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Flashcards in ENT - Rhinology Deck (39)
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Benign nasal tumours

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


Malignant nasal tumours

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


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

- 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)


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

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.


How should tension type headaches be treated?

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.


What is midfacial segment pain?

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.


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

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


How is midfacial segment pain treated?

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.


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

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.