Rhinology | Flashcards
1
Q
What is rhinosinusitis?
A
An inflammatory process involving the mucosa of the nose and sinuses
2
Q
Why is the term sinusitis no longer used?
A
Because inflammation of the mucosa is rarely confined to the sinuses and usually affects the whole URT
3
Q
What are the 3 classifications of rhinosinusitis according to its length of time?
A
- Acute (<4 weeks)
- Subacute (4-12 weeks)
- Chronic (>12 weeks)
4
Q
Chronic rhinosinusitis is a multifactorial disease. What are some of the factors that can contribute to it? (4)
A
- Bacterial infection
- Allergy
- Mucociliary impairment
- Swelling of the mucosa for other reasons
5
Q
Which meatus do the maxillary, frontal and anterior ethmoid sinuses drain into?
A
Middle meatus (between the inferior and middle turbinate)
6
Q
Which meatus does the posterior ethmoids drain into?
A
Superior meatus
7
Q
Which meatus does the sphenoid sinus drain into?
A
Sphenoethmoidal recess in posterior nasal cavity
8
Q
Which is the most commonly affected sinus?
A
Maxillary
9
Q
What usually precedes rhinosinusitis?
A
Viral URTI
10
Q
What is the pathophysiology of rhinosinusitis? (3)
A
- URTI involves all the respiratory epithelium including the paranasal sinuses
- This causes hyperaemia and oedema of the mucosa which block sinus drainage
- Stasis of secretions predisposes to 2o bacterial infection
11
Q
What are the 2 most common causal organisms of rhinosinusitis?
A
- Streptococcus pneumoniae
2. Haemophilus influenzae
12
Q
What are the clinical features of acute rhinosinusitis?
Main (4)
Others (3)
A
Main symptoms:
- Follows an acute viral URTI
- Severe unilateral pain over the infected sinus
- Malaise
- Pyrexia
Others:
- Nasal obstruction
- Mucopurulent rhinorrhoea
- Poor smell
13
Q
What does pain developing in the cheek or upper teeth indicate?
A
Maxillary sinus involvement - tends to be unilateral
14
Q
What does pain above the eye and tenderness of the supraorbital margin indicate?
A
Frontal sinusitis
15
Q
What does retro-orbital pain or pain at the vertex of the head indicate?
A
Sphenoid infection - but pain can be referred to temporal region or to whole head
16
Q
What does tenderness on percussion of the upper first or second molar indicate?
A
Rhinosinusitis of dental origin
17
Q
What would anterior rhinoscopy show in a patient with rhinosinusitis (2)?
A
- Inflamed or oedematous nasal mucosa
2. Mucopurulent secretions in nasal cavity
18
Q
What could a throat examination in patient with rhinosinusitis show?
A
Mucopurulent secretions in the posterior oropharynx
19
Q
What investigations would be done for rhinosinusitis?
A
Usually unnecessary
-Can do plain sinus x-ray
20
Q
What are the treatments for rhinosinusitis (3)?
A
- Analgesia
- Steam inhalations
- Decongestant
21
Q
How does the decongestant work? How long should it be used for?
A
Reduces nasal oedema and improves natural drainage of the sinuses
No longer than 5 days
22
Q
Why should the decongestant spray not be used long-term?
A
To avoid rhinitis medicamentosa - nasal vasculature becomes habituated and damaged by the sympathomimetic action of the drug resulting in rebound congestion and chronic nasal obstruction
23
Q
When are Abx recommended for rhinosinusitis?
A
In severe cases or where symptoms are persisting or progressing
24
Q
What Abx is recommended for severe acute maxillary sinusitis? For how long?
A
Penicillin/Amoxicillin for 7-14 days
25
When does someone with rhinosinusitis need to be referred to an ENT surgeon (2)?
1. If there is progressive pain in the sinuses - may need draining
2. If signs of complications arise
26
What signs indicate complications of rhinosinusitis requiring immediate referral (4)?
