The Stuffy Nose

Question 1

4S symptoms that are core nasal?

Answer 1

Stuffy (blockage)

Smell (loss of smell)

Snot (discharge)

Sore (facial pain)

Question 2

Other nasal symptoms?

Answer 2

Sneezing
Itch
Crusting
Epistaxis

Question 3

Secondary nasal symptoms?

Answer 3

Dry mouth (when unable to breathe through nose)

Sore throat

Snoring

Halitosis

Loss of taste

Question 4

3 main points to cover in a nasal examination?

Answer 4

Airway patency:
• Adults - cover one nostril and ask them to breathe out through the other
• Children - place a mirror under the nose for nasal vapour

Question 5

When do nasal symptoms warrant further Ix?

Answer 5

Esp. if they are UNILATERAL

Question 6

Potential causes of stuffy nose?

Answer 6

Rhinitis (+ sinusitis)

Nasal trauma

Question 7

2 categories of causes of rhinitis?

Answer 7

1. Infective:
   • Viral URTI
2. Non-infective:
   • Allergic
   • Non-allergic

Question 8

Timing of stuffy nose?

Answer 8

Intermittent (seasonal)

Persistent (perennial)

Question 9

Potential allergic causes of intermittent rhinitis?

Answer 9

Tree pollen (spring)

Grass pollen (summer)

Fungal spores (autumn)

Question 10

Potential allergic causes of persistent rhinitis?

Answer 10

House dust mite

Cat

Dog

Question 11

Classification criteria for intermittent rhinitis?

Answer 11

Symptoms for <4 days per week

OR

Symptoms for <4 weeks

Question 12

Classification criteria for persistent rhinitis?

Answer 12

Symptoms >4 days per week

AND

> 4 weeks duration

Question 13

Classification criteria for mild rhinitis?

Answer 13

All of the following:
• Normal sleep
• No impairment of daily activities, sport, leisure
• Normal work/school
• No troublesome symptoms

Question 14

Classification criteria for moderate-severe rhinitis?

Answer 14

One or more of:
• Abnormal sleep
• Impairment of daily activities, sport, leisure
• Missing work/school
• Troublesome symptoms

Question 15

Stepwise management of allergic rhinitis?

Answer 15

Allergic avoidance is key along with:

1. Anti-histamines
2. Topical steroids
3. Topical steroids + anti-histamines

Immunotherapy is for selected patients with IgE-mediated disease
Surgery has specific indications and is for relief of obstruction

Question 16

Consqeuences of allergic disease?

Answer 16

Mucosal (turbinate) hypertrophy

Question 17

Occurrence of nasal polyps assoc. with?

Answer 17

Often with non-allergic asthma and Samter’s triad

Question 18

Treatment of nasal polyps?

Answer 18

Oral then topical steroids

If no relief, surgery

Question 19

Symptoms of acute infective rhinosinusitis?

Answer 19

Facial pain

Nasal blockage and discharge

Question 20

Cause of acute infective rhinosinusitis?

Answer 20

Majority are viral

Question 21

Treatment of acute infective rhinosinusitis?

Answer 21

Analgesics and decongestants

If persistent/worsening, add an antibiotics

Question 22

Complications of rhinosinusitis?

Answer 22

Orbital cellulitis and abscess - pus in the orbit due to proximity to ethmoid sinus; can lead to blindness, meningitis and death and so requires urgent referral

Question 23

Presentation of orbital abscess?

Answer 23

Unilateral periorbital puffiness

Question 24

In summary, what are the causes of rhinitis?

Answer 24

ADD PICTURE

Question 25

Ix in rhinitis?

Answer 25

Skin prick tests

RAST (specific IgE levels)

NOTE: nasal and sinus X-rays are not useful in rhinitis

Question 26

Management of non-infective rhinitis?

Answer 26

Behavioural changes:
• Allergen/irritant avoidance
• House dust mite exposure reduction
• Change drug therapy
• Alcohol reduction

Pharmacological therapy:
• Topical nasal steroid
• +/- anti-histamine
• Topical anticholinergic

Question 27

Management of infective rhinosinusitis?

Answer 27

Nasal decongestant

Analgesia

Potential broad-spectrum antibiotic

Question 28

Potential cause of congestion in children if they are not allergic and auroscope shows normal nose?

Answer 28

Plug of adenoid tissue

Question 29

Difference in potential cause of unilateral discharge in children and adults?

Answer 29

Young children - foreign body in the nose

Adult - nasal/paranasal tumour

BOTH REQUIRE URGENT REFERRAL

Question 30

Pharmacological therapies for stuffy nose?

Answer 30

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