NOSE Flashcards
blood supply of nose
anterior ethmoid
posterior ethmoid
sphenopalatine artery
what is little’s area
kiesselbach’s plexus
highly vascular region of nose
recieves from ICA and ECA
role of conchae
slow the air flow by causing turbulence
increases surface area over which area passes
paranasal sinus drainage sphenoid post, ethmoidal cells frontal, max, ant ethmoidal cells naslacrimal duct
sphenoid - spheno-ethmoidal recess
posterior ethmoidal cells - superior meatus
frontal, maxillary and anterior ethmoidal cells (all other sinuses) - middle meatus
nasolacrimal duct - inferior meatus
what is angiofibroma
benign vascular neoplasm composed of dermal fibrous tissue and blood vessels.
localised causes of epistaxis
Trauma — injury from nose-picking, nasal fractures, septal ulcers or perforations, foreign body, or blunt trauma (such as falls in children).
Inflammation — infection (for example chronic sinusitis), allergic rhinosinusitis, or nasal polyps.
Topical drugs — for example cocaine, decongestants, or corticosteroids.
Vascular causes — for example hereditary haemorrhagic telangiectasia or Wegener’s granulomatosis.
Post-operative bleeding — for example following ear, nose, and throat surgery; maxillofacial surgery; or ophthalmic surgery.
Tumours — benign (such as angiofibroma — a rare nasopharnygeal tumour largely affecting adolescent males) or malignant (such as squamous cell carcinoma — more likely in older people)
Nasal oxygen therapy — causes drying of the nasal mucosa and possible direct mucosal trauma via prongs of cannulae.
general causes of epistaxis
More general causes of damage may include:
Atherosclerosis.
Increased venous pressure from mitral stenosis.
Haematological conditions affecting clotting — such as thrombocytopenia, platelet dysfunction, Von Willebrand disease, leukaemia, and haemophilia.
Environmental factors — temperature, humidity, altitude, exposure to irritants such as dust, certain chemicals, and cigarette smoke.
Systemic drugs — including anticoagulants and antiplatelet drugs (for example aspirin and clopidogrel).
Excessive alcohol consumption.
complications of nasal bleeding
Hypovolaemia.
Anaemia.
Aspiration from dislodgement or malpositioning (especially with posterior epistaxis).
Death
complications of nasal packing
Pressure necrosis to collumella
Blockage of :
Nasolacrimal duct epiphora
Sinus drainage sinusitis
Nasal airway hypoxia
o Septal haematoma or abscess (due to traumatic packing).
o Pressure necrosis (secondary to excessively tight packing).
o Toxic shock syndrome (from prolonged packing).
o Apnoeic episodes (associated with bilateral anterior or posterior nasal packs).p
complications of nasal cautery
septal perforation if you do it on both sides as when you cauterising perichondium is burnt so losing its blood supply ischaemia
What do you do when someone comes with bleeding nose
1) First Aid – lean forward while pinching the cartilage of nose
a. Consider topic antiseptic to reduce crusting or vestibulitis – NASEPTIN (VHLORHEXIDINE AD NEOMYCIN) – 4X daily for 10 days
who cant use naseptin
b. Allergic to neomycin or peanut or soya then you cant prescribe above give mupirocin nasal ointment – 2/3x for 5-7 days
what to do if bleeding carries on after 10-15 minutes
Nasal cautery — if the bleeding point can be seen ANTERIOR RHINOSCOPY ANT BLEED/ RIGID ENDOSCOPE POST BLEEDand the procedure can be tolerated (for example in adults and older children, but not younger children).
Nasal packing — if nasal cautery is ineffective or the bleeding point cannot be seen. Admit the person to hospital if a nasal pack has been inserted in primary care.
BOTH CASES APPLY LOCAL ANAESTHETIC - LIDOCAINE AND PHENYLEPIPHERINE - WAIT 3-4 MINUTES
what to advise patients after cessation of bleeding
Blowing or picking the nose. Heavy lifting. Strenuous exercise. Lying flat. Drinking alcohol or hot drinks.
