Nose and sinus problems

Question 1

What can cause obstruction to drainage of paranasal sinuses?

Answer 1

Anatomical- septal deviation, polyps

Mucosal- viral infection causing mucosal oedema

Question 2

What are the features of acute bacterial rhinosinusitis?

Answer 2

Discoloured discharge and purulent secretion in the nasal cavity
Severe local pain
Fever (>38)
Elevated CRP/ESR
Double sickening- i.e. deterioration after milders symptoms

Question 3

Is swelling a common feature of sinusitis?

Answer 3

No- visible swelling is uncommon. Exclude cancers or dental root infections

Question 4

What are some organisms causing rhinosinusitis?

Answer 4

S.pneumoniae
H.infuenzae
S.aureus

98% of causes of are viral

Question 5

What investigations might be considered for recurrent acute or chronic sinusitis?

Answer 5

CT of the paranasal sinuses

Nasal endoscopy

Question 6

What is the management for acute sinusitis?

Answer 6

98% case are viral and self limiting, taking around 2.5 weeks to resolve

Simple analgesia
Nasal saline irrigation
Nasal decongestants e.g.ephedrine 0.5% max 1 week
Intranasal corticosteroids- if severe symptoms or have been present for more than 10 days.

If bacterial infection suspected give ABx- amoxicillin or doxycycline.

Smoking cessation is also beneficial and should be recommended

Question 7

What might be done for recurrent sinusitis?

Answer 7

Imaging and consideration for surgery- e.g. endoscopic sinus surgery.

Question 8

What are some complications of sinusitis?

Answer 8

Orbital cellulitis/abscess
Intra-cranial involvement- meningitis, encephalitis, cerebral abscess, cavernous sinus thrombosis
Mucocele- sinus may become a pus filled cavity
Osteomyelitis- bone infection

Question 9

When should intra-nasal corticosteroids be considered for sinusitis

Answer 9

If symptoms persist for 10 days or more or the symptoms are severe

Question 10

What is sinusitis?

Answer 10

Inflammation of the mucosal surfaces of the paranasal sinuses

Question 11

Why might patients who smoke be at increased risk of developing sinusitis?

Answer 11

Smoking decreases the motility of the cilia and so decreases clearance which increases the risk of developing infection

Question 12

What are the symptoms of acute sinusitis?

Answer 12

Facial pain- typically frontal pressure pain which worsens when bending forward
Nasal discharge- thick and purulent
Nasal obstruction

Question 13

If a bacterial cause is suspected in acute sinusitis what antibiotics may be prescribed?

Answer 13

Phenoxymethylpenicillin

Co-amoxiclav is systemically very unwell, signs and sx of a more serious illness or at high risk of complications

Question 14

What are some warning flags for cancer of the paranasal sinuses?

Answer 14

Bleeding
Blood stained nasal discharge
Unilateral nasal obstruction
Swelling
Any signs of local invasion

Question 15

What are some factors that are associated with nasal polyps?

Answer 15

Asthma- particularly late onset
Aspirin sensitivity
Infective sinusitis
Cystic fibrosis
Kartagener's syndrome

Question 16

What are some symptoms of nasal polyps?

Answer 16

Nasal obstruction
Rhinorrhoea
Sneezing
Poor sense of taste and smell- a large amount of taste comes from the sense of smell

Polyps are concerning if any of the features are occuring unilaterally

Question 17

What should the management be fore all patients with suspected nasal polyps?

Answer 17

Refer to ENT for a full examination as they could be cancerous. Nasal endoscopy will be carried out.

Topical corticosteroids can be used to shrink the polyps in around 80% of patients

Question 18

What is rhinosinusitis?

Answer 18

Inflammation of the nasal cavity and paranasal sinuses

Question 19

What are the symptoms of rhinosinusitis?

Answer 19

Blockage
Obstruction
Congestion
Nasal discharge
Facial pain or pressure (esp with sinusitis)
Reduction in sense of taste/smell

Question 20

When might intranasal corticosteroids be considered for acute rhinosinusitis?

Answer 20

If symptoms persist for more than 5 days

E.g. Mometasone, fluticasone

Normally this is a self limiting infection

Question 21

What are nasal polyps?

Answer 21

Swellings of the nasal or sinus mucosa that prolapses into the nasal cavity

Question 22

Why is a unilateral poly concerning?

Answer 22

Polyps usually occur bilaterally and so a unilateral polyp could be a sign of malignancy.

Any persistent unilateral bleeding/obstruction/blood stained discharge is concerning

Question 23

What are the symptoms of nasal polyps with associated chronic rhinosinusitis?

Answer 23

Rhinorrhoea 
Sneezing
Nasal obstruction
Recurrent/chronic sinusitis
Mouth breathing
Snoring
Headaches

Question 24

What should be done for any patient presenting with nasal polyps?

Answer 24

Referral to ENT for full evaluation

Question 25

What investigations should be done for nasal polyps?

Answer 25

Anterior rhinoscopy Nasal endoscopy If there is any suspicion of cancerous lesion/unilateral polyp a biopsy should be taken

Question 26

What are the treatment options for nasal polyps

Answer 26

Topical steroid drops/spray e.g. fluticasone, betamethasone Surgical- Endoscopic sinus surgery to relieve any obstructions

Question 27

Why might nasal polyps be a cause of chronic sinusitis?

Answer 27

The outflow from the sinuses is obstructed and this leads to recurrent/chronic infection

Question 28

What are some conditions nasal polyps are associated with?

Answer 28

``` Allergic rhinitis Non-allergic rhinitis Chronic ethmoid sinusitis Cystic fibrosis Aspirin hypersensitivity Asthma ```

Question 29

What is the management for chronic rhinosinusitis without nasal polyps?

Answer 29

Intranasal corticosteroids Nasal saline irrigation Consider taking samples for MC+S testing in case of bacterial infection of the mucosa Surgery if failure of medical therapy

Question 30

What is allergic rhinitis?

Answer 30

This is inflammation of the nasal mucosa due to allergic processes. This is IgE mediated allergy.

Question 31

What are some symptoms of allergic rhinitis?

Answer 31

Sneezing Rhinorrhoea Pruritus Bilateral itchy and red eyes

Question 32

What is the management for allergic rhinitis?

Answer 32

Allergen avoidance where possible Nasal saline irrigation to wash out the allergens Antihistamines e.g. Loratadine Intranasal steroid sprays e.g. Fluticasone Oral steroids e.g. Prednisolone (short course) Immunotherapy for severe cases not responding Desensitisation

Question 33

What are some causes of allergic rhinitis?

Answer 33

Pollens Animal dander House dust mite

Question 34

What else might you want to ask about in a history for allergic rhinitis?

Answer 34

Any history of atopy e.g. Eczema, Asthma or Allergic Rhinitis

Question 35

What are some other causes of nasal congestion?

Answer 35

``` Think of any cause of obstruction Foreign body Tumour Large adenoids Polyps Deviated nasal septum ```

Question 36

What type of hypersensitivity reaction is allergic rhinitis?

Answer 36

Type I- IgE mediated

Question 37

What can be done to test for the causative organism of allergic rhinitis?

Answer 37

Skin prick testing