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Nose Flashcards

1
Q

Where does anterior epistaxis usually arise?

A

Septal - Little’s Area (Kiesselbach’s plexus)

  • Area where anterior ethmoidal, sphenopalatine and facial arteries anastamose for form anterior anastamotic arcade.
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2
Q

Why are posterior bleeds more serious?

A

More invasive procedures may be required

  • Examination under anaesthesia – if discrete bleeding point is found it can be treated with diathermy.
  • Arterial ligation – endoscopic ligation of sphenopalatine artery
  • Embolization – of internal maxillary or facial artery (can be life-saving but can cause stroke)
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3
Q

Causes of epistaxis?

A
  • Local trauma (nosepicking)
  • Facial trauma
  • Dry/cold weather
  • Dyscrasia/haemophilia
  • Septal perforation
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4
Q

Things to ask in epistaxis history? Bloods?

A

Which side? Trauma? How much loss? Warfarin/aspirin? PMH?

FBC, G+S/X-match, coagulation

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5
Q

Management steps in epistaxis?

A
  1. Resuscitation (if low BP or dizzy on standing)
  2. General
    • Pinch lower part of nose for 20 mins. Breathe throuh mouth, spit blood into bowl.
    • Ice pack on dorsum of nose.
  3. Cauterisation
  4. Nasal packing
  5. After bleed care
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6
Q

Cauterisation in epistaxis?

A

With Silver Nitrate

  • Look inside and remove clots
  • Apply cotton ball soaked in 1:200,000 adrenaline for 2 mins or use LA spray
  • Find bleeding points (with Thudicum nasal speculum) –> apply cautery for 2 sec at a time, starting from edge of bleeding point moving in a circle
    • Avoid using if actively bleeding as this will wash the chemical away and cause unwanted burns to lips or throat.
    • Never cauterise both sides of septum à risk of perforation.

If bleeding point can’t be seen –> refer to ENT.

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7
Q

Anterior nasal packing?

A

Rapid Rhino; Merocel

  • Lubricate/soak pack as instructed; advance into nose horizontally and parallel to hard palate (not up)
  • Inflate if required, and tape securely to face.
  • Remove after 24h if bleeding stops. If not, try postnasal pack.
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8
Q

Postnasal packing?

A

Foley urinary catheter (16-18G) is effective

  • Pass via nostril into nasopharynx. Inflate balloon with >10mL water and pull anteriorly through mouth to occlude the posterior choana (junction between nasal cavity and nasopharynx)
  • Clamp (with padding over the skin) at the nasal vestibule, to prevent it falling backwards into the airway.
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9
Q

Advice for after epistaxis?

A
  • Don’t pick or blow
  • If you sneeze, send it through open mouth
  • Avoid bending, lifting or straining
  • No hot food or drink
  • If it restarts, apply ice to bridge of nose and hold soft lower part continuously for 20 mins; get help if this fails
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10
Q

How does a nasal fracture present?

How does septal haematoma present?

A

New nasal deformity, often with associated facial swelling and black eyes. X-rays not required by may help exclude other facial fracture.

Septal Haematoma

  • Boggy swelling on septum causing near-total nasal obstruction –> requires urgent incision and drainage.
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11
Q

How to treat nasal fracture?

A
  • Advise on analgesia/using ice
  • Reassess 5-7 post-injury (once swelling has resolved)
  • If manipulation (MUA) is required à perform 10-14 days post-injury (before nasal bones set)
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12
Q

What causes CSF rhinorrhoea?

Management?

A

Ethmoid fractures disrupting dura and arachnoid –> CSF leak

Management

  • Conservative management –> spontaneous resolution. 7-10 days bedrest (head elevated) +/- lumbar drain.
  • Cover with antibiotics and pneumococcal vaccine.
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13
Q

Management of nasal foreign bodies in children?

A
  • Ask child to blow nose (if able) – or ask parent to try ‘parental kiss’ by blowing into mouth whilst occluding other nostril (success rate >70%)
  • If child co-operative it may be possible to grasp object with crocodile forceps (avoid pushing deeper into nose)
  • Batteries need urgent removal –> refer to ENT if failed attempt or uncooperative patient.
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14
Q

Definition of rhinosinusitis?

A

Defined as inflammation in the nose and paransal sinuses with ≥2 symptoms:

  • MUST HAVE Nasal blockage/obstruction/congestion OR nasal discharge
  • Facial pain or pressure
  • Reduction or loss of smell
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15
Q

Classification of rhinosinusitis?

