Nose HEENT

Question 1

rhinitis etiologies

Answer 1

-allergic rhinitis
-vasomotor rhinitis- inflammation
-viral rhinitis (common cold)
-acute bacterial rhinosinusitis (sinusitis/ABRS)

Question 2

allergic rhinitis

Answer 2

-characterized by inflammation of the nasal passages with sneezing and rhinorrhea
-can be seasonal (spring and fall) or perennial (dust mites, year round)
-usually chronic and relapsing
-trouble rather than disabling
-hay fever, seasonal rhinitis, perennial allergic rhinitis, IgE mediated rhinitis

Question 3

allergic rhinitis etiology

Answer 3

-seasonal allergic rhinitis- pollens, especially grasses, trees, weeds
-perennial allergic rhinitis:
->2 hrs per day and for > 9 months
-house dust mites, animal dander, cockroaches, molds
-family hx of allergic rhinitis or other allergic disorder (atopy)
-coexisting allergies (asthma, eczema)
-similar classification as in asthma- intermittent, persistent, mild, moderate

Question 4

allergic rhinitis symptoms

Answer 4

-paroxysmal sneezing
-rhinorrhea
-nasal congestion- enlargement of mucosa
-decreased sense of smell
-itching of nose, palate, pharynx, eyes, sometimes ears
-scratchy / sore throat caused by postnasal drop
-irritability, fatigue- lack of sleep

Question 5

allergic rhinitis signs

Answer 5

-nasal crease can form from repeated allergic solute (wiping nose upward)- common in children and can lead to transverse nasal crease in severe cases
-allergic shiners- dark circle under eyes -> lack of sleep, vasculature
-Dennie-Morgan lines- swelling due to inflammation- lines under eyes
-clear nasal secretion
-edematous, blanched (pale)* or violaceous (blueish)* nasal mucosa
-mouth breathing caused by nasal congestion
-nasal polyps- hypertrophy of the mucosa

Question 6

associated disorders with allergic rhinitis

Answer 6

-asthma*
-eczema
-otitis media- middle ear infection
-rhinosinusitis- sinus infection

Question 7

differential diagnosis: allergic rhinitis

Answer 7

-upper respiratory tract infection (URTI)
-nonallergic rhinitis
-rhinitis medicamentosa- enlarged mucosa caused by excessive use of OTC meds
-sarcoidosis- enlarged lymphnodes
-wegener’s granulomatosis:
-inflammation of blood vessels (unknown etiology)
-bloodstained, crusts and friable mucosa
-biopsy- necrotizing granulomas and vasculitis

Question 8

allergic rhinitis diagnosis

Answer 8

-symptoms for >10 days
-sneezing
-rhinorrhea
-itching of the nose, palate, pharynx
-pale, edematous nasal mucosa
-dark rings under the eyes
-itching characteristic versus other rhinitis
-recurrence/chronicity points towards allergic rhinitis rather than URTRI
-confirmed by positive skin prick test or RAST -> shows you what allergen to avoid
-no clinical testing required for diagnosis

Question 8

test for allergic rhinitis

Answer 8

-skin prick test
-intradermal skin test- forearm
-nasal smear
-serum IgE- radioallergosorbent test (RAST)- blood test that tests the amount of specific IgE antibodies which are present for allergic reaction
-CT of sinuses
-refer to allergist if severe symptoms

Question 9

allergic rhinitis treatment

Answer 9

-identify causative allergens
-reduce symptoms of allergic rhinitis to a level acceptable to the pt
-lifestyle changes- mattress/pillow covers etc.
-first line:
-intranasal corticosteroids- can take weeks -> most effective *
-antihistamine (non sedating)- loratadine, cetirizine -> immediate -> most practical
-decongestant*
-adjunct treatment: (asthma)
-ipratropium
-cromolyn
-Montelukast
-immunotherapy

Question 10

allergic rhinitis- summary

Answer 10

-chronic, usually lasts for life
-can decrease with age
-good control of symptoms is the aim
-recurrent- nature of disease
-failure to respond within a month is indication to change treatment to either different antihistamine or a steroid
-systemic steroids can be used generally for < 10 days with intractable symptoms

Question 11

allergic rhinitis complications

Answer 11

-predisposes to asthma
-epistaxis- nose bleed from dryness
-serous otitis media
-secondary sinusitis- rhinosinusitis
-facial malformation in children with long stand allergic rhinitis with severe nasal congestion
-nasal speech
-eustachian tube dysfunction- congestion spreads
-increased susceptibility to URTI
-laryngeal edema

Question 12

vasomotor rhinitis

Answer 12

-nonallergic or vasomotor rhinitis
-caused by hyperactivity of the vidian nerve
-common cause of rhinorrhea in ELDERLY
-itching of nose and eyes is typically NOT present
-sneeze a lot
-response to numerous nasal stimuli- warm/cold air, odors, scents, light, particulate matter
-headaches anosmia, and sinusitis are common
-negative family hx
-negative skin tests

Question 13

olfactory dysfunction

Answer 13

-subjective hyposmia or anosmia (poor/lack of smell)
-anatomical blockage of nasal cavity
-polyps, septal deformities, and nasal tumors
-common cold, nasal allergies, perennial rhinitis
-COVID-19- cardinal early manifestation of infection -> immediate testing -> transient vs permanent change
-CNS tumors
-head trauma