***
1. Periorbital cellulitis
2. Severe headaches
3. Focal neurological signs
4. Symptoms of meningitis
27
What are the 3 main causative organisms of chronic rhinosinusitis?
1. Staph. aureus
2. Coagulase-negative staphylococcus
3. Anaerobic and gram-negative bacteria
28
What is the pathology of chronic rhinosinusitis (5)?
1. No frank purulent infection
2. Mucosal hyper-reactivity to staph superantigens can lead to nasal polyps
3. Hypertrophic mucosa with tenacious secretions
4. At histology, the lining is replete with eosinophils
5. No evidence of allergy
29
What are the 5 clinical features of chronic rhinosinusitis?
1. Nasal obstruction
2. Discoloured discharge (nasal or post-nasal) for >12 weeks
3. May experience a smell disturbance (anosmia or cacosmia)
4. May have intermittent frontal pain
5. It is USUALLY painless
30
What are the 5 key points in the history of chronic rhinosinusitis?
1. An exacerbation of pain during an URTI
2. An association with rhinological symptoms
3. Pain that is worse on flying
4. Responds to medical treatment
5. Longer than 12 weeks
31
What are possible diagnoses of facial pain or pressure on its own without nasal symptoms or signs? What is it not?
(5)
1. Not rhinosinusitis
2. Midfacial segment pain
3. Migraine
4. Cluster headaches
5. Atypical facial pain
32
What are 4 physical signs of CRS?
1. Mucosal swelling
2. Inflammation
3. Discharge
4. Nasal polyps
33
How do you distinguish between nasal polyps and the inferior turbinate (2) ?
1. Turbinates are red and sensitive
| 2. Polyps are pale, pendulousm opalescent, painless swellings
34
What are the principles aims of treating CRS?
Ventilate sinuses and restore mucociliary clearance
35
What are the treatments available for CRS (3)?
1. Broad-spectrum oral Abx for at least 3 weeks such as:
Amoxycillin-clavulanate
OR Clindamycin
OR a combo of metronidazole and penicillin
2. Topical nasal steroids such as betamethasone drops for 2 months
3. Nasal douching
36
How would you instruct a patient to administer nasal steroids?
Take drops while patient is lying on bed with the head upside down over the edge
37
When should someone with CRS be referred to ENT? What investigations would be done?
After 8 weeks of medical therapy with no improvement
-Should have nasendoscopy to confirm diagnosis
-In persistent cases that have not responded to max medical treatment, a CT scan of paranasal sinuses with a view to surgery may be considered
38
How do you instruct someone to perform nasal douching (4)?
1. Mix 1/2 teaspoon of salt, sugar, BOS in 2 pints of boiled water which has been left to cool
2. Put some on a saucer/draw up with a syringe
3. Block off one nostril with one finger and then sniff or squeeze up the solution into the other nostril, letting it run out afterwards
4. Topical sprays and drops should be taken after douching
39
What are complications of infective sinusitis (6)?
Which is the most common serious complication? *
****
1. Chronic sinusitis
2. Osteomyelitis
3. Peri-orbital cellulitis and orbital abscess*
4. Facial cellulitis
5. Mucoceles
6. Intracranial complications
- Meningitis
- Cavernous sinus thrombosis
- Brain abscesses
- Extradural abscess
- Subdural abscess
40
What are peri-orbital cellultis and orbital abscesses?
Direct/blood-bourne spread of infection from ethmoid sinus to the orbit as it is only separated by a thin plate of bone. It can lead to:
- Cellulitis = inflammation of skin anterior to orbital septum
- Orbital abscess whereby pus is subperiosteal but posterior to orbital septum
41
What is the management of peri-orbital cellulitis?
High dose Abx and careful observation
42
What are the dangers of an orbital abscess? How do you monitor it (3)?
***
Vision at risk from pressure on optic nerve
Careful monitoring of:
1. Colour vision (especially red)
2. Visual acuity
3. Eye movements
If in doubt CT scan
43
What needs to be done for an orbital abscess?
Urgent drainage
44
How does facial cellulitis arise (3)?
