Rhinology Flashcards
What occupations are at risk of nasal disorders? [1]
Woodworkers
What bloods are appropriate for nasal disorders? [5]
- FBC
- ESR
- Radioallergosorbent blood Test (RAST)
- ANCA (Anti-neutrophil cytoplasmic antibody) for vasculitis
- ACE (angiotensin Converting Enzyme)
Why would you use an ACE test for nasal disorders? [2]
Rhinosinusitis could be related to TB [1] or Sarcoid [1] which would show up on an Angiotensin Converting Enzyme test.
What is the RAST test [2]
What is its clinical significance [1]
Radioallergosorbent Test [1]
It tests the blood for specific IgE levels. [1]
Can identify allergic rhinosinusitis [1]
Define Choanal Atresia? [3]
How does it present?
Congenital [1] blockage of the posterior nasal aperture [1] by either a membrane or bone. [1]
Bilateral; tends to show up in babies with trouble feeding. [1]
If unilateral may not show up till later [1]
Whats the relevance of aspirin sensitivity?
Related to lots of atopic disease such as aspirin sensitive asthma or rhinitis
An URTI infection can causes periorbital swelling, how would we handle this situation? [5]
- Emergency ENT referral
- Ophthalmology Opinion to assess colour vision, its the first to go when the optic nerve is damaged
- Urgent CT to show up abscess
- IV antibiotics and Steroids
- Emergency Surgery
What is Pott’s puffy tumour?
Clinical features [4]
Its a complication of sinusitis, basically a subperiosteal abscess. [1] Sinusitis Fever Frontal headache Central forehead swelling
How do we treat Pott’s Puffy Tumor? [3]
Frontal Sinus Surgery or Endoscopic Sinus Surgery (ESS) followed by Abx
What is mucocele? [2]
Management [1]
A benign cyst lesion of a minor salivary gland [1] containing mucous [1] . Needs to be removed with endocopic sinus surgery
What would you see on sinusitis CT or MRI [2]
- Sinus opacification
- Or a visible air/fluid level
- and/or mucosal thickening
What is rhino sinusitis? [1]
How do we classifiy rhinosinusitis? [3] Define each classification
Rhinosinusitis is inflammation in nose and paranasal sinuses.
Into Acute, Recurrent Acute, Chronic and Acute exacerbation of chronic.
Acute = <12 wks & Symptoms resolve completely
Recurrent Acute = 1-4 episodes a yr with completely recovery and 8wks symptom free between episodes.
Chronic = >12wks with persistant inflammatory changes on imaging for >4wks
Acute Exacerbations of Chronic: = Worsening or new symptoms with the acute ones resolving completely but not the chronic ones
What microorganisms cause rhinosinusitis? [3]
Strep Pneumonia -31%
Haemophilus Influenzae - 21%
Both - 5%
What symptoms come with rhinosinusitis?
Main symptoms [2]
Associated symptoms [4]
Main symptoms:
- Nasal congestion
- Nasal discharge
Also possible to get:
- Facial pain/pressure
- Hyposmia/Anosmia
- Purulent postnasal drain
- Cough
How would you treat rhinosinusitis? [4]
- Topical CCS, nasal douching
- B-lactams (e.g. penicillins or cephalosporins)
- Macrolides (E.g. Erythromycin/Clarythromicin)
Or sinus surgery
Nasal polyps
Presenting features [6]
Histology [3]
Sites [3] and describe where an antrochoanal polyp can be found [1]
Presentation
- watery anterior rhinorrhea
- purulent postnasal drip
- nasal obstruction, change in voice
- smell/taste disturbance
- sinusitis, headaches
- mucocele
Ciliated columnar epithelium
Thickened basement membrane
Avascular edematous stroma
Sites:
- Middle turbinates
- Middle meatus
- Ethmoids
- Antrochoanal polyp - single maxillary polyp arising in maxillary antrum prolapsing to fill nasopharynx/
What is churg-strauss [2]
An allergic (i.e. autoimmune) granulomatosis causing vasculitis [1] of people with a history of airway allergic hypersensitivity. [1]
Nasal polyps Signs on examination [3] Investigations [4] Clinical significance of eosinophils vs neutrophils on nasal smear [2] Association with [4]
Signs
- Pale
- Mobile
- Insensitive to gentle palpation
- Sweat test in case of CF
- RAST/allergic skin tests for atopic disease
- Coronal CT/MRI
- Flexible or Rigid Nasoendoscopy
Can also do a nasal smear for eosinophils (allergic component) or neutrophils (chronic sinusitis)
Association with:
- Rhinitis, sinusitis
- CF
- Aspirin hypersensitivity
- Asthma
How do we treat nasal polyps?
