Nose Flashcards
Symptoms of septal perforation (min 4)
Nasal crusting
Whistling
Epistaxis
Nasal obstruction
Often asymptomatic
Most common cause and other causes of septal perforation:
Trauma (nasal picking) = most common
Iatrogenic (nasal cautery / septal surgery)
Neoplastic - SCC, Lymphoma etc
Autoimmune - Sarcoidosis, Granulomatosis with Polyangitiis
Irritant - Cocaine
Infective - Syphilis, TB, Leprosy rhinoscleroma (klebsiella), septal abscess
Causes of saddle nose:
Systemic diseases:
* Sarcoidosis
* Leprosy
* Relapsing polychondritis
* GPA
* Ectodermal dysplasia
Neoplasia
* T-Cell lymphoma
Trauma
Iatrogenic
Drugs - cocaine
Investigations for septal perforation (min 5):
Routine bloods FBC / U&E / ESR
c-ANCA (p-ANCA, MPO, PR3)
ACE levels
Rheumatoid factor (Sarcoid, RA etc.)
Biopsy (to rule out malignancy, inflammatory)
Radiographic: CXR - Sarcoid / TB -
Mantoux test, Blood test - interferon gamma release assay
Syphilis - venereal disease research laboratory (VDRL) and rapid plasma reagin (RPR)
Urine dipstick - haematuria (renal disease)
Treatments for septal perforation (min 3):
Nasal hygiene - Saline douches (25% glucose in glycerin), nasal cream
Nasal septal prosthesis (e.g. silicone button obturator)
Surgical repair (local or free flap)
Structures of the nasal septum (5)
1 - Perpendicular plate of the ethmoid
2 - Vomer
3 - Cartilage
4 - Maxillary crest
5 - Palatine crest
PVC MP
Septal perforation questions to ask:
Open - what symptoms
Closed
- sinusitis / discharge/ infections / pain / nasal obstruction
- Recent trauma (picking / forceful blowing)
- Ear infections / sinusitis / chest infections (? GPA)
- Eye problems (episcleritis + septal perf = ? autoimmune)
- Previous operations on nose
- Weight loss / fevers / lethargy / B symptoms (GPA / Neoplasia)
PMH - autoimmune?
DH - Cocaine / intranasal drugs
SH - exposure to chrome / arsenic / smoker
Allergies
Blood supply to nasal septum
Internal carotid artery
- Anterior ethmoidal (from opthalmic)
- Posterior ethmoidal (if question asks for 4, omit this one!)
External carotid artery
- Sphenopalatine (from maxillary)
- Greater palatine (from maxillary)
- Superior labial (from facial)
Management of epistaxis
A-E approach
IV access:
FBC / Coag or INR / G&S + CROSSMATCH / LFTS / U&E
Fluids / Blood
Full history and examination e.g. risk factors
ENT UK guidelines / Algorythm:
1) First aid (Ice pack / ice cibes in mouth, head forwartds, anterior nasal pressure)
2) Anterior rhinoscopy
- Clean with co-phenylcaine (lidocaine + phenylephrine spray) soaked cotton wool
- SIlver nitrate / electrocautery if visible vessel
3) Medical adjuncts
- Analgesia +/- stat antihypertensive
- If anticoag consider reversal
- If difficult to control consider TXA
4) Anterior packing
- If low flow, insert soft dissolvable pack (e.g. nasopore) or consider Floseal
- If high flow, insert tigid non-dissolvable pack (remove at 24-48hr) - Rapid Rhino
5) Posterior packing if still bleeding
- Foley catheter / BIPP
6) Surgical
- ?SPA ligation
- Traumatic ? Anterior ethmoidal atyery ligation
- Uncontrollable ECA ligation (rare)
7) Adjuncts - Intervemntional radiology for coiling / embolisation
Severe epistaxis, patient on warfarin for metallic valve.
Has stopped with packing.
How else do you treat this patient?
