Nose and Sinuses Flashcards
What makes up the nose?
Quadrangular Cartilage Perpendicular plate of the Ethmoid (septum) Vomer (Septum) Nasal bones Maxilla Palatine bones Cartilage - minor and major alar, lateral Fibro-fatty tissue
What vessels supply the nose with blood?
Anterior and Posterior Ethmoidal (from opthalmic artery)
Sphenopalatine
Superior Labial
Branch of Greater Palatine
What is Littles/Kiesselbach’s area?
Vascular area in anterior 1/3 of septum
Receives supply from all nasal arteries
How can the causes of epistaxis be split up?
Local
Systemic
What are the local causes of epistaxis?
Idiopathic (85%) Trauma Iatrogenic Foreign Body Inflammatory - Polyps, Rhinitis Neoplastic
What are some systemic causes of epistaxis?
Hypertension
Coagulopathies
Vasculopathies
Hereditary Haemorrhagic Telangiectasia/Osler-Weber-Rendu
How is epistaxis managed?
First Aid - head forward, pinch nose, ice on forehead/back of neck
Examine - anterior or posterior bleed
Conservative options
Surgical options
What are the conservative management options for epistaxis?
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
What surgical/radiological options are there for managing epistaxis?
Surgical ligation or radiological embolisation of:
Sphenopalatine
Anterior ethmoidal artery (ligated only)
Internal maxillary artery
Last line - external carotid
How can nasal trauma be complicated?
Septal haematoma
CSF leak
What is CSF Rhinorrhoea associated with?
Basilar skull fracture
How can nasal trauma be managed?
ABC - epistaxis normally self limit
Examine septal haematoma
No X-Ray needed
If nose deviated - MUA within 2 weeks, can do septoplasty
What are the 4 paranasal sinuses?
Ethmoidal
Sphenoidal
Maxillary
Frontal
What important structures are around the paranasal sinuses?
Lamina papyracea - medial wall of the orbit
Anterior cranial fossa
Internal carotid artery
What does the sphenoid sinus drain into?
Spheno-ethmoid recess
What do the posterior ethmoid cells drain into?
Superior Meatus
What drains into the middle meatus?
Anterior ethmoid cells
Maxillary sinus
Frontal Sinus
What drains into the inferior meatus?
Nasolacrimal duct
What complications can arise from sinus sugery?
Damage to the orbit - Lateral to ethmoid and superior to maxillary sinus
Anterior skull base can be breached –> CSF leak/brain damage
Where can infective sinusitus spread?
Orbit –> periorbital sinusitis
Intracranially - esp. if frontal sinus. Lead to meningitis or intracranial abscess
What is Rhinosinusitis?
Inflammation of the nose and paranasal sinus characterised by:
2+ symptoms AND
Endoscopic signs or CT changes
What symptoms are characteristic of Rhinosinusitis?
Nasal blockage/discharge
Nasal drip - anterior or posterior
Facial pain/pressure
Reduced/loss of smell
What Endoscopic signs and CT changes can be seen in Rhinosinusitis?
Endoscopic - Polyps, mucopurulent discharge, oedema in middle meatus
CT - Meatus changes in osteomeatal complex or sinuses
How can rhinosinusitis be characterised?
Acute or Chronic
What is Acute Rhinosinusitis (ARS)?
<12 week complete resolution of symptoms
viral or non viral
What is Chronic Rhinosinusitis (CRS)?
12 without complete symptom resolution
With or without polyps
What commonly causes Viral Acute Rhinosinusitis (common cold)?
Rhinovirus or Influenza virus
Normally resolve within 5 days
What causes Non Viral Acute rhinosinusitis?
Strep Pneumoniae, H Influenzae, Moraxella Catarrhalis
Last longer than 5 days
How is viral acute rhinosinusitis managed?
Analgesia if req.
Nasal decongestants - no more than 5 days
Warm compress
What predisposes people to chronic rhinosinusitis?
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
What is a nasal polyp?
Abnormal mass found in the nose
What are polyps associated with chronic rhinosinusitis due to?
Inflammation
When do nasal polyps require biopsy?
Worrying signs if bilateral
Any unilateral polyp
How does chronic rhinosinusitis present?
Facial pain - worse on bending forward
Nasal discharge - thick and purulent
Nasal obstruction - mouth breathing
Post nasal drip - chronic cough
How is chronic rhinosinusitis diagnosed?
Skin prick test - allergy suspected
Radiology - CT (not diagnostic as asymptomatic patients can have changes). Plain X-ray has no use
How is chronic rhinosinusitis managed?
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)
What is allergic rhinitis?
IgE mediated hypersensitivity reaction in the mucous membranes of the nasal airways
How can allergic rhinitis be cyclical?
Seasonal - summer hayfever
Perennial - seasonal exacerbations
What are some common allergens associated with allergic rhinitis?
Pollen
Mould
House dust mites
Animal epithelia
Describe the pathophysiology of allergic rhinitis
IgE mediated inflammation of nasal mucosa.
