Nose (ENT) + sinuses Flashcards
Outline some functions of the nose
- Smell
- Breathing
- Humidify + warms air
- Protection against pathogens
- Resonating chamber for speech
List the bones making up the roof, medial wall and floor of the nasal cavity
Roof:
- Nasal bone + frontal (anterior aspect)
- Ethmoid
- Sphenoid
Medial wall:
- Ethmoid
- Vomer
Floor:
- Hard palate
Outline the nerves innervating the nasal cavity
Anterior (soft) portion = trigeminal ophthalmic branch
Posterior (hard) portion = trigeminal maxillary branch
+ roof of oral cavity = trigeminal mandibular branch
State the ‘region’ from which epistaxis usually begins from
Kiesselbach’s plexus (anterior septum)
+ sphenopalatine artery is less common but more difficult to treat at the posterior aspect of the nose
State some features of acute sinusitis which makes it more likely to be a bacterial infection
- Severe symptoms at onset
- Symptoms last more than 10 days without improvement
- Symptoms that worsen after initial improvement (suggested secondary bacterial infection)
List some causes of nasal blockage
- Nasal polyps
- Nasal tumors (malignant)
- Deviated septum
- Enlarged adenoids
- Choanal atresia
- Foreign body
Outline some signs and symptoms of nasal blockage
- Mouth breathing
- Snoring / difficulty sleeping
- Runny nose / postnasal drip
- Facial pain / pressure
- Headaches
List some causes of rhinitis
- Allergic (hay fever)
- UTRI
- Weather changes e.g. temperature or humidity
- Alcohol / spicy food
- Hormonal changes (pregnancy, puberty, HRT)
- Hypothyroidism
- Medications e.g. ACEi, beta blockers, aspirin
Outline some signs and symptoms of rhinitis
- Rhinorrhoea
- Blocked nose
- Itchy nose
- Sneezing
- Reduced sense of smell
List some causes of epistaxis (local vs general)
Local:
- Idiopathic / spontaneous
- Trauma incl. picking nose or iatrogenic e.g. post-operatively
- Foreign body
- Inflammatory e.g. rhinitis, polyps
- Tumours
General:
- HTN
- Coagulation defects e.g. haemophilia, thrombocytopenia
- Leukaemia
- Anticoagulation medication e.g. DOACs
Outline the management steps for epistaxis
ABC approach
Initial steps:
- Head forward
- Pinch soft part of nose
- Spit out blood (don’t swallow)
- Locate source of bleed
Management - stepwise approach:
- Cautery (silver nitrate sticks or diathermy) +/- topical adrenaline
- Nasal packing (anterior pack first, then posterior pack)
- Surgical intervention (ligate or embolise arteries)
Outline the management steps for nasal fracture
ABC approach
If recently broken and no swelling (within minutes) then can attempt to reset but otherwise need to bring them back in 7-10 days to reset
Initial steps:
- Examine for septal haematoma
Management - stepwise approach:
- Manipulation under anaesthetic (LA or GA) within 2 weeks of initial injury
List some causes of facial pain
- Trauma e.g. fracture
- Sinusitis (acute or chronic)
- Salivary gland pathology e.g. inflammation, stones
- Shingles in facial area
- Malignancy
- Giant cell arteritis
- Trigeminal neuralgia
- Temporomandibular joint dysfunction
- Dental issues
- Referred pain e.g. otalgia or tonsillitis
Outline the 3 main categories of rhinitis
- Infectious
- Rhinoviruses
- Coronaviruses
- Influenza
- Adenovirus
- RSV - Non-allergic (multiple causes)
- Occupational (chemical)
- Smoking
- Hormonal
- Senile (rhinitis of the elderly)
- Medication-induced - Allergic
Outline rhinitis and how it can present
Irritation and inflammation of the mucous membrane, leads to excessive mucus production
Presentation:
- Runny nose
- Blocked nose
- Sneezing
- Post-nasal drip
+ associated symptoms depending on cause e.g. watery eyes if allergic cause
Outline how infective and allergic rhinitis cases are managed
Allergic:
- Avoid triggers if possible
- Oral antihistamines
- Regular nasal corticosteroid sprays e.g. Fluticasone and Mometasone
- Nasal antihistamines for rapid onset symptoms in response to a trigger
Consider referral to immunology if symptoms are unmanageable with management above
- Skin prick tests for specific allergens
List some examples of non-sedating antihistamines (3) and sedating antihistamines (2)
Non-sedating antihistamines:
- Cetirizine
- Fexofenadine
- Loratadine
Sedating antihistamines:
- Chlorphenamine (Piriton)
- Promethazine
Acute sinusitis - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management (acute)
Pathophysiology:
- Inflammation of the paranasal sinuses (usually also the nasal cavity, also known as rhinosinusitis)
- Caused by blockage of ostea draining the sinuses, therefore accumulation of fluid and subsequent inflammation
- Can be a variety of causes
- Acute (< 3 months) or chronic (> 3 months, +/- nasal polyps)
Presentation - face and nose symptoms:
- Facial pressure worse on leaning forward
- Headache (facial)
- Tenderness to palpation
- Facial swelling over affected area
- Nasal discharge
- Nasal congestion / anosmia
- Nasal oedema on examination
+ fever, tachycardia etc. if bacterial infection
Investigations:
Usually not required unless chronic and unresolving
- Nasal endoscopy
- CT head
Management:
Symptoms < 10 days = nasal decongestants and analgesia, no antibiotics (resolve 2-3 weeks)
Symptoms not improving after 10 days = nasal steroid spray for 10 days e.g. Mometasone
Delayed antibiotic prescription if not improving after a further 7 days of Penicillin V
Admission if evidence of systemic infection / sepsis
Outline some of the main causes of sinusitis
- Infection (especially following an URTI)
- Allergies
- Smoking
- Obstruction of drainage e.g. foreign body, trauma or polyps (more associated with chronic sinusitis)
If asthma, more common to develop sinusitis
Outline how chronic sinusitis is managed
Generally no cure, aimed at symptomatic management
Avoidance of allergens
Nasal douching
Medical:
- Antihistamines
- Topical nasal steroid spray or drops e.g. Mometasone
Surgical:
- Functional endoscopic sinus surgery (FES)
- Polyp removal (although high rate of recurrence)
Outline technique for spraying nasal spray
- Tilt head slightly forward
- Use opposite hand for nostril
- Don’t sniff during spray, gently inhale after spray
Shouldn’t taste the spray at the back of your throat
