Rhinology Flashcards
List the different components of inspection for nose examination
external- lesions, scars, alignment
internal- lift tip of nose- septal deviation, mucosal lesions, oral examination of hard/soft palate, dentitions, oropharynx
Which further investigations would you suggest in nose exam OSCE
blood tests- allergens
autoimmune screen
imagine- CT, MRI
smell test
skin prick testing for allergens
List four aspects of rhinology specific questions for history
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
State three red flags for nose symptoms
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
List two causes of nasal obstruction
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
Discuss two causes of rhinorrhoea= runny nose
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
List two causes of hyposmia= reduced ability to smell
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
List three differentials for facial pain
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
List two differentials for epistaxis
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
What is the management of nasal polyps?
intranasal steroids + saline douching
if not
systemic steroids
if not
surgery
State one complication of nasal fracture
septal haematoma
epistaxis
What is the time frame for nasal fracture for manipulaion post injury
<14 days
Which infections is associated with nasopharyngeal cancer?
EBV
Which population are at increased risk of nasopharyngeal cancers?
chinese population
How do nasopharyngeal cancers present
unilateral otitis media with effusion
neck lump
epistaxis
nasal obstruction
List two benign sinonasal tumours
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
List two malignant sionasal tumours
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
State two congenital anomalies of the nose
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)
Name two systemic diseases associated with nasal symptoms
- Wegener granulomatosis – destructive vasculitis, c-ANCA + ve, kidneys + lungs
- Sarcoidosis – Nasal obstruction, ACE +ve serology, Lungs (hilar lymphadenopathy)
- Churg-Strauss syndrome – Vasulitis + Asthma, GI tract p-ANCA +ve
- Chronic Infective disease – TB, Leporsy, Syphillis
- Cystic fibrosis – chronic sinusitis + polyposis (in children indicative of CF)
What is the most common ENT emergency presentation?
epistaxis
Which group is most commonly affected by epistaxis admissions?
Elderly >70
Classification of epistaxis?
primary
secondary- anticoagulants
acute
chronic
adult
childhood
What is the most important part of history for epistaxis?
OTC medications
warfarin
antiplatelets
trauma
alcohol
hypertension
What is a genetic condition that causes epistaxis?
Hereditary haemorrhagic telangiectasia (HHT)
What is the most common site of bleeding in the nose?
Kesselbach’s plexus/little’s area
Which is the most common artery that is ligated in epistaxis?
sphenopalatine artery
What is the management of epistaxis?
decongestant
…
adrenaline patch
silver nitrate cautery
What is the algorithm for epistaxis
resus
examination
ID vessel
Seal
If vessel not located, what should you do to stop the bleeding?
anterior packing (tampon in the nose)
If packing doesn’t work, what could you do?
surgery
septal surgery (if difficult access)
arterial ligation
Sphenopalatine artery branches off from which major artery?
external carotid artery (then from internal maxillary artery)
Can you stop warfarin in patient with epistaxis?
yes if they have something like AF, but not if they have metallic heart valve
What is floseal?
for secondary epistaxis
-gletain and human thrombim, helps form clot
Can you stop antiplatelets in someone with epistaxis?
yes if secondary CDV prevention but no if post-MI or recent insertion of stent…
Contraindication for TXA?
prev thrombosis
orbito-ethmoid fracture, which artery is at risk of bleeding?
anterior ethmoid artery
Causes of adult recurrent epistaxis?
liver disease
medication
nasal tumour
What is the mode of inheritance of hereditary haemorrhagic telagectasia?
AD
Management of HHT?
arterial ligation
antifibronlytic agent
TXA
selective embolisation
anticoagulate
young’s procedure??
What is Samter’s triad?
The association of asthma, aspirin sensitivity and nasal polyposis is known as Samter’s triad.
