Y4 Neurology and Special Senses SA > 21 - Nose > Flashcards

21 - Nose Flashcards

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1
Q

What bones make up the nose?

A
  • Ethmoid
  • Vomer
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2
Q

What is the blood supply to the nose?

A

All comes from internal and external carotid arteries

Little’s Area (Kiesselbach’s) (SEPTAL): LEGS

L - Septal branch of the superior labial artery

E - Anterior and Posterior Ethmoidals

G - Greater Palentine

S - Sphenopalentine

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3
Q

What are some of the causes of epistaxis?

A
  • Idiopathic
  • Traumatic e.g nose picking
  • Iatrogenic e.g anticoagulants
  • Foreign body
  • Inflammatory e.g polyps, rhinitis
  • Malignancy
  • Cocaine use
  • Coagulopathies
  • HTN
  • Hereditary haemorraghic telengectasia
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4
Q

What are some important questions to ask in a history when a patient presents with epistaxis?

A
  • Side, duration, approximate blood loss
  • Previous episodes and treatment?
  • Risk factors:
  • Recent trauma e.g pituitary surgery BEWARE
  • Recent URTI
  • HTN
  • Anticoagulants
  • Smoker?
  • Cocaine?
  • PMHx e.g coagulopathies
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5
Q

How should you treat epistaxis - is it an emergency?

A

All epistaxis should be deemed an emergency and as severe until proven otherwise.

e.g Posterior bleed may not be externally bleeding but could be swallowing a lot of blood

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6
Q

When is epistaxis classed as life-threatening and what is the management for this?

A
  • Large volume bleeds
  • Haemodynamically unstable
  • Not stopping with interventions

Mx: A to E, Airway trained personnel present, adequate IV access, resuscitation with blood products

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7
Q

What is the management of epistaxis in general (non-life threatening)?

A

STEPWISE TREATMENT - MONITOR OBS AND RESUS AS NEEDED

General:

- Sit up and head forward

- Spit out any blood in mouth

  • Pinch soft part or put nasal clip on anterior nose for 20 minutes for continuous compression

- Ice on nose for vasoconstriction

  • Look for source of bleeding on septum with thudicum and in patients mouth (ant or pos?)

- Send off for bloods e.g FBC, G+S, Clotting and reverse and coagulopathies

  1. offer topical vasoconstrictor + local anaesthetic
    (e.g. lidocaine + phenylephrine or oxymetazoline)
  2. Cauterisation if bleeding site is visible
    → Use silver nitrate sticks (only 1 side of septum at a time)
  3. Anterior nasal packing (e.g. with Merocel or ribbon gauze with BIPP)
    If still bleeding: Posterior nasal packing (e.g. balloon catheter)

SEE IMAGE FOR FURTHER MANAGEMENT

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8
Q

What advice should you give to patients post-cautery?

A
  • Avoid hot showers
  • Don’t bend, lift or strain
  • No food or hot drinks
  • Avoid picking nose
  • Send sneezes through mouth
  • Come back to A and E if bleeding again for >20minutes
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9
Q

Why should you not use silver nitrate if actively bleeding to cauterise and why shouldn’t you cauterise both sides?

A

. First Aid
Pinch nose and lean forward
Cold compress
Suction if available

  1. Apply topical vasoconstrictor
    e.g. lidocaine with adrenaline or phenylephrine spray
    This helps constrict vessels and reduce bleeding to allow visualisation
    1. Once bleeding slows/stops → then consider:
      Silver nitrate cautery if a single, visible bleeding point can be identified
      👉 Only one side of the septum at a time to avoid perforation
  • Bleeding will wash the chemical away and can burn lips
  • Risk of perforation
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10
Q

What are some of the risks with posterior packing and surgical embolisation for the treatment of epistaxis?

A

Posterior Packing:

  • Aspiration of Foley catheter
  • Packing induced OSA (nasopulmonary reflex - watch resp rate)

Embolisation:

  • Risk of stroke
  • Never embolise anterior ethmoidal as comes off of ICA
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11
Q

After treating a nose bleed what can you prescribe a patient?

A

Naseptin (chlorhexadine and neomycin) for 10 days to prevent crusting

Avoid in peanut and soy allergy

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12
Q

What are some examples of anterior packing devices and why should you avoid them if possible?

A
  • Rapid Rhino and Nasal tampons
  • Means they have to have an admission
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13
Q

What pathologies could cause recurrent epistaxis?

