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Neurology and Special Senses > Nose and Sinuses > Flashcards

Nose and Sinuses Flashcards

1
Q

What makes up the nose?

A 
Quadrangular Cartilage
Perpendicular plate of the Ethmoid (septum)
Vomer (Septum)
Nasal bones
Maxilla
Palatine bones
Cartilage - minor and major alar, lateral
Fibro-fatty tissue
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2
Q

What vessels supply the nose with blood?

A

Anterior and Posterior Ethmoidal (from opthalmic artery)
Sphenopalatine
Superior Labial
Branch of Greater Palatine

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3
Q

What is Littles/Kiesselbach’s area?

A

Vascular area in anterior 1/3 of septum

Receives supply from all nasal arteries

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4
Q

How can the causes of epistaxis be split up?

A

Local

Systemic

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5
Q

What are the local causes of epistaxis?

A 
Idiopathic (85%)
Trauma
Iatrogenic
Foreign Body
Inflammatory - Polyps, Rhinitis
Neoplastic
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6
Q

What are some systemic causes of epistaxis?

A

Hypertension
Coagulopathies
Vasculopathies
Hereditary Haemorrhagic Telangiectasia/Osler-Weber-Rendu

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7
Q

How is epistaxis managed?

A

First Aid - head forward, pinch nose, ice on forehead/back of neck

Examine - anterior or posterior bleed
Conservative options
Surgical options

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8
Q

What are the conservative management options for epistaxis?

A

Cautery - Silver nitrate/bipolar diathermy
Tranexamic acid
Anterior bleed - anterior rhinoscopy
Posterior bleed - rigid endoscope

Packing - if cautery fails
Initially anterior pack but if continue then posterior pack too

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9
Q

What surgical/radiological options are there for managing epistaxis?

A

Surgical ligation or radiological embolisation of:

Sphenopalatine
Anterior ethmoidal artery (ligated only)
Internal maxillary artery

Last line - external carotid

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10
Q

How can nasal trauma be complicated?

A

Septal haematoma

CSF leak

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11
Q

What is CSF Rhinorrhoea associated with?

A

Basilar skull fracture

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12
Q

How can nasal trauma be managed?

A

ABC - epistaxis normally self limit
Examine septal haematoma
No X-Ray needed
If nose deviated - MUA within 2 weeks, can do septoplasty

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13
Q

What are the 4 paranasal sinuses?

A

Ethmoidal
Sphenoidal
Maxillary
Frontal

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14
Q

What important structures are around the paranasal sinuses?

A

Lamina papyracea - medial wall of the orbit
Anterior cranial fossa
Internal carotid artery

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15
Q

What does the sphenoid sinus drain into?

A

Spheno-ethmoid recess

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16
Q

What do the posterior ethmoid cells drain into?

A

Superior Meatus

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17
Q

What drains into the middle meatus?

A

Anterior ethmoid cells
Maxillary sinus
Frontal Sinus

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18
Q

What drains into the inferior meatus?

A

Nasolacrimal duct

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19
Q

What complications can arise from sinus sugery?

A

Damage to the orbit - Lateral to ethmoid and superior to maxillary sinus

Anterior skull base can be breached –> CSF leak/brain damage

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20
Q

Where can infective sinusitus spread?

A

Orbit –> periorbital sinusitis

Intracranially - esp. if frontal sinus. Lead to meningitis or intracranial abscess

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21
Q

What is Rhinosinusitis?

A

Inflammation of the nose and paranasal sinus characterised by:
2+ symptoms AND
Endoscopic signs or CT changes

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22
Q

What symptoms are characteristic of Rhinosinusitis?

A

Nasal blockage/discharge
Nasal drip - anterior or posterior
Facial pain/pressure
Reduced/loss of smell

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23
Q

What Endoscopic signs and CT changes can be seen in Rhinosinusitis?

A

Endoscopic - Polyps, mucopurulent discharge, oedema in middle meatus

CT - Meatus changes in osteomeatal complex or sinuses

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24
Q

How can rhinosinusitis be characterised?

A

Acute or Chronic

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25
Q

What is Acute Rhinosinusitis (ARS)?

A

<12 week complete resolution of symptoms

viral or non viral

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26
Q

What is Chronic Rhinosinusitis (CRS)?

A

12 without complete symptom resolution

With or without polyps

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27
Q

What commonly causes Viral Acute Rhinosinusitis (common cold)?

A

Rhinovirus or Influenza virus

Normally resolve within 5 days

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28
Q

What causes Non Viral Acute rhinosinusitis?

A

Strep Pneumoniae, H Influenzae, Moraxella Catarrhalis

Last longer than 5 days

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29
Q

How is viral acute rhinosinusitis managed?

A

Analgesia if req.
Nasal decongestants - no more than 5 days
Warm compress

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30
Q

What predisposes people to chronic rhinosinusitis?

