis, CSF leak, cosmetic changes, septal haematoma
No imaging required for nose

Question 5

What is the management for a fractured nose?

Answer 5

Epistaxis intervention, treat septal haematoma
Clinic: 5-7 days post injury (allows soft tissue swelling to settle so bony nose can be assessed)
Manipulate bony deformity LA / GA
(can’t manipulate cartilage – needs septorhinoplasty at later date)
(in children greenstick fractures common, still worth MUA)
MUA (manipulation under anaesthesia)only works within 2-3 weeks after injury

Question 6

What is a septal haematoma?

Answer 6

Rare in children and to be caused by trauma
Post op (septoplasty): the usual cause
Fluctuant swelling usually on both sides of the septum (distinguish from septal deviation which is unilateral and hard)

Question 7

What is the management for a septal haematoma?

Answer 7

Refer to ENT: need drainage and IV abx to prevent infection and cartillage destruction with resultant deformed nose

Question 8

What is rhinosinusitis?

Answer 8

Inflammation of the nose and paranasal sinuses
characterised by two or more symptoms, one of which should be
either nasal blockage/obstruction/congestion
or nasal discharge (anterior/posterior nasal drip)
± facial pain/pressure
± cough (in adults loss of smell / taste)
and either:
endoscopic signs of polyps and/or mucopurulent discharge primarily from middle meatus and/or oedema/mucosal obstruction primarily in middle meatus
Or:
CT changes: mucosal changes within OMC and/or sinuses

Question 9

When is a diagnosis considered to be acute rhinosinusitis?

Answer 9

Common cold duration <10 days
ARS when symptoms last >10 d or get worse after 5 days
ARS: <12 weeks

Question 10

What is the treatment for acute rhinosinusitis?

Answer 10

Mostly self limiting
Steroid nose spray (oral steroids in very select cases?)
Antibiotics if high fever / severe pain (GPs have guidelines)
Decongestants
(watch for complications)

Question 11

What is the treatment for chronic rhinosinusitis?

Answer 11

> 12 weeks
Medical: douche (if accepted), steroid nose spray
Teenagers are treated like adults
Adenoidectomy (± sinus washout) helps if adenoids are still present (adenoids usually shrink down and disappear by 8 years of age): adenoidectomy would be safer than Functional Endoscopic Sinus Surgery in most (younger) children
However with adenoid shrinking and immune system maturation, conservative management is just as effective

Question 12

What are the predisposing factors for peri-orbital cellulitis?

Answer 12

Eye lid Trauma
Skin infection
URTI / sinusitis

Question 13

What is the presentation for peri-orbital cellulitis?

Answer 13

Unilateral eyelid swelling, pain, redness
Blurred vision
Nasal obstruction/ discharge / URTI
Fever, headaches, meningism, septicaemia
Rhinoscopy: pus
Reduced eye movements 
Proptosis 
Loss of red colour vision- early sign

Question 14

What is the chandler periorbital cellulitis classification?

Answer 14

1: Pre-septal inflammation. Lid erythema/oedema only, probably with open eye.
2: Orbital cellulitis. More severe symptoms, closed eye.
3: Subperiosteal abscess. Severe symptoms, proptosis, ophthalmoplegia, visual impairment.
4: Orbital abscess.
5: Cavernous sinus thrombosis. Bilateral symptoms, CNS signs.

Question 15

What are the indications for a CT in periorbital cellulitis?

Answer 15

CNS symptoms/signs, drowsiness, seizure, cranial nerves
Diplopia/ophthalmoplegia/proptosis/abnormal pupil reflex
Deteriorating acuity or colour vision
Unable to evaluate vision / Unable to open eye
Bilateral periorbital oedema
No improvement or deterioration at 24-36
Swinging pyrexia not resolving within 36h

Question 16

What is the management for periorbital cellulitis?

Answer 16

Majority need admission
Analgesia
IV antibiotics
Close observation of eye (red colour desaturation is an early sign of optic compression)
Topical nasal decongestants
Combined ENT /Ophthalmology / Paeds
May need abscess drainage and sinus washout
Watch for intracranial complications

Question 17

What are the types of nasal obstruction a newborn can have?

Answer 17

Choanal atresia at back of nose

Pyrifrom aperture at front of nose