ENT - Rhinology

Question 1

What is the glabella?

Answer 1

This is the most superior and forward projecting portion of the superior orbital ridges and marks an important landmark in the external nose.

Question 2

What is the columella?

Answer 2

This is the bridge of skin that joins the nasal bridge to the face and overlies the leading edge of the nasal septum.

Question 3

What structures form the shape of the nose?

Answer 3

The shape of the nose is formed by an underlying bony and cartilagenous skeleton.

There are the 2 paired nasal bones that meet in the midline by a fibrous union. These are attached to the nasal process of the frontal bone superiorly and the nasal processes of the maxillae laterally. They contribute to the shape of the dorsum of the nose.

The rest of the nose is composed of paired nasal cartilage. There is the upper lateral cartilage which is semi-mobile and forms the lower end of the nasa dorsum. There is also the lower lateral cartilage which is mobile and has medial and lateral projections that contribute to the nasal alar and columella respectively.

Question 4

Nasal septum - where does it run from? what is it composed of?

Answer 4

This is the structure that separates the two nostrils along their entire length until they meet at the posterior choanae, which is the opening to the nasopharynx.

It is composed of bone or cartilage and is covered by either periosteum or perichondrium with an overlying layer of mucosa.

The anterior part of the septum is formed from the quadrilateral cartilage that is attached to the upper lateral cartilage. Posteriorly, the septum is bone and formed from the perpendicular plate of the ethmoid and the vomer.

Question 5

What makes up the lateral wall of the nose?

Answer 5

The lateral wall of the nose is composed of 3 curls of bone called the turbinate bones that are covered by a layer of mucosa. Underneath these folds are the ostia or openings of the paranasal sinuses.

Question 6

Where do each of the paranasal sinuses drain to?

Answer 6

The sphenoid sinus drains into a recess medial to the superior turbinate bone.

Posterior ethmoid sinuses drain under the superior turbinate. The anterior ethmoid and maxillary sinuses drain underneath the middle turbinate.

The naso-lacrimal duct drains under the inferior turbinate.

Question 7

What are the relations of the sphenoid sinus?

Answer 7

The sphenoid sinus is located in the central portion of the sphinoid bone. Directly superior and posterior to it is the pituitary fossa. This is an access point for pituitary surgery.

Question 8

Epithelial lining of the nasal passages

Answer 8

Respiratory epithelium which is ciliated pseudo-stratified columnar epithelium.

This is in continuity with the epithelial lining of the lower respiratory tract, meaning that some conditions affecting the lower respiratory tract can predispose to pathology in the upper tract - e.g. nasal polyps associated with asthma

Question 9

What are the key symptoms to enquire about in a rhinological history?

Answer 9

1) Nasal obstruction - bilateral vs unilateral, constant vs intermittent
2) Nasal discharge - anterior (rhinorrhea - clear CSF, yellow green sinusitis) vs posterior (post nasal drip)
3) Olfaction
4) Epistaxis - anterior vs posterior, frequency, severity
5) Facial pain/ headaches
6) Sneezing
7) Smoking (diminishes nasal function)

Question 10

Important symptoms to ask in a Rhinitis history

Answer 10

1) Seasonality
2) Pets
3) Eye symptoms
4) Asthma (atopy)

Rhinitis = “hay fever”

Question 11

How should a rhinological examination be performed?

Answer 11

Inspection:

• look from side to side and above
• observe inspiration and misting (use a metal spatula placed under the nostrils)
• check the oral cavity for a large protruding antrochoanal polyp
• tip lift for anterior view

Palpation:

• tip support
• shape of underlying skeleton
• Cottle manouvre - reversibility of reduced airflow, ask the patient to breath in whilst pulling the skin of the chin on the affected side laterally which widens the nostril

Rhinoscopy:

• Thudicums nasal speculum
• endoscopy

Question 12

How should nasal trauma be assessed?

Answer 12

Use ABCs and current trauma guidelines. The nasal bones are easily broken and indicate likely other facial bone fractures. This should be assessed by palpating the facial bones, checking eye movements for fractures of the orbital walls, and facial x-rays (provided there is evidence of other fractures).

Question 13

What is a septal haematoma?

Answer 13

Nasal trauma may cause damage the nasal septum leading to haematoma formation. This can peel the perichondrium from the underlying cartilage and is a surgical emergency as it can lead to nasal collapse due to necrosis of the cartilage.

Question 14

What is the window of opportunity to manipulate nasal bone fractures?

Answer 14

Nasal bone fractures should be manipulated if they are causing gross deformity or discomfort, but is only possible up to 3 weeks after the injury, after which the bones will have set in the deformed position.

