Nose

Question 1

Symptoms of septal perforation (min 4)

Answer 1

Nasal crusting
Whistling
Epistaxis
Nasal obstruction
Often asymptomatic

Question 2

Most common cause and other causes of septal perforation:

Answer 2

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

Question 3

Causes of saddle nose:

Answer 3

Systemic diseases:
* Sarcoidosis
* Leprosy
* Relapsing polychondritis
* GPA
* Ectodermal dysplasia

Neoplasia
* T-Cell lymphoma

Trauma
Iatrogenic
Drugs - cocaine

Question 4

Investigations for septal perforation (min 5):

Answer 4

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)

Question 5

Treatments for septal perforation (min 3):

Answer 5

Nasal hygiene - Saline douches (25% glucose in glycerin), nasal cream
Nasal septal prosthesis (e.g. silicone button obturator)
Surgical repair (local or free flap)

Question 6

Structures of the nasal septum (5)

Answer 6

1 - Perpendicular plate of the ethmoid
2 - Vomer
3 - Cartilage
4 - Maxillary crest
5 - Palatine crest

PVC MP

Question 7

Septal perforation questions to ask:

Answer 7

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

Question 8

Blood supply to nasal septum

Answer 8

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)

Question 9

Management of epistaxis

Answer 9

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

Question 10

Severe epistaxis, patient on warfarin for metallic valve.

Has stopped with packing.

How else do you treat this patient?

Answer 10

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

Question 11

Causes of epistaxis

Answer 11

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)

Question 12

Symptoms of nasal polyposis

Answer 12

Nasal obstruction
Anosmia/Hyposmia
Runny nose
Catarrh
Post nasal drip
Nasal speech

Question 13

Differential diagnosis for nasal polyps

Answer 13

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

Question 14

Epidemiology of nasal polyps and what to tell patients

Answer 14

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

Question 15

Medical treatments (min 2) for nasal polyps

Answer 15

Intranasal steroids
Systemic steroids
? PO antihistamines (help with symptoms, but don’t treat the polyps

Question 16

Surgical treatment for nasal polyps

Answer 16

Nasal polypectomy
+/- endoscopic sinus surgery (can help elongate time until recrrence)

Question 17

Complications (specific) to surgical removal of nasal polyps (min 3)

Answer 17

CSF leak
Bleeding
Risk to vision/orbital injury

5-10% patientswill experience minor complications from FESS
0.5% majort complications

Question 18

Nasal polyps + wheeze, what should be avoided and why?

Answer 18

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

Question 19

Pathophyisology of nasal polyps ?
Where do they arise from ?

Answer 19

Almost all arise from ethmoid sinus

Benign, filled with inflammatory fluid

Question 20

Common organisms involved in Acute Rhinosinusitis

Answer 20

Rhinovirus
Parainfluenza virus Pneumococcus

Question 21

What is the definition of chronic rhinosinusitis (EPOS 2020)

Or easier question, name 3 symptoms:

Answer 21

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)

Question 22

What is the definition of acute rhinosinusitis (EPOS 2020)

Or easier question, name 3 symptoms:

Answer 22

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)

Question 23

Horizontal line across nose - sign and condition?

Answer 23

Chronic rhinosinusitis, especially in children,

= transverse nasal line caused
by repeated upward wiping of the nose

Question 24

What are the endoscopic signs of rhinosinusitis?

Answer 24

• nasal polyps, and/or
• mucopurulent discharge primarily from middle meatus and/ or
• oedema / mucosal obstruction primarily in middle meatus and/or

Question 25

CT changes found due to rhinosinusitis

Answer 25

Mucosal changes within the ostiomeatal complex and/or sinuses

Question 26

What are the alarm / red flag signs associated with rhinosinusitis? (Min 5)

Answer 26

Sepsis / Meningitis Eye signs or visual changes Severe headaches Neurological symptoms Unilateral symptoms Cacosmia (unpleasant smell) Bleeding Crusting

Question 27

Risks of endoscopic sinus surgery (7)

Answer 27

Bleeding Infection Damage to vision CSF leak Meningitis Nasolacrimal duct injury Anosmia /hyposmia Detailed: **Local complications:** bleeding infection hyposmia anosmia adhesions facial pain periorbital ecchymosis or emphysema nasolacrimal duct injury recurrence **Ocular complications:** diplopia (due to injury to medial rectus muscle) blindness (injury to optic nerve and orbital heamatoma), **Intra-cranial complications:** cerebrospinal fluid leak, pneumocephalus, meningitis, brain abscess, headache, intracranial bleed, stroke carotid injury.

