Rhinology Flashcards
What is the differential diagnosis list for someone who presents with a blocked nose?
Physiological - Nasal cycle Congenital - e.g. choanal deformity Traumatic - e.g. septal deformity Infective rhinitis Allergic rhinitis Non-allergic rhinitis Nasal polyps Adenoidal hypertrophy in children Malignancy of nose, sinus or postnasal space
What is the normal nasal cycle?
The often unnoticeable alternating partial congestion and decongestion of the nasal cavities. This has benefits both in breathing and smelling.
What is choanal atresia?
A congenital nasal defect, which occurs when there is failure of the bucconasal membrane to rupture and therefore the nasal cavities remain separate from the nasopharynx.
Is choanal atresia normally unilateral or bilateral?
Unilateral and as a result might not present until later in life. If a patient is born with bilateral choanal atresia then the newborn will have severe respiratory difficulties. Remember that newborns are obligate nose breathers.
Is choanal atresia more common in males or females?
Twice as common in females as males.
What other congenital abnormalities are associated with choanal atresia?
CHARGE association: Coloboma Hearing deficit choanal Atresia (particularly bilateral) Retardation of growth Genital defects (in males) Endocardial defects
What are the clinical features of choanal atresia?
Breathing difficulty Cyanosis within hours of birth Obstruction is relieved by crying as the baby begins to breathe through mouth Obstruction is worsened by attempts at feeding Other congenital abnormalities
How do you diagnose choanal atresia?
Failure to pass a naso-endoscope or Foley catheter through the nose into the nasopharynx confirms the diagnosis. CT scanning will help in determining the extent of the anatomical abnormality.
How do you manage a patient born with choanal atresia?
Airway control - oropharyngeal airway. However this is temporary as feeding is prevented. Devices such as the McGovern nipple allow feeding and airway maintenance. Surgical management - The atretic plate may be removed as soon as is possible. Fibreoptic endoscopy has made early intervention in neonates much easier.
What is a nasal dermoid cyst?
A dermoid cyst is a teratoma of a cystic nature that contains an array of developmentally mature, solid tissues. It frequently consists of skin, hair follicles, and sweat glands. In the nose, they usually form a midline mass on the dorsum of the nose which presents in childhood.
How do you manage someone with a nasal dermoid cyst?
MRI is performed to rule out cranial extension prior to surgical excision. Cranial extensions include gliomas or encephalocoeles both of which can also come down into the nose and hence look like a dermoid cyst.
When someone presents with a history consistent with a nasal bone fracture, what is it important to exclude as a complication?
Septal injuries and septal haematoma
How do you manage a displaced nasal bone fracture?
Usual strategy is to manipulate the bones back into place under anaesthetic (MUA). It is most effective if done in the first two weeks since injury.
What are the complications of a nasal septal haematoma?
Septal necrosis and abscess formation can lead to collapse of support for the tip of the nose and an ugly saddle deformity.
What symptoms would alert you to the presence of a nasal septal haematoma?
Severe bilateral nasal blockage. This is rare following more simple injuries. Also pain that worsens rather than decreases over the following few days may indicate the formation of a septal abscess.
What might you see on examination of a nose with a suspected septal haematoma?
A cherry red fluctuant swelling of the anterior part of the septum - usually bilateral - which is soft when pressed with a cotton bud.
How do manage a patient with a nasal septal haematoma?
This is an ENT emergency to avoid necrosis. The haematoma needs to be drained via an intranasal incision under local anaesthetic. Afterwards the nose is packed to prevent reaccumulation of the blood. Prophylactic antibiotics are also given orally.
What are local (to the nose) causes of epistaxis (nose bleed)?
Nose picking External trauma Infection Drying of the mucosa Effects of ageing on blood vessels Septal perforation Tumours
What are the systemic causes of epistaxis (nose bleed)?
Platelet factors - thrombocytopenia
Clotting abnormalities - eg haemophilia, von Willebrand’s disease, liver disease
Medication - anti-platelet, anti-coagulant
Hereditary haemorrhagic telangiectasia - rare abnormal vessle formation in skin, mucous membranes and often organs such as lung, liver and brain: can lead to increase in nose bleeds and red spots on lips, nose and fingers
Hypertension
Leukaemia
What is the single most common cause of epistaxis?
Idiopathic
Why does the nose have such a prolific vascular supply?
Rapid humidification and warming of inspired air
What are the four main arteries whose branches make up Little’s area in the nose?
LEGS:
superior Labial artery (from the facial artery)
anterior Ethmoidal artery (from the ophthalmic artery)
Greater palatine artery (from the maxillary artery)
Sphenopalatine artery (terminal branch of the maxillary artery)
What is another name for Little’s area in the nose?
Kiesselbach’s plexus
Describe the differences between anterior and posteriro epistaxis
Anterior: more common, occurs in children and young aduls, usually due to mucosal dryness, alarming as bleeding seen readily but usually less severe
Posterior: Usually older population, HTN and ASVD are most common causes, significant bleeding in posteror pharynx, more severe and treatment challenging - typically brittle vessles
How do you manage a patient with epistaxis in the acute setting?
