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N&SS - ENT > Nose > Flashcards

Nose Flashcards

1
Q

What are the important questions in a “nose” history?

A

Ask about OPAD:

Obstruction
Pain
Anosmia
Discharge

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2
Q

What do we need to ask someone who has recurrent nosebleeds?

A

S - which nostril? Both?
Q - how long do they last? Heavy or not?
I - associated pain?
T - When do thy occur, how long do they last, how frequently do they occur?
A - trauma/sport/blowing nose/other identifiable cause.
R - do they stop spontaneously, or have they needed hospital admission?
S - clotting disorders, blood thinners, other nasal or systemic symptoms?

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3
Q

A patient presents to the GP with chronic runny nose, sneezing, and a tickling throat. They report dull headaches, and feel there nose is more blocked than it used to be.

What is your top differential?

A

If bilateral, nasal polyps secondary to chronic sinusitis

If unilateral, think foreign body or malignancy.

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4
Q

What are nasal polyps?

A

Lesions arising from the nasal mucosa of the nasal cavity or paranasal sinuses.

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5
Q

Where are nasal polyps most commonly found?

A

In the nose. Lol.

But seriously, in the clefts of the middle meatus.

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6
Q

What do nasal polyps in children make us want to test for?

A

Cystic fibrosis

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7
Q

How common are nasal polyps?

A

Very - 4% of the population has them, with a M:F of 2:1

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8
Q

Which conditions are nasal polyps linked to?

A 
Sinusitis
Rhinitis
Vasculitis
Asthma
CF
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9
Q

Is the blood supply to a nasal polyp good or bad? What colour does this make them?

A

Bad - they are therefore pale.

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10
Q

How do patients with nasal polyps present?

A
  • Nasal airway obstruction
  • Nasal discharge
  • Dull headaches
  • Snoring
  • Hyposmia/anosmia/reduced taste
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11
Q

How can we examine the nose?

A

With a nasal speculum + light

Nasendoscopy in ENT clinic

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12
Q

How can we confirm good airflow through the nostril on examination?

A

Misting of the nasal speculum confirms it.

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13
Q

How can you tell a turbinate from a polyp?

A

The turbinates are more sensitive and pink.

Polyps are less sensitive and yellowish-green.

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14
Q

What are the general principles to managing nasal polyps?

A

Treat the underlying cause plus:

  • Medical - topical corticosteroids
  • Surgical - endoscopic polyp removal if failure to improve after medical Rx.
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15
Q

When should a patient with nasal polyps be referred to ENT?

A
  • Unilateral polyp ?malignancy

- Children ?CF

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16
Q

What kind of topical corticosteroids are best for nasal polyps?

A

Steroid drops (rather than spray)

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17
Q

What Rx might someone with nasal polyps need to treat th eunderlying causes of the polyps?

A
  • Antihistamine (allergic rhinitis)
  • Nasal douche (good for pretty much everything)
  • Systemic corticosteroids
  • Leukotriene receptor antagonists
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18
Q

What complications are associated with nasal polyps?

A
  • Acute bacterial sinusitis
  • Infection spread intracranially
  • Sleep disruption
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19
Q

What is the prognosis associated with nasal polyps?

A

They commonly recur, and there is no single curative treatment. But they won’t kill you…

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20
Q

Nasal polyps can occur as part of a sensitivity to which drug?

A

Aspirin

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21
Q

What is anosmia?

A

Loss of sense of smell

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22
Q

What can cause anosmia acutely?

A
  • Stroke/TIA

- Head injury

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23
Q

Which chronic conditions are associated with anosmia?

A 
Epilepsy
Alzheimer's
Parkinson's
Schizophrenia
Cushing's syndrome
Age, lol.
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24
Q

What inflammatory conditions can cause anosmia?

A

Viral infections (cold/flu)
Sinusitis
Hay fever/allergies

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25
Q

What are the iatrogenic causes of anosmia?

A

Medications inc. some abx, neurological drugs, statins, thyroid medications, and antidepressants.

Radiation therapy for H+N cancer

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26
Q

What are the lifestyle choices that can cause anosmia?

A

Occupational exposure to certain chemicals
Cocaine snorted through nose
Cigarette smoking

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27
Q

Pretend to consent a patient for a nasoendoscopy.

A

Procedure involves putting a thin flexible telescope in through the nostrils to visualise the nose, throat, and voice box.

It has a small camera in it so we can see what’s going on as we do it.

