Nose Conditions Flashcards
Nasal Polyps: Definition
Benign swellings of nasal mucosa of paranasal sinus - associated with chronic sinusitis
Nasal Polyps: Risk Factors
Asthma
Aspirin sensitivity
Genetics
Cystic fibrosis
Often associate with chronic sinusitis
Not associated with allergy
Nasal Polyps: Symptoms
Nasal obstruction»_space; usually bilateral
Nasal discharge
Reduced sense of smell
Cough
Nasal Polyps: Signs
Visualization of nasal polyps during physical examination
Nasal Polyps: Investigation
Clinical diagnosis based on examination.
Nasal endoscopy: Useful if polyps are not visualized via anterior rhinoscopy.
CT scan of the sinuses: Indicated if polyps are unilateral (requires a 2-week referral for evaluation).
Nasal Polyps: Management
First-Line Treatment- Intranasal corticosteroids
Daily use for 3 months followed by re-evaluation.
Continue indefinitely with reviews every 6 months.
Second-Line Treatment- Surgical polypectomy
Allergic Rhinitis: Definition
Seasonal allergies
Acute phase»_space; minutes»_space; sneezing and nasal secretion or 15-20 minutes
Late phase»_space; nasal obstruction for 6-12 hours
Seasonal (hay fever), perennial (persistent), occupational (due to exposure to allergens at work)
Allergic Rhinitis: Epidemiology
It affects approximately 26% of UK adults and 10% of 6- and 7-year-olds.
Allergic Rhinitis: Aetiology
Allergic rhinitis is an IgE-mediated inflammatory disorder of the nasal mucosa.
When sensitized to allergens, the nasal mucosa releases histamines, causing typical symptoms of allergic rhinitis.
Allergic Rhinitis: Risk Factors
Genetic Predisposition
Environmental Triggers-
House dust mites
Grass, tree, weed pollen
Moulds
Animal dander
Allergic Rhinitis: Symptoms
Seasonal or perennial presentation
Sneezing
Nasal itching
Rhinorrhoea»_space; runny nose
Postnasal drip»_space; mucus drips down throat
Nasal congestion
Cough
Bilateral eye itching, watering, redness
Allergic Rhinitis: Signs
Oedematous nasal mucosa with greyish discoloration
Nasal discharge
Nasal polyps
Hypertrophic nasal turbinates»_space; enlarged turbinates
Transverse nasal crease»_space; across the bridge of the nose»_space; pushing nose up to clean
Allergic shiners»_space; darkened, swollen shadows under the eyes
Bilateral eye redness with clear discharge
Allergic Rhinitis: Investigation
Clinical Examination
Allergy test
Immunotherapy
Refer to ENT»_space; unilateral symptoms, blood-stained discharge, epistaxis (nose bleed)
Allergic Rhinitis: Management
General Measures-
Nasal irrigation with saline
Allergen avoidance
Mild Persistent or Intermittent Symptoms-
Intranasal corticosteroids»_space; anti inflammatory and immunosuppressive
Intranasal or non-sedating oral antihistamines»_space; reduce inflammation
Moderate-Severe Persistent Symptoms or Unresponsive Cases-
Daily intranasal corticosteroid with or without intranasal antihistamine»_space; full effectiveness up to 2 weeks
For eye symptoms: Antihistamine or chromone eye drops»_space; sodium cromoglycate
Allergic Rhinitis: Further Management
Consider stepping-up treatment-
Nasal congestion- add intranasal decongestant x5-7 days
Rhinorrhoea- add intranasal anticholinergic (ipratropium bromide)»_space; blocks acetylcholine reducing secretion from nasal passage.
Nasal itching, sneezing- add regular oral antihistamine or combination intranasal antihistamine with corticosteroid (Dymista)
Concurrent asthma- add leukotriene receptor antagonist (montelukast)
Severe symptoms affecting QOL-
Short-course oral corticosteroid (prednisolone)
Refer for immunotherapy-
Objective confirmation of IgE sensitivity to predominantly one allergen
Expose patient to increasing amounts of allergen over several weeks to induce tolerance
Allergic Rhinitis: Complications
Poor asthma control
Sinusitis
Nasal polyps
Chronic otitis media
Negatively affecting quality of life
Impaired school performance
Atopy: asthma, eczema, hay fever, allergies
Acute Sinusitis: Definition
Acute sinusitis, commonly known as a sinus infection.
Symptomatic inflammation of the paranasal sinuses and nasal cavity lasting less than 12 weeks.
