Nose diseases Flashcards
Acute sinusitis, chronic rhinosinusitis, nasal polyps,
What is acute sinusitis?
Symptomatic inflammation of the paranasal sinuses, usually following a viral respiratory tract infection, with symptoms lasting less than 12 weeks
Another name for ‘Acute Sinusitis’
rhinosinusitis
What are the common causes of acute sinusitis?
It is commonly preceded by rhinitis and can spread from dentition
= Common organisms include
(1) Streptococcus pneumoniae
(2) Haemophilus influenzae
(3) Moraxella catarrhalis
What are the paranasal sinuses involved in acute sinusitis?
Frontal, maxillary, ethmoid, and sphenoid sinuses
What are the symptoms of acute sinusitis in adults?
- Nasal blockage
- Nasal discharge
- Facial pain/pressure
- Headache
- Reduced sense of smell
How is acute sinusitis diagnosed?
- based on nasal blockage or discharge
- facial pain or pressure
- and/or reduced sense of smell.
What are first and second-line antibiotics for acute sinusitis?
after 10 days
- Phenoxymethylpenicillin
- Doxycycline
(contraindicated in children)
Chronic sinusitis
What is chronic sinusitis?
Long-term inflammation of the sinuses, often with symptoms lasting more than 12 weeks causing nasal polyps to appear.
Treated with Topical steroids
What is the diagnostic criteria for acute rhinosinusitis?
Sudden onset of symptoms for less than 12 weeks duration, including one symptoms from each line
(1) Nasal blockage/congestion OR nasal discharge
(2) Facial pain/pressure OR loss/reduction of sense of smell
‘Facial pain worse on leaning forward’
This suggests what?
Acute sinusitis
A 45-year-old man presents to his GP complaining of recurrent episodes of central facial pain and nasal congestion that have been occurring over the past 12 weeks. He reports that during these episodes there is a clear nasal discharge and he experiences loss of smell. The patient has a past medical history of asthma. He requests advice from the GP about treatment options available to him.
What treatment option can be considered in this patient?
Nasal irrigation with saline solution
A 26-year-old man presents with a new headache for 4 days. He complains of facial pain, fevers, dry cough, rhinorrhoea with thin yellow discharge and nasal congestion. He is afebrile at 37.4ºC and maxillary pressure reproduces the pain.
Given the likely diagnosis, what is the most appropriate treatment option?
Analgesia
= Intranasal steroids should only be considered for sinusitis if symptoms have persisted for 10 days or more
Paul is a 54-year-old man who comes to see you with a 4 month history of nasal congestion affecting his right nostril. He explains that he has also noticed his sense of smell has reduced on the right side. His symptoms have come on gradually and are now worsening. He is a smoker with a 15 pack-year history.
On examination, there is slight mucosal oedema but no significant nasal inflammation. There are no focal neurological signs.
What is the best option for initial management and why isn’t it Nasal irrigation with saline solution
Urgent referral to an ear, nose and throat specialist
= Unilateral symptoms are a red flag for patients with chronic rhinosinusitis
A 26-year-old man books an urgent appointment in your duty clinic. He reports a two-week history of left-sided facial pain and malaise. He tells you that his symptoms initially were improving after seven days however they then worsened again and he is now feeling worse than he did initially. He is normally fit and well.
On examination he has a low grade pyrexia of 37.9 degrees but other observations are within normal limits. Anterior rhinoscopy shows a purulent discharge coming from the left middle meatus. There is no abnormalities of the eyes or periorbital tissues.
Why is the answer bacterial sinusitis rather than viral sinusitis?
‘Double-sickening’ suggests bacterial sinusitis
= an initial period of recovery followed by a sudden worsening of symptoms. It is thought to be caused by a secondary bacterial infection following a viral rhinosinusitis
What are nasal polyps?
Soft, painless, noncancerous growths on the lining of the nasal passages and lateral walls
What are the common causes of nasal polyps?
Allergies, infection, aspirin sensitivity, and nickel exposure, and often associated with non-allergic asthma.
In young patients, consider cystic fibrosis
What is the pathophysiology of nasal polyps?
Inflammation and oedema of the sinus nasal mucosa cause the mucosa to prolapse into the nasal cavity, leading to obstruction
What is the typical clinical presentation of nasal polyps?
Blocked nose, runny nose, and reduced sense of taste or smell
How are nasal polyps diagnosed?
Nasoendoscopy, where polyps are visible
What is the treatment for nasal polyps?
Treatment with oral then topical steroids.
If large or unresponsive, surgical removal may be necessary
A 51-year-old man who has suffered from hay fever all his life now presents with snoring that has gradually worsened over one year. His partner has to sleep in the next room because of it. He also breathes from his mouth. He used to experience watery discharge from his nose with itchy eyes only during the summer but now suffers from profuse discharge from his nose all the time. He also suffers from frequent headaches.
What is the most appropriate management option for the most likely diagnosis?
Nasal steroid drops
diagnosis is likely nasal polyps as a complication of chronic sinusitis
A 42-year-old man presents to his general practitioner 6 weeks after developing a cold. Whilst all of his other symptoms have now resolved, the patient is experiencing persistent blockage of his left nostril associated with rhinorrhoea and sneezing. He is otherwise well.
On examination, a large polyp is seen in the left nostril. Examination of the right nostril is unremarkable.
What is the most appropriate next step in management?
Unilateral polyps are a red flag symptom therefore routine referral to the ENT
A 35-year-old man with a history of asthma presents to his GP with a 6-month history of bilateral nasal obstruction with rhinorrhoea. There is no blood-stained discharge or epistaxis. He is otherwise well. His asthma is well controlled with a medium-dose inhaled corticosteroid. He has tried saline nasal washes from the pharmacist and is wondering if there is anything else he can try.
On examination, his observations are within the normal range. His ears and throat are unremarkable. You can see suspected nasal polyps in both nostrils.
What is the most appropriate initial management?
Intranasal steroid spray or drops
= can be used to shrink nasal polyps
You review a 23-year-old woman who presents with a three-week history of bilateral nasal obstruction, cough at night and a clear nasal discharge. She had similar symptoms around this time last year and the only history of note is asthma. What is the most likely diagnosis?
Allergic rhinitis
A 25-year-old woman presents to the GP clinic complaining of the sensation of nasal obstruction for the past six months
Two months ago she reported that she was diagnosed with asthma and did not report any symptoms of this as a child. On questioning she reports that she has recently had a runny nose and has felt slightly fatigued over the past couple of months.
On examination of the nose, there are numerous nasal polyps bilaterally and inflamed mucosa
What is the single most likely diagnosis?
Eosinophilic granulomatosis with polyangitis
What is snoring more of a symptom of?
polyps
What does an extended use of topical decongestants cause?
rebound nasal congestion
tachyphylaxis meaning
rapid decrease in the effectiveness of a drug after repeated doses
Persistent bleeding/crusting with unilateral nasal obstruction suggests what?
Sinonasal carcinoma