May then take a biopsy, as appropriate.

Can use local anaethetic if needed.

Benefits - see whats going on, nearly all have no complications.
Risks - uncomfortable, may be a little sore afterwards. May cause a very small bleed which will stop very quickly.

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28
Q

What are the nose indications for doing a nasoendoscopy?

A
  • Recurrent nosebleeds
  • Nasal polyps
  • Chronic sinusitis
  • Suspected cancer
  • Forgein body
  • OSA
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29
Q

What are the throat indications for doing a nasoendoscopy?

A
  • Suspected malignancy
  • Dysphonia
  • Dysphagia
  • OSA
  • Foreign body
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30
Q

How common are nasal injuries?

A

Most common injury to the face.

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31
Q

Why do nasal injures need assessing?

A

To check for fractured bones, other nasal problems, and to check the structures surrounding the nose aren’t compromised.

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32
Q

Who are nasal fractures most commonly seen in?

A

Young men aged 15-30

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33
Q

What elements of a hx of nasal fracture are important?

A
  1. Any significant head injury???
  2. Mechanism of injury (high impact?)
  3. Timing
  4. Pt age
  5. Previous nasal procedures/trauma/ENT hx
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34
Q

How should a nasal injury examination be done?

A

From distal to proximal i.e. have a look outside first

35
Q

What can come out of the nose following a nasal injury?

A

Blood or CSF, or mucus if they’re a snotty one.

36
Q

What might have happened to the septum following nasal injury?

A
  • Haematoma formation
  • Haemorrhage
  • Deviation
  • Malposition
37
Q

A pt has a mild nasal injury but there is no significant swelling or deformity.

What advice do we send him home with?

A
  • Ice and simple analgesia
  • Review in 5 days e.g. by GP
  • A fracture may take 2-3 weeks to heal.
38
Q

What is the second most common facial bone to fracture?

A

zygoma

39
Q

What is the most common orital injury?

A

Blowout fracture

40
Q

How is an uncomplicated nasal fracture usually treated?

A

Pain relief and cold compress.

Reduction can be done once the swelling has reduced.

41
Q

What is rhinitis?

A

Inflammation of the mucosa of the nose

42
Q

What are the different types of allergic rhinitis?

A
  • Seasonal i.e. hay fever
  • Perennial i.e. persistent
  • Occupational
43
Q

Which Ig mediates allergic rhinitis?

A

IgE

44
Q

How does IgE cause allergic rhinitis?

A

Causes mediators, including histamine, to be released from mast cells in nasal mucosa in response to an allergen. The epithelium becomes more permeable and inflammatory cells migrate into the area.

45
Q

By what is the acute phase of allergic rhinitis characterised?

A

Sneezing and increased nasal secretions within minutes of exposure

46
Q

By what is the late phase of allergic rhinitis characterised?

A

Nasal obstruction 6-12 hours after exposure, although acute phase sympotms may persist.

47
Q

How common is allergic rhinitis?

A

Very - affects over 20% of the population.

48
Q

What kind of allergic rhinitis do children tend to get?

A

Seasonal i.e. hay fever

49
Q

What kind of allergic rhinitis do adults tend to get?

A

Persistent allergic rhinitis

50
Q

When is peak onset of allergic rhinitis?

A

In childhood/adolescence.

51
Q

What genetic factors predispose someone to allergic rhinitis?

A

PHx of atopy

FHx of atopy or rhinitis

52
Q

What environmental factors predispose someone to allergic rhintis?

A
  • Exposure to common allergens
  • Air pollution
  • Reduced exposure t infection
  • Cigarette smoke exposure
53
Q

What is the most common allergen for perennial rhinitis?

A

House dust mite

54
Q

When does seasonal rhinitis occur?

A

Spring and summer

55
Q

How can we tell what allergen is causing seasonal allergic rhinitis?

A

Tree pollen tends to affect people in spring.

Grass pollens affect people late spring to early summer.

Weed pollens affect people from early spring to early autumn.

56
Q

What are the typical symptoms of allergic rhinitis?

A
  • Sneezing
  • Rhinorrhoea
  • Nasal congestion
  • Itchy nose/throat (post-nasal drip)
  • Bilateral
  • Worse on waking
  • Eye symptoms e.g. watering, itching, redness
57
Q

What part of SQITARS can help us identify rhinitis as allergic?

A

The “Does anything relieve it?” question - antihistamines and topical nasal steroid typically do.

58
Q

What drugs can cause allergic rhinitis in some people?

A
  • Topical sympathomimetcis
  • Some antihypertensives
  • Aspirin
  • NSAIDs
59
Q

When should someone with ?allergic rhinitis be referred to secondary care?

A
  • If the symptoms are consistently unilateral
  • If there is pain, visual distrubance, or bleeding
  • If uncontrolled by primary care intervention
60
Q

What does the nasal mucosa look like on examination of a pt with allergic rhinitis?

A

Swollen and greyish

61
Q

What signs can be observed from general insepction of a pt with allergic rhinitis?

A

Signs of nasal congestion e.g. mouth breathing, cough, halitosis.

62
Q

What should the eyes be examined for in ?allergic rhinitis?

A

Signs of conjunctivitis

63
Q

What are the differentials for allergic rhinitis?

A 
Non-allergic rhinitis
Infective rhinitis
Nasal polyps
Sinusitis
Adenoidal hypertrophy
CF
Deviated nasal septum
Nasal neoplasm (rare)
64
Q

How is allergic rhinitis diagnosed?

A

History and examination are usually sufficient!

65
Q

What investigation can be done for allergic rhinitis provided you know the allergen?

A

Skin prick testing

66
Q

What can suppress the results of a skin prick test?

A

Antihistamines, topical corticosteroids, and tricyclic antidepressants

67
Q

What are the main lines of treatment in allergic rhinitis, and how should they be used?

A

A stepwise approach involving:

  • Education
  • Allergen avoidance
  • Antihistamines
  • Topical steroids
68
Q

What allergens can generally be avoided to a certain extent?

A
  • Pollen
  • Animal
  • Occupational
  • House dust mites
69
Q

How can people avoid pollen?

A

Avoid open grassy spaces, keep windows shut in cars and buildings, and use a pollen filter when available

70
Q

How can people avoid animal hair?

A

Don’t get a pet, don’t let them in the house, or if that’s not possible, restrict them to one area e.g. the kitchen

71
Q

How can people avoid dust mites?

A

Extensive dust mite avoidance needs to be used to be effective:

  • Impermeable covers for mattresses and pillows
  • Synthetic duvets and pillows
  • Keep soft tos off the bed
  • Wash all bedding at a high temp at least once a week
  • Wooden/hard floors over carpet where possible
  • Fitted blinds rather than curtains
72
Q

What preparations do antihistamines come in?

A

Topical nasal and oral

73
Q

Who can use topical nasal antihistamines?

A

Anyone over the age of 5 who doesn’t prefer oral treatment.

74
Q

What are the benefits of topical nasal antihistamines in allergic rhinitis?

A

Equal efficacy to oral antihistamines

Fast acting i.e. good rescue therapy

75
Q

In what way are oral antihistamines better than nasal antihistamines for allergic rhinitis?

A

They act on other sites too - nasal sprays do not reduce symtpoms in the eyes for example.

76
Q

What are the recommended oral antihistamines for allergic rhinitis?

A

Certirizine
Loratadine
Fexofenadine

OD, non-sedating.

77
Q

When are topical intranasal steroids better for the treatment of allergic rhinitis?

A

When nasal congestion is the main symptom, or when nasal polyps are present.

78
Q

When are topical intranasal steroids first-line Rx for allergic rhinitis?

A

In pregnant or breast-feeding women.

79
Q

What non-drug therapy can reduce the need for intranasal steroids?

A

Nasal saline washouts (“douching”)

80
Q

How can a steroid and antihistamine be given at the same time?

A

Through azelastine/fluticasone combined nasal preparation - more effective than either agent alone.

81
Q

What surgical intervention might be able to help a pt with allergic rhinitis?

A
  • Reduction of inferior turbinate
  • Correction of deviated septum
  • Nasal polyps that have not responded to medical treatment

Only done as required as an adjunct to medication and lifestyle changes.

82
Q

Can allergic rhinitis be managed with immunotherapy?

A

Yes via desensitisation, usually performed for 3 years from the age of 5. The requires the trigger allergen to be indentified.

83
Q

What complications are associated with allergic rhinitis?

A
  • Poor QoL
  • Poor asthma control
  • Sinusitis
  • Nasal polyps
  • Chronic otitis media
84
Q

What is the prognosis associated with allergic rhinitis?

A

It usually improves over the years, particularly seasonal allergic rhinitis.

N&SS - ENT (7 decks)

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