Nose Flashcards
Define epistaxis
Bleeding from the nose
- most causes insignificant but small proportion can result in massive haemorrhage and shock
Causes of epistaxis
Local - idiopathic - traumatic - nose-picking - iatrogenic - foreign body - inflammatory - rhinitis, polyps - neoplastic Systemic - hypertension - coagulopathies - vasculopathies - hereditary haemorrhagic telangiectasia
Mx of epistaxis
A-E assessment - bleeding into oropharynx can compromise breathing - massive bleed can cause hypotension First aid - pinch soft part of nose - lean head forward - spit out blood of mouth Cautery - silver nitrate or bipolar diathermy - topical adrenaline to control bleeding before cautery - anterior = anterior rhinoscopy - posterior = rigid endoscopy Nasal packing if cautery fails Surgical ligation or radiological embolisation of vessels
Define nasal trauma
Fracture of nasal bones complicated by
- septal haematoma
- CSF leak with associated basal skull fracture
Mx of nasal trauma
A-E assessment
Examine for septal haematoma
No x-ray required
If nose deviated consider manipulation under anaesthetic within 2 weeks
- nerve block of external nasal branch of anterior ethmoid nerve, infraorbital nerve and nasopalatine nerves
Define acute rhinosinusitis
Inflammation of mucosal lining of the nose and paranasal sinuses
- lasting less than 4 weeks
Types of rhinosinusitis
Viral - most common
- symptoms last less than 10 days
Bacterial
- often secondary to viral sinusitis
- commonly strep pneumoniae, haemophilus influenzea, morexella catarhalis
- symptoms longer than 10 days but less than 4 weeks
Epidemiology of rhinosinusitis
Affects 16% of adult population each year
Pathophysiology of rhinosinusitis
Colonisation of nasal mucosa by viruses causes increased oedema and mucus production
Sinuses become obstructed, blocking normal ventilation and drainage
Decreased clearance, stasis of secretion occurs
Secondary bacterial infection
Presentation of rhinosinusitis
Purulent nasal discharge
Nasal obstruction - swollen septal or turbinate mucosa on examination
Facial pain/pressure - worse on leaning forward
Cough, myalgia and hyposmia
Ix for rhinosinusitis
Clinical diagnosis
Nasal endoscopy - signs of polyps, mucopurulent discharge, oedema in middle meatus
Sinus culture
CT sinuses (non-contrast) - mucosal changes within osteomeatal complex or sinuses
Mx of rhinosinusitis
Supportive therapy - oral fluids, simple analgesia
Oxymetazoline nasal or pseudoephedrine - decongestant
Mometasone nasal - steroids if congestion persists longer than 5 days
Amoxicillin if bacterial
Define chronic sinusitis
Inflammation of paranasal sinuses lasting > 12 weeks
Types of chronic sinusitis
Without polyps
With polyps
- abnormal mass arising in nose due to chronic inflammation
- normally bilateral
- unilateral polyps require biopsy for histological diagnosis
Epidemiology of chronic sinusitis
25 cases per 100,000 per year in UK
Risk factors for chronic sinusitis
Allergy/atopy Ciliary dysfunction - cystic fibrosis - primary ciliary dyskinesia Airway hyperactivity/asthma Previous sinus surgery Immunodeficiency Anatomical abnormalities - mid-septal deviations - concha bullosa deformity - paradoxically bent middle turbinates - craniofacial abnormalities Foreign bodies Smoking or other environmental irritants
Pathophysiology of chronic sinusitis
Osteomeatal complex obstruction due to local inflammation within the channels
Sinus outflow tract obstruction
Impaired mucus clearance by respiratory cilia
Bacterial growth - staph aureus, haemophilus influenzae, group A strep
Presentation of chronic sinusitis
Nasal obstruction - swollen septal/turbinate mucosa
Facial pain/pressure - worse on leaning forwards
Nasal discharge/post nasal drip
Headache, fatigue, cough
Ix for chronic sinusitis
Anterior rhinoscopy
- intranasal purulence, posterior oropharyngeal purulence, polyps, structural abnormalities
Nasal endoscopy
CT sinuses - if surgery planned
Mx of chronic sinusitis
Supportive therapy
- avoid allergens
- simple analgesia
- nasal saline irrigation
Oral abx - amoxicillin
Intranasal corticosteroids - mometasone nasal
Antihistamines if allergic rhinitis present
Consider endoscopic sinus surgery if no improvement
Define allergic rhinitis
IgE mediated type 1 hypersensitivity reaction in mucus membranes of nasal airways
Pathophysiology of allergic rhinitis
Allergic reaction leads to synthesis and release of prostaglandins, leukotrienes and histamine
Capillary permeability increases
Leads to oedema, rhinorrhoea, congestion, sneezing and irritation
Epidemiology of allergic rhinitis
30% of Western population Strong association with asthma Can be seasonal or perennial Commonest allergens - pollen - mould - dust mites - animal epithelia
Classification of allergic rhinitis
Duration
- intermittent = symptoms < 4 days a week lasting < 4 weeks
- persistent = symptoms > 4 days a week lasting > 4 weeks
Severity of symptoms
- mild = normal daily activities and sleep not interupted
- moderate to severe = impairment of daily activities and sleep, troublesome symptoms
Ix for allergic rhinitis
Skin prick test for specific allergens
RAST (radioallergosorbent test) - blood test using radioimmunoassay to detect specific IgE antibodies
Mx of allergic rhinitis
Allergen avoidance
Antihistamines
Topical nasal steroids
Immunotherapy
Define orbital cellulitis
Site-threatening emergency
Infection/inflammation within orbital cavity
Often results from direct spread of pus from ethmoid sinus or from thromboephlebitis of mucosal vessels
Presentation of orbital cellulitis
Pain followed by oedema of eyelid and orbital collection
Eye becomes proptosed and eye movements reduced
Risk of blindness as result of tension and septic necrosis of optic nerve
Colour blindness early sign
Ix for orbital cellulitis
CT scan - confirm collection and extent of disease
Mx of orbital cellulitis
IV abx
Nasal decongestants
Urgent surgical drainage of any abscess
Causes of non-allergic rhinitis
Infection Environmental triggers - smoke - perfume - paint fumes - changes in weather - alcohol - spicy foods - stress Medicines and recreational drugs - ACEi - beta-blockers - NSAIDs - snorting cocaine Overuse of nasal decongestants Hormone imbalance Nasal tissue damage