Extension of:
1. Orbital cellulitis
2. Frontal sinusitis
3. Maxillary sinusitis or osteomyelitis
45
How is facial cellulitis treated (2)?
High dose Abx
| Sinus drainage
46
What is a mucocele?
Swelling of the lip/mouth lining
47
How does a mucocele usually arise?
As a late complication of acute sinusitis - collections of sterile mucus occupy an obstructed sinus
48
How does a mucocele present (2)?
1. Facial swelling
| 2. Visual disturbances due to displacement of eye or 2o infections
49
What is the treatment of a mucocele?
Surgical drainage (usually endoscopic)
50
How do intracranial complications arise from rhinosinusitis (3)?
1. Direct spread
2. Venous thrombophlebitis
3. Along the perineural tissue of the olfactory nerve
51
Which is the most common intracranial complication of rhinosinusitis?
Meningitis
52
How can a cavernous sinus thrombosis arise from rhinosinusitis?
Spreading thrombophlebitis from the frontal, ethmoidal and sphenoid sinuses
53
What is the pathology of cavernous sinus thrombosis?
Decreased venous return from eye causing orbit to swell and congestion of the retinal vessels
54
What are the 5 clinical features of a cavernous sinus thrombosis?
***
1. High fever with rigors
2. Severe headache
3. Reduced level of consciousness
4. Cerebral irritation
5. Symptoms often become bilateral
55
What are the 2 signs of a cavernous sinus thrombosis?
1. III, IV and VI nerve palsies i.e. opthalmoplegia
| 2. Parasthesia of the upper 2 divisions of the Vth
56
What is the treatment of cavernous sinus thrombosis?
High dose Abx
57
How do brain abscesses usually occur? Where do they usually occur?
Usually arise 2o to frontal sinusitis
| Occur most commonly in frontal lobe
58
What are the 4 clinical features of a brain abscess?
***
1. Subtle changes in personality
2. Headaches
3. Convulsions
4. May be found incidentally on a CT scan
59
What is the treatment for a brain abscess?
Neurosurgical drainage or aspiration
60
How does an extradural abscess usually arise?
Usually 2o to frontal sinusitis, and due to dehiscence of the posterior wall of the frontal sinus
61
How may extradural abscesses be identified?
On CT scan
62
What is the treatment of an extradural abscess?
Drained into the frontal sinus and hence externally
63
How does a subdural abscess usually arise?
2o to frontal sinusitis
64
What are the 4 clinical features of a subdural abscess?
***
1. General malaise
2. Headache
3. Neck stiffness
4. Signs of raised intracranial pressure
65
How is a subdural abscess diagnosed?
Examination and CT scan
66
How common is a subdural abscess as a complication of rhinosinusitis?
What is its prognosis?
Rare
Poor prognosis
67
What are the clinical features of allergic rhinitis?
Nasal (5)
Eye (3)
1. Nasal obstruction
2. May have hyposmia
3. Nasal irritation/itching
4. Sneezing
5. Nasal discharge
May also have eye symptoms:
1. Bilateral itching
2. Redness
3. Swelling
68
What are the signs on examination for allergic rhinitis?
Pale and swollen turbinates though mucosa can be red
69
When is the rhinitis more likely to be due to an infective cause (3)?
1. acute onset of 1 week or less.
2. Associated with features of an URTI
3. Nasal discharge is green/yellow
70
What would indicate an allergic rhinitis (4)?
1. Personal or family history of atopy
2. Occurance of symptoms following exposure to a known allergic cause of rhinitis
3. Rhinitis is associated with nasal itching
4. Symptoms are controlled by antihistamines or topical corticosteroids
71
What are the triggers for allergic rhinitis (6)?
1. House dust mites
2. Animal dander
3. Tree pollens
4. Grass pollens
5. Weed pollens
6. Allergens encountered at work - intermittent or chronic symptoms tend to imrpove when person is away from work
72
What is the management of allergic rhinitis in primary care (2)?
1. Antihistamines or topical corticosteroids
| 2. Nasal douching
73
Which blood vessel does epistaxis usually arise from in children?