Question 14

hyposmia & anosmia

Answer 14

-hx- systemic illnesses, medication, injuries etc.
-PEx- nose and nervous system focus
-testing:
-University of Pennsylvania Smell Identification Test (UPSIT)- self administered scratch and sniff test useful for hyposmia, anosmia, and malingering
-treatment- secondary causes -> endoscopic sinus surgery
-education- seasoning, safety issues

Question 15

nose and sinus disorders

Answer 15

-epistaxis
-nasal polyps
-foreign bodies

Question 16

epistaxis

Answer 16

-90% pts with this can be treated in ED
-nose bleed from septum (midline)
-often from dryness
-can be caused by nasal corticosteroids or antihistamines
-classification dependent on primary bleeding site
-anterior- most common
-posterior- bleeding from plexus in the back

Question 17

VINDICATE

Answer 17

-used to build up differentials for any case
-VASCULAR
-INFLAMMATORY
-NEOPLASTIC
-DEGENERATIVE/DEFICIENCY
-IDIOPATHIC/IATROGENIC, INTOXICATION
-CONGENITAL
-AUTOIMMUNE/ALLERGIC/ANATOMIC DEFECTS
-TRAUMA
-ENDOCRINE/EXPOSURES (ENVIRONMENTAL, OCCUPATIONAL) OSLER-WEBER-RENDU SYNDROME (HHT)

Question 18

anterior epistaxis treatment

Answer 18

-apply pressure to anterior part of nose (tip) for anterior bleed and look down slightly

Question 19

nose exam

Answer 19

-speculum inside
-look for clot on septum where bleed originated
-cauterize the bleed
-have them gently blow nose to clear visual
-make sure no large clot/ hematoma is there bc it needs to be cleared
-the septum’s only blood supply is through the perichondrium -> if a clot is blocking -> cartilage dies -> saggy nose
-pack the nose with gauze
-silver nitrate- tap, rization of arteries

Question 20

epistaxis testing

Answer 20

-no real testing
-can check CBC for platelets -> clots
-ask if they are taking blood thinner -> Aggravates

Question 21

merocel

Answer 21

-gel packs
-dressing
-different shapes
-can cut to different shape
-similar to tampon
-can use lidocaine -> uncomfortable
-go in horizontal -> floor of nose is horizontal

Question 22

balloons/catheters

Answer 22

-folley catheter
-put it in
-for posterior bleeds
-inflate with water once its in -> stays in

Question 23

epistaxis management

Answer 23

-antibiotics- (usually posterior) insertion of foreign bodies in the nose
-analgesics
-follow up out patient care
-avoid strenuous activity
-may have to admit patient depending on cause of bleed (hypertension,)
-follow up with primary care

Question 24

epistaxis complications

Answer 24

-sinusitis -> blockage of sinus can cause inflammation
-septal hematoma/perforation-> check for this before discharge from ED -> necrosis -> saddle nose
-external nasal deformity
-mucosal pressure necrosis- especially with packing -> follow upn
-vasovagal episode
-balloon migration
-aspiration

Question 25

nasal polyps

Answer 25

-hypertrophic nasal mucosa
-pale, edematous
-mucosal covered masses
-common in pts with allergic rhinitis
-complications- chronic nasal obstruction, sense of smell
-Samter triad- allergic rhinitis, asthma, nasal polyps
-cystic fibrosis
-management- topical corticosteroids and surgery

Question 26

foreign bodies (FBs)

Answer 26

-FBs of the ear and nose- common in children 1-6years
-more common in girls
-can be removed without complication if they come to attention soon after placed
-true ENT emergency: magnets, button alkaline batteries -> severe damage, necrosis, perforation of nasal septum
-repeated manipulation- local injury and/or migration into the trachea
-only try once - you can push farther
-forceps

Question 27

inhaled foreign body (FB)

Answer 27

-acute
-M(1):F(1)
-sudden onset of respiratory difficulty
-coughing, stridor, wheezing
-clinical course- self limiting
-obstruction seen on chest x-ray
-test- blood gases to assess extent of respiratory compromise
-heimlich

Question 28

FBs

Answer 28

-measure blood lead levels
-aural- crawling insects to inanimate objects found in the home
-> asymptomatic or may complain of pain, bleeding, discomfort, decreased hearing
-nasal FB- asymptomatic or unilateral nasal occlusion, fetid, purulent, blood stained nasal discharge
-complications (nasal)- unilateral sinusitis or periorbital cellulitis

Question 29

FB management

Answer 29

-nasal speculum- headlight or lamp
-alligator forceps- wire loop or curette
-suction apparatus- catheters of various sizes
-irrigating devices- high flow room temp, (cant do if tympanic membrane is ruptured)
-8 french foley catheter or fogarty catheter
-topical anesthesia (lidocaine without epi)
-topical vasoconstrictors- can cause damage if you use at end of artery
-super glue (cyanoacrylate glu)- put on q tip

Question 30

FB complications

Answer 30

-most serious- button batteries and failed removal attempts
-size, shape, content, length of time FB has been stuck
-infection- otitis media, sinusitis, periorbital cellulitis, barotrauma
-epistaxis
-aspiration of nasal FB
-refer

Question 31

nasal trauma

Answer 31

-most frequently fractured bone in body
-history
-associated features- racoon eyes -> can indicate skull fracture
-diagnosis
-do not miss1- look for CSF leaks - pH paper
-treatment