Nose and paranasal sinuses

Question 1

what important anatomical consideration must be made in management of epistaxis?

Answer 1

that little’s area/kiesselbach’s plexus on the nasal septum receives contribution from branches of BOTH ICA and ECAs, so haemorrhage may be from 1 or a combination of these arteries.

Question 2

causes of epistaxis?

Answer 2

idiopathic (85%)
traumatic, ?nose picking
iatrogenic
FB
inflammatory-rhinitis, polyps
neoplastic-malignancies e.g. NP carcinoma, or benign e.g. juvenile angiofibroma.

systemic: HTN-bleed for longer?
coagulopathies e.g. drugs-warfarin, aspirin, haemophilia, von Willebrand disease, liver disease
vasculopathies e.g. wegener’s granulomatosis
hereditary haemorrhagic telangiectasia/Osler-Weber-Rendu disease-AD inherited disorder in which deficient tunica media allows aneurysms to form producing a petechial (non-blanching) rash-lips, tongue, fingertip pads and mucous membranes lining gut and nose, also AV malformations-telangiectases, and worry in pulmonary or cerebral due to STROKE risk. recurrent epistaxis and bleeding from gut can cause Fe deficiency anaemia.

Question 3

management of epistaxis?

Answer 3

ABCDE approach-are they haemodynamically stable? need initial 1st aid, b.loss assessment, cause evaluation and procedures to stop bleeding.
1st aid-pinch soft part of nose for at least 15 MINS, head forward, spit out any bld in mouth-keep open
?blood loss-measure BP, pulse, pallor, sweating-IV line for fluids/blood, take FBC, clotting profile and X match.
exam-where is bleeding source?-Anterior or Posterior? bleeding from above middle turbinate?-ICA
conservative: cautery-silver nitrate or bipolar diathermy-anterior rhinoscopy if anter. bleed, rigid endoscope if post. bleed, topical adrenaline can help control bleeding before cautery.
nasal packing (merocel-nasal tampon) if cautery fails to control bleed-anterior pack, and posterior if bleeding continues into oropharynx-also consider packing other nostril to increase pressure on bleeding vessel?
inflatable balloon tamponade may be used as alternative method of packing
formal gauze postnasal pack may need GA for insertion, need Abx cover, some packs e.g. ribbon gauze, impregnated with BIPP-can cause iodine toxicity and delirium to develop in elderly patients.

surgical/radiological: following failed packing, can ligate vessels surgically or embolise radiologically:
sphenopalatine
anterior ethmoid-CANNOT EMBOLISE as from ICA
ECA-last resort!

embolise-gelfoam blockage

Question 4

complications of nasal bone fractures?

Answer 4

septal haematoma

CSF leak with assoc. skull base fracture (rare)

Question 5

nasal trauma management?

Answer 5

ABC-epistaxis normally self-limiting
examine for septal haematoma
no X-ray needed
if nose deviated consider MUA-local or general, within 2 wks of injury

Question 6

what do we worry about when performing surgery involving the paranasal sinuses?

Answer 6

orbit damage-orbit is lateral to ethmoid sinus and superior to maxillary sinus, in severe cases sight loss may result from sinus surgery
anterior skull base damage-lies just above sphenoid and ethmoid sinuses, breach can cause CSF leak and in worst cases brain damage.

Question 7

complications of rhinosinusitis?

Answer 7

periorbital sinusitis (?orbital cellulitis)-can be sight threatening
intracranial infection-part. if infective rhinosinusitis involves frontal sinus can spread intracranially, causing meningitis and intracranial abscess.

Question 8

define rhinosinusitis

Answer 8

inflammation of nose and paranasal sinuses characterised by 2 or more symptoms, 1 of which should be:
either nasal blockage/obstruction/congestion/discharge
anterior/posterior nasal drip:
with or without facial pain/pressure
with or without reduction or loss of smell

and either:
endoscopic signs of polyps, mucopurulent discharge, or middle meatus oedema
and/or:
CT changes-mucosal changes within osteomeatal complex, or sinuses.

Question 9

viral acute rhinosinusitis/common cold, is defined as?

Answer 9

lasting for less than 3 months, with complete resolution of symptoms-normally resolves within 5 days

Question 10

causes of viral rhinosinusitis?