But assessment should not be too early, as soft tissue swelling may lead to over treatment.

Question 15

Causes of epistaxis

Answer 15

Epistaxis can be either local or systemic.
Local causes include:
- spontaneous 
- trauma
- tumours
- hereditary telangiectasia 

Systemic causes include:

• cardiovascular conditions - HTN, raised venous pressure
• coagulation disorders - anticoagulant therapy
• thrombocytopaenia
• fever (rare)

Question 16

Approach to epistaxis management

Answer 16

There is an annual fatality rate with epistaxis so patients should be assessed for hypovolaemia and resuscitated appropriately.

After that management involves stepwise escalating treatments:

1) direct pressure over the lower nose with a cold compress on the forehead
2) topical application of silver nitrate cautery for small bleeds
3) nasal packing
4) topical haemostatic agents
5) surgery - if conservative measures fail then gold standard intervention is end artery ligation usually of the sphenopalatine artery
6) endovascular embolisation - used in life threatening epistaxis but carries a risk of stroke and blindness (due to retinal artery occlusion)

NB - the further from the end artery the ligation, the greater chance of the ligation being compromised by collateral supply

Question 17

What is rhinitis?

Answer 17

This is inflammation of the nose irrespective of the aetiology and a number of terminologies are used:

• allergic rhinitis is a type 1 hypersensitivity reaction caused by re exposure to an antigen
• intrinsic rhinitis indicates non allergic rhinitis
• perennial rhinitis means year long symptoms

Question 18

How is it diagnosed?

Answer 18

Generally diagnosis is made by history and examination. Nasal mucosa may appear hyperaemic and red or pale. Inferior turbinate is typically affected.

Allergen tests can also be performed, as can serology for IgE called RAST or radio-allergo sorbent testing

Question 19

How is rhinitis managed?

Answer 19

There is no cure for rhinitis but symptoms can be managed with topical steroids, anti-histamines, lifestyle modification and exposure desensitisation.

Question 20

What is acute rhinosinusitis? Complications?

Answer 20

This is a severe bacterial infection of the paranasal sinuses. Patients can be severely unwell with pain, pyrexia and erythema over the affected sinus.

It is complicated by spread of infection to other neighbouring regions, such as:

• osteomyelitis of the frontal bone (Potts puffy tymour)
• intraorbital extension potentially threatening vision
• intracranial extension via the cribriform plate leading to meningitis or abscess formation

Question 21

How should acute rhinosinusitis be managed?

Answer 21

Infection generally responds well to penicillin based antibiotics such as amoxycillin or co-amoxiclav.

Nasal decongestion using sympathomimetic drugs such as xylometazaline or potent nasal steroids such as betamethasone is also used.

Failure to respond to oral antibiotics requires IV treatment and surgical drainage.

Question 22

Chronic rhinosinusitis

Answer 22

This is defined as symptoms of rhinosinusitis lasting longer than 3 months. It implies that there is colonization of a sinus with a pathological biofilm of bacteria that do not respond to antibiotics.

Patients have low grade symptoms such as nasal congestion, mucopurulent discharge, post nasal drip, facial discomfort.

Diagnosis is made clinically, with endoscopic examination showing a train of discharge from a specific sinus ostia or CT findings of opacification of a sinus.

Question 23

How should chronic rhinosinusitis be managed?

Answer 23

Initially, management involves nasal decongestion with topical steroids and steam inhalation. Sometimes long courses of low dose antibiotics (e.g. doxycycline and macrolides) can be successful.

Failure of conservative management is an indication for endoscopic intervention called functional endoscopic sinus surgery. This involves opening the sinus ostia.

If surgery is unsuccessful then immunological investigation for deficiency should be performed.

Question 24

What is sinonasal polyposis?

Answer 24

These represent extreme swellings of the nasal mucosa that have an uncertain aetiology. They are common in cystic fibrosis and primary ciliary dyskinesia and are associated with asthma and aspirin sensitivity (as part of a condition called Samter’s triad). This may point to an underlying role of salicylic acid in the aetiology.

Question 25

What are the symptoms of sinonasal polyposis?

Answer 25

Polyps are relatively asymptomatic and often grow quite large before causing nasal obstruction.
Symptoms include nasal discharge from secondary chronic rhinosinusitis and loss of smell.

They are diagnosed as visible grey masses on rhinoscopy with some mucopurulent discharge seen on endoscopy.

Question 26

How should sinonasal polyps be managed?

Answer 26

They cannot be cured but can usually be kept under control with:

• topical steroids
• low salicylate diet
• surgical debridement

Question 27

What fungi cause sinusitis?