Bloods:
INR, FBC, LFTS, U&E
G&S + Crossmatch
Obs: HR / BP / RR etc
Analgesia
IV Fluids
STOP WARFARIN
Switch to LMWH or Heparin infusion given his INR for his metallic valve (discuss with haematology)
Consider antibiotic cover
If re-bleeds: consider reversong warfarin with Vitamin K
Monitor for further bleeding and regular obs showing signs of shock e.g. BP/HR/RR
Causes of epistaxis
Local
- Trauma (picking / #)
- Malignancy
- Inflammatory: rhinosinusitis
- Endocrine: Pregnancy
- Iatrogenic: Surgery
Systemic
- Hypertension
- Anticoagulation
- Coagulation disorder (haemophilia)
- Hereditary Heamorhagic Telengectasia (red spots on lips + mucous membranes, telengectasia face, AVM, lesions in the gut)
Symptoms of nasal polyposis
Nasal obstruction
Anosmia/Hyposmia
Runny nose
Catarrh
Post nasal drip
Nasal speech
Differential diagnosis for nasal polyps
Brain or Tumour …
Pyogenic granuloma
Meningocele
Encephalocele
Mucocele
Nasal glioma
Antrochoanal polyp
Benign nasal polpy
Malignant:
Inverted papilloma
Adenocarcinoma
Squamous cell carcinoma
Metastasis
Sarcoma
Glioma
Harmatoma
Lots of others
Epidemiology of nasal polyps and what to tell patients
4:1 M:F
1-20:1000 incidence
Associated with late onset asthma
Rare in children (therefore investigate for cystic fibrosis if found)
Rarely unilateral - therefore investigate for CA
75% will recur
Average time to recurrence is 4 years
Medical treatments (min 2) for nasal polyps
Intranasal steroids
Systemic steroids
? PO antihistamines (help with symptoms, but don’t treat the polyps
Surgical treatment for nasal polyps
Nasal polypectomy
+/- endoscopic sinus surgery (can help elongate time until recrrence)
Complications (specific) to surgical removal of nasal polyps (min 3)
CSF leak
Bleeding
Risk to vision/orbital injury
5-10% patientswill experience minor complications from FESS
0.5% majort complications
Nasal polyps + wheeze, what should be avoided and why?
Aspirin & NSAIDS
(Aspirin-exacerbated respiratory disease)
= Samters triad of
- Chronic rhinosinusitis
- Asthma
- Nasal polyps
+ intolerance of aspirin/NSAIDs
Seen in 8% of polyp patients, and theyre more at risk of recurrence
Onset after apirin/NSAIDs - bronchoconstriction occurring in close to 90% of patients and nasal congestion and rhinorrhea occurring in more than 40%
Affects an estimated 0.3–0.9% of the general population,
- around 7% of all asthmatics
- 14% of adults with severe asthma
- 5-10% of patients with adult onset asthma
Pathophyisology of nasal polyps ?
Where do they arise from ?
Almost all arise from ethmoid sinus
Benign, filled with inflammatory fluid
Common organisms involved in Acute Rhinosinusitis
Rhinovirus
Parainfluenza virus Pneumococcus
What is the definition of chronic rhinosinusitis (EPOS 2020)
Or easier question, name 3 symptoms:
Presence of two or more symptoms, one of which should be either:
**nasal blockage **/ obstruction / congestion
nasal discharge (anterior / posterior nasal drip):
- ± facial pain/pressure;
- ± reduction or loss of smell;
for ≥12 weeks;
(Acute Rhinosinusitis is the same but < 12 weeks)
What is the definition of acute rhinosinusitis (EPOS 2020)
Or easier question, name 3 symptoms:
Presence of two or more symptoms, one of which should be either:
**nasal blockage **/ obstruction / congestion
nasal discharge (anterior / posterior nasal drip):
- ± facial pain/pressure;
- ± reduction or loss of smell;
for < 12 weeks;
(Chronic Rhinosinusitis is the same but => 12 weeks)
Horizontal line across nose - sign and condition?
Chronic rhinosinusitis, especially in children,
= transverse nasal line caused
by repeated upward wiping of the nose
