Rhinology

Question 1

How is rhinosinusitis classified?

Answer 1

acute (symptoms for < 4 weeks), sub acute (4-12 weeks) and chronic (>12 weeks)

Question 2

What is the drainage of the nose and sinuses?

Answer 2

The maxillary, frontal and anterior ethmoid sinuses drain into the middle meatus between the inferior and middle turbinate. The posterior ethmoids drain into the superior meatus whilst the sphenoid sinus drains into the sphenoethmoidal recess in the posterior nasal cavity

Question 3

What are the clinical features of acute rhinosinusitis?

Answer 3

commonly follows an acute viral URTI, with a severe, unilateral pain over the infected sinus, malaise, and pyrexia. Other symptoms include nasal obstruction, mucopurulent rhinorrhoea and poor smell. Acute facial pain without nasal symptoms is highly unlikely to be due to ARS.

Question 4

What will anterior rhinoscopy in rhinosinusitis show?

Answer 4

using an auriscope (ask the patient to mouthbreathe to stop the lens from misting up) may show inflamed or oedematous nasal mucosa and mucopurulent secretions in the nasal cavity. Throat examination may reveal mucopurulent secretions in the posterior oropharynx.

Question 5

What are the treatments for rhinosinusitis?

Answer 5

try simple analgesics, steam inhalations, and a decongestant (xylometazoline spray)

Question 6

What is rhinitis medicamentsa?

Answer 6

a condition where the nasal vasculature becomes habituated and damaged by the sympathomimetic action of the drug resulting in rebound congestion and chronic nasal obstruction

Question 7

What occurs in complicated rhinosinusitis?

Answer 7

Sinuses may need draining

Periorbital cellulitis, severe headaches, focal neurological signs, meningitis

Question 8

What is chronic rhinosinusitis?

Answer 8

S. aureus, stapylococcus, anaerobic and gram-negative bacteria predominate
Many patients have hypertrophic mucosa with tenacious secretions and at histology the lining is replete with eosinophils yet there is no evidence of allergy as we understand it (Type I IgE mediated hypersensitivity). Very occasionally, sinusitis can be secondary to dental disease and the organisms are anaerobic producing a foul smelling discharge.

Question 9

What are the clinical features of chronic rhinosinusitis?

Answer 9

Nasal obstruction and commonly a discoloured discharge (nasal or post-nasal) for longer than 12 weeks. They may also experience a smell disturbance (anosmia or cacosmia = unpleasant smell) or intermittent frontal pain
Usually painless.

Question 10

What can causes discoloured nasal discharge in the mornings?

Answer 10

Snorers whose clear nasal secretions (we all produce about half a cup a day) collect in the nasopharynx and become discoloured with the commensals that collect there.

Question 11

How does allergic rhinitis present?

Answer 11

nasal obstruction and may have hyposmia, nasal irritation, and sneezing. They often have a slightly yellow nasal mucus due to staining with eosinophils but this is not indicative of active infection. On examination they classically have pale and swollen turbinates though the mucosa can be red. Patients with an idiopathic rhinitis (non-infective, non-allergic) also complain of nasal obstruction and clear rhinorrhoea or post-nasal discharge but itching and sneezing are less common than in allergic rhinitis. CRS, allergic rhinitis and idiopathic rhinitis can occur concurrently.

Question 12

What is the treatment for chronic rhinosinusitis?

Answer 12

ventilate the sinuses and restore mucociliary clearance
A course of broad-spectrum oral antibiotics, such as amoxycillin-clavulanate, clindamycin or a combination of metronidazole and a penicillin is given for at least 3 weeks.7 Topical nasal steroids such as betamethasone drops (2 drops, left+right tds) should be given for 2 months followed by a steroid nasal spray. Nasal drops are best taken whilst the patient is lying on the bed with the head upside down over the edge.
Nasal douching

Question 13

When should rhinosinusitis be referred to an ENT specialist?

Answer 13

If there is no improvement after eight weeks medical therapy, consider referring the patient to an ENT specialist
Patients should undergo nasendoscopy to confirm the diagnosis
. In Functional Endoscopic Sinus Surgery (FESS), the natural drainage pathways of the sinuses are cleared, to allow adequate drainage and resolution of the CRS.

Question 14

What are causes of CRS?

Answer 14

Many patients do not have an active infection but have developed a persistent allergic rhinitis due to perennial allergens. Other common causes of CRS are patients with mucosal hypertrophy or polyps associated with late onset asthma who often have hyposmia and yellow stained secretions due to eosinophils. Chronic infection is associated with green secretions throughout the day along with nasal obstruction and this usually responds to the correct anti-bacterial treatment

Question 15

What is nasal douching?

Answer 15

Mix ½ teaspoon of salt, ½ teaspoon of sugar and ½ teaspoon of bicarbonate of soda in 2 pints of boiled water, which has been left to cool. Place some of the mixture into a saucer, or draw some mixture up with a syringe. Block off one nostril with one finger and then sniff or squeeze up the solution into the other nostril, letting it run out afterwards. Topical sprays and drops should be taken after douching.

Question 16

What are the complications of infective sinusitis?

Answer 16

Chronic sinusitis 
Osteomyelitis 
Peri-orbital cellulitis and orbital abscess (ethmoiditis)
Facial cellulitis 
Mucoceles 
Intracranial complications: (occur by direct spread, by venous thrombophlebitis or along the perineural tissue of the olfactory nerve)
meningitis 
Cavernous sinus thrombosis 
Brain/extradural/subdural abscesses

Question 17

What are mucoceles?

Answer 17

• Usually form as a late complication of acute sinusitis
• Collections of sterile mucus occupying an obstructed sinus (especially frontal and ethmoidal)
• Present with facial swelling, visual disturbances due to displacement of eye or secondary infections
• Treatment is by surgical drainage (usually endoscopic)

Question 18

What is cavernous sinus thrombosis?

Answer 18

o Due to spreading thrombophlebitis from the frontal, ethmoidal and sphenoid sinuses
o There is decreased venous return from the eye causing the orbit to swell and congestion of the retinal vessels
o Symptoms include high fever with rigors, severe headache, reduced level of consciousness and cerebral irritation
o Signs include IIIrd, IVth, VIth nerve palsies causing opthalmoplegia in addition to paraesthesia of the upper two divisions of the Vth (due to the close proximity of these nerves to the cavernous sinus)
o Frequently the symptoms become bilateral
o Treatment is with high dose antibiotics but there is still a high associated mortality

Question 19

How do brain abscesses present?

Answer 19

Secondary to frontal sinusitis
o occur most commonly in the frontal lobe
o may cause subtle changes in personality, headaches a grand mal convulsion or may be found incidentally on a CT scan
o treatment requires neurosurgical drainage or aspiration

Question 20

How do extradural abscesses present?

Answer 20

secondary to frontal sinusitis
o May be found on CT scan and is usually due to a dehiscence of the posterior wall of the frontal sinus
o Are usually drained into the frontal sinus and hence externally

Question 21

How do subdural abscesses present?

Answer 21

secondary to frontal sinusitis
o Is difficult to diagnose in early stages
o Patients have general malaise, headache and some neck stiffness and signs of raised intracranial pressure
o The diagnosis is generally made on the examination and CT scan
o The prognosis of this rare complication is poor