Nose Flashcards
What is more convenient between an inflattable balloon and ribbon gauze packs in the treatment of epistaxis?
Inflattable balloons are less traumatic to the mucosa
What percentage of epistaxis happens in littles area?
90%
Name the arteries that converge in kiesselbach’s plexu?
- Anterior ethmoidal artery 2. Posterior ethmoidal artery 3. Sphenopalantine artery 4. Greater palantine artery 5. Superior labial artery
What are the local causes of epistaxis?
- Trauma/nose picking 2. Viral infection 3. foreign body 4. Neoplasia 5. Idiopathic
What are the general/systemic causes of epistaxis?
- Hypertension 2. Drugs(anticoagulants) 3. Blood diseases such as leukemia 4. Hereditary haemorrhagic telangiectasia 5. Arteriosclerosis or other cardiovascular defects
What is hereditary hemorrhagic telangiectasia?
It is a hereditary condition associated with recurrent epistaxis. It presents with melena, haematuria and subarachnoid or cerebral haemorrhage
What is your initial treatment of epistaxis?
- Patient must sit up and lean forward(to reduce BP and not swallow blood)- trotters manoeuvre 2. Squeeze nostrils tightly 3. Anaesthetise and then use a silver nitrate stick application 4. If that does not work use a nasal pack with ribbon gauze bismuth iodoform paraffin paste(bipp)
What do you do if the patient continues to bleed from the nose after your initial management?
-use a postnasal pack that you insert with anaesthesia -Give antibiotic cover if nasal pack is in situ for more than 48 hrs
What is the classical triad of allergic rhinitis?
-nasal obstruction due to the the mucosal vasodilation and oedema -sneezing -rhinorrhea due to stimulation of the glandular tissue
What other atopy do you have to ask the patient about in allergic rhinitis?
You have to ask about -asthma -exzema -allergic dermatitis -drug allergies
What do anti-histamines do?
They stop the itching
What does rhinitis mean?
It means inflammation of the lining of the nose and can be intermittent or persistent
Name some of the causes of allergic rhinitis/hay fever?
-flowers -weeds -pet dander -grass -pollen -dust mites -feathers
How does allergic rhinitis occur?
The allergens bind to IgE and causes degranulation of the mast cells and that releases mediator substances such as histamine, leukotrienes and SRSA(slow reacting substance of anaphylaxis
What is the management of allergic rhinitis?
- Avoid allergens- in perennial allergic rhinitis clean out bed sheets and chage curtains etc. 2. Desensitisation injections 3. local decongestants-either steroidal or sympathomimetic 4. systemic drug therapy- antihistamines that block the H1 nasal mucosa receptors 5. Surgery- turbinate resection or cautery
What are 2 examples of local steroid nasal sprays?
- mometason 2. fluticasone
What is a downfall to using systemic antihistamines?
Drowsiness
What is nasal hyperreactivity(vasomotor rhinitis)?
It is prevalent in about 10-15% of people and it is caused by the imbalance between the parasympathetic and sympathetic autonomic nerve supply of the nasal mucosa
What are the clinical features of vasomotor rhinitis?
-nasal obstruction -rhinorrhea -sneezing(although significantly less than allergic rhinitis) The inferior turbinate is usually red, swollen and congested
What are some of the triggers of vasomotor rhinitis?
-pregnancy -menopause -hyerthyroidism -ambient changes in temperature and humidity -alcohol or tobacco
What is the Rx of vasomotor rhinitis?
- local and systemic decongestants 2.laser treatment 3. partial turbinectomy
What is rhinitis medicamentosa?
Rhinitis caused by the overuse of topical agents that contain sympathomimetic agents and the patient becomes addicted to the short period of relief
What is the treatment of rhinitis medicamentosa?
Substitute the one used with a steroidal nasal decongestant, or use systemic decongestants or surgery like-partial turbinate resection
What is sinusitis?
It is inflammation in the lining of the paranasal sinuses
What are the causes of sinusitis?
-Rhinitis -dental disease -facial trauma -neoplasia
Where does the frontal, maxillary and sphenoid sinuses drain into?
The drain into the ethmoidal sinus and into the nasal fossae
What is the most common cause of a sinusitis?
Viral rhinosinusitis
What are the mechanisms that cause the blockage?