As with any emergency, the ABCDE approach must be taken.
Pressure is applied to the anterior part of the nose (the soft area), while the patient is told to lean forward to avoid swallowing blood.
Ice packs may also be used to help stem blood flow to the nose.
If bleeding continues and there is an obvious bleeding point, then cautery may be used. If there is no obvious bleeding point then the nose should be packed.
How do we cauterise a vessel in the nose in the management of epistaxis?
Local injection vasoconstrictors - soaked gauze for 5 mins
Either using silver nitrate
Diathermy
What types of nasal packs can be used in the management of epistaxis?
Anterior packs: Ribbon gauze soaked in iodoform paste (BIPP packing)
Sponge tampons (Merocel)
Rapid rhinos (inflatable and deflatable)
Posterior packs: Gauze packs Foley catheter
Apart from packing someone’s nose, what else must you do for a patient whose epistaxis had to be controlled in this way?
Patients who required nasal packing should be admitted to hospital and given oxygen face masks.
Packs should be left in for 24 hours. If any longer than this is needed then prophylactic antibiotics should be considered to prevent staphylococcal toxic shock.
You must also look for a cause if none has been found (eg thrombocytopenia)
If cautery and nasal packing have been unable to arrest epistaxis, what should be done for the patient?
Endoscopic ligation of the sphenopalantine arteries within the nose plus sometimes clipping the ethmoidal arteries via a medial orbital incision.
In extreme circumstances, radiographic embolisation may be required to arrest the epistaxis.
Investigations you may consider once nosebleed has settled
Hb, clotting screen, G+S
Anterior rhinosopy, endoscopy rhinoscopy
What is rhinosinusitis?
Inflammation affecting the mucosal surfaces of the nose and paranasal sinuses.
(sinusitis is correctly called rhinosinusitis because inflammation of nasal mucosa usually accompanies sinusitis
What are the symptoms of rhinosinusitis?
Nasal blockage Rhinorrhoea (mucous fluid in the nasal cavity) Hyposmia / anosmia (reduction in / loss of smell) Facial pain (often worse bending forwards)
What is the difference between acute and chronic rhinosinusitis?
Time difference, which may also indicate the cause: Less than 12 weeks - acute infective More than 12 weeks - chronic
What is the time difference between viral and bacterial rhinosinusitis?
Less than 10 days - viral More than 10 days but less than 12 weeks - bacterial
What are the common causative organisms of a bacterial rhinosinusitis?
Streptococcus pneumonia
Haemophilus influenzae
Moraxella catarrhalis
Anaerobes, staph aueus, strp pyogenes, gram neg
Rhinosinusitis is commonly a blockage of what meatus
Middle meatus
Where do the majority of facial sinuses drain to?
Ostiomeatal complex
On examination of someone with rhinosinusitis with an endoscope, what might you see?
Pus in the ostiomeatal complex
How do you manage someone with bacterial rhinosinusitis?
Antibiotics (same as pneumonia)-
Amoxicillin, co-amoxiclav or cephalosporins
Macrolides - eryhtomycin, clarithromycin
Topical decongestant - ephedrine drops or xylometazoline spray If this doesn’t work, surgical intervention may be needed
Chronic - FESS (fucntional endoscopic sinus surgery) - operative enlargement of middle meatus when medical surgery has failued
What are the complications of acute bacterial rhinosinusitis?
Orbital complications - especially in children. Ranging from periorbital cellulitis (swelling of upper eyelid, periorbital tissues). emergency referral to opthalmology.
Cavernous sinus thrombosis.
May result in vision loss or even death if not treated appropriately.
Osteomyelitis of the frontal bone - Potts puffy tumour - soft boggy swelling on skin of forehead
Intracranial complications - meningitis, subdural and extradural empyema, encephalitis, brain abscess.
Ethnoidal mucocele - eye swelling, diplopia (complication of chronic sinusitis)
What are the symptoms of chronic rhinosinusitis?
Nasal blockage Rhinorrhoea Anosmia Facial pain All lasting more than 12 weeks
What are the different types of chronic rhinosinusitis?
CRS with polyps CRS without polyps Wegener’s granulomatosis Sarcoidosis
What are nasal polyps?
Multiple oedematous outgrowths of mucosa with a profuse eosinophilic reaction.
Associated with intrinsic rhinits and allergy
Nearly always bilateral - if unilateral investigate further: tumour?
Causes of nasal polyps
Allergic: asthma, allergic rhinitis, aspirin intolerance, alcool intolerance
Non allergic conditinos - cystic fibrosis, AFS, churg strauss sundrome (rare vascular)
What is Samter’s triad?
Chronic rhinosinusitis with polyps Asthma Allergy to aspirin
Are nasal polyps in children a common presentation?
No. When they are seen a generalised mucociliary clearance disorder such as Kartagener’s syndrome or cystic fibrosis must be excluded.