Acute Sinusitis: Aetiology
Often follows a viral upper respiratory tract infection (URTI)
Bacterial infection occurs in 0.5-2% of cases, commonly caused by:
» Streptococcus pneumoniae
» Haemophilus influenzae
» Moraxella catarrhalis
Acute Sinusitis: Risk Factors
Allergy rhinitis
Asthma
Smoking
Anatomical variations»_space; deviated nasal septum, nasal polyps
Acute Sinusitis: Symptoms
Upper respiratory tract infection (URTI) symptoms»_space; sore throat, cough, malaise
Nasal blockage or congestion
Nasal discharge
Facial pain or pressure
Reduction or loss of smell
Acute Sinusitis: Signs
Maxillofacial sinus swelling, erythema, or tenderness
Discoloured or purulent nasal discharge
Oedematous nasal mucosa»_space; nasal mucosa becomes inflamed»_space; oedema
Fever
Acute Sinusitis: Investigation
Diagnose using symptoms-
Acute viral (common cold)»_space; symptoms less than 10 days
Post-viral acute sinusitis»_space; symptoms more than 10 days or worsening symptoms after 5 days
Acute bacterial sinusitis»_space; at least 3 present-
Symptoms more than 10 days
Discoloured or purulent nasal discharge
Severe localized pain
Fever
Double sickening
Acute Sinusitis: Treatment
Acute:
Symptoms less than 10 days: no antibiotics, paracetamol, nasal decongestant, saline spray
Symptoms more than 10 days: high dose nasal corticosteroid for 14 days
Consider back-up antibiotic prescription -evidence shows little effects on symptoms
» phenoxymethylpenicillin
» doxycycline if allergic to penicillin (not for pregnant women)
Chronic:
Supportive care, control underlying condition, stop smoking, avoid allergic triggers, nasal saline irrigation, intranasal corticosteroid for 3 months
Chronic Sinusitis: Definition
Symptomatic inflammation of the paranasal sinuses lasting for 12 weeks or more.
Chronic Sinusitis: Aetiology
Inflammatory and typically multifactorial
Bacterial aetiology different from acute:
» Staphylococcus aureus
» Enterobacteriaceae
» Pseudomonas
Chronic Sinusitis: Risk Factors
Allergic rhinitis
Asthma»_space; atopy
Smoking
Immunocompromised
Ciliary impairment»_space; ciliary in sinuses cant clear pathogens»_space; cystic fibrosis
Aspirin sensitivity»_space; associated with nasal polyp formation
Chronic Sinusitis: Symptoms
SAME AS ACUTE»_space; LONG-TERM AND CHRONIC
Upper respiratory tract infection (URTI) symptoms»_space; sore throat, cough, malaise
Nasal blockage or congestion
Nasal discharge
Facial pain or pressure
Reduction or loss of smell
Chronic Sinusitis: Signs
SAME AS ACUTE»_space; LONG-TERM AND CHRONIC
Fever
Maxillofacial sinus swelling, erythema, or tenderness
Discoloured or purulent nasal discharge
Oedematous nasal mucosa»_space; nasal mucosa becomes inflamed»_space; oedema
Chronic Sinusitis: Investigation
Clinical diagnosis
CT scan of sinuses»_space; only if ENT orders
Chronic Sinusitis: Management
Supportive care-
Control underlying condition
Stop smoking, avoid allergic triggers, good dental hygiene
Nasal saline irrigation
Intranasal corticosteroid»_space; x3 months
ENT referral if-
Considering antibiotic therapy
Persistent symptoms after 3 months
Immunocompromised
Epistaxis: Definition
Nosebleed
80-95% in anterior nasal septum»_space; Kisselbach’s Plexus
Epistaxis: Aetiology
Trauma»_space; nose picking, fracture, ulcers
Inflammations
Topical drugs»_space; cocaine, decongestants, corticosteroids
Systemic drugs»_space; anticoagulants
Tumours
Nasal oxygen therapy»_space; hospital oxygen not well humidified»_space; dries out nose and makes tissue delicate.
Clotting disorders
Excessive alcohol consumption»_space; affect on liver»_space; clotting
Environmental factors
Epistaxis: Investigation
Anterior rhinoscopy»_space; visualise bleed
FBC»_space; check coagulation factors
Suspect posterior bleed if-
Unable to visualise bleed
Bleeding going down throat»_space; profuse bleeding
Bilateral bleeding
Epistaxis: Management
Anterior bleed-
First aid»_space; sit upright, lean forward, pinch nose.
If bleeding stops»_space; prescribe topical antiseptic, avoid trauma to nose.
If bleeding doesn’t stop»_space; nasal cautery, nasal packing.
Posterior bleed-
Refer to ENT
Nasal Fracture: Definition
Broken nose
Nasal Fracture: Symptoms and Signs
Nasal deformity
Nasal obstruction
Painful palpation
Swelling and discolouration
Epistaxis
Nasal Fracture: Investigation
Clinical and visual
Typically no X-ray needed
Nasal Fracture: Management
Refer to Manipulation Under Anasthesia (MUA)
» to be seen within 7 days
Refer immediately if-
Gross displacement
Compound
Uncontrolled bleed
CSF rhinorrhoea
Septal haematoma»_space; collection of blood around fracture»_space; swelling and tender
Nasal Foreign Body: Definition
Obstruction
Nasal Foreign Body: Symptoms and Signs
Nasal discharge»_space; usually unilateral
Halitosis»_space; bad breath
Epistaxis
Septal perforation
Ingestion or aspiration of foreign body
Nasal Foreign Body: Investigation
Clinical and Visual
Nasal Foreign Body: Management
Topical vasoconstrictors to reduce swelling
Mother’s kiss»_space; parent hold nostril and blows into child’s mouth to push out FB
Crocodile forceps
Balloon catheter»_space; pass behind FB, inflate and withdraw
Suction catheter
Magnet