Types of nasal packing products
Nasal tampons (for example Merocel®) — effective and easy to use. Inflatable packs (for example Rapid-Rhino®) — effective and may be easier and more comfortable to insert and remove than nasal tampons. Ribbon gauze impregnated with Vaseline® or bismuth-iodoform paraffin paste — packing with ribbon gauze is not recommended in primary care without specific training.
what if nasal packing fails
Surgical/Radiological
If nasal packing fails to stop the bleeding the following vessels can either be ligated surgically or embolised radiologically
• Sphenopalatine
• Anterior ethmoid (can not be embolised because comes from internal carotid artery)
• External carotid (last resort)
how long can nasal pack saty in the nose for
upto 48 hours
if longer prescribe ABx
red flag signs for nasal tumours
unilateral nasal obstruction, rhinorrhoea, facial pain, hearing loss, persistent lymphadenopathy, and/or evidence of cranial neuropathy – older 50
, crusting, facial parasthesia, facial swellings, neck lumps
what samter triad
asthma
aspirin sensitivity
nasal polyposis
what drugs should be avoided in patients with asthma
aspirin
NSAIDs
Whats associated with nasal polyps
asthma (particularly late-onset asthma) aspirin sensitivity infective sinusitis cystic fibrosis Kartagener's syndrome Churg-Strauss syndrome
features of nasal polyps
nasal obstruction
rhinorrhoea, sneezing
poor sense of taste and smell
management of nasal polyps
all patients with suspected nasal polyps should be referred to ENT for a full examination
topical corticosteroids shrink polyp size in around 80% of patients
A 34-year-old man presents to his GP complaining of nasal congestion, a post-nasal drip and sneezing. He has been using nasal decongestants for 1 month, and after initially improving noted his symptoms returned.
rhinitis medicamentosa
condition of rebound nasal congestion brought on by extended use of topical decongestants
what is allergic rhinitis
inflammatory disorder of the nose where the nose become sensitized to allergens such as house dust mites and grass, tree and weed pollens.
causes of allergic rhinitis
house dust mites
grass
tree
weed pollens
classification of allergic rhinitis
seasonal: symptoms occur around the same time every year. Seasonal rhinitis which occurs secondary to pollens is known as hay fever
perennial: symptoms occur throughout the year
occupational: symptoms follow exposure to particular allergens within the work place
features of allergic rhinitis
- feeling of nasal congestion
- sneezing
- bilateral nasal obstruction
- clear nasal discharge
- post-nasal drip
- nasal pruritus
- reduced or absent sense of smell
management of allergic rhinitis
allergen avoidance
nasal irrigation
if the person has mild-to-moderate intermittent, or mild persistent symptoms:
oral or intranasal antihistamines
intranasal chromone such as sodium cromoglicate to be used ‘as needed
if the person has moderate-to-severe persistent symptoms, or initial drug treatment is ineffective
intranasal corticosteroids
a short course of oral corticosteroids are occasionally needed to cover important life events
there may be a role for short courses of topical nasal decongestants (e.g. oxymetazoline) 5-7 days. They should not be used for prolonged periods as increasing doses are required to achieve the same effect (tachyphylaxis) and rebound hypertrophy of the nasal mucosa (rhinitis medicamentosa) may occur upon withdrawal
what is acute sinusitis
inflammation of the mucous membranes of the paranasal sinuses.
causative organisms of sinusitis
Streptococcus pneumoniae, Haemophilus influenzae, moraxella cattarhalis and rhinoviruses.
predisposing factors of sinusitis
- asthma
- allergic rhinitis
- nasal obstruction e.g. septal deviation or nasal polyps
- recent local infection e.g. rhinitis or dental extraction
swimming/diving - smoking
- impaired ciliary motility - CF, kartagener
features of acute sinusitis
facial pain
typically frontal pressure pain which is worse on bending forward
nasal discharge: usually thick and purulent
nasal obstruction
loss of smell
management of acute sinusitis
analgesia
intranasal decongestants or nasal saline may be considered - LESS THAN 10 DAYS
intranasal corticosteroids may be considered if the symptoms have been present for MORE THAN 10 DAYS
oral antibiotics are not normally required but may be given for severe presentations.
