Rhinology Flashcards
What is rhinosinusitis?
Defined as inflammation in the nose and paranasal sinuses with >/=2 symptoms, one of which must be nasal discharge or nasal congestion
What are features of rhinosinusitis?
- Facial pain/pressure
- Decreased olfaction
- Rhinorrhoea
- Nasal congestion
What would be classed as chronic rhinosinusitis?
Symptoms lasting >/= 12 weeks
What are causes of nasal congestion in children?
- Big adenoids
- Rhinitis/rhinosinusitis
- Choanal atresia
- Postnasal space tumour
- Foreign body
What are causes of nasal congestion in adults?
- Deflected nasal septum
- Granuloma
- Tricyclic antidepressants
- Topical vasoconstrictors/decongestants - rhinitis medicamentosa
What is the most comon cause of acute infective rhinitis?
Viral
How would you treat acute rhinosinusitis?
- Topical corticosteroids - nasal sprays
- Oral antibiotics
How would you treat chronic rhinosinusitis?
- Topical steroids - nasal sprays
- Nasal douching
What are red flag symptoms associated with nasal congestion?
- Numbness
- Tooth loss
- Bleeding
- Unilateral obstructing mass
When assessing nasal congestion, what would you want to ask about it?
- Symptom variation
- Uni/Bilaterality
- Affects speech, eating, smell, sleep
When examining someone with nasal congestion, what would you look for?
- Facial pain
- Nasal polyps
- Pus discharge from sinuses
- Post-nasal space
- Septal deviation/Nasal deflection
What is allergic rhinosinusitis?
IgE-mediated inflammation from allergen exposure to nasal mucosa causing inflammatory mediator release from mast cells
What substances are released by mast cells in allergic rhinosinusitis?
Histamines, prostaglandins
What are symptoms of allergic rhinitsinusitis?
- Sneezing
- Pruritis
- Rhinorrhoea (bilateral + variable)
What are signs of allergic rhinosinusitis?
- Swollen turbinates - pale mucosae
- Nasal polys
What is the following?
Nasal polyp
What are typical allergens implicated in allergic rhinosinusitis?
- Dust
- Pollen
- Moulds
- Pets
What investigation(s) might you perform in someone presenting with features of allergic rhinosinusitis?
Skin prick test/RAST
How would you manage allergic rhinosinusitis?
- Allergen avoidance
- Antihistamines
- Decongestants
- Nasal steroids
- Oral steroids - in severe attacks
What is perrenial allergic rhinitis?
Allergic rhinitis which is caused by allergens which are present all year round
What is seasonal allergic rhinitis?
Caused by seasonal allergens e.g. pollen
If nasal sprays were not working for someone diagnosed with allergic rhinitis, what could you consider using?
Montelukast
When allergic rhinitis co-exists with asthma, what would you consider giving as a part of your management?
- Nasal steroids
- Anti-leukotriene agent
What is the risk of allergic rhinitis in someone with asthma?
May trigger an asthma attack
What are causes of rhinorrhoea?
- Allergies
- Infection - bacteria, viruses
- Foreign body
- CSF
- Primary ciliary dyskinesia
- RA
- Pregnancy
- OCP
- NSAIDs
- Decongestant overuse
What are nasal polyps?
Descriptive term for a pedunculated swelling arising in the nose or paranasal sinuses. They can develop in both benign and malignant conditions
Which type of polyp would cause more concern; unilateral or bilateral nasal polyps?
Unilateral - bilateral are more likely to occur in inflammatory conditions (e.g. infection etc.) whereas unilateral occur more commonly in malignancy
What cranial structures can mimic polyps?
- Meninges - meningocele
- Brain tissue - encephalocele
What are symptoms of nasal polyps?
- Watery anterior rhinorrhoea
- Purulent post-nasal drip
- Nasal obstruction - Leads to mouth breathing
- Change in voice
- Anosmia/taste disturbance
- Sinusitis
- Headaches
- Snoring
What are nasal polyps associated with?
- Allergic rhinitis
- Non-Allergic rhinitis
- CF
- Aspirin hypersensitivity
- ASthma
What are signs of nasal polyposis?
Turbinates often mistaken for polyps!!! Don’t do this
- Pale, mobile and insensitive to gentle palpation
- May appear translucent
What might childhood nasal polyposis point to as a cause?
Cystic Fibrosis
How would you manage nasal polyps?
Mainstay - Steroids
Other:
- Antihistamines
- Nasal decongestants
- Surgery - polypectomy
What post-op advice would you give someone who had had a nasal polypectomy?
