surgery - ENT NOSE Flashcards
what is acute rhino sinusitis?
acute inflammation of the mucosal linings of the nasal passage (rhinitis) and paranasal sinuses (sinusitis)
what causes acute rhinosinusiits?
infection and allergy
Inflammation of mucosa results in blockage of the paranasal sinuses and subsequently can lead to a bacterial infection.
what are the causes viral + bacterial organisms + allergic of acute rhinosinusiits?
rhinovirus, influenza, or adenovirus
S. pneumoniae, H. Influenzae, or M. catarrhalis
dust, pollen, and cat or dog hair.
what are the paranasal sinuses?
name them
hollow spaces within the bones of the face, arranged symmetrically around the nasal cavity
frontal, ethmoid, sphenoid + maxillary
name the sinuses 1-4
1= frontal
2= ehtmoidal
3= sphemoid
4 = maxillary
RF for acute rhinosinusiits?
features of acute rhinosinusiits?
<12 wks symptoms
nasalobstruction
discoloured nasal discharge
facial pain/pressire
altered sense of smell
ix for acute rhinosinusiits?
clinical diagnosis
CT scan for complciations
skin price testing for allergies
mx for acute rhinosinusiits?
analgesia, nasal douche and nasal decongestants
bacterial
If there is no improvement after 7-14 days of treatment or the presence of red-flag symptoms, referral to ENT services should be considered.
red flag symptoms of acute rhinosinusiits?
what is the specialist mx for acute rhinosinusiits?
nasal endoscopy - identify abnormal anatomy/patholgy
CT paranasal sinuses - identify complications
admit if serious infection - give oral steroids, IV abx + surgery
complications of acute rhinosinusiits?
what is chronic Rhinosinusitis?
symptoms lasting longer than 12 weeks
RF for chronic Rhinosinusitis?
asthma or atopy, aspirin sensitivity, ciliary impairment (e.g. cystic fibrosis or primary ciliary dyskinesia), smoking, and immunosuppression
septal deviation, nasal polyps, or sinus hypoplasia
features of chronic Rhinosinusitis?
Symptoms must be present for ≥12 weeks.
nasal blockage
nasal discharge
facial pain/ressure
altered sense of smell
tenderness or swelling in maxillofacial area
rhinoscopy =mucosal swelling, mucopurulent (green/yellow) discharge, or nasal polyps
ix for chronic Rhinosinusitis?
nasal endoscopy = mucosal swelling, mucosal occlusion of middle meatus, or nasal polyps
mx for chronic Rhinosinusitis?
mild disease = nasal saline douching and topical steroid spray
avoid any known triggers, smoking cessation
moderate to severe disease = long term treatment with topical steroids and referral for consideration for surgery.
what is the surgery done for chronic Rhinosinusitis?
Functional Endoscopic Sinus Surgery
what is Functional Endoscopic Sinus Surgery?
remove any polyps that have formed and to open up the sinuses
done via endoscope
complications for FESS?
bleeding, infection, need for nasal packing, recurrence, orbital haematoma leading to visual loss, and injury to the anterior skull base leading to cerebrospinal fluid leak.
complications of chronic Rhinosinusitis?
mucocele = collection of mucous in epithelial-lined cavity
can erode bone and invade local structure ie orbit + brain
what is epistaxis?
bleeding from nose
where can epistaxis occur from?
anterior or posterior
explain anterior bleed anatomy
originate from ruptured blood vessels in Little’s area, a highly-vascularised region formed by the anastomosis of 5 arteries, and cause around 90% of cases
explain posterior bleed anatomy
originate from the posterior nasal cavity, typically from branches of the sphenopalatine arteries of the nose, and cause around 10% of cases (more common in older patients)
what is little’s area?
Little’s area (also known as Kiesselbach’s plexus) is found on the anterior nasal septum and is an anastomosis of 5 arteries: anterior ethmoidal artery, posterior ethmoidal artery, sphenopalatine artery, greater palatine artery, and the septal branch of the superior labial artery.
what can cause epistaxis?
COMMON = trauma, hypertension, iatrogenic (e.g. anti-coagulants), or foreign bodies (nose-picking is the most common cause in children!)
LESS COMMON = coagulopathies, platelet disorders, vascular malformations, vasculitis, rhinosinusitis (including allergies), malignancy, or cocaine use.
what to check in epistaxis history?
check which side + for other symptoms eg nasal obstruction, congestion, discharge and anosmia
facial pain*, otalgia, systemic symptoms?
Any recent trauma, co-morbidities or familial conditions (especially clotting abnormalities), relevant drug history (antiplatelets or anticoagulants), and any previous episodes should also be clarified.
what must be done in life-threatening epistaxis?
