Rhinology

Question 1

List the different components of inspection for nose examination

Answer 1

external- lesions, scars, alignment
internal- lift tip of nose- septal deviation, mucosal lesions, oral examination of hard/soft palate, dentitions, oropharynx

Question 2

Which further investigations would you suggest in nose exam OSCE

Answer 2

blood tests- allergens
autoimmune screen
imagine- CT, MRI
smell test
skin prick testing for allergens

Question 3

List four aspects of rhinology specific questions for history

Answer 3

Nasal obstruction – unilateral / bilateral, intermittent / persistent, onset, duration
Sense of smell – normal, decreased, absent
Nasal discharge – anterior / posterior, unilateral / bilateral, watery / mucoid
Sneezing / Itch – triggers, persistent or seasonal
Facial pain – site, onset, duration, triggers, alleviating factors, type

Question 4

State three red flags for nose symptoms

Answer 4

Unilateral symptoms – obstruction, sero-sanguinous discharge, altered sensation
Alteration of vision – diplopia, opthalmoplegia (suggests invasion of orbit)
Pain – face, retro-orbital
Swelling – face, maxilla (dentures not fitting)
Epistaxis – persistent cases suspicious

Question 5

List two causes of nasal obstruction

Answer 5

Infective - Viral infection – “the common cold”
Autoimmune - Rhinitis – Allergic / non-allergic, persistent / seasonal
Inflammatory - Nasal polyps – Bilateral with hyposmia
Traumatic - Deviated nasal septum
Neoplasms – Squamous cell carcinoma, inverted papilloma

Question 6

Discuss two causes of rhinorrhoea= runny nose

Answer 6

Allergic rhinitis – Watery, bilateral, associated with sneezing + nasal itch +/- eye symptoms
Chronic rhinosinusitis - > 12 weeks of obstruction / discharge / pain / decreased smell
Head trauma – CSF leak, unilateral, increased with position / straining – Ix β2-transferrin
Viral infection – the common cold
Nasal foreign body – unilateral, offensive is indicative

Question 6

List two causes of hyposmia= reduced ability to smell

Answer 6

Rhinosinusitis – cardinal symptom of chronic rhinosinusitis
Nasal polyps – “Conductive loss” – blockage of airflow to olfactory mucosa
Viral infection / idiopathic – post influenza virus infection – “senori-neural loss”
Neoplasms – Conductive or sensorineural if from olfactory mucosa
Head trauma – shearing of olfactory nerves as pass through cribiform plate

Question 7

List three differentials for facial pain

Answer 7

Acute sinusitis – unilateral, fever, purulent discharge <14 days
Neoplasms – associated paraesthesia, other unilateral symptoms
Trigeminal neuralgia – lancinating pain, trigger points, treat with carbemezapine
Dental infection – poor dentition, dull ache, needs dental exclusion
Migraine – unilateral, visual effects, triggers, nausea & vomiting

Question 8

List two differentials for epistaxis

Answer 8

Idiopathic – spontaneous, can be associated with infection
Trauma – nose picking / post surgical
Neoplasms – recurrent persistent cases this should be considered
Anti-coagulants – increase risk especially with supra-theraputic levels
Bleeding disorders – primary or secondary, need treatment in recurrent cases

Question 9

What is the management of nasal polyps?

Answer 9

intranasal steroids + saline douching
if not
systemic steroids
if not
surgery

Question 10

State one complication of nasal fracture

Answer 10

septal haematoma
epistaxis

Question 11

What is the time frame for nasal fracture for manipulaion post injury

Answer 11

<14 days

Question 12

Which infections is associated with nasopharyngeal cancer?

Answer 12

EBV

Question 13

Which population are at increased risk of nasopharyngeal cancers?

