Nose Flashcards
Give four roles of the nose
- Warms and humidifies
- Removes and traps pathogens
- Responsible for smell
- Drains and clears Paranasal sinuses and lacrimal ducrs
Describe the anatomy of the nose
Root - as it joins forehead Bridge - top of the nose Dorsum Nasi Nares - Nostrils Apex - between nostrils Ala - side of nostrils
Name two bones in the external nose
Nasal Bone (ethmoid) Maxilla
Name four cartilages associated with the external nose
Septal
Lateral
Major Alar
Minor Alar
Describe the blood supply to the external nose
Facial Artery (Angular and Lateral Nasal) Branches of Maxillary and Opthalmic
The external nose is drained by the facial vein. Why is this relevant?
Valveless structure that runs into opthalmic and then cavernous sinus so infection in this region can cause intracranial spread (danger triangle)
What are the three regions of the nasal cavity?
Area surrounding external opening - Vestibule
Respiratory region
Olfactory region
What are conchae/turbinates?
Bony shelves protruding into cavity (superior, middle and inferior)
Increase SA of cavity and slows air flow down
What are meatuses?
4 Pathways between conchae
Inferior - between inferior conchae and floor
Middle - between inferior and middle conchae
Superior - between middle and superior conchae
Sphenoethmoidal - Superoposterior to superior
What structures open up into middle meatus?
Frontal, Maxillary and Ethmoid Sinuses
What structures open up into inferior meatus?
Nasolacrimal duct
Eustacian tube
What are two gateways of the nasal cavity?
Cribriform plate - into Ethmoid bone
Sphenopalantine - Between nasal cavity and Pterygopalantine fossa
The vasculature of the nasal cavity has to be rich. Describe this
Internal Carotid - Anterior and Posterior Ethmoidal (branches of opthalmic through cribriform plate)
External Carotid - Sphenopalantine, Greater Palantine, Superior Labial, Lateral Nasal
Anastamose in Little’s Area
Describe the innervation of the nasal cavity
Special Sensory - Olfactory
General Sensory - Nasociliary (Opthalmic) and Nasopalantine (Maxillary)
How would a Cribriform plate fracture present?
CSF Rhinorrhoea
Anosmia
What are Paranasal Sinuses?
Air filled extensions of nasal cavity, lined with pseudostratified epithelium and interspersed with goblet cells
Name four roles of Paranasal SInuses
Reduce weight of head
Supports immune defence
Humidifies inspired air
Increases vocal resonance
Describe the anatomy of the Frontal Sinus
Triangular shaped within the frontal bone
Drainage into middle meatus
Sensation by Supraorbital (CNV1)
Describe the anatomy of the Ethmoidal Sinus
Made up of three
Anterior - into middle meatus
Middle - into middle meatus
Inferior - into superior meatus
Describe the anatomy of the Maxillary Sinus
Drains into middle meatus (just below frontal so fluid can enter maxillary)
Maxillary nerve also supplies teeth - referred toothache
Give three broad causes of Nasal Obstruction
Anatomical
Nasal lining
Autonomic
Name three anatomical causes of nasal obstruction
Septal Deflection
Adenoidal Hypertrophy
Chonal Atresia
Chonal Atresia is a part of CHARGE Syndrome. How would it present?
Unilateral - persistent nasal drainage, recurrent sinus infections
Bilateral - RDS or Cyanosis
Name two nasal lining causes of nasal obstruction
Rhinitis
Nasal Polyps
Name an autonomic cause of nasal obstruction
Vasomotor Rhinitis (increased parasympathetic flow causes engorgement)
Nasal discharge has two different terms, what are they?
Rhinorrhoea - out of nostrils
Catarrh - Post nasal drip
Give two causes of watery nasal discharge
Allergic
CSF
Give two causes of mucopurulent nasal discharge
Bacterial Rhinitis
Foreign Body
Give two causes of serosanguinous nasal discharge
Neoplasia
Give two causes of bloody nasal discharge
Trauma
Neoplasia
How do allergies to dust mites present?
Sneezing upon waking (bed acts as resevoir)
What is Cacosmia?
Unpleasant smell detected mainly by others
Indicated nasal sepsis
Name two nasal causes of Halitosis
Chronic Sinusitis
Post Nasal Drip
Describe the pathophysiology of Allergic Rhinitis
IgE mediated inflammation of nasal mucosa due to mast cell degranulation
Describe the acute and late response of Allergic Rhinitis
Acute - Stimulation of afferent nerves (sneezing), Increase in nasal secretions 15-20 mins later
Late - 6 to 12h later nasal obstruction
Other than sneezing and nasal obstruction, name two features of Alllergic Rhinitis
Mouth Breathing
Halitosis
Allergic Rhinitis may require further investigation to determine allergen. What would these be?
