Rhinology

Question 1

What is Epistaxis?
Is it typically unilateral or bilateral?

Answer 1

Nose bleed
Epistaxis is typically unilateral but may be bilateral. It is important to take the whole history of it into consideration. Unilateral epistaxis consistently may be a JNA (if young male for ex). But if someone constantly picks their nose, probably in the long hx itll be bilateral, once from each side. Another thing is how much blood? Could be it sphenopalatine or is it the little’s area. Unilateral epistaxis is considered a red flag but is also the normal presentation!

Question 2

Why do we tilt the head forward in the management of epistaxis and not backwards logically?

Answer 2

Ingestion of blood leads to GI upset

Question 3

A patient presents with bleeding from the nose. What are the most common sources?

Answer 3

Most common: Little’s area or Kiesselbach’s plexus (90%) followed by sphenopalatine artery (if a lot of bleeding)

Question 4

What arteries form Little’s area or Kiesselbach’s plexus (its in the book so know it)

Answer 4

This plexus is the anastomosis of the external and internal carotid arteries

External carotid -> Imax (internal maxillary) -> SPA - Sphenopalatine + GPA - Greater Palatine
External carotid -> Facial artery -> SLA - Superior labial artery

Internal carotid -> Ophthalmic artery -> Anterior and posterior ethmoidal arteries

Question 5

A patient presents with a large volume of nasal bleed or epistaxis. What artery is the most likely source?

Answer 5

Sphenopalatine artery

Question 6

A 16 year old male presents to the OPD with long-standing epistaxis unilaterally. what is the most likely diagnosis?

Answer 6

JNA tumour (juvenile nasopharyngeal angiofibroma)

Question 7

List the causes/RFs of Epistaxis (5)

Answer 7

Digital trauma/nose picking
Mucosal irritation: Allergic rhinitis, recurrent sinusitis, cold, coughs, flu)
Acquired coagulopathy (Liver failure, Vit. K deficiency)
Neoplastic (JNA in young male)
Drugs : Anti-coag, warfarin, heparin, aspirin - CVD patients!!!)
Coagulopathies (e.g. VWF, hemophilia)
HHT - Hereditary Hemorrhagic Telangiectasia
HTN

Question 8

Your nephew begins to have a nose bleed. How would you manage them?

Answer 8

Pinch anterior 1/2 of nose (Nasal alar) for 10 minutes x2, with head tilted slightly forward. If this does not stop the bleed, I will probably have to take them to the hospital for silver nitrate cautery

Question 9

What artery is most commonly embolized in the last-line treatment of epistaxis?

Answer 9

Sphenopalatine artery most commonly cause of major epistaxis => embolizing the Imax or internal maxillary would be best

Question 10

What part of the nose do you pinch when there is a nose bleed?

Answer 10

Nasal Alar

Question 11

There is both anterior and posterior nasal packing as part of the escalation for management of epistaxis. What must also be given when doing this step?

If this fails what is the next step?

Answer 11

Oral Antibiotics to prevent infections such as sinusitis, otitis media, and cavernous sinus thrombosis

That was step 3. Step 4 is surgical:
FESS (Functional endoscopic sinus surgery) for sphenopalatine artery ligation

Question 12

If Sphenopalatine artery ligation (FESS) did not resolve or if it did not turn out to be the causative vessel what arteries are next in line?

Answer 12

Anterior Ethmoidal artery
External carotid artery ligation

Question 13

State your management escalations for Epistaxis starting with first aid.

Answer 13

1) Pinch anterior 1/2 of nose (nasal alar) for 10 minutes x2, with head tilted slightly forward.
Take to hospital for review
Correct coagulation, correct HTN,
2) Silver Nitrate/Electro- Cautery
3) Nasal Packing (ant and posterior) with antibiotics
4) FESS (Functional endoscopic sinus surgery) for sphenopalatine artery ligation -> anterior ethmoid -> external carotid
5) IR Embolization of Imax/sphenopalatine

Question 14

An adolescent male presents to the OPD reporting nasal bleed on the left side happening more often in the past 2 months. They report weight loss but arent sure if it is from starting to practice on a new college football team. What is the most likely diagnosis?