Answer 13

chinese population

Question 14

How do nasopharyngeal cancers present

Answer 14

unilateral otitis media with effusion
neck lump
epistaxis
nasal obstruction

Question 15

List two benign sinonasal tumours

Answer 15

Inverted papilloma – aka scheridan’s papilloma, local erosive, recurrence a problem
Fibroma – Juvenile nasal angiofibroma – adolescent male, nasal obstruction + epistaxis
Haemangioma – rare paediatric
Meningioma
Adenoma

Question 16

List two malignant sionasal tumours

Answer 16

Squamous cell carcinoma – smoking, soft woods
Adenocarcinoma – hard wood working
Olfactory neuroblastoma – decreased smell arise from olfactory mucosa
Malignant melanoma – mucosal type, poor prognosis
Fibrosarcoma

Question 17

State two congenital anomalies of the nose

Answer 17

Nasal dermoid cyst – midline, hair tuft in pit, can extend intracranially, surgical excision
Nasal encephalocele – skull base defect, brain (non-functioning) / meninges in nasal cavity
Choanal atresia – posterior nose remains occluded, bony / membranous
Haemangioma – vascular lesion, self limiting, cosmetically disfiguring
Arrhinia – non-formation of nose (very rare)

Question 18

Name two systemic diseases associated with nasal symptoms

Answer 18

1. Wegener granulomatosis – destructive vasculitis, c-ANCA + ve, kidneys + lungs
2. Sarcoidosis – Nasal obstruction, ACE +ve serology, Lungs (hilar lymphadenopathy)
3. Churg-Strauss syndrome – Vasulitis + Asthma, GI tract p-ANCA +ve
4. Chronic Infective disease – TB, Leporsy, Syphillis
5. Cystic fibrosis – chronic sinusitis + polyposis (in children indicative of CF)

Question 19

What is the most common ENT emergency presentation?

Answer 19

epistaxis

Question 20

Which group is most commonly affected by epistaxis admissions?

Answer 20

Elderly >70

Question 21

Classification of epistaxis?

Answer 21

primary
secondary- anticoagulants
acute
chronic
adult
childhood

Question 22

What is the most important part of history for epistaxis?

Answer 22

OTC medications
warfarin
antiplatelets

trauma

alcohol

hypertension

Question 23

What is a genetic condition that causes epistaxis?

Answer 23

Hereditary haemorrhagic telangiectasia (HHT)

Question 24

What is the most common site of bleeding in the nose?

Answer 24

Kesselbach’s plexus/little’s area

Question 25

Which is the most common artery that is ligated in epistaxis?

Answer 25

sphenopalatine artery

Question 26

What is the management of epistaxis?

Answer 26

decongestant
…
adrenaline patch
silver nitrate cautery

Question 27

What is the algorithm for epistaxis

Answer 27

resus
examination
ID vessel
Seal

Question 28

If vessel not located, what should you do to stop the bleeding?

Answer 28

anterior packing (tampon in the nose)

Question 29

If packing doesn’t work, what could you do?

Answer 29

surgery
septal surgery (if difficult access)
arterial ligation

Question 30

Sphenopalatine artery branches off from which major artery?

Answer 30

external carotid artery (then from internal maxillary artery)

Question 31

Can you stop warfarin in patient with epistaxis?

Answer 31

yes if they have something like AF, but not if they have metallic heart valve

Question 32

What is floseal?

Answer 32

for secondary epistaxis
-gletain and human thrombim, helps form clot

Question 33

Can you stop antiplatelets in someone with epistaxis?

Answer 33

yes if secondary CDV prevention but no if post-MI or recent insertion of stent…

Question 34

Contraindication for TXA?

Answer 34

prev thrombosis

Question 35

orbito-ethmoid fracture, which artery is at risk of bleeding?

Answer 35

anterior ethmoid artery

Question 36

Causes of adult recurrent epistaxis?

Answer 36

liver disease
medication
nasal tumour

Question 37

What is the mode of inheritance of hereditary haemorrhagic telagectasia?

Answer 37

AD

Question 38

Management of HHT?

Answer 38

arterial ligation
antifibronlytic agent
TXA
selective embolisation
anticoagulate
young’s procedure??

Question 39

What is Samter’s triad?

Answer 39

The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad.