Rhinology Flashcards
What are the three classification of rhinosinusitis in terms of acute/chronicity?
acute less than 4wks
sub-acute 4-12wks
Chronic longer than 12 wks
What is the cause of chronic rhinosinusitis?
It is multfactorial
Which sinuses drain into the middle meatus?
Maxillary
Frontal
Anterior ethmoid
Which sinuses drain into the superior meatus?
Posterior ethmoid
Where does the sphenoid sinus drain into?
Sphenoethmoidal recess in the posterior nasal cavity
Which is the order of sinuses most commonly affected by acute rhinosinusitis?
Maxillary
Ethmoidal
Frontal
Sphenoid
What does acute rhinosinusitis commonly follow and what can it lead to?
Viral URTI which causes swelling of mucosa and blockage of sinus drainage predisposing to bacterial infection (e.g. streptococcus)
What are the signs of acute rhinosinusitis (ARS)?
An accompanying acute viral URTI
Severe unilateral pain over affected sinus
Malaise and pyrexia
(must have some nasal symptoms or unlikely to be ARS)
What are the investigations for ARS?
They are not usually indicated
How long should decongestants be given for ARS?
5 days
What are the two courses of chronic rhinosinusitis (CRS)?
Following ARS or
it may have had a more insidious onset
What is the cause of chronic rhinosinusitis?
It is multfactorial
What is the treatment for ARS?
Analgesics
Steam inhalations
Decongestants
(surgical washout or drainage in severe cases)
How often do antibiotics alter the course of ARS?
3%
What are the types of rhinosinusitis?
Acute rhinosinusitis (ARS) Sub-acute rhinosinusitis Chronic rhinosinusitis (CRS) Allergic rhinosinusitis Non-allergic rhinosinusitis (a.k.a idiopathic rhinosinusitis)
How are sinuses examined in CRS?
Nasoendoscope (X-rays are not specific)
What types of CRS have increased and decreased of previous decades?
Infective CRS has decreased due to better health and antibiotics
Allergic CRS has increased
How can allergic and non-allergic rhinosinusitis be differentiated?
Non-allergic rhinosinusitis rarely has itching or sneezing
What are the signs and symptoms (S/S) of CRS?
Nasal obstruction
Purulent discharge around the clock (not just in the morning)
Anosmia or cacosmia (unpleasant smell)
Usually painless
What are key symptoms of sinus pain?
Worse with URTI
Associated with rhinological symptoms
Worse when flying
What does bending forward causing increase in facial pain indicate?
Not much it is NOT specific for sinus pain
What is required to make a diagnosis of CRS?
Matching history symptoms:
(Nasal obstruction
Purulent discharge around the clock (not just in the morning)
Anosmia or cacosmia (unpleasant smell)
Usually painless)
AND physical findings such as:
Mucosal inflammation
Mucosal discharge
Nasal polyps
How are physical findings elicited in CRS?
Via nasoendoscope
Anterior rhinoscopy can be used but less can be seen
How can polyps and turbinates be differentiated?
Turbinates - red and sensitive
Polyps - Pale, pendulous, painless
What are the S/S of allergic rhinosinusitis?
Nasal onstruction
Hyposmia (a reduced ability to smell)
Nasal irritation -> Sneezing
Slightly yellow mucus (non-infective, due to eosinophils)
What is often diagnosed incorrectly as chronic infective rhinosinusitis?
Persistent allergic rhinosinusitis due to perennial (plant) allergens
What is non-allergic rhinosinusitis?
Essentially idiopathic rhinosinusitis, not due to infection or allergy.
Can different types of rhinosinusitis occur concurrently?
Yes
What are the S/S of non-allergic rhinosinusitis?
Nasal obstruction
Clear rhinorrhoea
How can allergic and non-allergic rhinosinusitis be differentiated?
Non-allergic rhinosinusitis rarely has itching or sneezing
What is the main aim of treatment for rhinosinusitis?
Ventilate sinuses
Restore mucocilliary clearance
What is the treatment of CRS?
At least 3 wks of broad spectrum antibiotics
Topical nasal steroids for at least 2 mnths followed by a nasal spray
Instructions of how to perform nasal douching
Should drops or topical sprays be used before or after douching?
After douching
What are the complications of infective sinusitis?
Mucoceles (muscous cyst)
CRS
Periorbital abscess or cellulitis (most common serious complication))
Facial cellulitis
Osteomyelitis
Intracranial complications
What is the limit for the use of nasal steroids
There isn’t one if improvement is being seen clinically
What is osteomyelitis?
inflammation of bone or bone marrow
How can chronic rhinosinusitis be treated surgically?
Functional endoscopic sinus surgery (FESS) to clear natural pathways of sinuses
It is very successful over classical “open” surgery
What is a classic sign of chronic infective rhinosinusitis?