Answer 14

JNA (juvenile nasopharyngeal angiofibroma). Unilateral epistaxis in an adolescent male.

Question 15

List the causes of Nasal Obstruction
List the common symptoms of Nasal Obstruction

Answer 15

Categorize!!!
Congenital: Choanal atresia, Craniofacial abnormalities (high arched palate)
Anatomical: Deviated septum, turbinate hypertrophy, fracture
Inflammatory: Polyps, Rhinosinusitis, allergic rhinitis, sarcoidosis, wegner’s granulomatosis
Neoplastic: SCC, JNA, inverted papilloma
Foreign body

Symptoms of Nasal Obstruction:
NASEEM: Nasal obstruction, Anosmia, Sinusitis, Epistaxis, External Deformity, Middle ear infection + Headaches, breathing difficulties, sleeping difficulties…

Question 16

What congenital syndrome is most associated with high arched palate?

Answer 16

Marfan’s Syndrome

Question 17

What is a spur?

Answer 17

Shelf-like septal deformity that touches the lateral wallL

Question 18

NOT IN BOOK: Deviated Nasal Septum: There are 4 types including anterior dislocation info one of the chambers, C-shaped dislocation, S-shaped deformity (affecting bothchambers), or spurs (shelf).
State 3 causes
State 5 Symptoms
How would you manage a patient with DNS

Answer 18

Causes: Trauma, Congenital (high arched palate/Marfan’s), Family Hx, Idiopathic

Symptoms: Most commonly asymptomatic
NASEEM: Nasal obstruction, Anosmia, Sinusitis, Epistaxis, External Deformity, Middle ear infection + Headaches, breathing difficulties, sleeping difficulties…

Management: Conservative: No tx indicated if no sx
Surgical: Septoplasty or Submucosal Resection

Question 19

NOT IN BOOK: What is septoplasty?

Answer 19

Procedure whereby most deviated parts of septum are removed and repositioned. Used in the tx of deviated nasal septum

Question 20

NOT IN BOOKSubmucosal resection is a procedure used in the treatment of

Answer 20

Deviated nasal septum (septoplasty typically chosen first)

Question 21

Define Nasal Polyposis
What are the clinical features of Nasal polyposis?
What are some findings expected on examination?
How would you manage a patient suffering from

Answer 21

Inflammatory process where the now oedematous mucosa of the (most commonly ethmoid) sinus prolapse into nasal cavity leading to nasal obstruction

Clinical features: Nasal Obstruction ( NASEEM + Headaches, breathing difficulties, sleeping difficulties…) + Allergy part: !sneezing, itchy nose

Exam: Pale, boggy (soft and wet), oedematous mucosa (not inflamed or erythematous, just oedematous)

Management:
Medical: Steroids (Spray 6/12 and taper with PO)
Surgical: If refractory to medical management -> FESS and Endoscopic Polypectomy

Question 22

Nasal polyps are an Inflammatory process where the now oedematous mucosa of the (most commonly ethmoid) sinus prolapse into nasal cavity leading to nasal obstruction. So which meatus is most commonly obstructed?

Answer 22

Middle meatus (ethmoid sinus)

Question 23

What population characteristically have Nasal polyposis?

Answer 23

Asthma population, Allergic rhinitis

Question 24

What is Samter’s Triad?

Answer 24

Triad encompassing pattern of symptoms in individuals
1) Polyposis
2) Asthma
3) Aspirin Sensitivity!!

Question 25

Are Nasal Polyps typically unilateral or bilateral?

Answer 25

Bilateral => If you find a unilateral polyp it is important to be suspicious of a neoplastic process

Question 26

You are called to see a patient in A&E suffering from recurrent sinusitis and otitis media due to nasal obstruction. On exam you see a polyp in the left nostril and none in the right. What is your general workup

Answer 26

Polyps are typically bilateral but it is unilateral here => workup for cancer. Normal polyps dont really have a workup unless checking if patient has asthma cuz of samter’s triad

Always biopsy, CT sinus, and MRI brain/skull base

Question 27

What is the most common location for a nasal polyp?
What is the most involved sinus in polyposis? Where does it drain?