A

Always consider leukaemia

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14
Q

What are some important questions to ask with nasal trauma?

A
  • Mechanism of injury (impact, force, direction)
  • Pain?
  • Nasal deviation?
  • Obstruction?
  • Epistaxis?
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15
Q

How do you manage a nasal laceration?

A

- Clean wound

  • Consider if need tetanus prophylaxis based on mechanism of injury
  • Oppose edges of skin with steri-strips or sutures for primary intention healing
  • If cannot get skin to oppose, refer to plastics as may need to heal by secondary intention
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16
Q

After nasal trauma what are two complications you need to assess for?

A
  • Septal haematoma (risk of AVN if left)
  • Rhinorrhea (CSF leak from basilar skull fracture)
  • Anosmia
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17
Q

How does a septal haematoma present?

A

On anterior rhinoscopy a boggy red/purple swelling from the nasal septum

Use a Jobson-Horne probe to see if fluctuant as this distinguishes it from a septal deviation

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18
Q

How is a septal haematoma treated and why does it need to be treated?

A

- Incision and drainage under general anaesthetic

- Risk of avascular necrosis as septum gets its blood supply from overlying perichondrium

  • Avascular necrosis of septum can lead to saddle nose deformity, septal perforation and infection/abscess formation
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19
Q

What is the risk with a nasal septum abscess?

A

Ascending cavernous sinus infection and the associated intracranial or ocular complications

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20
Q

How may a nasal fracture present and what investigations should you do?

A
  • New nasal deformity with swelling and black eyes

- Look for septal haematoma and treat promptly if so

- Treat any epistaxis

- No X-ray needed, if suspect other facial fractures then can do CT

  • If uncomplicated nasal fracture (no septal haematoma) can send home and see in clinic after 7-10 days
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21
Q

When a patient with a nasal fracture comes to ENT clinic 7-10 days later, what are you assessing for? (seen 7-10 days later to allow swelling to settle)

A

Nasal deformity – objective assessment for any bony or septal deviation, patient’s perception of the appearance of their nose

Nasal obstruction – ask how the patient is symptomatically, air flow can be assessed by holding a metal tongue depressor below the nose and observing misting during nasal breathing

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22
Q

How is a nasal fracture treated if there are symptoms?

A

- Manipulation under anaesthesia: local or general anaesthetic within 2-3 weeks before bones set

  • If still issues after this can have rhinoplasty (changing shape of nasal bones) and septoplasty (nasal septum alteration)
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23
Q

Why can rhinorrhea occur after nasal trauma and how can you test it to see if it is CSF?

A
  • Fracture through cribriform plate
  • Test the fluid for high levels of beta-2 transferrin
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24
Q

How is a CSF leak following nasal trauma managed?

A

Conservative: most will resolve spontaneously after 2 weeks with some bed rest and head elevation of 10-15 degrees. Avoid coughing and sneezing