Green discharge from nose
What is the commonest cause facial pain?
Midfacial segment pain
What are the symptoms of midfacial segment pain and how can it be differentiated from rhinosinusitis?
Symmetrical sensation of pressure (sometimes described as a “blockage”)
NO airway impairment
What can midfacial segment pain be likened to?
Tension headache that affects the midface
What is the treatment for midfacial segment pain?
Amitriptyline for 6 mnths
takes 6 wks to have an effect
What are the ingredients for nasal douching?
1/2 teaspoon of salt
1/2 teaspoon of sugar
1/2 teaspoon of bicarb of soda
2 pints of boiled water
leave to cool
How is nasal douching performed?
Draw up mixture with syringe
Block one nostril
Sniff or squeeze liquid into other nostril
Leave to run out
What are the intracranial complications of infective sinusitis?
Meningitis
Cavernous sinus thrombosis
Brain/extradural/subdural abscess
What is the first sign that a periorbital obscess maybe sight threatening?
Loss of colour vision
What are mucoceles?
Collections of sterile mucus occupying an obstructed sinus
Late complication of ARS
What do mucoceles present as?
Facial swelling
Visual distubrances
How are mucocele treated?
Surgical drainage usually endoscopically
What is the post nasal space also known as?
nasopharynx
What is the job of vestibule of the nose?
The stiff hairs block large particles
How are smaller particles in the nose removed?
via enzymatic destruction from the nose mucosa
If someone is reporting poor taste what maybe the cause?
Nasal pathology as it gives about 85% of taste
What is the vestibule of the nose? (what encloses it)
the nasal entrance (it is enclosed by the alar cartilages)
What is the nasal septum made up of?
Ethmoid and vomer posteriorly, cartilage anteriorly
What makes up the floor of the nose?
The maxilla
Which area of the nose is most likely to be the source of nose bleeds and why?
Little’s area (part of the septum)as it is an area where four arteries anastomose
What is the space between the turbinates called?
Meatus (inferior meatus below inferior turbinate)
Which meatus does the nasolacrimal duct and eustachian tube drain into?
The inferior meatus
Which meatus do the frontal and maxillary sinuses drain into?
The middle meatus
What are the best methods for investigating rhinosinusitis?
History and allergy testing
What is infective rhinosinusitis effectively?
The nasal effects of the common cold
What is allergic rhinosinusitis colloquially known as?
Hay fever
What is more common allergic or infective rhinosinusitis?
Infective rhinitis
What immunoglobulin is indicated in the hypersensitivity in allergic rhinosinusitis (and thus what does this cause the release of)?
IgE (histamine)
What occurs in long-term allergic rhinosinusitis?
The turbinates undergo permanent hypertrophy
What is the pathophysiology of rhinosinusitis medicamentosa?
When the decongestant wears off there is a rebound vasodilation so further decongestant is taken.This causes a cycle and leads to turbinate hypertrophywhich is then unresponsively blocking the nasal cavity
What is the treatment for rhinosinusitis medicamentosa?
Stop decongestants
Steroids
Potentially tubinate surgery
Which type of sinusitis can be life and sight threatening?
Frontal sinusitis
Which types of sinusitis commonly has periorbital sinusitis as an adverse outcome?
Ethmoidal sinusitis
How is periorbital sinusitis sight threatening?
It can compress the optic nerve
How is periorbital sinusitis treated?
High dose antibiotics and observation
Are mucocoeles an early or late complication of acute sinusitis?
mucocoeles are a late complication of acute sinusitis
Which sinuses are mucocoeles most common in?
frontal and ethmoidal sinuses
Which sinusitis is most commonly associated with extradural abscesses?
frontal
Which sinusitis is most commonly associated with subdural abscesses?
frontal
Which type of abscess 2ry to sinusitis has a worse prognosis?
subdural abscess
Which part of the septum should NOT be removed when the pt has a deviated septum and why?
The anterior portion as it gives a bad cosmetic result
If a pt has a damaged external nasal skeleton within how much time is there for the nose to be re-maniulated?
2 weeks
What is epistaxis?
A nose bleed
What is the initial first aid for epistaxis?
get the pt to sit forward and pinch the fleshy part of the nose (not the bridge) for 10 minutes
The patient should spit out the blood (if swallowed may vomit)and an ice pack on the nasal bridge may be helpful.
What should be the treatment for severe epistaxis?
IV access, FBC, coagulation screen and croup + save
Spray the bleeding point with 5% cocaine
Attempt nasal cautery
Pack if very severe (generally in posterior bleeds)
How long is the packing in posterior nasal epitaxis generally left for?
24-48 hours
What can be given prophylactically with nasal packing?
antibiotic
What is a rare cause of severe unilateral epistaxis in adolescent boys?
Angiofibroma