Retrocolumellar vein at the anterior end of Little's area
74
What are the 3 common sites for epistaxis in adults?
1. Anterior septum - most common site
2. Prominent vessels
3. Lateral nasal wall more posteriorly
75
What are the 8 more common causes of epistaxis?
1. Often there is no obvious cause
2. Follow an URTI
3. Follow allergic rhinitis
4. Nose picking
5. Crusting in the nose
6. Facial and nasal trauma
7. Rarely tumours
8. Older patients taking warfarin/aspirin
76
What are the 2 rare causes of epistaxis?
1. Hereditary haemorrhagic telangiectasia
| 2. Coagulopathies such as von Willebrand's disease, leukaemia and DIC
77
How do you assess severity of epistaxis?
Estimate amount of blood lost (difficult)
78
How would you instruct someone on first aid management of epistaxis (4)?
1. Lean forward
2. Pinch fleshy part of nose (not the bridge) for 10 mins
3. Spit blood out (do not swallow as they are liable to vomit)
4. Apply ice pack to bridge of nose or back of neck
79
How would you manage epistaxis in ED (5)?
1. Estimate amount of blood lost
2. Measure pulse and bp while pressure on nose
3. They should be seated
4. IV access gained and iv fluid commensed
5. FBC, coagulation screen and Group+save as a minimum
80
How would you manage epistaxis in 2o care (8)?
After doing what you would do in ED/GP:
1. Wear facial and clothing protection and gloves
2. Remove clot
3. Anaesthetic and vasoconstrictor spray applied to nasal mucosa
4. If bleeding point is seen it can be cauterised with silver nitrate on a stick
5. If not possible, then anterior vaseline, Marocel or Bismuth and iodine parafffin paste pack can be inserted into nasal cavity.
6. If this fails, a posterior balloon can be inserted as well as the anterior pack. Should be left for 36-48 hours. Abx are often given aswell to prevent 2o infections
7. If packing fails, the patient is frequently taken to theatre for further packing, insertion of a postnasal pack and septal surgery to allow for more effective packing.
8. If this fails, arterial ligation is done - usually the splenopalatine artery
81
What is important to establish in the history of trauma to the facial bones and nose (2)?
1. The manner of the injury - gives clues to possible injury
| 2. Pre or post-traumatic amnesia - tells you severity of head injury
82
What is important to check in the patient after an accident (6)?
1. Airway is clear
2. No fractured teeth have been inhaled
3. No orthopaedic chest
4. No intra-abdominal injuries
5. Pupillary reflexes and vision
6. Eye movements to exclude "blow-out" or zygomatic fracture
83
Why is it usually difficult to assess the extent of any nasal or zygomatic deformity clinically?
Unless you examine them shortly after the accident, there is often too much swelling
84
When is the need for nasal reduction assessed for (2)?
1. Immediately after incident
| 2. Or 5-10 days after when soft tissue swelling has settled
85
What 5 complications must you exclude when faced with facial bone trauma?
1. Head injury and other injuries
2. Septal haematoma
3. Zygomatic or middle third fracture
4. CSF leak
5. "blow out" fracture of the orbit
86
What is a septal haematoma caused by?
Bleeding underneath the mucoperichondrium of the septum.
87
What are the clinical features of a septal haematoma (4)?
1. Soft bluish bulge on either side of the septum.
2. Does not cause a lot of discomfort
3. Usually blocks both nasal air passages
4. When prodded with the side of forceps, it feels soft, whereas deformed cartilage feels hard
88
What are the complications of septal haematoma?
It nearly always gets infected producing a septal abscess ad subsequent necrosis of the cartilage which leads to gross collapse of the nasal bridge and a "saddle deformity"
89
How should a septal haematoma be managed? How urgently?
| 2
1. Drained - urgent
| 2. Broad spectrum Abx covering staphylococci for 10 days
90
What are the 2 complications of a blow out fracture?
1. A blow can compress the orbital contents which can result in herniation of the orbital fat through the damaged orbital floor
2. The inferior rectus muscle can become trapped in the defect causing diplopia
91
What are the 6 signs of a zygomatic fracture?