A

Symptoms classified as mild, moderate or severe.

Acute, Chronic (>12 weeks) or Allergic

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16
Q

Presentation of acute rhinosinusitis?

A

Common cold.

Acute post-viral sinusitis = ↑symptoms after 5 days or persistent symptoms >10 days

17
Q

Presentation of chronic rhinosinusitis?

A

Same as acute but persistent and +/- nasal polyps

18
Q

Presentation of allergic rhinosinusitis?

A

(IgE-mediated inflammation from allergen exposure to nasal muscosa –> mast cell degranulation)

House dust mites (perennial); pollens or animal dander (seasonal)

  • Sneezing; pruritis; nasal discharge (bilateral); bilateral itchy red eyes
19
Q

Management of acute rhinosinusitis?

A
  • Self-limiting (80% resolve within 14 days). Avoid abx.
  • If >5 days, consider intranasal corticosteroids (non-systemically bioavailable – mometasone; fluticasone).
20
Q

Management of chronic rhinosinusitis?

A
  • Intranasal corticosteroids + nasal saline irrigation
  • If no improvement after 4 weeks consider micro cultures and long-term (>12 weeks) abx.
  • CT if poor response to treatment consider surgery.
21
Q

Management of allergic rhinosinusitis (hay fever)?

A

General

  • Allergen/irritant avoidance
  • Nasal/saline irrigation (Patient sniffs a saline solution into the nostril)

Medical

  • Antihistamines (non-sedating = loratadine)
  • Intransal corticosteroid spray if no response
  • Short course of prednisolone can help rapid resolution of severe symptoms (e.g. during exams)

Later

  • Immunotherapy –> can induce long-term tolerance to allergens.
22
Q

Definition of sinusitis (acute bacterial?

A

At least 3 symptoms/signs of:

  • Discoloured discharge (with unilateral predominance) and purulent secretion in the nasal cavity
  • Severe local pain (with unilateral predominance)
  • Fever (>38)
  • Elevated ESR/CRP
  • “Double sickening” (i.e. a deterioration after an initial milder phase of illness)
23
Q

Aetiology/causes of acute sinusitis?

A

Mostly follow viral infection. Other causes…

  • Direct spread (dental root infection or diving/swimming in infected water)
  • Odd anatomy (septal deviation, large ethmoidal bulla, polyps, large uncinated process)
  • ITU (mechanical ventilation, recumbency, NG tubes)
  • Systemic (Kartagener’s syndrome, immunodeficiency, general debility)

Bacterial = Strep, H.influenzae, Staph, Moraxella

24
Q

Complications of sinusitis?

A
  1. Orbital cellulitis/Abscess
  2. Intracranial involvement - meningitis, encephalitis, cerebral abscess, cavernous sinus thrombosis
  3. Mucoceles - frontal sinus filled with mucous –> pus
  4. Osteomyelitis - staph - frontal bone
  5. Pott’s puffy tumour - Subperiosteal abscess arising from frontal osteomyelitis
25
Q

Investigations in recurrent sinusitis?

A

CT paranasal sinuses/Endoscopy – if recurrent (can identify anatomical problems and plan for surgery)

ESS = endoscopic sinus surgery (if recurrent problems)

26
Q

Management of sinusitis?

A

98% cases viral, self-limiting in 2 weeks.

  • Simple analgesia
  • Nasal saline irrigation
  • Intra-nasal decongestants (ephedrine 0.5%)
  • NOT antihistamines – thicken secretions and complicate drainage

If bacterial suspected –> amoxicillin or doxycycline

27
Q

What are nasal polyps and what are they associated with?

A
  • Swellings of the nasal or sinus mucosa prolapsing into the nasal cavity. Part of rhinosinusitis spectrum.
  • Prevalence = 2%
  • Associations
    • Allergic rhinitis, non-allergic rhinitis, chronic ethmoid sinusitis, CF, aspirin hypersensitivity, asthma
28
Q

Presentation of nasal polyps?

A
  • Typically males >40. Sites = usually bilateral.
  • Symptoms
    • Watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth-breathing, snoring, headaches
29
Q

Management of nasal polyps?

How do you put drops in?

A

Investigations

  • Anterior rhinoscopy or nasal endoscopy

Management

  • Topical steroids
  • Long-term abx
  • Surgery (ESS)

- FINALS (24 decks)

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