Answer 10

rhinovirus

influenza virus

Question 11

acute rhinosinusitis management?

Answer 11

analgesia if required
nasal decongestants e.g. phenylephrine
if persists longer than 5 days (suggesting bacterial cause) consider topical nasal steorids and oral Abx

Question 12

how is chronic rhinosinusitis defined?

Answer 12

lasting for 3 mnths without complete symptom resolution

divided into that with and without nasal polyps

Question 13

why are cystic fibrosis patients prone to developing chronic rhinosinusitis?

Answer 13

due to ciliary impairment-cilia unable to clear mucus

due to this also develop inflammatory nasal polyps-seen in about 40% of CF patients

Question 14

what must be done in all patients with unilateral polyps?

Answer 14

BIOPSY for histological diagnois

Question 15

how is the ethmoid sinus separated from the orbit?

Answer 15

by the lamina papyracea
*risk of orbital? cellulitis with extension of ethmoid sinus infection, can be sight threatening, surgical emergency if colour vision affected.

Question 16

features of orbital cellulitis? what does it commonly result from?

Answer 16

eye pain, followed by eyelid oedema and orbital collection-causing eye proptosis, and opthalmoplegia with reduced eye m.ments.
colour blindness early sign of optic nerve damage-risk of blindness due to nerve tension and septic necrosis
usually infection extension into orbit of ethmoid sinusitis, soft tissues behind orbital septum infected vs. anterior to septum in commoner pre-septal cellulitis. can be infection spread from elsewhere e.g. dental infection via intermediary maxillary sinusitis, distant bacteraemia, direct inoculation from trauma-developing within 72hrs of injury, and occasionally pre-septal cellulitis spread-more common in children-orbital septum not fully developed.

Question 17

gold standard for orbital abscess diagnosis e.g. following spread of ethmoid sinus infection?

Answer 17

CT scan of sinuses and orbit

Question 18

management of orbital cellulitis and orbital abscess?

Answer 18

admission to hospital
IV antibiotics e.g. cefotaxime and flucloxacillin
nasal decongestents
urgent surgical drainage of any abscess

Question 19

why is a CT of the sinuses NOT good for diagnosing nasal polyps, although required if planned surgery or atypical features to hx or examination?

Answer 19

large numbers of asymptomatic patients have sinus changes on CT scanning.

Question 20

what are nasal polyps?

Answer 20

oedematous mucosal masses, inflammatory if assoc. with chronic rhinosinusitis
most frequently arise from ethmoid cells and prolapse into the nose via the middle meatus (anterior ethmoid sinus, plus frontal and maxillary sinuses drain into middle meatus)
usually bilateral and painless
suspect neoplasia if unilateral and haemorrhage

Question 21

predisposing factors to chronic rhinosinusitis with or without nasal polyps?

Answer 21

allergy e.g. allergic rhinitis, eczema, asthma
infections-s.aureus, strep pneumonia and fungal infections
immunocompromised host
aspirin hypersensitivity
ciliary impairment e.g. in cystic fibrosis
anatomical abnormalities e.g. septal deviation and abnormal uncinate process leading to narrow infundibulum and osteomeatal complex occlusion
trauma-nasal sinus fracture, surgical-oroantral fistula
atmospheric irritants e.g. smoking, dusts, fumes
FB in nose or sinuses
swimming and diving
hormonal-pregnancy-nasal congestion high due to oestrogen and progesterone effect on nasal mucosal vascularity, and hypothyroidism

Question 22

symptoms of nasal polyps?

Answer 22

progressive nasal obstruction
rhinorrhoea
maybe hx of recurrent sinusitis due to ostial blockage
hyposmia and anosmia
ontological symptoms may occur

Question 23

management of nasal polyps and chronic rhinosinusitis?

Answer 23

avoid possible allergens
topical nasal corticosteroids=mainstay of medical management to improve symptoms and reduce recurrence post surgery-nasal drops. limited risk of systemic absorption with fluticasone and mometasone, both growth monitoring advised in children e.g. CF patients with nasal polyps.
antihistamines for allergic rhinitis
nasal douche (saline rinsing of nasal passages)
oral steroids (1 wk course) in severe cases e.g. in medical polypectomy regimen to treat large polyps, with topical steroids, also may use post surgery
oral Abx e.g. doxycycline

surgery-functional endoscopic sinus surgery to improve ventilation/drainage of sinuses
nasal polypectomy
may consider other procedures to improve nasal airways e.g. septoplasty and reduction of inferior turbinates.

