Nasal Congestion

Question 1

Nasal anatomy

Answer 1

Inferior turbinate - tear duct comes out below
Middle turbinate - most sinuses enter wall lateral to this
Olfactory mucosa on roof, superior side wall, septum

Question 2

LHS of nose with septum (nice pink mucosa, usually not completely straight, cartilage anteriorly and bone posteriorly)
Inferior turbinate

Answer 2

View

Question 3

Sinus anatomy

Answer 3

Bone-targeted non-contrast coronal CT through the paranasal sinuses
3 - orbital globe
1,2 - frontal sinuses (unusual to be so symmetrical)
4 - maxillary sinuses (grey stuff could be mucus, pus, other fluid, soft tissue mass including tumour, swollen mucosa; looking at other slices might help, if entire space blacked out an MRI may help)
Centrally - ethmoid sinus

Question 4

Sinus anatomy 2

Answer 4

Bone-targeted non-contrast coronal CT through the paranasal sinuses
Back of inferior turbinate
Sphenoid sinuses all the way back
Front of C1 below

Question 5

Turbinate

Answer 5

Conchae

Question 6

Function of the nose

Answer 6

Airway
Filtration
Humidification
Warming
Olfactory sensation

Question 7

6 main nasal symptoms patients will complain of

Answer 7

Block: congestion vs total obstruction, uni- vs bi-lateral
Run (“rhinorrhoea”)
React to irritation: itching, sneezing, pain
Change in smell (+/- taste): decreased/absent, foul
Facial pressure/pain
Bleed (“epistaxis”)

Question 8

Anatomical DDx

Answer 8

Deviation of nasal septum, hypertrophy of turbinates

??

Question 9

Septal deviation

Answer 9

Deviation of dorsum of nose to right will result in deviation of septum to left, and vice versa
Nose will always be partially blocked

Question 10

Choanal atresia

Answer 10

Congenital condition
Bilateral - obligate nasal breathers from birth, becomes obvious when newborn (will go into immediate respiratory distress); treat by holding mouth open (e.g. Galdel airway)
Unilateral - age of presentation variable (might be old enough to express that they can’t breathe through that side, or parent might notice one side is more snotty)

Question 11

Space-occupying lesions

Answer 11

1 - mucopurulent discharge due to foreign body
2 - bilateral obstruction of nasal cavity or obstruction in nasopharynx, most common reason is adenoid hypertrophy (“adenoid facies” - long face due to mouth open with developing skeleton)
3 - inflammatory nasal polyp (also go looking for them in the other side; bilateral polyps are better as this suggests allergic rhinosinusitis, unilateral polyp may suggest inflammatory reaction to underlying tumour)
4 - mass in maxillary sinus (probably primary malignant neoplasm)

Question 12

Functional causes of nasal congestion

Answer 12

Infections
Rhinitis (e.g. infectious, atopic, irritation, vasomotor, atrophic, drugs including cocaine, heroine, speed, long term nasal decongestant use)

Question 13

Rhinitis

Answer 13

Clinical triad of nasal congestion, rhinorrhoea and nasal irritation (itching and sneezing)

Question 14

Rhinitis medicamentosa

Answer 14

Nasal congestion caused by longterm decongestant use

Question 15

Atrophic rhinitis

Answer 15

“Crusting” in the nose - block, stuffy, dried, smelly (mucus and bacteria)
Consider AI rhinitis (e.g. sarcoidosis, ??)

Question 16

Acute bacterial rhinosinusitis

Answer 16

Symptoms for 7-28 days
Diagnosis clinical: at least 2 of, one of which must be P or O
P - facial pain/pressure/fullness
O - nasal obstruction
D - purulent nasal discharge
S - smell: hyposmia/anosmia

Question 17

Chronic rhinosinusitis

Answer 17

Symptoms lasting 8-12 weeks
Lack of signs of acute inflammation (facial pressure but not so much pain)
Requires clinical demonstration of sinus inflammation (via endoscopy or imaging)
Multiple causes

Question 18

Facial pain syndromes - likely the nose

Answer 18

Other nasal symptoms (e.g. discharge, difficulty breathing through nose, etc)
Ache/pressure
Location (maxillary, bridge, potentially retro-orbital)
Commonly bilateral
Typical triggers
Systemic symptoms (e.g. fever)
Changes with head position (headache worse with head forward)
Worse with respiratory symptoms/during hayfever season

Question 19

Facial pain syndromes - probably not

Answer 19

Lack of nasal symptoms
Pain, not pressure
Location
Unilateral
Typical triggers (menstrual cycle, stress, musculoskeletal problems with neck)

Question 20

Gate theory for pain

Answer 20

Operative pain gives the patient other pain to focus on

6 weeks later comes back

Question 21

Concerning features

Answer 21

Head and neck cancers don’t cause weight loss until end stage
Small but frequent bleeding
Unilateral symptoms
Progressive symptoms
Crusting
Dysfunction of adjacent structures (e.g. nasolacrimal duct, orbit, facial sensation or cheek swelling, eustachian tube obstruction, brain)

Question 22

Wegener’s granulomatosis

Answer 22

If untreated 100% mortality

Question 23

With age, tip of nose droops, cartilage droops - nasal obstruction

Answer 23

Can intervene surgically or just leave it

Question 24

Imaging

Answer 24

Most likely CT (MRI has soft tissue benefit - can figure out exactly what is going on)

Question 25

Allergies

Answer 25

Short-cuts: IgE titres

Skin-prick testing with allergist (can be tricky to get in)