Answer 27

Aspergillus species are commonly associated with fungal sinusitis. This may be part of an allergic spectrum with rhinitis and polyposis called allergic fungal sinusitis, or there can be infection of a single sinus resulting in a fungal ball called a mycetoma.

Question 28

What is the course of fungal sinusitis?

Answer 28

Fungal sinusitis is normally an indolent disease but severe forms can occur in the context of chronic invasive fungal sinusitis or an acute form that affects immunocompromised patients. This is called a mucomycosis, and is typically highly aggressive and invasive. This causes black and necrotic turbinate bones and characteristic CT changes.

Question 29

How is fungal sinusitis treated?

Answer 29

The treatment for all fungal sinusitis is with surgical resection. This needs to be done urgently in mucomycosis alongside parenteral anti fungal agents.

Question 30

What granulomatous conditions can affect the nasal passages?

Answer 30

1) Wegener’s granulomatosis - necrotising vasculitis and necrotising glomerulonephritis + granulomatous infection affecting the URT
- c-ANCA associated, high ESR, CXR and urinalysis, nasal biopsy

2) Sarcoidosis - multisystem granulomatous disease affecting the lower respiratory tract
- serum ACE, CXR, nasal biopsy

3) TB
4) Syphilis

Question 31

Benign nasal tumours

Answer 31

Benign tumours are usually asymptomatic but can cause nasal obstruction.

Important examples include:
- inverted papilloma: epithelial tumour associated with carcinoma in 15% of cases, managed by surgical resection but has high recurrence rates

• juvenile nasopharyngeal angiofibroma: should be looked for with recurrent epistaxis in young men, benign vascular tumour of adolescent men, locally invasive and are treated by surgical resection +/- embolisation

Question 32

Malignant nasal tumours

Answer 32

Primary nasal tumours are rare, present with bleeding and pain.

• squamous cell carcinoma (sometimes associated with inverted papilloma)
• malignant melanoma
• olfactory neuroblastoma (malignant neuroendocrine tumour that can present with anosmia)
• sinusoidal undifferentiated carcinoma

Question 33

What features are likely to suggest a patients facial pain is NOT caused by rhinosinusitis?

Answer 33

• facial pain and pressure being the primary symptoms in the absence of any nasal symptoms or signs
• normal nasal endoscopy
• patients with a normal CT (NB - CT changes on there own are not indicative of symptomatic rhinosinusitis)

Question 34

What is tension type headache and what are the clinical features?

Answer 34

Tension type headache (one of the primary headache syndromes) has the characteristics of tightness or pressure. It usually affects the forehead or temple and often the suboccipital region as well. It is either episodic or chronic.

Question 35

How should tension type headaches be treated?

Answer 35

Patients frequently take large quantities of NSAIDs to little effect. Hyperaesthesia of the skin or forehead occur giving patients the impression that they have rhinosinusitis as they know their sinuses lie under their forehead.

The majority of patients respond well to low dose amitriptyline, but they usually require up to 6 weeks of 10mg and sometimes 20mg at night before it works. Amitriptyline should be continued for 6 months and they should be warned of the sedative effect at low doses.

Question 36

What is midfacial segment pain?

Answer 36

This causes a symmetrical sensation of pressure or tightness across the middle third of the face. It is not uncommon to have co-existing tension type headache.

The nature of midfacial segment pain is like tension type headache, except that it affects the midface.

The areas of pressure involve under the bridge of the nose, either side of the nose, the peri and retro-orbital regions or across the cheeks. There may be hyperaesthesia of the skin and soft tissues over the affected area on examination. Nasal endoscopy is normal and CT of paranasal sinuses is normal.

Question 37

Are radiographic changes diagnostic of rhinosinusitis in patients with midfacial segment pain?

Answer 37

A third of asymptomatic patients have incidental mucosal changes on CT, and so radiographic changes are not diagnostic of rhinosinusitis.

Question 38

How is midfacial segment pain treated?

Answer 38

Majority of patients with this condition respond to low dose amitriptyline and are treated in the same way as patients with tension type headache.

Surgery should not be performed on these patients.

Question 39

What is the key feature of pain arising from the sinuses?

Answer 39

Sinogenic pain (i.e. sinusitis) is associated with rhinological symptoms and a response to medical treatment.

Acute sinusitis usually follows an URTI and pain is usually unilateral, intense, associated with fever and unilateral nasal obstruction and there may be a purulent discharge.

Chronic sinusitis is often painless, causing nasal obstruction due to mucosal hypertrophy and with purulent discharge that continues throughout the day.