Surgical: not often needed

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25
What are some ways of getting a foreign body out of a child's nose?
- Ask them to blow their nose - Parental kiss (blow into mouth whilst occluding other nostril) - Crocodile forceps - If battery needs to be removed ASAP
26
What are some causes of septal perforation?
- Septal surgery - Trauma (nose picking, foreign body, septal haematoma) - Inhalants (nasal steroid/decongestant sprays, cocaine abuse) - Infection (TB; syphilis; HIV) - Inflammation/malignancies
27
What is the management for a septal perforation?
- Saline nasal irrigation - Closure with septal prosthesis
28
When doing surgery on the sinuses, what are some structures that can be damaged?
- Lamina papyracea (medial wall of orbit) - Anterior cranial fossa - Internal carotid artery
29
Where do each of the paranasal sinuses in the head drain into?
Hiatus Semilunaris is important drainage for most of the sinuses
30
Thinking about the anatomy of the paranasal sinuses, what could be some complications of rhinosinusitis?
**Orbit:** periorbital sinusitis could spread to the orbit and be sight threatening **Intracranial Spread:** from frontal sinus could spread to cause meningitis or intracranial abscess formation
31
What are the different classifications of rhinosinusitis?
**_Acute_** - Lasts \<12 weeks. Complete resolution of symptoms - Split into viral and non-viral **_Chronic_** - Lasts \>12 weeks without complete resolution of symptoms - Split into CRS with polyps or without polyps
32
What is the definition and clinical features of rhinosinusitis?
Inflamation of the mucoses of the nose and paranasal sinuses characterised by **two or more symptoms one of which must be:** - Nasal blockage/obstruction/congestion - Discoloured nasal discharge (anterior or posterior nasal drip) - Facial pain or pressure - Altered or loss of sense of smell AND EITHER - Endoscopic signs of polyps, mucopurulent discharge or oedema in middle meatus OR - CT signs of mucosal changes in the sinuses
33
What are some of the organisms that tend to cause acute rhinosinusitis and how can you tell which organism is likely causing the sinusitis?
Viral usually resolves within 5 days, bacterial if more than 5 days ## Footnote **- Viral:** rhinovirus, influenza virus **- Bacterial:** S.Pneumoniae, Haemophilus Influenzae, Moraxhella Catarrhalise - **Allergic**
34
What are some risk factors for developing acute rhinosinusitis?
- Cigarette smoke (active or passive) - Air pollution - Anatomical variations, e.g septal deviation, nasal polyps, or sinus hypoplasia - Anxiety or depression - Asthma - Diabetes
35
What are some differentials for acute rhinosinusitis?
**- Viral URTI** **- Allergic rhinitis**: patient has history of atopy, unlikely to have anosmia and mucopurulent discharge **- Facial pain syndromes** e.g migraine: no nasal symptoms
36
What are some investigations you can do to diagnose rhinosinusitis?
- Clinical symptoms enough to diagnose - CT if complications - Skin prick testing if recurrent and suspect allergic cause
37
How is acute sinusitis managed?
**Symptoms up to 5 days:** Analgesia and Nasal Decongestants **Symptoms over 5 days and not improving:** Topical Nasal Steroids and Oral Antibiotics **Refer to ENT:** if any red flags or if not improving after 7-14 days
38
What are some red flag symptoms with acute rhniosinusitis that would make you refer to ENT?
- Eye signs: periorbital swelling or erythema, displaced globe, visual changes, ophthalmoplegia - Severe unilateral headache, bilateral frontal headache, or frontal swelling - Neurological signs or reduced conscious level
39
If a patient is reffered to ENT with sinusitis what can they do that cannot be done in primary care?
**Ix:** Flexible Nasoendoscopy, CT **Mx:** admission for IV abx, oral steroids and consider surgery
40
What are some complications of acute rhinosinusitis?
- Preseptal cellulitis, orbital cellulitis, or abscesses - Osteomyelitis - Pott’s puffy tumour (osteomyelitis of the frontal sinus result in a soft boggy swelling over forehead) - Intracranial abscesses - Venous sinus thrombosis
41
What are some of the risk factors for chronic rhinosinusitis?
- Atopy - Cilliary impairment e.g CF - Aspirin sensitivity - Smoking - Immunosuppressants - Anatomical variants e.g septal deviation - Trauma - Foreign body - Swimming and diving
42
Chronic rhinosinusitis has the same symptoms as acute. What difference is there between acute and chronic rhinosinusitis on examination?
In chronic, rhinoscopy will reveal generalised mucosal swelling, mucopurulent discharge, **and/or polyps** Polyp is overgrowth of swollen mucosa that has prolapsed from sinus into nose
43
What are the differential diagnoses for chronic rhinosinusitis?
**- Recurrent acute rhinosinusitis** **- Foreign body** **- Malignancy:** blood stained discharge, unilateral polyps/symptoms/eye signs
44
What investigations should you do if you suspect chronic rhinosinusitis?
- Need to do **anterior rhinoscopy and nasendoscopy** to look for polyps!!! - Skin prick tests if allergy suspected - CT sinuses if surgery planned
45
When do you need to refer someone with chronic rhinosinusitis to ENT urgently?
- Unilateral polyps - Blood stained discharge - Eye symptoms Need to be biopsies for histological diagnosis!
