Nose

Question 1

What is rhinusitis?

Answer 1

Inflammation of nose and paranasal sinuses with 2 or more of:

• Nasal blockage / obstruction
• Nasal discharge
• Facial pain / pressure
• Reduction or loss of smell

Question 2

How is rhinusitis defined?

Answer 2

Acute

Chronic (>12wks)

Question 3

What is the management of acute rhinositus (common cold)?

Answer 3

Self limiting

If >5 days, can give intranasal corticosteroids eg mometasone or fluticasone

Question 4

What can be given in allergic rhinosinutis?

Answer 4

1st line NASAL ANTIHISTAMINES in flare 
2nd line (mod-severe) Intranasal corticosteroid
3rd line (severe/uncontrolled): oral dose of Pred 5-20 days

Question 5

What would make you consider acute bacterial sinusitis?

What is the treatment?

Answer 5

• 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).

Amoxicillin

Question 6

What is the treatment of acute sinusitis?

Answer 6

• Less than 10 days COMPLETELY SELF LIMITING

- More than 10 days: high-dose nasal corticosteroid

Question 7

How long can chronic sinusitis last?

What is the managment?

Answer 7

-Chronic sinusitis can last months

Management

• Avoid triggers, stop smoking
• Consider a course of intranasal corticosteroids (for example, mometasone or fluticasone) for up to 3 months,

Question 8

How does chronic sinusitis with nasal polyps present?

Important to test for what in kids?

Answer 8

Sneezing 
Nasal drip 
Nasal obstriction 
Sinusitis 
Mouth breathing 
Snoring 
Headaches
**test for CF in children!!

Question 9

When do nasal polyps require urgent referral for biopsy?

Answer 9

RED FLAGS

• Single unilateral polyp (unilateral discharge)
• Bleeding

May be intranasal pathology eg nasopharyngeal cancer or lymphoma

Question 10

What is the medical management of chronic rhinosinusitis with nasal polyps?

Answer 10

REFER ALL PATIENTS TO ENT (full exam)

Topical steroids 2 weeks eg BETAMETHACONE 0.1% (shrink polyps)

Followed by FLUTICASONE (steroid spray) 100mcg 2 sprays / 24 hours in both nostrils for 3 months

Consider long term abx eg doxycycline

Question 11

What is the surgical management of chronic rhinosinusitis with nasal polyps?

Answer 11

Endoscopic sinus surgery - watch out for CSF leak in recovery

Dont blow nose until you are better

Question 12

How does a septal haematoma present?

Answer 12

Following trauma

-A boggy, bilateral cherry red swelling from septum

Question 13

How is a septal haematoma managed?

Complication of septal haematoma?

Answer 13

Refer to ENT for urgent incision and drainage

***Damage to septal cartilage can occur within 24 hours and if it is left untreated can lead to irreversible septal perforation and necrosis - saddle-nose deformity

Question 14

What is the management of a nasal fracture?

Answer 14

Analgesia
Ice
Close skin injury
Reassess 5-7 days post injury once swelling resolved
If manipulation under anaesthesia (MUA) required, perform day 10-14 after injury before nasal bones set

Question 15

Sign of ethmoid fracture?

Answer 15

CSF rhinorrhoea through disrupting dura and arachnoid layers

Question 16

How does a nasal FB present?

Answer 16

Purulent unilateral discharge

Question 17

How can a nasal FB be removed?

Answer 17

Ask child to blow nose
or blow into mouth whilst occluding the other nostril
Crocodile forceps to retrieve

Question 18

Describe the usual presentation and cause of hearing loss in nasopharyngeal cancer

Answer 18

Usually unilateral due to conductive deafness from eustachian tube blockage

Question 19

Common causes of epistaxis?

Answer 19

• Trauma - nose picking children, fractures
• Bleeding disorders (think women with menorragia)
• Acquired: High alcohol intake - low clotting factors
• Hypertension
• Vasculitis e.g. Wegener’s granulomatosis
• Drugs (Anticoagulants)

Question 20

Where is the most common site of epistaxis?

Answer 20

Little’s area (anterior)

Question 21

What is Little’s area?

Answer 21

The site of anastomosis of 5 arteries:

1. Anterior ethmoid artery
2. Posterior ethmoid artery
3. Sphenopalatine artery
4. Great palatine artery
5. Superior labial artery

Twins names ETHEL and their dog SPHENO went with their GREAT PAL to see their SUPERIOR, LABILE, aunt

Question 22

Stepwise managment of epistaxis? (4)

Answer 22

EPISTAXIS
1. Pinch fleshy part for 15 mins whilst sitting up and leading forwards

2. Lidocaine + phenylephrine gauze or spray (uncommonly done but is 2nd step on NICE)
3. CAN SEE: Silver nitrate cautery
   CAN’T SEE: Pack (balloon, ribbon, nasal tampon)
4. Call ENT
   a. Ligation of sphenopalatine artery
   b. Posterior packing with urinary catheter