Rhinology Flashcards
What is typical presentation in rhinology?
Signs and symptoms such as
Nasal obstruction
nasal discharge
epistaxis
facial pain
nasal deformity
anosmia
sneezing
What occupation commonly presents to rhinology?
Woodworkers
What do all smokers have?
Some degree of Rhinitis
Which turbinate are you most likely to see on nasal endoscopy?
Inferior turbinate, and probably middle
What is the cause of nasal polyps?
Unknown
What prevents nasal polyps from coming back after resection?
Steroid spray
What are the relevant investigations in Rhinology?
Blood tests-FBC, ANCA, ESR, ACE, RAST
CT SCAN
MRI SCAN
SKIN TESTS
RHINOMANOMETRY
When are CT scans most likely to be used?
Pre-operatively - ensures safe surgery
Allows identification of anatomical relationships of the key structures (optical nerve, orbital contents and carotid artery)
Shows nature and extent of disease as well as anatomical abnormalities
What is rhinomanometry?
Rhinomanometry is a standard diagnostic tool aiming to objectively evaluate the respiratory function of the nose. It measures pressure and flow during normal inspiration and expiration through the nose.
What are common nasal disorders?
Nasal trauma
Epistaxis
Rhinosinusitis
Nasal Polyps
Nasal Deformity
Nasal Tumours
Choanal artresia - feeding problems
What nasal pathology can happen as a result of nasal trauma?
Septal haematoma
Why is early detection of septal haematoma important?
Early diagnosis and treatment is important to prevent abscess formation, septal perforation, saddle-nose deformity, and potentially permanent complications
What exactly is a septal haematoma?
Perichondrium is pulled away from the cartilage which tears submucosal blood vessels. Blood now collects between perichondrium and septal cartilage. Stagnant blood can easily result in infection.
40 year old man with constant blocked nose, PN drip and hyposmia. He also has history asthma and aspirins sensitivity.
WHAT IS IT?
Nasal Polyps
What is the cause of nasal polyps?
Unknown, involves chronic inflamamtion, autonomic nervous system dysfunction and genetic predisposition.
What are the two clases of nasal polyps?
Allergic and non-allergic
What are associated allergic conditions with nasal polyps?
Associated with allergic conditions
20-50% have asthma
Allergic rhinitis
8-26% have aspirin intolerance
50% have alcohol intolerance
What are non-allergic conditions associated with nasal polyps?
Non allergic conditions
Cystic Fibrosis 6-48% have polyps
AFS (allergic fungal sinusitis) 85% have polyps
Churg-Strauss syndrome
What are investigations for nasal polyps?
Sweat test (to see if cystic fibrosis is present)
RAST / skin testing
Nasal smear
- Microbiology
- Eosinophils (allergic component)
- Neutrophils (chronic sinusitis)
Coronal CT scan
MRI
Flexible nasoendoscopy
Rigid nasoendoscopy
What is non-surgical treatment for nasal polyps?
Oral and Nasal steroids
(¡High dose prednisolone and nasal steroid for 20 days will eliminate 50% of polyps)
Immunotherapy
What is surgical treatment for nasal polyps?
Traditional polypectomy
Microdebrider - tube used to cut tissue
Endoscopic sinus surgery
What is the likelihood of recurrence of nasal polyps?
Recurrence:
Multiple small polyps common
Large and antro-coanal less so
What is the condition?
23yr old presents with runny nose, nasal blockage, general malaise and sore throat for 10 days. Otherwise fit and well, with no systemic upset.
Acute sinusitis
What is the treatment for sinusitis?
Usually self limiting virus
May require over the counter pain killers, over the counter decongestants, cleaning the inside of the nose with salt water solution.
GP therapy may be indicated if symptoms do not improve after 7-10- days or symptoms becomes worse, treatment includes corticosteroid drops or sprays / antibiotics.
Surgery may be indicated if these treatments don’t work - functional endoscopic sinus surgery
Surgery involves balloon catheter dilation / nasal polyp removal if blocking sinus
What is the diagnosis of rhinosinusitis?
Sinus - radiographs
What is meant by acute sinusitis?
Acute
– Acute onset of symptoms
– Duration of symptoms <12 weeks
– Symptoms resolve completely
• Recurrent acute
– >1 to <4 episodes of acute rhinosinutitis per year.
– Complete recovery between episodes.
– Symptom-free period of >8 weeks between acute attacks in
absence of medical treatment.
What is meant by chronic sinusitis?
Chronic
– Duration of sysmptoms >12 weeks
– Persistent inflammatory changes on imaging >4 weeks after starting appropriate therapy
What are acute exacerbations of chronic sinusitis?
Worsening of existing symptoms or appearance of new
symptoms
– Complete resolution of acute (but not chronic)
symptoms between episodes
What are the common causative organisms of acute rhinosinusitis?
S pneumoniae
H influenzae
What are the major and minor factors for sinusitis?
Major Factors Minor Factors
Facial pain and pressure Headache
Hyposmia/anosmia Fever
Nasal congestion/obstruction Fatigue
Purulent postnasal drain Halitosis
Olfactory disturbance Dental pain
Cough not due to asthma (children only) Cough (adults)
What are the antimicrobial choices for rhinosinusitis?
β-lactams – penicillins, cephalosporins
Macrolides - e.g erythromycin,clarithromycin
What is the treatment for periorbital swelling of the eyes?
Emergency referral
Ophthal opinion
Urgent CT
IV Antibiotics
Emergency surgery
What is the treatment for frontal sinusitis / pott’s puffy tumor?
Emergency referral
Frontal sinus surgery
ESS (endoscopic sinus surgery)
Pus can erode the bone of the frontal sinus, can affect the brain, frontal lobe oedema, abscess in frontal lobe.
What are mucocele?
Cystic masses that generally affect the sinuses, results from obstruction of ostium of a sinus,
Why can ethmoidal mucocele cause diplopia?
Cyst forms which presses on the orbit
What are the causes of epistaxis?
- Infection
a. Rhinitis
b. Nasopharyngitis
c. Sinusitis - Trauma
a. Accidental or self-induced
b. Iatrogenic - Allergy
- Hypertension and atherosclerotic vascular disease
- Hereditary hemorrhagic telangiectasia
- Blood dyscrasias
a. Iatrogenic (drug induced)
b. Disease mediated
c. Alcoholism - Atrophic rhinitis
- Tumor
a. Primary
b. Secondary - Congenital or acquired nasal defects.
Telangectasia - a condition characterized by dilatation of the capillaries causing them to appear as small red or purple clusters, often spidery in appearance, on the skin or the surface of an organ.
Dyscrasia - an abnormal or disordered state of the body or of a bodily part.
What is the initial management of epistaxis?
ABC’s
Medical history/Medications
Vital signs—need IV?
Physical exam involving -
- Anterior rhinoscopy
- Endoscopic rhinoscopy
Laboratory exam
Nasal packing
What is surgical treatment of epistaxis?
Artery ligation (sphenopalatine, transmaxillary IMA, intraoral IMA, anterior/posterior ethmoidal, external carotid)
Septodermoplasty/laser ablation
Embolisation
What is the treatment for HHT (hereditary haemorrhagic telangiectasia?)
LASER COAGULATION
YOUNG’S PROCEDURE
SEPTODERMOPLASTY - Definition: Operation to graft stratified squamous epithelium and dermis to replace the mucous membrane of the nasal septum, especially for patients with hereditary hemorrhagic telangiectasia.
What is the treatment of angiofibroma?
Do not biopsy! Can lead to death
- Pre-operative embolisation
- Surgery
