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MBBS IV - Junior Clerkship WCS > JC96 (ENT) - Common nasal conditions and NPC > Flashcards

JC96 (ENT) - Common nasal conditions and NPC Flashcards

1
Q

Key question in history taking for nasal conditions

A

Nose:

  • Congestion/ blockage/ obstruction
  • Nasal discharge
  • Sneezing, itchiness (allergy)
  • Olfactory disturbances/ anosmia
  • Epistaxis (anterior/ posterior)
  • Snoring

Associated features:

  • Facial pressure/ pain
  • Eye itchiness, Visual disturbances
  • Otalgia/ aural fullness (connected to nasopharynx via Eustachian tube)
  • Dental pain
  • Fever
  • Atopy, asthma
  • Smoking, drugs, social
  • Family history of NPC, Allergies
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2
Q

Outline exams for the nose

A

External nose:

  • Skin changes, wounds, scars
  • Frontal: Nasal bridge
  • Base: Rhinoplasty scar
  • Side: Nasal ridge, proportion

Internal nose:

  • Anterior rhinoscopy (speculums)
  • Nasoendoscopy (nasopharynx)
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3
Q

Ddx Nasal obstruction in adults

A

Nasal deformities:

  • Crooked, deviated nose, saddle nose
  • Injuries: Septal haematoma, Fracture nasal bone, Fracture/ dislocation of the septum

Mucosal swelling:

  • URTI
  • Nasal vestibulitis
  • Acute/ Chronic bacterial rhinosinusitis
  • Allergic rhinitis
  • Non-allergic rhinitis
  • Mucoceles

Neoplasm:

  • Sinonasal tumors
  • NPC
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4
Q

Patient presents with swelling, discoloration over the nose with tenderness and nasal obvstruction

Most likely causes of nasal obstruction?

A

Nasal deformity

  • Septal haematoma
  • -Fractured nasal bone
  • Nasal septal fracture or dislocation
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5
Q

Nasal bone fracture

  • Causes
  • S/S
  • Treatment
A

Causes: Blunt force trauma, laceration

S/S:

o May have open wound in the skin
o Swelling/ discoloration of skin over nasal bone
o Tenderness
o Mobility of the nose
o Deformity

Treatment:

 Treat epistaxis, open wound (need suturing/ dressing)
 Closed reduction within 7-10 days (no treatment if no deformity)

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6
Q

Nasal septum fracture/ dislocation

Causes

S/S

Management

A

Causes:
 Trauma (birth/ long-forgotten/ recent)
 Developmental
 Nasal surgery

Symptoms:
 Can be asymptomatic if minor
 Nasal obstruction (e.g. deviated nasal septum impinge on inferior turbinate)
 Obstruction to normal sinus drainage pathway
 Epistaxis (due to turbulent airflow)

Management (if symptomatic): septoplasty/ septorhinoplasty

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7
Q

Ddx nasal mucosal swelling

A

URTI

Nasal vestibulitis: Staphylococci infects skin of nasal vestibule

Acute and chronic bacterial rhinosinusitis

Allergic rhinitis

Non-allergic rhinitis

Mucocele

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8
Q

Acute bacterial rhinosinusitis

Causes

Causative pathogens

Risk factors

A

Causes:
 Upper respiratory tract infection
 Dental abscess, extraction (pre- molar/ molar teeth: infection spreads upward to maxillary sinus)
 Trauma

Organisms:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 Anaerobic organisms (look for dental source)

Predisposing factors:
 Poor drainage, e.g. septal deviation, turbinate hypertrophy, nasal polyposis
 Poor immunity

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9
Q

Acute bacterial rhinosinusitis

S/S

A

Symptoms:

  • Symptoms of viral URTI >10 days or worsening after 5-7 days (double sickening)
  • Nasal obstruction
  • Nasal discharge (anterior/ post- nasal drip)
  • Anosmia ***
  • Facial pain (collection of fluid distends sinus) ***
  • Fever

Signs:
 Facial tenderness ***
 Edema, mucopurulent discharge in middle meatus/ nasopharynx

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10
Q

Acute bacterial rhinosinusitis

Complications

Treatment

A

Complications need urgent surgical intervention:
Orbital cellulitis, abscess
cavernous sinus thrombosis (Posteriorly along sinus drainage)
Intracranial infection: meningitis, encephalitis, abscesses (Superiorly: ethmoid
and frontal sinus separated from brain by only thin bone)

Treatment:

 Analgesics
 Antibiotics (if bacterial)
 Intranasal steroid spray
 Short-term (<7 days) nasal decongestant, e.g. oxymetazoline, ephedrine
 Nasal douching (rinsing with saline)

