Nose and Eye

Question 1

where does the blood supply of the nose come from

Answer 1

internal and external carotid arteries

external - superior labial, greater palatine, sphenopalatine

internal - anterior ethmoid, posterior ethmoid

Question 2

which blood vessels can be tied off during epistaxis

Answer 2

external carotid arteries - superior labial, greater palatine sphenopalatin

Question 3

where does most nosebleed occur

Answer 3

in the keisseback’s plexus (Little’s area) - anterior part of the septum where 4 arties anastomose

Question 4

aetiology of epistaxis

Answer 4

• 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

Question 5

clinical features of epistaxis

Answer 5

• 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

Question 6

investigation for epistaxis

Answer 6

• Light and nasal speculum – look for clots and bleeding point
• Recurrent/heavy bleeding: FBC, coagulation (if clotting issue is suspected), G&S,

Question 7

what are some red flags for nasal tumour

Answer 7

• > 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

Question 8

management of epistaxis

Answer 8

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

Question 9

what are some aetiology of nasal trauma and foreign body

Answer 9

trauma eg sporting event, assault, fall

children most likely to present with foreign body

Question 10

clinical features of nasal trauma

Answer 10

swelling of the nose 
bruising of the nose 
epistaxis 
change in sense of smell 
step deformity of the nose

Question 11

clinical features of foreign body

Answer 11

no symptoms most of the time 
blocked nose 
nasal drainage on one side 
bad odour 
bloody nose

Question 12

investigation of the foreign body

Answer 12

Visual inspection
Xray of skull - if suspecting fractures of any facial bones

FBC + G&S - extensive blood loss

Question 13

management of nasal trauma

Answer 13

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

Question 14

management of nasal foreign body

Answer 14

+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

Question 15

what is the ENT emergency that can arise in nasal trauma

Answer 15

septal haematoma
- • Nasal obstruction, pain
• Can lead to a saddle nose deformity
- if not correct, nose can become necrotic within 3-4 days

Question 16

what are the different classification for allergic rhinitis

Answer 16

• 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

Question 17

symptoms of allergic rhinitis

Answer 17

• 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

Question 18

signs of allergic rhinitis

Answer 18

• 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

Question 19

investigation of allergic rhinitis

Answer 19

• Clinical diagnosis
• therapeutic trial of antihistamine or intranasal corticosteroid
• Can consider allergen skin prick testing or in-vitro specific IgE determination

Question 20

management of allergic rhinitis

Answer 20

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

Question 21

what is sinusitis

Answer 21

inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses

Question 22

different types of sinusitis

Answer 22

acute - < 4 weeks

chronic - > 12 weeks

Question 23

aetiology of acute sinusitis

Answer 23

Acute
• viral or bacterial  viral most common
• if bacterial  strep. pneumoniae, Haemophilus influenzae and Moraxella catarrhalis

Question 24

clinical features of acute sinusitis

Answer 24

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

Question 25

investigation for acute sinusitis

Answer 25

clinical diagnosis

nasal endoscopy - shows mucosal erythema, purulent discharge
CT paranasal sinuses
microbiology - sinus culture
allergy testing

Question 26

management of acute sinusitis

Answer 26

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

Question 27

causes of chronic sinusitis

Answer 27

• 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

Question 28

clinical features of chronic sinusitis

Answer 28

• 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)

Question 29

investigation for chornic sinusitis

Answer 29

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

Question 30

management of chronic sinusitis

Answer 30

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