Skin Prick Test (note - surpressed by antihistamines, steroids and TCAs) Blood IgE (useful if patient is on antihistamines
Name some general advice for pollen allergy
Avoid exposure to open grassy spaces
Keep windows shut
Regular servicing of car pollen filter
Name some general advice for house dust mite allergy
Special bedding
Soft toys off of bed
Wash bedding weekly
Laminate>carpet
Describe the possibly medical managements for allergic rhinitis
1) Topical Antihistamines for symptom relief and oral for prevention
2) Nasal Corticosteroids
3) Consider using Corticosteroid and Antihistamine combination (Dimysta) or adding LTRA
4) Short course of oral steroids
Increasing immunological tolerance? Nasal Douching with Saline? Avoiding allergens
Describe a possible surgical management for allergic rhinitis
Reduce inferior turbinates to improve airways
Vasomotor Rhinitis presents similarly to allergic but without the positive test. Describe the pathophysiology
Imbalance in sympathetic and parasympathetic, increasing vascularity and secretions
Causes - Humidity, temperature, pregnancy, alcohol
How can Vasomotor Rhinitis be managed?
Nasal Antihistamines +/- Corticosteroids
Laser treatment or partial turbinectomy
What is Rhinitis Medicamentosa and how is it managed?
Reactive vasodilation of nasal mucosa due to prolonged use of topical agents
Substitution of offending drug to one containing a steroid (if established - partial turbinate resection)
What is Hormonal Rhinitis?
May be linked to increased oestrohen or hypothyroidism
What is Gustatory Rhinitis?
After eating hot and spicy foods, vagus nerve causes nasal vasodilation
Watery rhinorrhoea typically 2h after ingestion
Can be managed with Ipratropium Bromide Spray
What are Nasal Polyps?
Sac like entities of eosinophil rich oedematous walls, arise from nasal mucosa, most commonly in the clefts of the middle meatus
Considered part of the spectrum of chronic rhinosinusitis
Name three associations of Nasal Polyps
Asparin Sensitvity
Asthma
CF
What is Asparin Sensitivity?
Within 20-120 minutes of ingestion - facial flushing, rhinorrhoea and congestion
How do Nasal Polyps present?
Nasal airway obstruction Nasal discharge Dull headaches Snoring Hypo-osmia
How can you distinguish nasal polyps from inferior turbinate?
Paler in colour (poor blood supply)
Ability to get between wall and the polyp
How are nasal polyps investigated?
Rhinoscopy
CT if failing medical therapy/severe disease
What Nasal Polyps should you refer to ENT?
Unilateral
Children (underlying CF)
How are Nasal Polyps managed?
Educated on recurrent nature
Mild - Steroid Spray
Mod - Topical Steroid
Severe - oral steroid
If Beclometasone - monitor childs growth
Antihistamines if allergy
What is the gold standard definitive management for Nasal Polyps
Endoscopic Sinus Surgery
Why is time an important factor in Nasal Injuries
After about four hours, swelling obscures diagnosis
What are important things to look for OE in a nasal injury?
Septal haematoma Epistaxis/CSF Rhinorrhoea Septal Deviation Opthalmoplegia Facial Anaesthesisa
How are nasal injuries managed?
Mild - ice and analgesia, review in 5d
Deviation - seen by ENT within 7-10 days
Fracture reduction - 5-10d for adults and 3-7 for children (allows swelling to settle)
How could Nasal Foreign Bodies present?
Directly after if observed
Nasal obstruction
Foul discharge
What are the management options for Nasal FB
Topical anaesthetic and vasoconstrictor in affected nostril ?Blow positive presure through nose ?Strong Suction ?Thin forceps ? Fogarty balloon
Button batteries should be removed immediately
Refer to ENT after two unsuccessful attempts
What is a Septal Perforation?
Defect through any part of the cartilagenous/bony septum with no overlying perichondrium/periosteum
How does Septal Perforation present?
Nasal whistle
Discharge
Congestion
Epistaxis
Give four causes of Septal Perforation
Nose picking
Trauma
Steroids
Cocaine
Describe some early signs of Septal Perforation
Bothersome bleeding and crusting
How is Septal Perforation managed?
Nasal Douching/Emollients
Adjust nasal cannulae if relevant
Surgery if affecting QoL
How does a common nasal infection present?
Hyperaemic nasal lining Nasal Obstruction Sneezing Rhinorrhoea Headache
What would you advise patients regarding management of common infective rhinitis?
Steam inhalation
Nasal Congestants
Simple Analgesia
May get post nasal drip if glands don’t return to normal
What is Nasal Vestibulitis?
Excoriation of skin of vestibule (from nose picking, rhinorrhoea, allergy)
How would you manage Nasal Vestibulitis?
Topical Abx
Steroid based ointments
If persistent with ulceration - BCC/SCC
What is Atrophic Rhinitis?
Severe crusting in the nasal cavities and atrophy of mucosa and turbinates (often secondary to poor hygiene and malnutrition
Associated with foul odour that patients can’t smell
How is Atrophic Rhinitis managed?
Douching nose 3-4 times a day
Prolonged Abx based on cultures
Narrow nasal cavities using bone/cartilage
What is Nasal Furunculosis?