1. Diplopia
2. Subconjunctival haemorrhage without a posterior limit
3. Infraorbital nerve anaesthesia
4. An infraorbital 'step' on palpation
5. Trismus
6. Deformity of the zygomatic prominence
92
What indicates a frontoethmoidal fracture?
How urgently does it need to be managed?
Periorbital swelling which 'crackles' when palpated or increases in size when patient blows their nose - due to surgical emphysema
Immediate repair is indicated
93
How is a CSF leak in closed injuries managed? Where should it be managed?
(3)
Conservatively in hospital as they often heal spontaneously
1. Nursed 30 degrees head up
2. Should not blow nose
3. Prophylactic Abx given
94
What is the test to see if clear (often unilateral) nasal discharge is CSF?
Presence of beta-transferrin
95
What investigation is essential in the assessment of zygomatic fractures?
X-ray
96
What on X-ray would indicate a zygomatic fracture?
Fluid level in the maxillary sinus
| Could also be die to a collection of blood from an epistaxis
97
When reviewing a patient with a nasal fracture after swelling has resolved, what is important to ask?
Whether they have had a previous nasal fracture and whether it is the most recent injury which caused the displacement of the nose - it will not be possible to reduce the fracture
98
What is the management of compound nasal injuries? (5)
1. Cleaning
2. Tetanus prophylaxis
3. Abx cover
4. Closure of skin defect
5. Review at 5-10 days to consider nasal reduction
99
By how many days should fractured noses be reduced by?
14 days
100
If the nose is not reduced in the first 14 days, what surgery will be needed?
Rhinoplasty
101
Where can reduction of nasal fractures be done?
Under LA in outpatients
OR
GA
102
What is a common complication of a nose reduction?
| How can it be managed?
Bleeding for a few minutes after the procedure
| Patients under GA need an oropharyngeal pack to prevent aspiration
103
What are complications related to lacerations within the nose?
Adhesions between the turbinate mucosa and septum, causing the nasal valve area to become narrowed
104
What are the 6 complications of a nasal fracture?
1. Septal haematoma/septal abscess
2. Septal perforation
3. Deformity
4. A bent septum with obstruction
5. Anosmia
6. CSF leak
105
What are the 4 problems that occur with a septal perforation following a haematoma?
1. Altered air flow
2. Turbinate hypertrophy
3. A sensation of nasal obstruction
4. Crusting and bleeding occur
106
What are 6 symptoms of sleep apnoea?
1. Excessive daytime sleepiness and snoring and/or impaired concentration.
2. Witnessed apnoeas or choking noises while sleeping.
3. Feeling unrefreshed on waking.
4. Mood swings, personality changes, or depression.
5. Nocturia
6. Rarely, nocturnal sweating, reduced libido, and gastro–oesophageal reflux disease (GORD)
107
What 4 factors contribute to snoring in adults?
1. The anatomy of the mouth
-A thickened or floppy soft palate or an elongated uvula can narrow the
airway and obstruct airflow
-Enlarged tonsils or a large tongue base
-Jaw shape
2. Nasal congestion
- Allergies
- Septal deviation
3. Alcohol consumption before bed + smoking
4. Being overweight
108
How is snoring managed in primary care (7)?
1. Diet and lifestyle
2. Reduce alcohol + smoking
3. Sleep on side
4. Treat nasal allergies and congestion
5. Refer for sleep studies
6. Assess risk of CVD and diabetes
7. Monitor bp
109
What are some surgeries available for snoring and OSA?
What are their limitations (3)?
Palatal surgery is done to reduce or stop the collapsibility of the oropharyngeal segment. This is usually done by reducing the amount of soft palate and/or removing the tonsils. The uvula may also be removed.
Limitations:
1. Snoring may return in a few months
2. Snoring may not be associated with the soft palate at all - it may be to do with the base of the tongue and surgery will not alleviate that
3. If patient puts on weight after surgery, snoring may return
