JC96 (ENT) - Common nasal conditions and NPC Flashcards
Key question in history taking for nasal conditions
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
Outline exams for the nose
External nose:
- Skin changes, wounds, scars
- Frontal: Nasal bridge
- Base: Rhinoplasty scar
- Side: Nasal ridge, proportion
Internal nose:
- Anterior rhinoscopy (speculums)
- Nasoendoscopy (nasopharynx)
Ddx Nasal obstruction in adults
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
Patient presents with swelling, discoloration over the nose with tenderness and nasal obvstruction
Most likely causes of nasal obstruction?
Nasal deformity
- Septal haematoma
- -Fractured nasal bone
- Nasal septal fracture or dislocation
Nasal bone fracture
- Causes
- S/S
- Treatment
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)
Nasal septum fracture/ dislocation
Causes
S/S
Management
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
Ddx nasal mucosal swelling
URTI
Nasal vestibulitis: Staphylococci infects skin of nasal vestibule
Acute and chronic bacterial rhinosinusitis
Allergic rhinitis
Non-allergic rhinitis
Mucocele
Acute bacterial rhinosinusitis
Causes
Causative pathogens
Risk factors
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
Acute bacterial rhinosinusitis
S/S
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
Acute bacterial rhinosinusitis
Complications
Treatment
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)
Chronic rhinosinusitis with polyposis
S/S
Purulent nasal and post-nasal discharge
Nasal obstruction
Facial discomfort
Headache
Halitosis (purulent discharge goes into mouth)
No fever
Chronic rhinosinusitis
Treatment
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
Compare nasal polyposis (e.g. due to chronic sinusitis) and nasal polyps
Inferior turbinate
- Sensitive to touch/ tender
- Attached to lateral nasal wall
Nasal polyp
- Pale, grey, translucent
- Insensitive to touch/ not tender
Causes of nasal polyposis
Asthma
Allergic fungal sinusitis
Cystic fibrosis
Aspirin -induced (Samter’s triad)
Define Samter’s triad
Pathogenesis
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
Nasal mucoceles
- Histological structure and pathogenesis
- Common site of occurence
- Presentation
- Treatment
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)
Allergic rhinitis
- Pathogenesis
- S/S
- Associated complications
- Associated atopy
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
Allergic rhinitis
Treatment options
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
Tests to find allergen causing allergic rhinitis
o Skin prick test
o In vitro specific IgE blood test: radioallergosorbent test (RAST)
Non-allergic rhinitis
Etiologies/ causes
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
Drugs that cause drug-induced rhinitis
Anti-hypertensive (β blockers, calcium channel blockers)
Sedatives
Antidepressants
Oral contraceptives
Prolonged use of topical sympathomimetic agents nasal decongestants*) >>> rhinitis medicamentosa
drug-induced rhinitis
Treatment options
Prevention (do not use decongestants for extended period of time)
Intranasal steroid
Surgery, e.g. turbinate reduction/ turbinectomy
Red flag signs of nasal neoplasm
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))
First line investigations for nasal neoplasms
Investigations:
Biopsy
Computed tomography
Magnetic Resonance Imaging
General treatment options for nasal neoplasms
Surgery:
o Endoscopic approach
o Open approach
o Craniofacial/ cranionasal resection, reconstruction
If tumor is sensitive: adjuvant chemotherapy, radiotherapy
Ddx sinonasal tumors
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
Inverted papilloma
Morphology
Cause
Location of occurrence
Tx
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
Nasal carcinoma
Histological types
2 major risk factors
Squamous cell carcinoma
Adenocarcinoma
Sinonasal undifferentiated (anaplastic) carcinoma
Adenoid cystic carcinoma
Risk factors:
Smoking
Hard-wood exposure (adenocarcinoma)
Olfactory neuroblastoma
Presentation
Tx
From olfactory epithelium (near CN I)
Late presentation: occurs superiorly, asymptomatic until epistaxis, intracranial
extension (frontal lobe)
Craniofacial/ cranionasal resection + adjuvant RT
NPC
- Prevalence in HK
- Demographics
- Risk factors
- 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
NPC
Screening methods
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)
First-line investigations for NPC
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)
NPC
Histological subtypes
a) Non-keratinizing:
Differentiated
Undifferentiated (>95% cases in endemic area, EBV infection)
b) Keratinising squamous
c) Basaloid squamous
NPC
Treatment options
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
Paediatrics nasal obstruction
Ddx for obstruction in neonates, infants, toddlers and children
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
Choanal atresia
Age of presentation
Clinical presentation
Neonatal presentation
Clinical:
- Cyclical hypoxia, obligate nasal breather: Cycle of hypoxia, cry and relief, close mouth and hypoxia again
- Growth failure/ stunted growth
Adenoid hypertrophy
Age of presentation
Clinical presentation and complications
Treatment options
Toddler age presentation
Clinical presentation:
- Recurrent rhinosinusitis
- Recurrent otitis media with effusion
- OSAS
Tx:
- Watchful waiting for resolution (Most)
- Adenoidectomy
Foreign body nasal obstruction in children
Presentation
Risks/ complications
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