Question 24

what must be excluded in the presentation of a child with a foul-smelling unilateral nasal discharge?

Answer 24

nasal foreign body

Question 25

nasal polyps are very rare in children, therefore if found, what investigation should be performed?

Answer 25

investigate for cystic fibrosis with sweat test-looking for Cl- concentration of more than 60mmol/L.

Question 26

what characteristics of epistaxis would prompt you to consider a posterior bleed?

Answer 26

profuse bleeding
BOTH nostrils
bleeding site cannot be identified on speculum examination

patient needs hospital admission

Question 27

where is kiesselbach’s plexus? what does it comprise?

Answer 27

localised at anterior portion of nasal septum
rich anastomotic supply formed here by end arteries: anterior and posterior ethmoidal (from ophthalmic from ICA), greater palatine (from maxillary from ECA), sphenopalatine (from maxillary from ECA) and superior labial (from facial from ECA)

Question 28

what condition do we think about in the presentation of recurrent epistaxis along with lip and tongue petechiae?

Answer 28

hereditary haemorrhagic telangiectasia (osler-weber-rendu disease)
patients may also present with haematuria, melaena, Fe deficiency anaemia-SOB, fatigue, palpitations, headache, dizziness, and SA or cerebral haemorrhage.

Question 29

how are pts managed following epistaxis which resolved with 1st aid care?

Answer 29

consider topical antiseptic to reduce crusting and vestibulitis-naseptin QDS for 10 days, NOT if peanut allergy-instead could give mupirocin
self-care advice-for next 24hrs don’t blow or pick nose, heavy lift, strenuous exercise, lie flat or drink alcohol or hot drinks, avoid blowing nose for few hrs post nasal cautery
consider admission or r/f to secondary care e.g. if child under 2-more likely underlying cause, if underlying cause likely or systemic disease e.g. CAD or HTN.

Question 30

epistaxis still ongoing after 15 mins, next management?

Answer 30

nasal cautery-silver nitrate or electrocautery. use topical LA spray with vasoconstrictor e.g. phenylephrine, before cauterising. cauterise 1 side of septum only to avoid nasal septal perforation.
nasal packing if cautery unsuccessful or bleeding point cannot be seen

Question 31

what potential lethal complication can occur with a septal haematoma?

Answer 31

cavernous sinus thrombosis if an infection occurs

Question 32

nasal speculum used in assessment of epistaxis, what is the other name given to a nasal speculum?

Answer 32

thudicums nasal speculum

Question 33

in terms of epistaxis, why are posterior bleeds more concerning than anterior bleeds?

Answer 33

posterior result of bleeding from deeper areas, bleeds tend to be more profuse with greater risk of AIRWAY compromise
anterior-*kiesselbach’s plexus

Question 34

typical person affected by a juvenile angiofibroma?

Answer 34

adolescent male

=highly vascular benign tumour, px-epistaxis, headaches, rhinorrhoea, nasal obstruction, anosmia

Question 35

why should facial pain and otalgia be enquired about in hx of pt with epistaxis?

Answer 35

may be presenting features of a NP carcinoma

Question 36

complications of nasal packing for epistaxis managment?

Answer 36

anosmia
pack falling out and continued bleeding
breathing difficulties and clot aspiration
posterior migration of the pack, causing airway obstruction and asphyxia
nasal septum perforation or pressure necrosis of cartilage
nasal packs are usually left for two or three days and the patient should see an ENT specialist. The blood is an excellent culture medium for bacteria and so BS Abx e.g. amoxicillin, usually given.

Question 37

usual blood vessels involved in posterior bleeds causing epistaxis?

Answer 37

arterial bleeding (anterior bleeds usually capillary or venous bleeding) usually branches of sphenopalatine artery in posterior nasal cavity or nasopharynx.

Question 38

what vessels are implicated in posterior nosebleeds?

Answer 38

branches of the sphenopalatine artery

bleeds are less common but more serious as blood can cause airway obstruction, also more likely to result in haematemesis.