Rhinology Flashcards
List some specific symptoms associated with rhinology
o Nasal obstruction o Nasal discharge – colour, viscosity, rhinorrhea (profuse clear fluid), pus (infection) o Epistaxis (nose bleeds) o Facial pain – can mimic sinusitis o Nasal deformity o Anosmia (lack of smell) o Sneezing – allergic rhinitis o Wound – cocaine use and nasal septum perforation
List some specific aspects of past medical history associated with rhinology
o Medical treatment
o Nasal surgery
o Nasal trauma
o Asthma/aspirin sensitivity
Describe methods of examining the nose in rhinology
o Lift and look up nose e.g. if kid doesn’t like otoscopes
o Otoscopes
o Cold spatula test
o Rigid endoscopy of nose – examines posterior aspect of nose
o Fibroscope – examines posterior aspect of nose
List some investigations used in rhinology
Blood tests e.g. FBC, ESR, ACE, RAST CT scanning MRI Skin tests for allergens Rhinomanometry
What is rhinomanometry?
Rhinomanometry - form of manometry used in evaluation of the nasal cavity. Rhinomanometry is a standard diagnostic tool aiming to objectively evaluate the respiratory function of the nose. Increased pressure during respiration is a result of increased resistance to airflow through nasal passages (nasal blockage), while increased flow, which means the speed of airstream, is related to better patency. Nasal obstruction leads to increased values of nasal resistance. Rarely used in clinic, more for research
Why might ACE levels in the blood be increased?
Sarcoidosis
What does RAST test for?
A radioallergosorbent test (RAST) is a blood test using radioimmunoassay test to detect specific IgE antibodies, to determine the substances a subject is allergic to.
List some nasal disorders
- Nasal trauma
- Epistaxis
- Rhinosinusitis
- Nasal polyps
- Nasal deformity
- Nasal tumors – red flags are unilateral epistaxis obstruction, smoker, chronic discharge
- Sleep apnoea
- Choanal atresia - a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development.
What are some red flag symptoms of a nasal tumour?
red flags are unilateral epistaxis obstruction, smoker, chronic discharge
What is choanal atresia?
Choanal atresia - a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed recanalization of the nasal fossae during fetal development.
What are some complications associated with nasal trauma?
o Psychological issues
o Difficulty breathing
o May be predisposed to sinusitis now later in life – eustachian tube disruption
o Septal haematoma – can follow trauma, needs to be drained and packing inserted, as well as perhaps antibiotics, as it can develop into an abscess and cause necrosis of the nose, leading to collapse of the nose (saddle nose)
What can cause septal perforation?
o Cocaine
o Trauma
o Previous septoplasty
What is Samters triad?
Samter’s Triad - This is a condition in which patients have a combination of symptoms such as airway problems like asthma; nasal problems like blockage and discharge with nasal polyps; and then develop a hypersensitivity reaction to aspirin. This hypersensitivity reaction is non-allergic.
A 40-year-old man presents with constant blocked nose, PN drip and hyposmia. He also has history of asthma and aspirin sensitivity. On examination, nasal polyps are seen. What do you suspect is the diagnosis?
Samter’s triad - a condition in which patients have a combination of symptoms such as airway problems like asthma; nasal problems like blockage and discharge with nasal polyps; and then develop a hypersensitivity reaction to aspirin. This hypersensitivity reaction is non-allergic.
How are nasal polyps treated?
Oral and nasal steroids
o High dose prednisolone and nasal steroid for 20 days will eliminate 50% of polyps
o Lower bioavailability in modern nasal steroids
o Poor response in certain groups
o Intranasal injection not effective
o Lifelong nasal steroids to prevent recurrence
Immunotherapy – used in aspirin sensitive individuals (Samter’s triad)
Surgery
How are nasal polyps caused by Samters triad treated?
Immunotherapy
Describe the possible surgical treatments of nasal polyps
- Traditional polypectomy
- Microdebrider
- Endoscopic sinus surgery
How likely is recurrence of nasal polyps?
o Multiple small polyps = common
o Large and antro-coanal = less so
23yr old presents with runny nose, nasal blockage, facial pain, general malaise and sore throat for 10 days. Otherwise fit and well, with no systemic upset.
What do you suspect is the diagnosis?
Sinusitis
How is sinusitis treated?