S.Aureus causing hair follicle infection in nasal vestibule often initiated by nose picking)
How is Nasal Furunculosis managed?
Systemic and Topical Abx (based on swabs)
Don’t squeeze pus - danger triangle
How does a Septal Deflection present?
Unilateral obstruction typically
Facial Pain
Nasal discharge
Compensatory Hypertrophy of inferior turbinates on opposite side
If Septal Deflections are symptomatic, how are they treated?
Submucous resection
Septoplasty (repositions septum after removal)
Why are Septal Haematomas most common in children?
Mucoperichondrium is only loosely adherent to underlying cartilage
How does Nasal Haematoma present?
Severe nasal obstruction
If not adequately drained - avascular necrosis
How are Nasal Haematomas managed?
Drained (by aspiration or by formal incision and evacuation)
Nasal packing to prevent recurrence
Abx
What is Choanal Atresia?
Presence of bony septum between nose and pharynx
Commonly on the right side
How is Choanal Atresia investigated?
No fogging under nostril
CT
How is Choanal Atresia managed?
Surgery (Pt may require periodic dilations)
Bilateral - emergency oral airway
Name four causes of Epistaxis
Trauma
Inflammatory Conditions
Post Op
Vascular Malformations
95% of Epistaxis comes from the Anterior Plexus. What is the posterior plexus?
Woodruff’s Plexus
What is the initial management for Epistaxis?
- A to E assessment
- Lean forward and pinch nose for 10-20 minutes (ice pack on back of neck)
- Spit out any blood (it is an emetic)
How should refractory Epistaxis be managed?
IV Access (clotting, fbc, g+s)
- ?Anticoag reversal
- Cautery (with NO, Naseptin afterwards)
- Nasal Packing and Admission (local anaesthetic, vasoconstrictor, rapid rhino)
How are posterior Epistaxis managed?
Double balloon catheter
What post Epistaxis advice would you give the patient?
Naseptin cream (not if peanut allergic)
Avoid: Hot drinks, blowing nose, heavy lifting and lying flat for 24-48h
When should you refer an Epistaxis?
Under 2y - NAI
Recurrent - ?Leukaemia?Nasopharyngeal Ca?HHT
What is Sinusitis?
Inflammation of the membranous lining of the sinuses (may also implicate rhinitis)
Acute - 7-30d
Subacute - 4 to 12 weeks
Chronic - >90d
Recurring - >3 episodes in a year, each lasting atleast 10 days
What indicates Bacterial Sinusitis?
Worsening symptoms beyond 5d, or persisting beyond 10d
Give five risk factors for Sinusitis
URTI Allergy Polyps CF (Kartageners, Youngs) Smoking
What is Samter’s Triad?
Aspirin Sensitivity
Rhinitis
Asthma
How would you palpate for the sinuses?
Frontal - upwards beneath medial supraorbital ridge
Axillary - against anterior wall below infraorbital margin
Ethmoidal - medial orbit
How could you percuss the Sinuses for Sinusitis?
Technically difficult as the area is very small
Dullness indicates infection
How can you transilluminate for SInusitis?
Frontal - place under supraorbital ridge and look for reddish glow
Maxillary - patients mouth open but lips sealed around torch
Describe the pathophysiology of Acute Sinusitis
Normally viral causing blockage and then a secondary bacterial infection
Strep Pneumoniae, Haemophilus Influenza, Moraxella Catarrhalis
Normally involves maxillary sinus
How does Acute Sinusitis present?
Non resolving cold
Biphasic
Pain/Pressure over affected sinuses - worse on leaning forward
Unresponsive to nasal decongestants
Sinusitis is a clinical diagnosis. How should it be aimed to be managed?
Reassure it will take a little longer to settle
Simple analgesia and intranasal decongestants
Warm face packs
Irrigation with warm saline
When should you treat sinusitis with Abx?
<10d if severely at risk
>10d - Deferred 5d Pen V (or co amoxiclav if systemic) only after a trial of 2 weeks nasal steroid
Who should you refer with sinusitis?
Severe
High risk
Suspicious unilateral symptoms
Name two complications of sinusitis
Meningitis
Orbital Cellulitis
Chronic Sinusitis can be infective/inflammatory/structural in aetiology. How does it present differently
Not as florid as acute
Dull ache
May have middle ear fluid
Loss of smell is more common
Apart from acute exacerbations, how is Chronic Sinusitis managed?
Dental Hygiene
Smoking Cessations
8-12 weeks nasal steroids
Antihistamines if allergic aetiology
If refractory still consider function endoscopic sinus surgery
What is Fungal Sinusitis?
Associated with immunocompromised or diabetics
Associated with high humidity
Can involve orbit
How is Fungal Sinusitis investigated?
Serum IgE
CT
Microbiology
How is Fungal Sinusitis managed?
Surgical debridement
Steroids
Antifungal
What is Barosinusitis?
Pressure changes disrupt gas and mucous exchange leading to accumulation
Pain on returning to sea level, congestion and occasional epistaxis
Managed the same as acute sinusitis