Answer 27

Middle Turbinate/Middle meatus
Remember it is a cyst-like sac => from drainage from all 3 sinuses => most likely there at the osteomeatal complex

The most involved sinus in polyposis is the Ethmoidal sinus which drains into 2 places
Post. Ethmoidal -> Superior meatus
Ant. Ethmoidal -> Middle Meatus

Question 28

The nasal cavity is composed of 3 turbinates. Each of which has a meatus. What drains into each?

Answer 28

Superior Meatus: Post-ethmoidal
Middle Meatus/Osteomeatal complex: Ant. Ethmoidal, frontal, maxillary
Inferior Meatus: Nasolacrimal duct

Question 29

Give the Diagnostic Definition of Sinusitis
i.e. Definition that encompasses diagnostic criteria of sinusitis

Answer 29

Nasal Obstruction(/congestion/nasal discharge) (encompassing RF)
+ At least 1: Facial pain, hyposmia, anosmia (clinical features)
+ Endoscopic/CT findings showing polyposis, obstruction, or discharge in the osteomeatal complex (Diagnosis)

Question 30

What are sinuses?
Humans have 4 paired sinuses. List them along with where they drain.

Answer 30

Sinuses are hollow spaces in bone around the nasal cavity. They typically only have one opening => easily obstructed especially when mucosal layer is inflamed (oedematous => polyposis and obstruction)

Maxillary sinus -> osteomeatal complex, middle meatus
Frontal Sinus -> osteomeatal complex, middle meatus
Ethmoidal Sinus Ant. ->osteomeatal complex, middle meatus. Post. Superior meatus
Sphenoid Sinus -> Sphenoethmoidal recess. Close to sup. Meatus.

Question 31

What is a turbinate? What is its main function?

Answer 31

Bone structures covered by mucosa. They regulate, warm, and humidify airflow. That is why when you breathe through your mouth, it becomes so dry so fast

Question 32

What causes sinusitis?
List Clinical features for sinusitis (not complications)
What is the gold standard to diagnose Sinusitis?
How would you manage a patient with acute Sinusitis

Answer 32

Typically, it is a viral infection => viral rhinosinusitis (98%). This can then be superinfected with bacterial => Bacterial rhinosinusitis. Alternatively, in the immunocompromised population, fungal sinusitis may also occur.

Clinical features
1) Nasal obstruction: NASEEM + Headaches, breathing difficulties, sleeping difficulties…
2) Sinusitis: pyrexia, !!!Facial pain/pressure, Anosmia, sneezing

Diagnosis:
Endoscopy (or CT) findings showing polyposis, mucopurulent discharge, or oedema/mucosal changes in osteomeatal complex

Add these 3 together = Diagnostic definition of sinusitis

Management of acute sinusitis:
Antibiotics
Analgesia
Nasal decongestant
If failed -> FESS (Functional endoscopic sinus surgery)

Question 33

Typically, it is a vital infection => viral rhinosinusitis (98%). This can then be superinfected with bacterial => Bacterial rhinosinusitis. List the organisms responsible for acute and chronic bacterial rhinosinusitis

Answer 33

Acute (<12 weeks) = S. Pneumonia, H. Influenzae, M. Catarrhalis (same as AOM)
Chronic (>12 weeks) = Anaerobes, staph aureus

Question 34

List RFs/causes for Sinusitis

Answer 34

1) Obstructive: Nasal obstruction e.g. polyps, neoplastic, DNS
2) Allergic -> Allergic rhinitis, asthma (both give polyps)
3) Environmental -> Smoking exposure, occupational, chemical, medications
4) Congenital -> Anatomical abnormalities (craniofacial abnormalities), high arched palate, DNS, Choanal atresia
5) Immunodeficiency -> Diabetes, HIV, Chemotherapy, radiotherapy, splenectomy, autoimmune drugs…
6) Reduced mucocilliary clearance: CF, primary cilliary dyskinesia, kartagener syndrome (increased stasis => infection)

Question 35

What is Otia?

Answer 35

Obstruction of a sinus opening, typically from inflammation

Question 36

NOT IN BOOK:What would warrant ENT referral for sinusitis AKA for surgery?