- Antibiotics
- Steam inhalation
- Nasal decongestants – only used for a couple days as it can cause rebound congestion
- Steroid spray
- Antihistamines
Describe the clinical classification of acute sinusitis
– Acute onset of symptoms
– Duration of symptoms <12 weeks
– Symptoms resolve completely
Describe the clinical classification of chronic sinusitis
– Duration of symptoms >12 weeks
– Persistent inflammatory changes on imaging >4 weeks after starting appropriate therapy
Describe the clinical classification of recurrent acute sinusitis
– >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
Describe the clinical classification of an acute exacerbation 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 2 most common causative agents in acute rhinosinusitis?
- S. pneumoniae
* H. influenzae
Describe the symptoms of rhinosinusitis
o Facial pain and pressure o Hyposmia/anosmia o Nasal congestion/obstruction o Purelent postnasal drian o Olfactory disturbance o Cough not due to asthma (children only) Cough (adults) o Headache o Fever o Fatigue o Halitosis o Dental pain
What antimicrobial agents are used to treat rhinosinusitis?
- β-lactams – penicillins, cephalosporins
* Macrolides - e.g erythromycin, clarithromycin
10yr old boy presents with acute onset fever, frontal headache and nasal discharge. When examining boy, you notice a lump on their forehead. What do you suspect?
Frontal sinusitis – pus in frontal sinus, can erode bone and cause Pott’s puffy tumour
How is frontal sinusitis with Pott’s puffy tumour treated, and what are the possible complications if left untreated?
- Emergency referral
- Frontal sinus surgery
- ESS
- Can cause frontal lobe oedema and abscess in frontal lobe
- Infections can spread through the brain – refer on to neurology surgeons after ENT examination
List some possible causes of epistaxis
Idiopathic (most common) Trauma - Littles area, accidental or iatrogenic Allergy Hypertension/atherosclerosis Hereditary hemorrhagic telangiectasia Blood dyscrasias Atrophic rhinitis Tumour Congenital or acquired nasal defects
How is epistaxis initially managed?
• ABC’s • Medical history/Medications • Vital signs—need IV? • Physical exam o Anterior rhinoscopy o Endoscopic rhinoscopy – find where theyre bleeding from and cauterize site o May require anaeasthesia o If site of bleed cannot be identified and sprays aren’t helping, pack nose • Laboratory exam
List some possible surgical treatment options for epistaxis
- Endoscopic Sphenopalatine artery ligation
- Transmaxillary IMA ligation
- Intraoral IMA ligation
- Anterior/Posterior Ethmoidal ligation
- External carotid artery ligation
- Septodermoplasty/Laser ablation
- Embolisation
What is Hereditary hemorrhagic telangiectasia (HHT)?
• Hereditary hemorrhagic telangiectasia (HHT), also known as Osler–Weber–Rendu disease and Osler–Weber–Rendu syndrome, is a rare autosomal dominant genetic disorder that leads to abnormal blood vessel formation in the skin, mucous membranes, and often in organs such as the lungs, liver, and brain.
How is Hereditary hemorrhagic telangiectasia (HHT) treated?
- Don’t use standard epistaxis treatment
- Airflow can cause trauma to patients nose + cause bleeds
- Skin grafts of mucosa, hard to treat
• Rx
o Laser coagulation
o Young’s procedure – nasal closure surgery
o Septodermoplasty
What is a angiofibroma?
Nasopharyngeal angiofibroma (also called juvenile nasopharyngeal angiofibroma) is a histologically benign but locally aggressive vascular tumor that grows in the back of the nasal cavity. It most commonly affects adolescent males. Patients with nasopharyngeal angiofibroma usually present with one-sided nasal obstruction and recurrent bleeding
Can bleed and cause fatalities - do not miss it
How is angiofibroma treated?
o Preoperative embolisation
o Surgery
How is angiofibroma diagnosed?
If nasopharyngeal angiofibroma is suspected based on physical examination (a smooth vascular submucosal mass in the posterior nasal cavity of an adolescent male), imaging studies such as CT or MRI should be performed. Biopsy should be avoided as to avoid extensive bleeding since the tumor is composed of blood vessels without a muscular coat.
Antral sign or Holman-Miller sign (forward bowing of posterior wall of maxilla) is pathognomic of angiofibroma.
DSA (digital subtraction angiography) of carotid artery to see the extension of tumors and feeding vessels
