Rhinology

Question 1

What are the specific questions you should ask for a patient complaining of rhinology problems?

(10)

Answer 1

• Sneezing
• Rhinorrhoea
• Nasal discharge
• Post nasal drip
• Nasal obstruction
• snoring
• excessive tiredness (sleep apnoea)
• Loss of sense of smell
• Epistaxis
• Facial pain.

Question 2

What is rhinosinusitis and how does it present?

Answer 2

Rhinosinusitis is inflammation of the lining of the nose or paranasal sinuses.

• With 2 or more of the following symptoms:
  
  • Nasal congestion (nasal cycle of congestion)
  • Reduced sense of smell
  • Nasal discharge or post nasal drip
• And either endoscopic signs of:
  
  • polyps
  • purluent discharge
  • oedema OR
  • mucosal obstruction of the middle meatus.

Question 3

How can you classify rhinosinusitis?

Answer 3

Acute (symptoms for <4 weeks)

Subacute (symptoms 4-12 weeks)

Chronic (symptoms >12 weeks)

Question 4

What are the ways of differentiating between the allergic, infective and other non allergic causes of rhinosinusitis?

Answer 4

Rhinorrea/Sneezing/Itchy eyes (allergic)

Crusting or bleeding (Non allergic/infective)

Feeling of pressure/pain in the face, usually a unliateral severe pain. Patient will also be pyrexial. (Infective)

Question 5

How can you manage allergic rhinosinusitis?

Answer 5

• Avoid allergen if possible.
• Skin prick tests can be used to try and identify the causative allergen.
• 1st line medical treatment: Antihistamines and topical corticosteroid spray
• Subcutaneous leukotriene inhibitors and oral immunotherapies may be used in more severe cases

Question 6

Describe the main types of bacterial rhinosinusitis?

Answer 6

Usually follows a viral upper respiratory tract infection.

Acute: HIB or Strep. Pneumoniae

Chronic: Anaerobes. Only painful during an exacerbation, chronically producing a mucky green mucous throughout the day.

Question 7

What are some of the complications of rhinosinusitis?

Answer 7

Periorbital cellullitis, emergency as can cause blindness.

Raised Intracranial pressure. (Drowsiness, progressive headache and vomiting) could be due to a cerebral extra or sub dural abscess.

Meningitis

Question 8

Describe the treatment of chronic non-allergic (non infective) rhinosinusitis?

Answer 8

Mild: Nasal douche and topical steoids. ———————> macrolides (for the antinflammatory effects)

Moderate/Severe: douche, topical steroids and macrolides. If failure after 3 months consider surgery

Question 9

Describe the treatment of chronic rhinosinusitis with nasal polyposis?

Answer 9

Note chronic rhinosinusitis with nasal polyposis is associated with late onset asthma.

Mild: Topical steroid spray

Moderate: Topical steroid drops

Severe: Oral and topical steroids CT and Surgery: Following surgery douche + steroids

If failure after 3/12 in any of the steps excalate to the next level. If secretions become purulent, 2 week course of co-amoxiclav.

Note surgery is not a cure as polyps will reoccur

Question 10

What are the other non allergic causes of rhinosinusitis?

Answer 10

Hormonal (preganancy)

Drug Induced (cocaine)

Sarcoid

Autonomic (clear rhinorrhoea more common in elderly)

Vasculitis (wegner’s granulomatosis)

Question 11

What is wegners granulomatosis?

Answer 11

A systemic vasculitis causing multisystem symptoms. Patient’s will feel systemically unwell. Majority have rhinosinusitis with crusting and bloodstained discharge, may also cause septal perforation. Petechial rash. Renal failure. Lung cavitations

Question 12

What is the treatment for a deviated nasal septum?

Answer 12

Can use medication to help alleviate symptoms of congestion, phenylephirine.

Surgical septoplasty, where excess bone and cratilage is removed to make the septum even on both sides.

Question 13

What is a surgery called if it involves correction of the external nasal skeleton?

Answer 13

Rhinoplasty

Question 14

What are treatments of obstructive sleep apnoea?

Answer 14

Lifestyle: Lose weight Sleep on side

CPAP machine: Continuous Positive Airway Pressure

In some cases (usually children) patients can have abnormally large tonsils which contributing towards there OSE in these cases they can have a tonsillectomy.

Question 15

How would you treat and assess someone with acute epistaxis?

Answer 15

ABCDE.

Check patient is haemodynamically stable.

If bleeding from the posterior area of the nose is suspected (bleeding is profuse, from both nostrils, and the bleeding site cannot be identified on speculum examination), admit the person to hospital.

Sit patient forward as reduces bloodflow through the nasopharynx and allows the patient to spit out blood more easily.

Pinch the cartiliginous part of the nose for 10-15mins continously.

If bleeding continues consider either:

• Nasal cautery
• Nasal packing

Question 16

How would you manage a patient with recurrent epistaxis?

Answer 16

Determine underlying cause, likely to be a cause in those

Question 17

Why is little’s area important?

Answer 17

It is an area where many blood vessels in the nose anastamose and therefore it is prone to bleeding.