-paralysis of the mucociliary clearance mechanism and the blockage of the sinus ostia -mechanical obstruction such as nasal polyposis, deflected nasal septum, turbinate hypertrophy
What is the treatment of acute sinusitis?
- Analgesia 2. nasal drops- oxymetazoline or ephedrine 3. broad spectrum antibiotics 4. steam or menthol inhalants last resort is aspiration of sinus contents
What is acute frontal sinus?
Potentially serious condition if it includes intracranial and orbital involvement-do CT scan to rule out these complications
What is the Rx of acute frontal sinuses?
- Topical vasoconstrictor nose drops 2. Broad spectrum AB 3. Proof puncture or endoscopic drainage 4. trephination and drainage(making a hole in the skull) 5. balloon dilatation and ethmoidal drainage
What is chronic sinusitis?
Inflammation of the paranasal sinuses for more than 12 weeks and the retained secretions have allowed bacteria to colonise
What are the signs/symptoms of chronic sinusitis?
- postnasal discharge/ chronic purulent discharge 2. nasal block 3. halitosis 4.headaches
What is a mucocele?
Expansion of an obstructed sinus specifically in the frontal and ethmoid sinuses
What is the Mx of chronic sinusitis?
1.intranasal ethmoidectomy 2. external ethmoidectomy 3.antrostomy(for the maxillary sinus) 4. frontoethmoidectomy
What other medical conditions are nasal polyps associated with?
- Asthma 2. Chronic allergic rhinitis 3.cystic fibrosis in children
What are nasal polyps?
They are bags of oedematous mucosa that usually arise from the ethmoidal cells and prolapse into the nose via the middle meatus
What are the symptoms of nasal polyps?
-nasal obstruction -rhinorrea -recurrent sinusitis -hyposmia/anosmia
What are the clinical features of nasal polyps?
-pale grey, single or multiple polypoid masses which are insensitive to palpation and do not bleed. CT scan may show radio-opacity of the maxillary sinus
What is the Mx of nasal polyps?
-small polyps: topical steroids -large polyps: short course of systemic steroids followed by long course of topical steroids -Definitive treatment is a endoscopic ethmoidectomy and long term use of topical steroids
What is epiphora?
Epiphora is the blockage of the vasolacrimal duct
What are the 3 types of polyps?
- antrochoanal polyps 2. neoplastic polyps 3. miscellaneous polyps
How does an antrochoanal polyp present?
-An antrochoanal polyp is not common -unilateral -oedematous lining in maxillary sinus -enlarges towards the posterior choana and nasopharynx -usuallyyoung adult with nasal obstruction on expiration
How do we treat a antrochoanal polyp?
-surgical- pernasal excision with removal of the cystic antral part endoscopically
How do neoplastic polyps present?
-foul smelling discharge -epistaxis -nasal obstruction -epiphora -fleshy and usually bleed on palpation Biopsy is mandatory
Miscellaneous polyps include?
chidlren epecially cystic fibrosis Exclude meningocele and encephalocele which is prolapse that can occur at an anterior cranial fossa defect
What are the clinical features of a foreign body in the nose?
-foul smelling discharge -nasal obstruction -excoriation of the nasal vestibular skin or upper lip might be present -
What is the Mx of a foreign body in a child?
-Use general anaesthesia if the child is unco-operative -Use cupped forceps or blunt hooked probe
What is a rhinolith?
A large foreign body that occurs in some adults. Consists of calcium and magnesium on some gauze or clotted blood
How does a rhinolith present?
With unilateral foul smelling discharge
What are the symptoms of the common cold?
-rhinorrhea -nasal obstruction -sneezing -headache -pyrexia
What are the viruses implicated in the common cold?
-adenovirus, rhinovirus -parainfluenzae -respiratory synctial influenzae
What is the Mx of the common cold?
-isolation -nasal decongestants -paracetamol or NSAIDS to combat pyrexia
What is nasal vestibulitis?
Excoriation of the nasal vestibule due to nose-picking, rhinorrhea from a nasal allergy and a dislocated columella. Herpes simplex or zoster vesicles can occur on the anterior nares and exzema can contribute to it too. The treatment is topical antibiotics
What should a persistent vestibulitis with ulceration point towards?
Squamous cell or basal cell carcinoma
What is atrophic rhinitis?
-Also known as ozaena -Occurs mostly to women and immune compromised, mal-nutritioned or poor hygienic people -crusting of the nasal cavities often associated with a foul smelling discharge and anosmia
How do you manage ozaenia/atrophic rhinits?
- Meticulous local toilet with normal saline or sodium bicarbonate or sodium chloride 3 to 4 times a day
What is nasal furunculosis?
Hair follicle infection which is caused by staphyoloccus aureus
What should patients avoid doing when they have furunculosis?
They should not squeeze the pus out because it could cause cavernous sinus infection
What are the 3 nasal dermatitides?
-psoriasis -rosacea -seborrhoeic dermatitis
What is lupus vulgaris?
It is the infection with mycobacterium TB that presents with an ulcer in the septum and nasal vestibule
What is lupus pernio?
-Associated with sarcoidosis -presents with bluish red nodules -treated with systemic steroids -sarcoidoisis can present with involvement of the lacrimal gland,eyes, chest and salivary gland
What is nasal syphillis and how does it present?
-If congenital a nasal fissuring and discharge happens(snuffles) -if acquired there are gummatous lesions on the skin and the tertiary form causes destruction of bone and cartilage in the septum
Which facial bones are affected most in trauma?
-maxilla -mandible -malar complex -nose
What is the main cause of soft tissue damage and what is the Mx?
-lacerations and you need to scrub to avoid tattooing and accurately suture the skin
What is the weakest part of the mandible?
The condylar neck
What is the definition of trismus?
-lockjaw
What is the clinical presentation of mandibular fractures?
-Haemmorhage -dental malocclusion if tooth area is fractured -on bimanual palpation there will be bony fragments
What is the Mx of mandibular fractures?
Reduction and immobilisation for several weeks by wiring the upper and lower teeth together
What are malar fractures?
-fractures to the cheek bone or zygoma
What is the presentation of the malar fracture?
-sensory loss in the cheek -depression and swelling over the fracture -step over the infra-orbital ridges on palpation
What is the Mx of a malar fracture?
-surgical correction by elevating the depressed fragment by making an incision in the temporal area
What are the most common types of maxillary fractures?
Le fort I,II,III fractures
What is the most NB function of the maxilla?
It provides protection and shock absorption into the skull and intra-cranial structures
What is this classification of maxillary fractures?
Explaing from 1 to 3
Le fort I- lies below the antrum and allow the the tooth bearing areas of the jaw to move in relation to the nose
II- allows the nose and the maxilla to move as a block
III- the most severe as it separates the facial bones from the skull base
What is the Mx of a maxillary fracture?
-reduction and spliniting for several weeks
What is a orbital blowout fracture?
It is a fracture that involves direct trauma that pushes the eye into the orbit and increases the pressure
is the weakest part of the orbital cavity?
The orbital floor
What is the Rx of orbital blow out fracture?
-graft or silastic reconstruction of the orbital floor
How do you treat a nasal fracture?
- Usually treat it immediately or within 7 days after the swelling has gone down and you can assess the deformity
- Reduce with general anaesthesia and plaster of paris to keep it together
- Cosmetic correction done by rhinoplasty
What are the 3 major complications of facial trauma?
- haemorrhage
- respiratory obstruction
- inhalational injuries
What are the different types of respiratory obstruction?
- intra-oral blood clots
- blockage due to tooth fragments or dentures
- facial fractures may narrow the orophyrangeal isthmus
- The tongue may cause posterior blockage
Wha is the Mx for respiratory obstruction?
- intubation an tracheostomy
- pulling the jaw forward to prevent posterior blockage of the tongue
How does haemorrhage occur in the nose and how do you treat it?
When there is damage to the lamina papyracea and a tear in the anterior ethmoidal artery leading to epistaxis
How do we treat bleeding in the nose?
-nasal packing and direct pressure to stop the flow of blood
What is ARDS?
- adult respiratory distress syndrome
- where gatsric and blood contents are comatose which increase the morbidity and mortality
What is treatment of ARDS?
- adequate oxygenation and multi-organ failure
- inhalation and tracheostomy
What is cerebrospinal fluid rhinorrhea?
CSF- is a clear watery discharge coming out of the nose after facial trauma
-The usual site of trauma is the cribriform plate and posterior wall of the posterior sinus
How do we distinguish between normal nasal secretions and CSF leaks?
- By testing for glucose
- There will be a halo on a white cloth if blood is mixed with CSF
What is cavernous sinus thrombosis?
How do you treat cavernous sinus thrombosis?
With high dose parenteral antibiotics