Complications of surgery [2]
Post-op advice [4]
- 1% bethametasone 48h
- Education on use of nasal sprays
- Oral prednisolone for short term benefit 50mg/day for 2w
- LTRA and continuous low dose clarithromycin
- Surgery (either a nasal polypectomy or Functional Endoscopic Sinus Surgery - FEST)
Complications: CSF leak, optic nerve damage
Post-op advice - Don’t blow your nose until better
- Watch for bleeding
- Topical steroids
- Saline douching to relieve crusting
What causes Epistaxis? [7]
- Infection, trauma, idiopathic
- Allergic rhinitis, atrophic rhinitis
- Vascular (Atherosclerosis/hypertension)
- Blood dyscrasias
- Tumor
- Hereditary Hemorrhagic Telangiectasia
- Septal perforation
What could cause blood dyscrasias? [3]
- Drugs
- Disease
- Alcoholism
What is hereditary Hemorrhagic Telengiectasia? [2]
Autosomal Dominant [1] condition leading to abnormal blood vessel formation [1]
One manifestation is Epistaxis
Management of epistaxis [4]
When to refer to ENT? [1]
Difference in management if anterior [2] vs posterior epistaxis [2]
- Remember this is an ENT emergency
- ABCDE
- Silver cautery
- Nasal Packs
- Surgery
Refer to ENT when you cannot see the bleeding point or >10-15 minutes with continuous pressure
Anterior epistaxis - almost always septal in Little’s area, silver cautery is usually adequate
Posterior epistaxis require more invasive procedures - examination under anesthesia, endoscopic ligation of maxillary/sphenopalatine artery
What types of nasal packs are there? [3]
Which one would you use first?
- Ant Nasal Packs*
- Post Nasal Pack
- Ant/Post Pack, uses balloons
What kind of surgery is there for epistaxis? [3]
Arterial Ligation
- Sphenopalatine
- Internal Maxillary
- Ant/post ethmoids
- ECA
Laser Ablation + Septodermoplasty
Embolisation (blocking abnormal vessels)
How do we treat Hereditary Haemorrhagic Telangectasia? [3]
- Laser Coagulation
- Septodermoplasty
- Young’s Procedure
What is youngs procedure? [1]
Involves closing the nasal cavity with mucocutaneous flaps.
How would a patient present with an angiofibroma? [3]
Epidemiology [1]
Should you biopsy such a tumor? [1]
Exclusively adolescent males
Profuse unilateral epistaxis.
Facial swelling
Nasal airway obstruction
Don’t Biopsy before excision as its a vascular tumor and theyll bleed.
Management of angiofibroma [3]
CT to assess intracranial extension
Pre-op Embolisation of feeder blood vessels to reduce operative hemorrhage
Surgery
Causes of nasal congestion
Child [5]
Adult [4]
Child:
- Big adenoids
- Choanal atresia
- Rhinitis
- Postnasal space tumor - angiofibroma
- Foreign body
Adult:
- Granuloma
- Deflected nasal septum
- Tricyclics
- Topical vasoconstrictors
Allergic rhinosinusitis
Type [2]
Cause [3]
Types: seasonal or perennial (dust mites)
Cause
- IgE mediated inflammation [1] from allergen exposure [1] to nasal mucosa causing inflammatory mediator release from mast cells [1]
Allergic rhinosinusitis Rx [3]
Indication for immunotherapy and what type [2]
Antihistamines systemic
Systemic decongestants
Nasal spray - sodium cromoglicate or beclonase
Use LTRA when rhinitis coexists with asthma
What should you watch out for when using decongestants [4]
Rhinitis medicamentosa [1] can occur from prolonged use of topical nasal decongestant substances [1]
Rebound vasodilation once stopped using pseudoephedrine [1]
Resulting in turbinate hypertrophy [1]
Adenoids (anatomy) [3]
A collection of loosely arranged lymphoid tissue
Lies at the post nasal space, attached to posterior wall of nasopharynx
Size increases gradually from birth until 6yo when it will atrophy
Adenoidal problems
Enlarged adenoids clinical features [4]
Infected adenoids [2]
Enlarged adenoids may cause:
- nasal obstruction
- nasal quality voice, mouth breathing
- Runny nose as nasal secretions are not properly cleared
- snoring
Infected adenoids
- Anterior rhinnorrhea may become profuse and offensive
- Otological sequelae due to ET dysfunction > glue ear