The BNF recommends phenoxymethylpenicillin first-line, co-amoxiclav if ‘systemically very unwell, signs and symptoms of a more serious illness, or at high-risk of complications’
‘double-sickening’ may sometimes be seen, where an initial viral sinusitis worsens due to secondary bacterial infection
what is chronic rhinosinusitis
nflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer.
predisposing factors of chronic rhinosinusitis
- atopy: hay fever, asthma
- nasal obstruction e.g. Septal deviation or nasal polyps
- recent local infection e.g. Rhinitis or dental extraction
- swimming/diving
- smoking
features of chronic rhinosinusitis
facial pain: typically frontal pressure pain which is worse on bending forward
nasal discharge: usually clear if allergic or vasomotor. Thicker, purulent discharge suggests secondary infection
nasal obstruction: e.g. ‘mouth breathing’
post-nasal drip: may produce chronic cough
management for recurrent or chronic sinusitis
avoid allergen
intranasal corticosteroids
nasal irrigation with saline solution
red flags of sinusitis
unilateral symptoms
persistent symptoms despite compliance with 3 months of treatment
epistaxis
bacterial sinusiits features
- Symptoms for more than 10 days
- Discoloured or purulent nasal discharge (with unilateral predominance).
Severe local pain (with unilateral predominance). - A fever greater than 38°C.
- A marked deterioration after an initial milder form of the illness (so-called ‘double-sickening’).
- Elevated ESR/CRP (although the practicality of this criterion is limited).
double sickening - intialy recovery follwed by a sudden worsening of symptoms thought to be caused by a secondary bacterial infection following a viral rhinosinusitis. Other signs that point towards this are the fever and the purulent discharge seen on rhinoscopy.
what is a polyp
benign tumor growth
composed of swollen adn oedematous basal mucosa tissues
chronic rhinosinusitis w polyps Mx
oral steroids
anti leukotrienes
surgery
risk factors for polyps
- Asthma.
- Aspirin sensitivity - NSAIDs
- Cystic fibrosis (particularly nasal polyps in children).
- Allergic fungal sinusitis (rare in the UK but more common in warmer areas).
- Churg-Strauss syndrome.
Vit D deficiency
features of nasal polyps
- runny nose
- nasal discharge
- nasal obstruction
- snoring and obstructive
- sleep symptoms
hyposmia or anosmia - loss of sense of smell or reduced taste
signs
yellowish-grey, smooth, moist
Tx for nasal polyps
intranasal steroids or spray
fails - oral steroids
no improvement after 10 weeks
functional endoscopic sinus surgery (FESS) but can recur
complciations of polyps
acute bacterial sinusitis
sleep disruption
asthma
triad of kartageners syndrome
situs inversus, chronic sinusitis, and bronchiectasis
Common causes of chronic rhinosinusitis
allergic rhinitis - pollens, weeds, hiouse dustmite
infectious rhinitis
- hormonal ie pregnancy, hypothyroidism
- drug induced ie beta blockers, Cntraceptive
occupational rhinitis - chemicals and fumes
Neurogenic/vasomotor rhinitis
rhinitis medicamentosa - excessive use of nasal decongestatns causes rebound nasal congestion. Mx is to stop
atrophic rhinitis - drying and crusting of the nose. Following, extensive nasal surgery, radiotherapy, Sjogrens
Senile rhinitis - responds well to ipratropium bromide
DDx for chronicrhinosinusitis/nasal polyps
adenoidal hypertropy - nasal onstruction, discoloured nasal secretions
nasal septal deviation
foreign body
CF and primary ciliary dyskinesia
tumour
