Nasal Blockage Flashcards
1
Q
What are key questions to ask in someone presenting with nasal symptoms?
A
- Is it both sides or one side that feels blocked and if so which side?
- How long has it been blocked and is it intermittent or constant? Is either/both sides ever clear?
- Hx of trauma
- Hx of nasal surgery
- Are there any other nasal symptoms such as sneezing, rhinorrhoea, facial pain, postnatal drip or epistaxis
- What medications are they on?
- Alleviating/relieving factors?
- Anything changed when first started getting symptoms?
- Hyposmia?
- Allergies e.g. asthma, hay fever
- Social: triggers, new workplace/house/pet?
2
Q
What are differentials for nasal problems?
A
- Nasal polyps
- Septal deviation
- GPA - multisystemic disease, in nose causes extensive crusting and granuloma formation, destroys nose cartilage and can lead to nasal septal perforation and collapse of cartilaginous dorsum of nose
- Rhinosinusitis - look for significant nasal inflammation
3
Q
What are causes of septal deformity?
A
- Trauma
- Infective e.g. infective septal haematoma
- Congenital
- Inflammatory conditions e.g. GPA, sarcoidosis
4
Q
What is the management for nose structural problems?
A
- Adenoidectomy: removing adenoids e.g. adenoid cystic carcinoma, usually regress age 7 or 8, usually cause bilateral obstruction
- Septoplasty: to fix a deviated septum
- Rhinoplasty: corrects deformity of external nose
- Nose splints: sometimes inserted at the end of a rhinoplasty or septorhinoplasty to hold tissues in their new position. May be internal and sit either side of septum or external over nasal bones. Not usually used for treatment of nasal septal deformity alone.
5
Q
What are the risks of septoplasty?
A
- Numbness of upper teeth (maxillary nerve)
- Further procedure/revision surgery
- Numbness of nose
- Bleeding and infection
- Altered appearance - sometimes can weaken external tissues
- Septal perforation
- Anosmia/hyposmia
- Failure to improve symptoms
- Puncture in septum - can be treated via surgery but does not cause problems or require treatment (might cause whistling when breathing, crusting with blockage or epistaxis)
6
Q
What is the advice for after a septoplasty?
A
- Nose drops for 3 months - may take this long for nose to settle down and breathing to be normal, try to stay away from smoky and dusty places
- Nose will be blocked for 10-14 days like heavy cold
- Don’t blow nose for 1 week (may bleed)
- May get blood in nose for 2 weeks
- Surgery is day case, rest at home for at least 1 week
- May have to breathe via mouth
- No scars/bruises as all inside nose
7
Q
What is chronic sinusitis?
A
- Chronic nasal inflammation, bilateral nasal obstruction, anterior rhinorrhea and sneezing
- Clinical exam may show oedema of nasal mucosa and watery discharge in nose.
- RAST (radioallergosorbent test) - blood test to identify any allergies to specific allergens
8
Q
What is the treatment for chronic sinusitis?
A
- Antihistamine: symptomatic relief to allergy, also advise them to avoid the allergen
- Saline nasal irrigation: beneficial in conjunction with other topical therapy
- Topical nasal steroid: mainstay treatment, given as a spray, most sprays take up to 6 weeks to exert maximum effect
- Surgery: if unresponsive to medication
- Ask about OTC medication, particularly decongestants like Otravine and Sudafe - short-term use only (2 weeks), if used longer can cause rebound congestion
9
Q
What are the symptoms of chronic rhinosinusitis with nasal polyps?
A
- Lasting >12 weeks
- Nasal blockage, constant, bilateral
- Worse around allergens
- Associated with constant running nose and cheek pain
10
Q
What is the treatment for chronic rhinosinusitis with nasal polyps?
A
- Short course of prednisolone: helps shrink the polyps and provides rapid relief of symptoms
- Topical nasal steroid (drops or spray) - if one doesn’t work can change to a different one
- If medicine doesn’t work for polyps consider functional endoscopic sinus surgery - performed via nostrils using endoscopes and a debrider that sucks in the polyps and cuts them away (rare to remove them all). This procedure reopens airway to allow effective medical management - after need maintenance topical steroid.
11
Q
What are the risks of functional endoscopic sinus surgery?
A
- Hyposmia/anosmia (surgery cannot restore it)
- Blindness (optic nerve damage) - rare
- Bleeding
- CSF leak (if skull base and dura are breached)
- Synechiae (adhesions in nasal cavity)
- Infection
- Recurrence (long term maintenance on topical steroids)
- Orbital injury
- Epiphora (if nasolacrimal duct damaged»_space; watery eye)
- Meningitis
12
Q
Define acute and chronic rhinosinusitis
A
- Acute Rhinosinusitis (ARS): lasts <12 weeks with complete resolution of symptoms
- Chronic Rhinosinusitis (CRS): lasts >12 weeks without complete resolution of symptoms
13
Q
How do you diagnose rhinosinusitis?
A
Inflammation of nose and paranasal sinuses characterised by:
Nasal blockage/congestion/obstruction
+1 or more of the following:
- Facial pain/pressure
- Reduction or loss of sense of smell
- Nasal polyps +/or mucopurulent discharge, primarily from middle meatus +/or CT changes
14
Q
What is the management of chronic rhinosinusitis without nasal polyps?
A
- Topical nasal steroid
- Sprays include Fluticasone (Flixonase), Beclomethasone (Beconase), Mometasone (Nasonex), drop formation can also be used but short-term - Nasal saline irrigation: either spray or nasal douching
- Antibiotics if evidence of infection e.g. mucopus, macrolidea e.g. clarithromycin are recommended
- Antihistamines and allergen avoidance if documented allergy
- Functional endoscopic sinus surgery in cases that aren’t adequately treated with medical therapy
15
Q
What are the causes of nasal obstruction?
A
- Chronic rhinosinusitis (most common)
- Nasal polyps
- Foreign body in nose (especially in children)
- Nasal septal deviation
- Nasal valve collapse (rare): can collapse nostril on inspiration where lateral cartilage is weak