46
How is chronic rhinosinusitis managed?
Calculate Visual Analogue Score (VAS) **_Mild (VAS\<3)_** - Nasal saline douching - Topical steroid sprays - Allergen avoidance **_Moderate to Severe (VAS\>3)_** - Long term antibiotics - Oral steroids - Antihistamines - Topical steroid sprays - Refer for CT of sinuses and if refractory refer for surgery (FESS)
47
What is functional endoscopic sinus surgery and what are the complications with this?
- Need a CT beforehand - Remove any polyps that have formed and open up the sinuses - Reduces obstruction, drain any collections of mucus, and allow topical treatments to reach all areas to prevent recurrence **- Complications:** bleeding, infection, recurrence, injury to orbit, CSF leak
48
What are some complications of chronic rhinosinusitis?
**Mucocele** - Usually in frontal sinus so lump on forehead - Can erode bone and invade local structures e.g orbit and brain
49
How can you explain to a patient how to use a steroid spray?
- Tilt the head slightly forward - Use the left hand to spray into the right nostril, and vice versa (sprays slightly away from the septum) - DO NOT snif hard during the spray - Very gently inhale through nose after spray
50
What are some causes of exacerbations of allergic rhinitis?
IgE mediated type 1 hypersensitivity - Pollen - Mould - House dust mites - Animals
51
What is the pathophysiology of allergic rhinitis?
Allergic reaction leads to synthesis and release of prostaglandin D and leukotrienes and mast cell degranulation to release histamine This increases capillary permeability so congestion, oedema, rhinorrhoea, sneezing and irritation
52
How is allergic rhinitis classified?
Allergic Rhinitis according to its Impact on Asthma (ARIA) **_Duration of Symptoms_**: **- Intermittent:** symptoms \<4 days a week and \<4 weeks **- Persistent:** symptoms \>4 days a week and \>4 weeks **_Severity of Symptoms:_** **- Mild**: normal daily activities and sleep **- Moderate to severe:** impairment of daily activities and sleep
53
How is allergic rhinitis investigated and managed?
**_Ix_** - Skin prick tests - RAST blood test if above not possible **_Mx_** **Conservative:** allergen avoidance, nasal douching with saline **Medical:** antihistamines, topical nasal steroids (mometasone), LTRA antagonists **Immunotherapy**
54
How does peri-orbital cellulitis present and where does it arise from?
**Presentation**: pain, loss of colour vision, oedema of eyelids, proptosis, reduced eye movements Comes from direct spread of pus from the ethmoid sinus or from thrombophlebitis of mucosal vessels in any of the sinuses
55
Why is peri-orbital cellulitis an emergency?
**Sight threatening** - Risk of blindness as there is tension and septic necrosis of optic nerve
56
How is peri-orbital cellulitis managed in general?
DO A CT SCAN TO SEE EXTENT OF DISEASE - IV antibiotics - Nasal decongestants - Urgent surgical drainage if abscess
57
cause of chronic sinusitis
recurrent infection issues with draining the sinuses immunocompromised
58
what is FESS
flexible endoscopic sinus surgery
59
role of the meatus
allows the nasal cavity to communicate with the sinuses in the face, usually the middle turbinate will drain into the middle meatus -> maxillary sinus (main drainage in the nose) Under the inferior meatus -> the nasolacrimal gland drains, which shows why you get runny nose when crying
60
where is the most common location for a nasal polyp to occur and what are some associated symptoms
under the middle meatus usually bilateral and shouldn't bleed can cause a post nasal drip -> chronic cough dry cough, and tickle at the back of the throat. pseudo stratified columnar ciliated cells - so will produce mucus. chronic blocked nose / chronic runny nose can cause obstructive sleep apnoea -> mouth breath treat with nasal steroids
61
do nasal cancers and nasal polyps often affect kids
no if they have smelly discharge and blood stained mucus it is probably foreign body
62
nasopharyngeal cancer may present with what
otitis media with effusion as it causes problems with the drainage if the ear its unlikely to see this OME condition in adults
63
why is the structure of the nose so crowded and small
This allows time to, humidifies and warm the air
64
most common cause for epistaxis
idiopathic - main high blood pressure anticoagulant
65
what area is 90% of epistaxis come from
anterior -> littles area, arterial bleed
66
manage nose bleed
sit forward and pinch the cartilage then silver nitrate cauterise posterior packing sphenopalatine artery ligation poopoo bum bum
67
which blood vessel causes the posterior bleeding
sphenopaletine 10% will come out of both nostrils when its so far back
68
A 25-year-old male patient presents to the emergency department with a history of blunt trauma to his face. The patient was involved in a fistfight and sustained a punch to the nose. He complains of **nasal pain and swelling with some difficulty in breathing**. Examination reveals **deformity of the nasal bridge, tenderness over the nasal bones, and a bloody nasal discharge**. What is the next appropriate step in the management of this patient?
Obtain a CT scan of the nasal bones and perform a nasal endoscopy
69
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