Nasal Obstruction Flashcards
Where does nasal obstruction occur?
Internal nasal valve
- found 1/3 away from nasal vestibule
- bounded by anterior head of inferior turbinate, junction of upper lateral cartilage and lower lateral cartilage and septum medially
- narrowest area, highest resistance to nasal airflow
What test to do to confirm an obstruction at internal nasal valve?
Cottle’s manoeuvre
- lift cheek up laterally and patient comments that nasal obstruction is better or relieved
- opens internal nasal valve
Causes of nasal obstruction
Structural
1. Deviated nasal septum
- trauma, congenital
- one side worse than the other
- can cause hypertrophy of contralateral inferior turbinate –> Make sure to check other side
– Tx: Septoplasty, Reduction of inferior turbinate (Turbinoplasty)
- Turbinate hypertrophy especially inferior turbinate
- Tx: Turbinoplasty - Adenoid hypertrophy
- Foreign body
- Tumours
Mucosal
1. Acute rhinosinusitis (<1 month)
2. Chronic rhinosinusitis WITH polyps (>3 months)
3. Chronic rhinosinusitis WITHOUT polyps
Causes of acute rhinosinusitis
- <1 month in duration
- Infection** (most common)
- viral: “common cold”
- bacterial: S. pneumoniae, H. influenzae, M. catarrhalis - Allergic rhinitis (see next topic)
- Non-allergic rhinitis
- Irritants eg. haze, smoke
- Rhinitis medicamentosa
- Hormonal rhinitis (Pregnancy, hypothyroidism)
- Medications (OCP, anti-HTNsives)
- Idiopathic (Vasomotor rhinitis)
- Gustatory rhinitis - Systemic
- Granulomatous disease (Wegener’s granulomatosis)
Clinical features of acute rhinosinusitis 2’ to infection
Nasal obstruction
Rhinorrhea
Facial pain/pressure
Anosmia/hyposmia
Fever
Complications of acute rhinosinusitis 2’ to infection
Preseptal/orbital cellulitis/abscess
Cavernous sinus thrombosis
Meningitis
Intracranial abscess
Osteomyelitis
Facial cellulitis
How to differentiate between viral and bacterial cause of infectious acute rhinosinusitis?
Differentiate using duration: not getting better/getting worse within 3-5 days, likely superimposed bacterial rhinosinusitis
+ other clinical features:
- discoloured discharge
- severe local pain
- fever
- raised ESR/CRP
- double sickening effect (deterioration after initial recovery)
Causes of non-allergic rhinitis
- Irritants eg. haze, smoke
- Rhinitis medicamentosa
- Hormonal rhinitis (Pregnancy, hypothyroidism)
- Medications (OCP, anti-HTNsives)
- Idiopathic (Vasomotor rhinitis)
- Gustatory rhinitis
Rhinitis medicamentosa
Overuse of topical nasal decongestants (e.g. oxymetazoline, pseudoephedrine) causing rebound nasal congestion
- need to keep using it and causes rebound vasodilation when stopped -> more edematous and congested nose
Best way is to prevent it by asking patient to use it for max of 5-7 days and give systemic ephedrine instead
Idiopathic/vasomotor rhinitis
- usually in older people
- exaggerated response to changes e.g. temperature, eating
- hard to differentiate from irritant rhinitis
Chronic rhinosinusitis WITH polyps
Grape-like growth from mucosa of nose and sinuses
More translucent than turbinate as it is an edematous nasal mucosa with fluid inside
Samter’s triad (aspirin-exacerbated respiratory disease)
- Aspirin hypersensitivity
- Asthma
- Nasal polyps
Management of chronic RNS with polyps
1st line:
Medical - intranasal steroids +/- antibiotics
Nasal irrigation with saline may help with symptoms or mucociliary clearance
Biologics
2nd line: when medical fails
Surgical - functional endoscopic sinus surgery (polypectomy)
Diagnostic criteria of chronic rhinosinusitis
- Duration of symptoms > 3 months
- At least 2 of the following symptoms present:
1 of which must be:
- Nasal obstruction
- Rhinorrhea
+ at least 1 more
- Hyposmomia/Anosmia
- Facial pressure/pain - Endoscopic &/or CT findings of sinuses
Investigations for nasal obstruction
Not often indicated except in specific situations
- Microbiology (Cultures of discharge like mucopus)
- Histopathology (Biopsy of any suspicious mass)
- Any lesions that appears vascular or are suspected to originate from skull base should be biopsied under GA - Allergy testing (For AR)
- Skin prick test
- Serum specific IgE - Imaging (XR/CT/MRI paranasal sinuses)
- MRI for assessing how extensive the tumour is
- Coronal cuts are used
- Opacification (does not tell you the cause): Tumour/ Fluid/ inflammation
- XR of paranasal sinuses for fractures