Allergen detection stimulate:
Release of prostaglandin D and leukotrienes
Mast cell degranulation - release of histamine
How does allergic rhinitis present?
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
How is allergic rhinitis scored?
ARIA score (allergic rhinitis and its impact on asthma) Duration of symptoms - intermittent and persistent Severity of symptoms - mild, moderate to severe
What would be classified as mild allergic rhinitis?
Normal daily activities and sleep
No troublesome symptoms
How would you investigate allergic rhinitis?
Diagnosis from history
Skin prick test and IgE testing via ELISA - specific allergens
RAST blood test - if skin prick test not possible
How is allergic rhinitis managed?
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
Where can epistaxis occur?
Anterior - 95% commonly from kiesselbach’s plexus
Posterior - normally in elderly, profuse bleeding and airway risk
What is important to know about nasal packing?
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
What are some causes for nasal trauma?
Car accident
Sports injuries
Falls - elderly
Child abuse
How would you assess nasal trauma?
Look for other facial injuries and possible head trauma
- Rhinorrhoea
- Epistaxis
- Septal Haematoma
- Septal deviation
- Ophthalmoplegia
- Facial anaesthesia
How would you investigate nasal trauma?
No need for imagine - fractures are a clinical diagnosis
Just start management
How is nasal trauma managed?
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
When/where should you refer nasal trauma?
ENT - marked deviation, epistaxis not stopping or septal haematoma
Neuro - rhinorrhoea
Max fax if facial fractures/anaesthesia
What would widened inter-cantal distance suggest?
Nasoethmoidal fracture which needs surgical repair?
How does septal perforation present?
Nasal whistling sound Discharge Congestion Infection Epistaxis
What can cause nasal perforation?
Nose picking Untreated septal haematoma Iatrogenic - intubation Malignancy Ulcers Cocaine sniffing Intranasal steroid sprays
How are septal perforations managed?
Symptomatic:
- nasal douching - reduce crusting and bleeding
- nasal emollients
Surgical options if quality of life severely affected
How do nasal foreign bodies present?
Witnessed event - at time
Later - hx of nasal obstruction or persistent unilateral offensive discharge
When should nasal foreign bodies be referred to ENT?
History of prolonged unilateral discharge
FB in posterior position
Child uncooperative
BUTTON BATTERIES REQ. IMMEDIATE ATTENTION
How would you get out a nasal foreign body?
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
What are some differentials for nasal obstruction with discharge?
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
When does nasal obstruction with discharge require urgent investigation?
Unilateral
Blood tinged
What is rhinitis?
Mucosal swelling
Increased volume and viscosity of secretions
Impaired ciliary function
What is req. to diagnose rhinitis?
> =2 of:
- Discharge
- Sneezing
- Nasal itching
- Congestion
What are the 3 categories of allergic rhinitis?
Seasonal - hayfever
Persistent - dust mites/pets
Occupational - flour, wood dust
How can allergic rhinitis be classified?
Intermittent - symptoms <4 dyas per week + <4 weeks
Persistent >4 days pw and >4 weeks
What is the acute phase response in allergic rhinitis?
Sneezing followed by secretions
What is the late phase response in allergic rhinitis?
6-12 hours after you get nasal congestion
What risk factors are associated with allergic rhinitis?
Atopy
Smoker - active or passive
Air pollution
Family Hx of atopy
When does each type of pollen tend to affect people the most?
Tree - Spring
Grass - late spring - early summer
Weed - early spring - early autumn
What are some causes of non allergic rhinitis?
Vasomotor Hormonal NARES - non-allergic rhinitis with eosinophilia syndrome Occupational Gustatory Drug induced
What happens in vasomotor rhinitis?
Vascular engorgement and watery rhinorrhoea
Associated with weather changes and stress
Nasal mucosa bright red/purple
How is vasomotor rhinitis managed?
Humidified air
1 Topical antihistamines
2 Topical steroids
When is hormonal rhinitis seen?
Increased oestrogen:
- Pregnancy
- Menstruation
- Puberty
Hypothyroidism
What is NARES and how is it managed?
Eosinophilic reaction without evidence of allergy
Steroid nasal spray
What can cause occupational rhinitis and how is it managed?
Metal salts
Animal dander
Wood dust
Avoid trigger
Topical antihistamines/steroids
What causes gustatory rhinitis? How is it managed?
After eating spicy foods
Can be caused by other food
Use ipatropium bromide nasal spray
What causes drug induced rhinitis? How is it managed?
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
How is non-viral rhinosinusitis managed?
Topical nasal steroids - not for duration of illness
Oral abx - little evidence:
1 Phenoxymethylpenicillin
2 Co-amoxiclav
What is aspirin sensitivity associated with?
Rhinosinusitis
Polyps
Asthma
Where a polyps commonly seen?
Clefts of middle meatus
How do polyps appear on examination?
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
What do very large polyps appear like?
Grow down into oropharynx
Visible with tongue depressor
How are polyps managed?
Topical nasal steroid drops
Can do surgical options as with chronic rhinosinusitis
