Nose and Eye Flashcards
where does the blood supply of the nose come from
internal and external carotid arteries
external - superior labial, greater palatine, sphenopalatine
internal - anterior ethmoid, posterior ethmoid
which blood vessels can be tied off during epistaxis
external carotid arteries - superior labial, greater palatine sphenopalatin
where does most nosebleed occur
in the keisseback’s plexus (Little’s area) - anterior part of the septum where 4 arties anastomose
aetiology of epistaxis
- vessel problems mucosal problems, impairment of vasoconstriction and inadequate activation of clotting mechanism
- Neoplasm atypical cause, sinus tumours, Juvenile nasal angiofibroma
- patient factors elevated BP
- recent/high alcohol intake elevates risks
clinical features of epistaxis
- Bleeding from the nose – can be one or both
- if bleeding starts in the nose = anterior bleeding, if bleeding starts at the throat = posterior bleeding
- Blood going down the back of the throat
- recurrent epistaxis – can be due to intranasal polyp
- telangiectasia – can be due to hreditary haemorrhagic telangiectasia (HHT)
- Unstable: light-headedness, syncope, pallor
investigation for epistaxis
- Light and nasal speculum – look for clots and bleeding point
- Recurrent/heavy bleeding: FBC, coagulation (if clotting issue is suspected), G&S,
what are some red flags for nasal tumour
- > 50 yrs
- occupational exposure to wood dust or chemical
- South Chinese or North African
- unilateral nasal obstruction
- recurring nose bleeds
- rhinorrhoea
- facial pain
- hearing loss
- persistent lymphadenopathy
- evidence of cranial neuropathy - eg facial numbness or double vision
management of epistaxis
Severe/posterior bleed/frail: A&E for resus
1) Pinch nose at the front and bottom with the head tilted down
2) If bleeding stops with first aid, consider topical Naseptin
2) If bleeding does not stop after 10-15 mins consider:
• 1st - Cauterisation of vessels
• 2nd - Packing of nasal cavity to tamponade bleeding via nasal tampons/inflatable packs/ribbon gauze with Vaseline
• 3rd line – posterior packing via ENT specialist
• adjunct - topical vasoconstrictor +/- local anaesthetic
o vasoconstrictor eg oxymetazoline
o anaesthetic – lidocaine
what are some aetiology of nasal trauma and foreign body
trauma eg sporting event, assault, fall
children most likely to present with foreign body
clinical features of nasal trauma
swelling of the nose bruising of the nose epistaxis change in sense of smell step deformity of the nose
clinical features of foreign body
no symptoms most of the time blocked nose nasal drainage on one side bad odour bloody nose
investigation of the foreign body
Visual inspection
Xray of skull - if suspecting fractures of any facial bones
FBC + G&S - extensive blood loss
management of nasal trauma
analgesia
cut skin = cleaning and closure of wound
simple fracture = ENT outpatient clinic within 7-10 days of the injury
- if septical haematoma seen - uregent ENT referral for incision and drainage otherwise nose can become necrotic
- safety net for meningitis
- avoid contact sport or strenous exercise
management of nasal foreign body
+ve pressure through the nose (via parent blowing into the childs mouth and obstructing the unaffected nostil)
removal of object with LA spray and forceps
what is the ENT emergency that can arise in nasal trauma
septal haematoma
- • Nasal obstruction, pain
• Can lead to a saddle nose deformity
- if not correct, nose can become necrotic within 3-4 days
what are the different classification for allergic rhinitis
- Seasonal - symptoms occur at the same time each year in response to a seasonal allergen. If caused by grass and tree pollen allergens, it is also known as ‘hay fever’.
- Perennial - symptoms occur throughout the year, typically due to allergens from house dust mites and animal dander.
- Intermittent - symptoms occur for <4 days a week, and >4 consecutive weeks, typically due to allergens such as animal dander.
- Persistent - symptoms occur for > 4 days a week and for >4 consecutive weeks, typically due to allergens such as house dust mites.
