Smell and Nasal Disease Flashcards
Nose anatomy
3 Turbinates - increase SA of nasal lining
-cilia filter and warm air we breathe
Sinuses drain into nose
ECA => maxillary => Sphenopalatine artery - supplies nasal septum, source of post nosebleeds
Rich vascular network
Autonomic - VC => increases nasal resistance
SNS - VC mainly when exercising, VC
PNS - VD mainly when lying down, cold air
Nasal valve - narrowest part of the nasal airway
- nasal septum, inf turbinate, upper lateral cartilage
- surgical target when you want to increase nasal airflow
Nasal history
Onset, duration, severity
Intermittent, persistent
Precipitation
Key nasal symptoms Blockage Smell - anosmia, hyposmia, cacosmia Discharge - purulent/clear/blood, unilateral/bilateral, seasonal/all year around, intermittent/constant Bleeding - bilateral, unilateral, transfusions needed? Facial pain Itching Sneezing Post nasal drip
IMPACTS ON QOL
- activity
- sleep
Nasal red flags for cancer
Systemic - weight loss, sweating
Persistent unilateral obstruction Bloody discharge 50+, smoker Persistent pain Cervical LN - post triangle Occupational risk - woodoworkers, Environmental risk - EBV Ethnicity - areas that smoke fish (south east asia)
Past history
Past medical history
-surgery, procedures, hospital visits
Medications
Ask specifically about
- asthma
- allergies
Drug history
-use of inhaled substances - cocaine, decongestants (Aa that increases nasal airflow acutely but can become addictive)
Why is decongestant addiction an issue?
- MOA
- common examples
Aa => acutely increases nasal airflow by VC vessels
Pseudoephrine
Phenylephrine
Local areas of necrosis
Rhinitis medicamentosa
Examination
External inspection
- signs of trauma
- asymmetry
- signs of infection - calor, rubor, dolor
- skin changes
Internal inspection
-Anterior rhinoscopy, endoscopy - assess for polyps, adenoid
Cold mirror test for airflow
-symmetrical? Is there obstruction?
Cottles maneuvre - pull skin on side of face laterally => open up nasal valve
Assessing the
- turbinates vs polyps
- septum
- mucosa
- crusting, sinus drainage
- foreign bodies
Turbinates can be enlarged and mimic polyps
Polyp mucosa looks very different to to the rest of the nasal mucosa
-inflammatory polyp => bilateral
-malignant polyp => unilateral
Is it central or deviated?
Is there a perforation
-may be ulcerated or have clear edges
Mucosa - assess nasopharynx and ant nose
-any pus, inflammation, bleeding?
Crusting, drainage of sinuses
Foreign bodies
- aspiration risk
- batteries => EMERGENCY
Investigations
Nasal airflow
-nasal peak flow, rhinomonometry
Olfaction
Allergy testing
- skin pricks
- RAST IgEe
CT - PREOP FOR SINUS SURGERY
Chronic rhinosinusitis
- epidemiology and causes
- presentation
- management
V common Cause unknown but associated with -asthma -pollution -50+
12wk+ of -nasal blockage, discharge -facial pain -anosmia May have polyps
Nasal saline wash
Topical nasal CS
Surgery to remove polyps
Epistaxis
- key questions to ask
- risk factors
- initial management
- examination and definitive management
Which nostril Anterior or posterior - ANT more likely Frequency of nosebleeds Volume of blood lost Management so far -patient to bend forward, pinch soft part of nose to compress anastomoses in Little's area -icepack on neck
Risk factors
- HTN
- AC/AP use, tendency to bleed and bruise
- smoker
- low humidity
Inital management
- A-E resus
- IV fluids, blood transfusion if needed
Examination
- clean nose
- topical analgesia and decongestants
- look for source of bleed => direct coagulation, stop bleed (nasal cautery, packing for 24hrs)
- topical ABx
Sinuses
- function
- how to manage sinusitis
Frontal Sphenoid Maxillary - largest -nasal douching with saline -nasal spray - can develop tolerance Ethmoid
Filtration of air
Keeps skull light
Affects the quality of our voice - we sound congested when we have sinusitis