Answer 36

1) 3-4 infections per year (multiple)
2) Failure to improve after 2-3 weeks on antibiotics
3) Nasal Polyposis on exam (part of same surgery)
4) Complications of sinusitis

Question 37

V. IMP Q: List the complications of sinusitis
Which complication is the most common in adults?
What population do most of these complications occur in?

Answer 37

1) Orbital Complications (orbital cellulitis, abscess, and cavernous thrombosis)
2) Intracranial complications (meningitis, frontal lobe abscess)
3) Osteomyelitis
4) Acute Otitis Media
5) LRTI (most common adults)
6) Mucocele formation (-> obstruction)

Sinusitis and its complications are common in paediatric population

Question 38

How long does a patient have to have sinusitis to be considered chronic sinusitis?

Answer 38

Sinusitis lasting more than 12 weeks

Question 39

V. IMP QUESTION: Orbital complications of sinusitis are one of the more severe ones to keep an eye out for.
What is the relation of the orbit to sinusitis?
What sinus is most associated to orbital complications of sinusitis? What population is that seen most in?
What classification is used to grade the extent of these complications? List the complications.
What clinical features are associated with these complications?
How are these complications treated?

Answer 39

Howdoes Sinusitis lead to orbital complications?
Bacteremia occurs via veins and bones (!Lamina Papyracae) of the sinuses

What sinus is most associated to orbital complications of sinusitis? What population is that seen most in?
Ethmoidal sinuses seen typically in the paediatric population

What classification is used to grade the extent of these complications? List the complications.

Chandler’s Classification:
I - Preseptal/orbital cellulitis
II - Orbital Cellulitis
III - Preseptal/orbital abscess
IV - Orbital abscess
V - Cavernous Sinus Thrombosis

What clinical features are associated with these complications?
Lid swelling/redness +/- proptosis of the eye
Opthalmoplegia
Vision disturbances (color goes first)
Cavernous sinus disturbance (CNII, III, IV, Va, VI)

How are these complications treated?
IV antibiotics +/- nasal toilet
Drain abscess if abscess

Question 40

The cavernous sinus runs behind the sphenoid sinus, next to the optic chiasm (note that). What runs in the cavernous sinus?
How would you diagnose cavernous sinus thrombosis as a complication of sinusitis?

Answer 40

Internal carotid artery, CN2,3,4,5A,6
From this you should understand how to add all these sx to a patient that has this affected
CT sinus +/- MRI brain

Question 41

What intracranial complications may arise from Sinusitis?
What sinus is most associated with these complications?
How would you manage a patient with these complications?

Answer 41

Meningitis
Intracranial abscess (epidural… not hematomas)
!Frontal lobe abscess

Frontal sinus most associated => frontal lobe abscess. Frontal lobe contains many veins that penetrate post. of sinus

Tx: Aggressive antibiotics (3rd gen cephalosporins, cefotaxime, ceftriaxone)
Surgical drainage of abscess
Topical vasoconstriction

Question 42

What is “Potts Puffy Tumor”?
What sinus is most involved?

Answer 42

It is osteomyelitis of the frontal bone. Similar to how the frontal sinus may cause intracranial complications (abscess, meningitis) due to its proximity, the location of the sinus within the frontal bone makes this more likely.

Question 43

What is allergic rhinitis? What are the 2 types?
List clinical features and exam findings of Allergic rhinitis
What are some conditions that allergic rhinitis increases the risk for?
What population is this condition common in?
How would you diagnose allergic rhinitis?
State the full treatment ladder for allergic rhinitis (5)

Answer 43

Allergic rhinitis is inflammation of the nose due to allergens in the environment causing IgE Type 1 hypersensitivity. (you didnt actually need to say all that). It may be Seasonal or perennial.