A to E approach
airway-trained personnel present
adequate IV access
resuscitation with blood products if required.
initial mx for epistaxis?
routine bloods (including FBC, clotting screen, and Group & Save)
kept sat up and sat forward
spit out any blood in their mouth
Compression should be applied to the soft lower cartilage portion of the nose (the nares) for 20 minutes
Ice can be applied to the bridge of the nose
what can be done after first aid measures for epistaxis?
If unsuccessful, a Thudicum can be used to inspect the septum. If an anterior bleeding point is identified, the vessel can be cauterised using silver nitrate
If there is too much blood present to visualise the septum, adrenaline-soaked cotton wool ball can be inserted into the nasal cavity to cause localised vasoconstriction.
cautery of little area
what should pt be discharged with in epistaxis?
Naseptin cream or Bactroban ointment
when is anterior packing used in epistaxis?
If the epistaxis persists but no bleeding point is visualised
when is posterior pack used in epistaxis?
If the epistaxis persists and posterior bleed is suspected,
If that fails, the next step would be posterior packing with a Foley catheter, along with BIPP gauze
how long as nasal packs left in situ?
24 hours
what surgical intervention is done for epistaxis?
contributing blood vessels can either be ligated surgically or embolised radiologically.
usually sphenopalatine artery, anterior ethmoidal artery or external carotid (LAST)
how are nasal lacerations managed?
wound cleaned
skin edges opposed - sterile strips or sutures
refer to plastics/ENT
what is a septal haematoma?
develop following trauma, whereby the shearing forces involved result in a separation of overlying perichondrium from the nasal septal cartilage. This causes submucoperichondrial blood vessels to tear and blood to accumulate within this space.
how do septal haeamatomas present?
visible on anterior rhinoscopy as a boggy red/purple swelling from the nasal septum
fluctuant
how are septal haeamatomas mx?
incision and drainage
what can happen if septal haeamatoma untreated?
AVN of spatial cartilage leaving it susceptible to infection + abscess formation
can result in saddle nose deformity
what imaging used in nasal bone fractures?
CT imaging
what are you assessing for when suspecting nasal bone fracture?
how do you assess?
how do you manage nasal bone fracture?
Manipulation Under Anaesthesia 2-3 wks post injury
If the aesthetic result is unsatisfactory, further definitive surgery eg rhinoplasty or septoplasty
explain anaesthetics for nasal fracture MUA?
complications from nasal trauma?
CSF leak occurs following fracture through the cribiform plate and out the nose
anosmia
how can you test for CSF leakage?
by testing the fluid for high levels of beta-2 transferrin
what is periorbital cellulitis?
infection of the eyelid and surrounding skin and subcutaneous tissue of the orbit
how do you treat periorbital cellulitis?
IV abc
what happens if periorbital cellulitis untreated?
vision loss, intracranial infection, and overwhelming sepsis
pathophysiology of periorbital cellulitis?
pre-septal or post-septal
what is the orbital septum?
fibrous layer that forms an anterior boundary of the orbit, which acts to reduce the spread of infection between the pre-septal space to post-septal space
why is orbital cellulitis concerning?
can lead to abscess formation and impact eye function
what organisms cause periorbital cellulitis?
Haemophilia influenza, Streptococcus pneumonia, and Staphylococci.
RF for periorbital cellultiis?
recent trauma
recent ophthalmic or ENT procedure
recurrent upper respiratory tract infections
diabetes mellitus or any immunocompromise.
features of periorbital cellulitis?
acute onset pain and swelling in the periorbital region
visual changes
tenderness, swelling, and erythema
what prompts further ix in periorbital cellulitis?
bilateral symptoms - worry about cavernous sinus thrombosis
how do you classify periorbital cellulitis severity?
CHANDLER’S CLASSIFICATION
what is cavernous sinus thrombosis?
formation of a blood clot within the cavernous sinus, usually as result of an infection spreading from the face or scalp
how do pts present with CST?
severe bilateral eye pain (or frontal headache) and visual changes. Features of meningism (photophobia, neck stiffness), cranial nerve palsy (CN VI palsy most common), and exophthalmos can be present.
how do you ix CST?
CT or MRI scans.
how do you mx CST?
intravenous antibiotics
thrombectomy is required.
ix for periorbital cellultiis?
outine bloods, including FBC, U&E, CRP, and a clotting profile
blood cultures + pus was
CT
mx ofr periorbital cellulitis
IV abx
analgesia
topical nasal decongestant
surgical drainage if subperiosteal and orbital abscess
how is subperiosteal and orbital abscess drainage done?
open approach (i.e. Lynch Howarth incision) or endoscopically through the nasal cavity. Patients with a cavernous sinus thrombosis will require discussion with the neurosurgical team.
complications fo periorbital cellulitis?
optic nerve damage, cavernous sinus thrombosis, or intracranial infection