Typical nasal polyps patient
Male, >40 years
Which sinuses do nasal polyps usually originate from?
Ethmoid sinuses
Differentials of unilateral polyps
Nasopharyngeal caner
Glioma
Lymphoma
Lymphoma
Neuroblastoma
Sarcoma
Presentations of nasal polyps
Anosmia, progressive nasal obstruction, nasal discharge (watery, rhinorrhoea, post nasal drip). Green discharge suggests infection, unilateral (tumour?), sinusitis
Are inflammatory nasal polyps usually uni- or bi-lateral?
Usually bilateral. Unilateral polyps should raise the question of neoplasia and should prompt ENT referral
What mode of imaging is most commonly used to more closely examine nasal polyposis before surgical intervention?
CT
Differences between antochoanal polyps and ethmoidal polyps
Antochoanal - maxillary sinus, infective in origin, unilateral, usually single.
Ethmoidal - ethmoid, bilateral, multiple
Imaging in nasal polyps
Flexible/rigid nasoendoscopy (DO FIRST)
Then CT scan (cornoal)
How does you manage inflammatory nasal polyps?
- Steroid spray - fluticasone or mometasone
- Steroid nasal drops - Fluticasone or Betamethasone
- Oral steroids - Prednisolone (diminishes polyp size)
- Surgery - traditional polypectomy, functional endoscopic sinus surgery (FESS)
(Increase in SE as you work up)
What signs and symptoms might lead you to suspect neoplasia of the nose or sinuses?
Unilateral nasal blockage Bloody discharge Facial pain Numbness in the infraorbital region Loosening of teeth
What are the different types of malignant sinonasal tumours?
Adenocarcinomas Squamous cell carcinomas Melanomas Olfactory neuroblastomas Lymphomas
Describe common causes of nasal obstruction
May be due to anatomical abnormalities, disorders of mucous membrane lining or stimulation of autonomic nervous system.
Eg viral infections, neoplasia, allerfens
Describe causes of nasal discharge
Rhinnorea - runny nose
Catarrh/post nasal drip - nasal discharge, passing backwards in post nasal discharge
If discharge offensive - bacterial infection, neoplasia, presence of foreign body
Sneezing is typically
Allergic/infective rhinitis
What is ansomia?
Total loss of smell
What is hyposomia?
Reduced sense of smell
What is cacosomia
Unpleasant smell detected by others
What is ozaena
Foul smell
Aetiology of rhinitis
Allergic - pollen, house dust mites (type 1 hypersensitivity): occupational, perennial, seasonal
Non allergic - drugs, irritants, hormonal, idiopathic
Descibe a type 1 hypersensitivity reaction
IgE: degranulation of mast cells, release of histamines, leukotrienes
What is seen clinically in someone with rhinitis
Nasal mucosa has a boggy oedematous appearance covered by thin layer of waxy excretions
Investigations of rhinitis
Skin prick
RAST test - measurement of specific serum IgE against particular antigen
Management of rhinitis
Avoidance of allergens - change feather pillows, wash bed clothes twice weekly, sprays that inhibit dust mite, using a dust colour, exclude food allergens
Surgery - turbinate resection
Medical - antihistamines eg cetirizine, nasal steroids (beclometasone), decongestants
What is intrinsic rhinitis
Imbalance betwen the prasympathetic and sympathetic autonomic nerve supply. Attacks can be related to humidity/temperature, pregnancy, puberty, menopause and hyperthryoidism. OCP and antihypertensives also linked.
Most common perennial allergen
Dust
Most common seasonal allergen
Pollen
When are nasal fracture corrected
Correction of nasal fractures should be either immediately or after swelling resolved at 7-10 days.
Reduce uder GA
May need septoplasty/rhinoplasty.
Complications of nasal fracture
- CSF rhinorrhoea
- racture through roof of ethmoid labyrinth with disruption to the Dura and arachnoid matter resulting in CSF leaks.
- Nasal discharge tests +ve for glucose CSF uniquely contains B2-transferring, tested for immunoelectrophoresis
- Septal haematoma
- Exclude this - boggy swelling and nasal bstructions
- Rare but serious
- Septal abscess
- Fever suggests abscess formation
Describe basic exteral anatomy of the nose
1/3rd bone - frontal bone, nasal bone, maxillary bone
2/3rd septal cartilage
Tip contains fibrocartilage
Describe the basic internal anatomy of the nose
Perpendicular plate of ethmoid, vomer bone, septal cartilage
Roof = cribriform plate
Floor = hard palate
Within the nasl cavity: superior, middle and inferior choncae and superior, middle and inferior meatus.
Remeber that sinuses drain into middle meatus
They are lined by ciliated columnar epithelium
Function of the nose
Special sensation
Respiration
Filtration of dust
Humidification
Warming
Function of paranasal air sinuses
Reduce weight of the front of the skull
Humidifying and heating of inhaled air
Vocal resonance
Protection of intracranial stuctures/eyes
