ENT - Nasal blockage Flashcards
Stephen, a 23-year-old final year medical student who is complaining of a blocked nose.
What questions in the history would you like to ask about his blocked nose?
Nasal Symptom Questions:
- Is it one or both sides that feel blocked?
- Which side feels blocked?
- Is either/both sides ever clear?
- Duration of blocked feeling?
- Intermittent or constant?
- Hx of trauma?
- Previous nasal surgery?
- Any medications?
- e.g. nasal sprays, decongestants (designed for short term used, if used for > 2-weeks and then stopped –> can cause rebound congestion)
- Other conditions e.g. asthma, eczema i.e. atopic picture
- Other nasal symptoms:
- sneezing
- rhinorrhoea
- facial pain
- postnasal drip
- epistaxis
What does this image show?
Septal deviation
What are some causes of septal deformity?
- Congenital
- Infective e.g. infective septal haematoma
- Trauma
- Inflammatory e.g. granulomatosis Polyangitis Arteritis, sarcoidosis
Which of the following would be the most appropriate management for septal deviation?
- Septoplasty
- Rhinoplasty
- Nasal splints
- Adenoidectomy
Septoplasty
- Rhinoplasty = procedure which corrects a deformity of the external nose
- Nasal splints = plints are sometimes inserted at the end of a rhinoplasty or septorhinoplasty to hold the tissues in their new position
- Adenoidectomy = adenoids tend to regress after age 7/8, if they are large they can cause obstruction but it’s bilateral
What are the key components of consenting a patient for a procedure?
- About the procedure:
- What the procedure is for?
- What it involves?
- The intended benefits
- Risks or complications - common + serious/major + those specifically relating to pt
- Alternatives to the procedure and the pros/cons (must include no treatment)
What are the potential risks / complications of a septoplasty?
- Bleeding & infection
- Anosmia/Hyposmia
- Numbness of the nose
- Numbness of the upper teeth
- Altered appearance
- Septal perforation
- Failure to improve symptoms
- Further procedure/revision surgery
What blood test should be ordered in a Hx of chronic rhinosinusitis, that is worse in summer?
RAST testing
(Radioallergosorbent test - identifies any allergies to specific allergens)
What is Cetirizine?
2nd gen anti-histamine
- Uses:
- allergic rhinitis, dermatitis, urticaria
- Side effects:
- headache, dry mouth, sedation GI pain, tachycardia (rare)
- MoA:
- Selective H1 antagonist
What does this image show?
Nasal Polyps
How are nasal polyps managed?
-
1st line:
- Topical nasal steroid - drops (for short course in severe cases), sprays (for less severe cases & long-term maintenance)
- Oral prednisolone - for severe polyps
- 2nd line:
- Functional endoscopic sinus surgery - anatomy/physiology are preserved as much as possible, endoscopes + debrider are used to excise as much of the polyps as possible (produce more room for improved medical management)
What are the risks of functional endoscopic sinus surgery you need to disclose?
- Bleeding
- Infection
- Recurrence
- Hyposmia / anosmia
- Synechiae - adhesions in nasal cavity
- Orbital injury - due to proxmity to operative field
- Blindness - optic nerve is close + rarely an ethmoidal air cell can be wrapped around the optic nerve (this is called an Onodi cell)
- Epiphoria (watery eye) - if nasolacrimal duct is damaged
- Meningitis - if dura breached
- CSF leak - if skull base and dura are breached
What are the diagnostic criteria for rhinosinusitis?
Rhinosinusitis criteria (summary):
-
Nasal blockage / congestion / obstruction - +1 of the following:
- Facial pain / pressure
- ↓ or loss of smell
- Nasal polyps
- Mucopurulent discharge, primarily from middle meatus
- CT changes
How long does acute rhinosinusitis last?
How long does rhinosinusitis have to last to be considered chronic?
- Acute rhinosinusitis = lasts < 12 weeks with complete resolution of symptoms
- Chronic rhinosinusitis = lasts > 12 weeks without complete resolution of symptoms
How is chronic rhinosinusitis managed?
Polyps present:
- Consider short course of oral prednisolone
- Then continue as if poylps weren’t present
No polyps:
- Antihistamine + allergen avoidence if proven allergy
-
Topical nasal steroid OR short-course of topical drop steroid
- Fluticasone (Flixonase)
- Beclomethasone (Beconase)
- Mometasone (Nasonex)
- Nasal saline irrigation
-
Abx - if presence of infection
- Macrolides e.g. clarithromycin = recommended (in long-term shown to have anti-inflammatory effect)
- Functional endoscopic sinus surgery
Which of the following is not used to assess nasal patency?
- Nasal misting on the back of a metal spatula
- Acoustic rhinometry
- Nasal inspiratory peak flow
- Valsalva manouvre
Valsalva manouvre (used to test Eustachian tube)
- Acoustic rhinometry - not used in clinic, but in research to measure patency