Question 28

Management of chronic rhinosinusitis

Answer 28

Saline rinses OTC intra nasal steroids 6-12 weeks If no improvement primary care can offer advice about echnique / compliance with the above and consider and oral sterid If no improvement, secondary care referral for additional workup - Nasendoscopy (? polyps ? mucopurulent discharge? - Skin prick test - Bloods IgE and WCC differential ? Eosinophilia) - CT Sinuses (? blocked osteomeatal complexes (OMC) +/- polyps)

Question 29

Management of fractured nasal bones Acute and if arrives 3 months after injury?

Answer 29

Enasure no other injuries / head injury No ongoing epistaxis No septal haematoma Review in clinic 7 days once swelling subsided for possible MUA If 3/12 after, likely bones have healed and will therefore require a septorhinoplasty under GA

Question 30

Non-allergic causes of turbinate hypertrophy (4)

Answer 30

NAARC (‘d at having large turbinates) Neoplasia Congential Rhinitis medicometosa Acute infection (Allergic rhinits probably most common though)

Question 31

Surgical management of turbinate hypertrophy (3)

Answer 31

Out fracture of turbinates Submucous diathermy Turbinate trimming.

Question 32

Button battery in nose - two consequences

Answer 32

Septal perforation Chemical burns to nasal mucosa

Question 33

What is the classification for orbital infections (and the breakdown)?

Answer 33

**The Chandler Classification** **1 - Peri-orbital / Pre-septal cellulitis** * Eyelid swelling swelling without proptosis, opthalmoplegia or loss ofvision **2 - Orbital (post septal)cellulits** * Inflammation of orbital fat, connective tissue and skin **3 - Subperiosteal abscess ** * Pus collection between the eth- moid sinus and periosteal layer of the medial orbital wall **4 - Orbital abscess** * Pus within the orbit **5 - Cavernous venous sinus thrombosis**

Question 34

What's the difference clinically and anaotymically between pre and post septal cellulitis of the eye?

Answer 34

Pre occurs anterior to the tarsal plate of the eyelid, post is posterior to it

Question 35

Epidemiology and pathophysiology of pre & post septal orbital cellulitis

Answer 35

**Periorbital cellulitis** A disease of young children with an average of about 3.5 years. Usually a complication of acute rhinosinusitis Infection spreads generally from ethmoid sinuses into the orbit via lamina papyracea Can also be from trauma or haematogenous spread from e.g. chest infection

Question 36

Bacteria involved in pre-septal & post septal cellulitis

Answer 36

Make the answer non specific general consensus is **Streptococcus species,** **Staphylococcus aureus**, and **Haemophilus influenzae type B** (but less HI now due to immunisation) Staphylococcus and Streptococcus species (pyogenes and pneumonia). Streptococcus pneumoniae is a common etiology in preseptal cellulitis secondary to sinusitis. Staphylococcus aureus and epidermidis are commonly found after a penetrating eyelid trauma

Question 37

What are the signs and symptoms of pre vs post septal orbital cellulitis?

Answer 37

**Preseptal cellulitis** Eyelid edema erythema normal visual acuity absence of proptosis pupil with normal reaction to light, normal color saturation normal conjunctiva normal ocular movements. **Orbital cellulitis: ** eyelid edema erythema diminished visual acuit proptosis is present relative afferent pupillary defect may be present reduced color saturation chemotic conjunctiva reduced extraocular movements with pain elicited by these movements.

Question 38

Investigations and management of pre vs post septal cellulitis

Answer 38

Full eye exam (Pupillary reactions, Acuity, Colour vision, Fields, Fundoscopy, Movements, ? proptosis) MARK the erythema Bloods e.g. FBC, Cultures, CRP, U&E Swabs if able Opthamology input CT of the orbits, sinuses, brain (complications) WITH CONTRAST if indicated **Pre septal** PO vs IV abx depending on presentation Likely IV Co-amox / Ceftriaxone **Post Septal** IV abx Intranasal decongestants (e.g. xylometolazone) Intranasal steroids Intranasal saline rinses +/- surgery is abscess Drainage either by an open approach via a modified Lynch Howarth incision or endoscopic drainage by removing the partially dehiscent lamina papyracea

Question 39

Symptoms / Signs of cavernous venous sinus thrombosis

Answer 39

Headache Opthalmoplegia Trigeminal nerve hypoaesthesia Contralateral spread Palsies of CN 3,4,5,6 Sepsis!

Question 40

Complications of surgery for orbital cellulits

Answer 40

Orbital injury / loss of sight / decreased acuity Diplopia Enopthalmos Swelling Haemorrhage Residual infection Intracranial sepsis / abscess Scarring

Question 41

Indications for CT in orbital cellulitis?