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11
Q

Chronic rhinosinusitis with polyposis

S/S

A

 Purulent nasal and post-nasal discharge
 Nasal obstruction
 Facial discomfort
 Headache
 Halitosis (purulent discharge goes into mouth)
 No fever

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12
Q

Chronic rhinosinusitis

Treatment

A

Intranasal steroid

Antibiotics:
o Short-term for superimposed infection
o Long-term (macrolide, doxycycline) for anti- inflammatory effect than antibacterial

Nasal saline irrigation

Antihistamine for coexisting atopy

Surgery: endoscopic sinus surgery

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13
Q

Compare nasal polyposis (e.g. due to chronic sinusitis) and nasal polyps

A

Inferior turbinate

  • Sensitive to touch/ tender
  • Attached to lateral nasal wall

Nasal polyp

  • Pale, grey, translucent
  • Insensitive to touch/ not tender
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14
Q

Causes of nasal polyposis

A

Asthma

Allergic fungal sinusitis

Cystic fibrosis

Aspirin -induced (Samter’s triad)

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15
Q

Define Samter’s triad

Pathogenesis

A

Triad for aspirin exacerbated respiratory disease:

  • Asthma
  • Nasal polyposis
  • Aspirin sensitivity

Pathogenesis:

Aspirin inhibits cyclooxygenase >> arachidonic acid cannot be converted to prostaglandins/ thromboxanes, but instead to leukotriene >> causes asthma, polyposis

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16
Q

Nasal mucoceles

  • Histological structure and pathogenesis
  • Common site of occurence
  • Presentation
  • Treatment
A

epithelial-lined sac containing mucus:
Drainage of paranasal sinus is blocked >> mucus collects inside mucocele which expands and erodes bone

Most common in the fronto-ethmoidal region

Symptoms: orbital displacement, proptosis, nasal obstruction

Treatment: Surgical marsupialization (open up blocked pathway for drainage to nose)

17
Q

Allergic rhinitis

  • Pathogenesis
  • S/S
  • Associated complications
  • Associated atopy
A

Pathogenesis:

Type I hypersensitivity reaction: aeroallergens – immunoglobulin E

S/S:

  • Early: Sneezing, itching, rhinorrhea, nasal obstruction
  • Late: Nasal congestion, hyper-responsiveness to allergens and irritants
  • Complications: sinusitis, otitis media, sleep disturbances

Triggers: seasonal, pets, mites…etc

Atopy: Asthma, Eczema, Allergic conjunctivitis

18
Q

Allergic rhinitis

Treatment options

A

Avoid allergens

Drug options:

  • Oral antihistamine
  • Intranasal steroid
  • Leukotriene receptor antagonists (especially in patients with asthma)
  • Saline douching (wash away allergen in mucus)
  • Refractory: short-term systemic steroid (S/E), decongestant
  • Immunotherapy

Surgery

19
Q

Tests to find allergen causing allergic rhinitis

A

o Skin prick test
o In vitro specific IgE blood test: radioallergosorbent test (RAST)

20
Q

Non-allergic rhinitis

Etiologies/ causes

A

 Idiopathic – temperature, humidity, pressure (vasomotor rhinitis, intrinsic)
 Food-induced
 Hormonal
 Irritants
 Occupational (chemicals)
 NARES (non-allergic rhinitis with eosinophilia syndrome)
 Atrophic rhinitis
 Emotional
 Gastro-esophageal reflux disease
 Autonomic

21
Q

Drugs that cause drug-induced rhinitis

A

 Anti-hypertensive (β blockers, calcium channel blockers)
 Sedatives
 Antidepressants
 Oral contraceptives

Prolonged use of topical sympathomimetic agents nasal decongestants*) >>> rhinitis medicamentosa

22
Q

drug-induced rhinitis

Treatment options

A

 Prevention (do not use decongestants for extended period of time)
 Intranasal steroid
 Surgery, e.g. turbinate reduction/ turbinectomy

23
Q

Red flag signs of nasal neoplasm

A

Red flags:
 Unilateral obstruction
 Epistaxis
 Bleeding
 Cacosmia (sensation of bad smell)
 Proptosis, diplopia, epiphora (overflow of tear (obstruction of nasolacrimal duct))
 Neurological symptoms (tumor spreads superiorly to brain (frontal lobe))

24
Q

First line investigations for nasal neoplasms

A

Investigations:
 Biopsy
 Computed tomography
 Magnetic Resonance Imaging

25
Q

General treatment options for nasal neoplasms

A

Surgery:
o Endoscopic approach
o Open approach
o Craniofacial/ cranionasal resection, reconstruction

If tumor is sensitive: adjuvant chemotherapy, radiotherapy

26
Q

Ddx sinonasal tumors

A

Epithelial:

  • Benign: Inverted papilloma
  • Malignant: Carcinoma, Malignant melanoma

Mesenchymal:

  • Benign: Juvenile nasopharyngeal angiofibroma
  • Malignant: Sarcoma

Neural

  • Benign: Meningioma
  • Malignant: Olfactory neuroblastoma

Lymphoreticular: Non-Hodgkin’s lymphoma

Odontogenic: Ameloblastoma

27
Q

Inverted papilloma

Morphology

Cause

Location of occurrence

Tx

A

Inverted mucosal surface into stroma of papilloma
o Unilateral
o Lateral nasal wall

Benign, locally aggressive (can erode bone)

Cause: HPV

Tx: Surgery (2-10% risk of malignant transformation

28
Q

Nasal carcinoma

Histological types

2 major risk factors

A

 Squamous cell carcinoma
 Adenocarcinoma
 Sinonasal undifferentiated (anaplastic) carcinoma
 Adenoid cystic carcinoma

Risk factors:
 Smoking
 Hard-wood exposure (adenocarcinoma)

29
Q

Olfactory neuroblastoma

Presentation

Tx

A

 From olfactory epithelium (near CN I)
 Late presentation: occurs superiorly, asymptomatic until epistaxis, intracranial
extension (frontal lobe)

Craniofacial/ cranionasal resection + adjuvant RT

30
Q

NPC

  • Prevalence in HK
  • Demographics
  • Risk factors
A
  • Prevalence in HK = 10th most common
  • Demographics = middle age, male predominant
  • Risk factors:

1) Epstein-Barr virus infection***
2) Host genetics (family history)
3) Environmental factors:
 Preserved foods (nitrosamines; salted fish)
 Alcohol
 Poor oral hygiene
 Active and passive tobacco smoking

31
Q

NPC

Screening methods

A

1) Anti-EBV IgA antibodies (out of favor):
 Early antigen (EA-IgA)
 Viral capsid antigen (VCA-IgA)
 Nuclear antigen 1 (EBNA1-IgA)
(Low sensitivity, low specificity for asymptomatic participants)

2) EBV DNA (expensive; higher sensitivity and specificity)

32
Q

First-line investigations for NPC

A

Investigations:
o Nasoendoscopy + biopsy

o Ultrasound neck +/- fine needle aspiration cytology (if enlarged LN)

o Magnetic resonance imaging with contrast (better for soft tissue)

o 18F-FDG-PET/CT (for staging advanced disease)

33
Q

NPC

Histological subtypes

A

a) Non-keratinizing:
 Differentiated

Undifferentiated (>95% cases in endemic area, EBV infection)

b) Keratinising squamous
c) Basaloid squamous

34
Q

NPC

Treatment options

A

o Early stage: intensity-modulated radiotherapy

o Late stage: radiotherapy + concurrent chemotherapy

o Residual disease/ recurrence:
Surgery, e.g.:
 Open maxillary swing
 Endoscopic/robotic nasopharyngectomy
If not fit for surgery:
 Chemotherapy, second-dose radiotherapy
 Immunotherapy

35
Q

Paediatrics nasal obstruction

Ddx for obstruction in neonates, infants, toddlers and children

A

Neonate: Choanal atresia (nasopharynx not linked to nasal cavity)

Infant: Encephalocele (brain herniates into nose)

Toddler: Adenoid hypertrophy (B cell producing)

Children: Allergic dysfunction, cystic fibrosis, foreign body

36
Q

Choanal atresia

Age of presentation

Clinical presentation

A

Neonatal presentation

Clinical:

  • Cyclical hypoxia, obligate nasal breather: Cycle of hypoxia, cry and relief, close mouth and hypoxia again
  • Growth failure/ stunted growth
37
Q

Adenoid hypertrophy

Age of presentation

Clinical presentation and complications

Treatment options

A

Toddler age presentation

Clinical presentation:

  • Recurrent rhinosinusitis
  • Recurrent otitis media with effusion
  • OSAS

Tx:

  • Watchful waiting for resolution (Most)
  • Adenoidectomy
38
Q

Foreign body nasal obstruction in children

Presentation

Risks/ complications

A

Presentation:

  • Irritable child
  • Unilateral foul-smelling nasal discharge (sinusitis), sometimes blood-stained
  • Excoriation around the nostril
  • Occasionally radio-opaque

Risks:
 Button battery - septal perforation (emergency)
 Local spread of infection - sinusitis/ meningitis
 Inhalation of foreign body - aspiration
 Injury from clumsy attempts at removal by unskilled person

MBBS IV - Junior Clerkship WCS (131 decks)

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