A 
Allergy
Infection - S aureus, strep pneumoniae, fungal
Ciliary impairment - CF
Anatomical abnormality - septal deviation, abnormal uncinate process etc.
Immunocompromised
Aspirin hypersensitivity
Atmospheric irritants
Hormonal issues
Trauma
Swimming, Foreign body
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31
Q

What is a nasal polyp?

A

Abnormal mass found in the nose

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32
Q

What are polyps associated with chronic rhinosinusitis due to?

A

Inflammation

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33
Q

When do nasal polyps require biopsy?

A

Worrying signs if bilateral

Any unilateral polyp

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34
Q

How does chronic rhinosinusitis present?

A

Facial pain - worse on bending forward
Nasal discharge - thick and purulent
Nasal obstruction - mouth breathing
Post nasal drip - chronic cough

35
Q

How is chronic rhinosinusitis diagnosed?

A

Skin prick test - allergy suspected

Radiology - CT (not diagnostic as asymptomatic patients can have changes). Plain X-ray has no use

36
Q

How is chronic rhinosinusitis managed?

A

Symptomatic management

Conservative - avoid allergens, nasal douching

Medical - Antihistamines, topical steroids (beclametasone, budesonide), oral steroids (1 week if severe), oral antibiotics

Surgical - Nasal polypectomy (high recurrence), functional endoscopic sinus surgery (improve ventilation/draining of sinuses), septoplasty and turbinate reduction (improve airway)

37
Q

What is allergic rhinitis?

A

IgE mediated hypersensitivity reaction in the mucous membranes of the nasal airways

38
Q

How can allergic rhinitis be cyclical?

A

Seasonal - summer hayfever

Perennial - seasonal exacerbations

39
Q

What are some common allergens associated with allergic rhinitis?

A

Pollen
Mould
House dust mites
Animal epithelia

40
Q

Describe the pathophysiology of allergic rhinitis

A

IgE mediated inflammation of nasal mucosa.

Allergen detection stimulate:

Release of prostaglandin D and leukotrienes
Mast cell degranulation - release of histamine

41
Q

How does allergic rhinitis present?

A

Bilateral symptoms worse on waking

  • congestion
  • itchy nose
  • sneezing
  • clear/yellow discharge
  • Posterior nasal drip
  • Watery red eyes

nasal mucose swollen and grey on examination

42
Q

How is allergic rhinitis scored?

A 
ARIA score (allergic rhinitis and its impact on asthma)
Duration of symptoms - intermittent and persistent
Severity of symptoms - mild, moderate to severe
43
Q

What would be classified as mild allergic rhinitis?

A

Normal daily activities and sleep

No troublesome symptoms

44
Q

How would you investigate allergic rhinitis?

A

Diagnosis from history
Skin prick test and IgE testing via ELISA - specific allergens
RAST blood test - if skin prick test not possible

45
Q

How is allergic rhinitis managed?

A

Conservative - allergen avoidance, nasal douching

PRN - topical nasal antihistamines (if >5yo)
Reg. preventative - cetirizine (non drowsy anti histamine)
Nasal blockage - topical nasal steroids (careful!)

Topical nasal decongestants for 1 week max
Desensitise - gradual exposure to increasing amounts of allergen

46
Q

Where can epistaxis occur?

A

Anterior - 95% commonly from kiesselbach’s plexus

Posterior - normally in elderly, profuse bleeding and airway risk

47
Q

What is important to know about nasal packing?

A

Leave in for 2/3 days

Need to give amoxicillin as well - bad for culturing bacteria

Complications include:

  • anosmia
  • clot aspiration
  • posterior migration of pack leading to airway obstruction
  • perforation of septum
48
Q

What are some causes for nasal trauma?

A

Car accident
Sports injuries
Falls - elderly
Child abuse

49
Q

How would you assess nasal trauma?

A

Look for other facial injuries and possible head trauma

  • Rhinorrhoea
  • Epistaxis
  • Septal Haematoma
  • Septal deviation
  • Ophthalmoplegia
  • Facial anaesthesia
50
Q

How would you investigate nasal trauma?

A

No need for imagine - fractures are a clinical diagnosis

Just start management

51
Q

How is nasal trauma managed?

A

If no significant swelling/deformity - simple analgesics

Deviation –> refer to ENT within a week - allow time for swelling to go down

Laceration - Abx

Septal haematoma - incision needed

52
Q

When/where should you refer nasal trauma?

A

ENT - marked deviation, epistaxis not stopping or septal haematoma

Neuro - rhinorrhoea

Max fax if facial fractures/anaesthesia

53
Q

What would widened inter-cantal distance suggest?

A

Nasoethmoidal fracture which needs surgical repair?

54
Q

How does septal perforation present?

A 
Nasal whistling sound
Discharge
Congestion
Infection
Epistaxis
55
Q

What can cause nasal perforation?