• mild – none of the following are present
o sleep disturbance
o impairment of daily activities, leisure +/- sport
o impairment of school or work
o troublesome symptoms
• moderate/severe – 1 or more of the following are present
o sleep disturbance
o impairment of daily activities, leisure +/- sport
o impairment of school or work
o troublesome symptoms
symptoms of allergic rhinitis
- Rhinorrhoea
- Nasal congestion
- Sneezing
- Itchy nose +/- eye, ear, palate itchiness
- Post nasal drip
- Eyes: bilateral itching, redness, and tearing – suggests allergic
- fatigue and irritability due to poor sleep quality
signs of allergic rhinitis
- nasal intonation of the voice
- darkened eye shadows under the lower eyelid due to chronic congestion (so called - allergic shiners)
- horizontal nasal crease across the dorsum of the nose (in severe rhinitis)
- nasal mucosa swelling and greyish discolouration
nasal polyps
investigation of allergic rhinitis
- Clinical diagnosis
- therapeutic trial of antihistamine or intranasal corticosteroid
- Can consider allergen skin prick testing or in-vitro specific IgE determination
management of allergic rhinitis
avoid trigger
mild to moderate
1) oral / intranasal antihistamien
2) nasal irritation with salien
3) nasal decongestant - oxymetazoline
moderate to severe
1) regular nasal corticosteroids spray eg fluticasone/mometasone
2) nasal decongestant - oxymetazolien
3) water rhinorrhoea - intranasal anticholingeric –> ipratropium bromide
4) if still uncontrol - short course oral steriod
5) referral to immunologist if symptoms still not contolr for biological agent
what is sinusitis
inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses
different types of sinusitis
acute - < 4 weeks
chronic - > 12 weeks
aetiology of acute sinusitis
Acute
• viral or bacterial viral most common
• if bacterial strep. pneumoniae, Haemophilus influenzae and Moraxella catarrhalis
clinical features of acute sinusitis
facial pain - pressure behind nose/forehead/eyes (+tenderness over this area)
hyposmia - dec ability to smell
nasal blockage via swelling/discharge
purulent discharge - yeloow/ bornw/green
Maxillary teeth pain
cough due to post-nasal drip
viral symptoms
investigation for acute sinusitis
clinical diagnosis
nasal endoscopy - shows mucosal erythema, purulent discharge
CT paranasal sinuses
microbiology - sinus culture
allergy testing
management of acute sinusitis
1) Advise that most are viral, will resolve within 2-3 weeks. Symptomatic management with paracetamol/ibuprofen +/- nasal irrigation with saline or decongestant eg oxymetazoline nasal
2) ABx usually reserve for immunosupprised patients – 1st line Co-amoxiclav
3) > 10 days = Steroid nasal spray for 14 days e.g. mometasone 200 micrograms
4) >17 days = Phenoxymethylpenicillin for 5 days
causes of chronic sinusitis
- Anatomical obstruction of the osteometal complex = inadequates drainage of sinus
- genetic physiological factor (cystic fibrosis /primary ciliary dyskinesia)
- smoking
- structural factors severe mid-septal deviation
clinical features of chronic sinusitis
- headache
- purulent nasal discharge brown, yellow, green discharge
- Facial pain – behind the nose/forehead/eyes (+ tenderness over this area)
- Hyposmia (↓ ability to smell)
- Nasal blockage via swelling/discharge (nasal drip)
- Maxillary teeth pain
- cough due to post-nasal drip
- Rhinoscopy: nasal inflammation, mucosal oedema, purulent nasal discharge (bacterial)
investigation for chornic sinusitis
o 1st line anterior rhinoscopy (can be done in primary care or by specialist) +/- nasal endoscopy
o sinus CT/MRI looking for structural abnor
o cultures
o allergy testing
management of chronic sinusitis
Avoid allergic triggers, stop smoking, good dental hygiene
2) Consider nasal irrigation +/- steroid nasal spray
3) Long term Abx after seeking specialist advice
4) No improvement: functional endoscopic sinus surgery - Expansion of the osteomeatal complex