Clinical features:
Nasal obstruction: NASEEM + Headaches, breathing difficulties, sleeping difficulties…
Allergy: Sneezing and itching, watery eyes, Conjunctival swelling, headache
Exam findings: Pale, oedematous nasal mucosa, Darcyocystitis, swollen turbinates, oedematous mucosa, conjunctival swelling

Allergic rhinitis is common in asthma populations and can increase the risk of !Sinusitis, ET dysfunction (AOM, conductive hearing loss, glue ear…), and !Nasal polyps

Diagnosis:
RAST, Skin prick, FBC with raised eosinophils

Tx ladder:
1) Prevention: avoidance, face mask in pollen season, remove carpets, pets, dolls, avoid smoking at home! etc..
2) Antihistamines (topical or oral)
3) Nasal steroid spray (Fluticasone)
4) Antileukotrienes
5) Immunotherapy by immunologist (Desensititsation therapy if pollen)

Question 44

NOT IN BOOK:What is Non-Allergic Rhinitis?
Patients presenting with non-allergic rhinitis typically present similarly to that of allergic rhinitis. How would you differentiate to diagnose this?
What is the treatment approach?

Answer 44

It is Vasomotor rhinitis due to hyperactive nasal mucosa

Patients here typically complain of nasal blockage, clear discharge after a non-specific irritant exposure as opposed to allergic rhinitis which has an allergen.

To confirm this, the skin prick test should be negative in vasomotor rhinitis.

Another way is to inspect the nasal mucosa. It is often red and boggy here whereas it is pale and boggy in allergic rhinitis (and nasal polyps cuz same etiology)

Tx: Medical: Antihistamines
Surgical: All we can do is make more space => maybe adenectomy? (just get correct concept thats why “approach

Question 45

What is seen in this image?
What are the possible causes? (3)

Answer 45

Saddle nose dformity. It is caused by the necrosis of the cartilaginous pyramid (just cartilage) of the nose.

Wegner’s Granulomatosis/Granulomatosis with polyangitis. Chronic rhinosinusitis here leads to its eventual breakdown and collapse
Trauma
Congenital

Question 46

Features of which disease are displayed in this image?
In ENT, what clinical symptom does this mainly increase the risk of?

Answer 46

HHT - Hereditary Hemorrhagic Telangiectasia (these findings are also seen in liver disease)
It is widened hemorrhagic vessels

Epistaxis

Question 47

What is meant by vestibule? what are its parts?

Answer 47

Part of nose involved in anterior rhinoscopy involving the Septum, inferior turbinate and floor of nose

Question 48

When inspecting a patient in an ENT clinic, you would like to conduct anterior rhinoscopy
What are you inspecting and assessing?
With what instrument would you conduct this?

Answer 48

In anterior rhinoscopy, we are inspecting the vestibule (septum, inferior turbinate, and floor of nose) with a Thudicum or Killian speculum. During this inspecting, we will assess for turbinate size, septal deviation, presence of polyps, drainage, masses, foreign bodies…

Question 49

What is this?

Answer 49

This is Thudicum’s Speculum used in Anterior Rhinoscopy

Question 50

What is this?

Answer 50

This is Killian’s Speculum used in Anterior Rhinoscopy

Question 51

What device is used to inspect the nasopharynx?

Answer 51

Rigid/Flexible endoscopy

Question 52

Why would rigid endoscopy be used over flexible endoscopy

Answer 52

Rigid endoscopy allows for the other hand to be free as compared to flexible endoscopy which is a 2-hand operation to maneuver the scope

Question 53

What MRI would you order for ENT-related pathologies affecting the nose?

Answer 53

MRI skull base

Question 54

Nasopharyngeal carcinoma (NPC) is a malignant transformation of nasopharyngeal epithelial cells due to having a genetic pre-disposition + carcinogens.

Where exactly does NPC arise?
How does it spread
What population groups is this most common in?
How does it present?

There is no staging really of this cancer as it’s primary treatment is…

What diagnostic investigations (3) would you perform for this?

Answer 54

Arises from the epithelial cells in the Fossa of Rosenmuller
It spreads via direct extension (rather than metastasis)
Population: Chinese and southeast asia

Presentation:
Epistaxis
Nasal obstruction
Unilateral middle ear effusion
Cranial nerve dysfunction
Neck mass

Primary treatment is radiotherapy +/- chemo if advanced

Investigations:
!!Biopsy of post-nasal space via Pan-endoscopy (examination) under anaesthesia
CT neck & thorax
MRI skull base