A 
Nose picking
Untreated septal haematoma
Iatrogenic - intubation
Malignancy
Ulcers
Cocaine sniffing
Intranasal steroid sprays
56
Q

How are septal perforations managed?

A

Symptomatic:

  • nasal douching - reduce crusting and bleeding
  • nasal emollients

Surgical options if quality of life severely affected

57
Q

How do nasal foreign bodies present?

A

Witnessed event - at time

Later - hx of nasal obstruction or persistent unilateral offensive discharge

58
Q

When should nasal foreign bodies be referred to ENT?

A

History of prolonged unilateral discharge

FB in posterior position

Child uncooperative

BUTTON BATTERIES REQ. IMMEDIATE ATTENTION

59
Q

How would you get out a nasal foreign body?

A

Topical anaesthetic and vasoconstrictor spray - reduce swelling

  • Positive pressure blown through nose - parents blow into mouth while unaffected nostril obstructed
  • Nasal speculum and hook/forceps
  • Suction
  • Pass narrow balloon catheter past FB, inflate and retract
60
Q

What are some differentials for nasal obstruction with discharge?

A 
Rhinitis - infective, allergic, non-allergic, rhinosinusitis
Rebound congestion
FB
Septal deviation, perforation, haematoma
Occlusion of nasal valve
Hypertrophy of turbinate/adenoids
Polyps
Neoplasm
CSF rhinorrhoea
61
Q

When does nasal obstruction with discharge require urgent investigation?

A

Unilateral

Blood tinged

62
Q

What is rhinitis?

A

Mucosal swelling
Increased volume and viscosity of secretions
Impaired ciliary function

63
Q

What is req. to diagnose rhinitis?

A

> =2 of:

  • Discharge
  • Sneezing
  • Nasal itching
  • Congestion
64
Q

What are the 3 categories of allergic rhinitis?

A

Seasonal - hayfever
Persistent - dust mites/pets
Occupational - flour, wood dust

65
Q

How can allergic rhinitis be classified?

A

Intermittent - symptoms <4 dyas per week + <4 weeks

Persistent >4 days pw and >4 weeks

66
Q

What is the acute phase response in allergic rhinitis?

A

Sneezing followed by secretions

67
Q

What is the late phase response in allergic rhinitis?

A

6-12 hours after you get nasal congestion

68
Q

What risk factors are associated with allergic rhinitis?

A

Atopy
Smoker - active or passive
Air pollution
Family Hx of atopy

69
Q

When does each type of pollen tend to affect people the most?

A

Tree - Spring

Grass - late spring - early summer

Weed - early spring - early autumn

70
Q

What are some causes of non allergic rhinitis?

A 
Vasomotor
Hormonal
NARES - non-allergic rhinitis with eosinophilia syndrome
Occupational
Gustatory
Drug induced
71
Q

What happens in vasomotor rhinitis?

A

Vascular engorgement and watery rhinorrhoea

Associated with weather changes and stress

Nasal mucosa bright red/purple

72
Q

How is vasomotor rhinitis managed?

A

Humidified air

1 Topical antihistamines
2 Topical steroids

73
Q

When is hormonal rhinitis seen?

A

Increased oestrogen:

  • Pregnancy
  • Menstruation
  • Puberty

Hypothyroidism

74
Q

What is NARES and how is it managed?

A

Eosinophilic reaction without evidence of allergy

Steroid nasal spray

75
Q

What can cause occupational rhinitis and how is it managed?

A

Metal salts
Animal dander
Wood dust

Avoid trigger
Topical antihistamines/steroids

76
Q

What causes gustatory rhinitis? How is it managed?

A

After eating spicy foods
Can be caused by other food

Use ipatropium bromide nasal spray

77
Q

What causes drug induced rhinitis? How is it managed?

A

Rebound congestion after topical decongestant use

Many other drugs also cause rhinitis

Stop drug - 7-21 days to resolve. Use topical steroids in this time

78
Q

How is non-viral rhinosinusitis managed?

A

Topical nasal steroids - not for duration of illness

Oral abx - little evidence:
1 Phenoxymethylpenicillin
2 Co-amoxiclav

79
Q

What is aspirin sensitivity associated with?

A

Rhinosinusitis
Polyps
Asthma

80
Q

Where a polyps commonly seen?

A

Clefts of middle meatus

81
Q

How do polyps appear on examination?

A

Sac like entities

Pale - poor blood supply, become fleshy and red over time (squamous metaplasia)

Not sensitive to touch

Yellowish grey

Can get between them and side wall of nose

Grape like structures

Nasal bridge may appear widened

82
Q

What do very large polyps appear like?

A

Grow down into oropharynx

Visible with tongue depressor

83
Q

How are polyps managed?

A

Topical nasal steroid drops

Can do surgical options as with chronic rhinosinusitis

Neurology and Special Senses (28 decks)

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