Answer 41

Contrast enhanced CT orbit, sinuses and brain if: * Suspicion of underlying abscess * Suspicion cavernous sinus thrombosis * Evidence of meningism / intracranial abscess / CNS involvement * Unable to examine eye/open eyelids * Clinical progression despite 24 hours treatment or no improvement after 48 hours / continued pyrexia * Clinical signs of postseptal (orbital) cellulitis

Question 42

Orbital cellulitis signs / symptoms of serious pathology

Answer 42

Opthalmoplegia Loss of visual acuity (incl red desat) Proptosis Meningism / Focal neurology RAPD Systemically unwell (Sepsis - fever / tachycardia / tachypnoea)

Question 43

Recurrent epistaxis, red spots on tongue - possible diagnosis? And other manifestatioins of it?

Answer 43

Hereditary Heamorhagic Telengectasia (red spots on lips + mucous membranes, telengectasia face, AVM, lesions in the gut)

Question 44

Nasal trauma - what to assess for?

Answer 44

**Rule out significant head injury ** e.g. intracerebral or airway trauma, skull base #, penetrating neck etc ** Maxillofacial #'s?** - Inspect and palpate facial bones - Ocular injury - inspect eyes, movements, ? diplopia - Lower cranial nerves - e.g. facial sensation CNV disruption - Dental occlusion **Nose:** - ?Septal haematoma - ? Septal fracture or dislocation - CSF rhinorrhoea - Document any deformity and whether it is new OR PRE-EXISITING

Question 45

Paediatric nasal # which requires, operative, intervention - when do it?

Answer 45

Adolescence, when nasal skeleton fully developed

Question 46

Commonest type of nasal cancer?

Answer 46

SCC - Nasopharyngeal carcinoma

Question 47

Neck lump, unilateral hearing loss, recurrent epistaxis - possible Dx?

Answer 47

Nasopharyngeal carcinoma

Question 48

Unilateral conductive deafness Trigeminal neuralgia Soft palate immobility Difficulty opening mouth Dx? What's this called?

Answer 48

Trotter's syndrome: Nasopharyngeal carcinoma invading lateral nasopharynx / lesion arising in the region of sinus of Morgagni. CHL due to eustachian tube block, Trigeminal nerve neuralgia affecting the mandibular division initially and anaesthesia later, secondary to its invasion in foramen ovale, Palatal asymmetry owing to ipsilateral direct infiltration of levator palatini muscles. Trismus occurs late due to further invasion of pterygoid muscles.

Question 49

What is trotter's syndrome?

Answer 49

Unilateral CHL (+middle ear effusion) Palatial asymmetry Trigeminal neuralgia Trismus Trotter’s = Triple T: Trotters, Trigeminal, Trismus Nasopharyngeal carcinoma / CA affecting the sinus of Morgagni

Question 50

RF's / Causes of nasopharyngeal CA

Answer 50

* Epstein Barr Virus (EBV) * Genetic predisposition * Carcinogenic foods (nitrosamines) in particular salted fish * People of south east Asian descent (esp. Southern Chinese) * Smoking

Question 51

Treatment of nasopharyngeal SCC

Answer 51

Radiotherapy in most cases

Question 52

nasopharyngeal angiofibromas - what are they - who do they present in

Answer 52

Juvenile nasopharyngeal angiofibromas are a rare benign, but locally aggressive, vascular tumours that occur almost exclusively in young men.

Question 53

SPA ligation specific risk to warn patient about

Answer 53

Blindness <1:100

Question 54

Treatment of ondontogenic sinusitis

Answer 54

Medical > Antibitotics covering anaerobes (e.g. Taz / Co-Amox / Fluoroquinolones if Pen Allergy) because generally polymicrobial and anaerobic > Saline nasal rinses > Steroid nasal drops Dental extraction / root canal etc if source is dental FESS if above fails

Question 55

Types of nasal polyp?

Answer 55

Ethmoidal polyps (the common type) Antrochoanal polyps (originate from the maxillary sinus)

Question 56

Differences in presentation of nasal polyp (simple) vs antrochoanal polyp

Answer 56

Antrochoanal polyp: * Children and young adults vs adults (not children) in nasal polyps (unless CF...) * Generally unilateral = unilateral nasal obstruction * Worse on expiration due to ball valve effect of polyp on PNS * Can cause blockage of eustachian tube = middle ear effusions, CHL etc

Question 57

Investigation of antrochoanal polyp

Answer 57

Nasal endoscopy CT scan of the sinuses Could also do a plain radiograph of the sinus

Question 58

Management of antrochoanal polyp

Answer 58

Endoscopic removal If recurrent - Caldwell-Luc procedure to clear out the maxillary sinus