- Don’t blow your nose
- Watch for bleeding - abide epistaxis advice if bleeding
- Topical steroids
- Douched saline - relieve crusting
What are the main symptoms assocaited with paranasal sinus disease?
- Pain - maxillary, ethmoidal
- Discharge - post nasal drip
- Anosmia
- Nasal obstruction/congestion
- Systemic symptoms
What would be your differential diagnosis for someone with symptoms like sinusitis?
- Migraine
- TMJ dysfunction
- Neuralgias
- Cervical spine disease
- Temporal artertitis
- Herpes zoster
What can be complications of sinusitis?
- Peri/Orbital cellulitis/abscess
- Facial cellulitis
- Osteomyelitis
- Intracranial infection - meningitis, abscess, cavernous sinus thrombosis
- Mucocele formation
What tests might you do in someone with suspected sinusitis?
None usually needed, but may consider:
- ESR, CRP
- Endoscopy +CT
Where do the frontal and maxillary sinuses drain into?
Middle meatus
What is the pathophysiology of sinusitis?
Primary infection reduces ciliary function, causes oedema and increased nasal secretions. The stagnant secretions within the sinuses may become secondarily infected with strep or haemophilus
How would you manage acute sinusitis?
- Paracetamol
- Decongestants
What can be complications of acute frontal sinusitis?
- Blindness with litte warning
- Intracranial abscess
How would you manage chronic sinusitis?
- Antibiotics
- Smoking cessation
- Surgery - functional endoscopic sinus surgery
- Post op Steroid nasal spray
What drains into the middle meatus of the nasal cavity?
- Maxillary sinus
- Anterior ethmoidal sinus
- Middle Ethmoidal sinus
- Frontal sinus
What drains into the superior meatus of the nasal cavity?
Posterior ethmoidal sinus
What drains into the inferior meatus of the nasal cavity?
Nasolacrimal duct
Where does the sphenoid sinus drain?
Sphenoethmoidal recess
What are causes of epistaxis?
- Trauma - local/facial
- Hypertension
- Infection - local
- Dycarias/haemophilia/DIC
- Alcohol intake
- Septal perforation
- Neoplasm
- Medications - anticoagulants/antiplatelets
How is epistaxis divided in terms of location?
Anterior and posterior epistaxis
What is the most common cause of an anterior nose bleed (in terms of location)?
Bleed from little’s area
What is little’s area in the nose?
Where ethmoidal, sphenopalatine and facial arteries anastamose to form anterior anastamotic arcade
How would you initially manage epistaxis?
- ABCDE
- First aid - ask patient to hold nares together (see image), patient sitting forward, spitting any blood into a bowl
- Ephidrine drops - vasoconstrict nasal vessels
- Identify bleeding spot - clots over area
What would do if initial management of epistaxis didn’t work?
Anterior/Posterior nasal packing
How long would you wait before removing nasal packing for a nose bleed?
24 hours
If packing the nose of someone failed to stop epistaxis, what would you consider doing?
GET HELP
- Continue repeated ABCDE
- Bloods - FBC, U+E’s, Group and Save
- Surgery - ligation/diathermy
What would you want to advise a patient about post epistaxis care?
- Don’t blow your nose
- Avoid bending/lifting/straining on the toilet
- Sneeze through mouth
- No hot food or drink
- Avoid alcohol/tobacco
- Recurrence advise
How would you manage a displaced nasal fracture?
Reduction and post-op splintage - within 2 weeks fracture
What is the risk of a nasal fracture?
Septal haematoma - can necrose septum if left untreated
What would you want to establish in someone who had a nasal fracture?
- C-spine injury?
- Significant head injury?
- Facial injury/fracture?
- Septal haematoma?
What is the time limit for manipulation of a nasal fracture?
2 weeks
What are features of anterior epistaxis?
Bleeding through anterior nasal apeture
What are features of posterior epistaxis?
- Blood stained pharynx
- Haematemesis
- Failure of anterior packing to control bleeding
What is the most common site of bleeding in posterior nose bleed?
Lateral and posterior walls of nasal cavity - woodruff’s plexus
What are local causes of epistaxis?
- Nasal trauma - pciking
- Foreign body
- Dry nosa
- Nasal septum defects
- Infections
- Tumours
- Vascular malformations
What are systemic causes of nose bleed?
- Bleeding disorders - Anticoagulant, Severe thrombocytopaenia, Haemophilia
- Hypertension
