Nasal Congestion Flashcards
(25 cards)
Nasal anatomy
Inferior turbinate - tear duct comes out below
Middle turbinate - most sinuses enter wall lateral to this
Olfactory mucosa on roof, superior side wall, septum
LHS of nose with septum (nice pink mucosa, usually not completely straight, cartilage anteriorly and bone posteriorly)
Inferior turbinate
View
Sinus anatomy
Bone-targeted non-contrast coronal CT through the paranasal sinuses
3 - orbital globe
1,2 - frontal sinuses (unusual to be so symmetrical)
4 - maxillary sinuses (grey stuff could be mucus, pus, other fluid, soft tissue mass including tumour, swollen mucosa; looking at other slices might help, if entire space blacked out an MRI may help)
Centrally - ethmoid sinus
Sinus anatomy 2
Bone-targeted non-contrast coronal CT through the paranasal sinuses
Back of inferior turbinate
Sphenoid sinuses all the way back
Front of C1 below
Turbinate
Conchae
Function of the nose
Airway Filtration Humidification Warming Olfactory sensation
6 main nasal symptoms patients will complain of
Block: congestion vs total obstruction, uni- vs bi-lateral
Run (“rhinorrhoea”)
React to irritation: itching, sneezing, pain
Change in smell (+/- taste): decreased/absent, foul
Facial pressure/pain
Bleed (“epistaxis”)
Anatomical DDx
Deviation of nasal septum, hypertrophy of turbinates
??
Septal deviation
Deviation of dorsum of nose to right will result in deviation of septum to left, and vice versa
Nose will always be partially blocked
Choanal atresia
Congenital condition
Bilateral - obligate nasal breathers from birth, becomes obvious when newborn (will go into immediate respiratory distress); treat by holding mouth open (e.g. Galdel airway)
Unilateral - age of presentation variable (might be old enough to express that they can’t breathe through that side, or parent might notice one side is more snotty)
Space-occupying lesions
1 - mucopurulent discharge due to foreign body
2 - bilateral obstruction of nasal cavity or obstruction in nasopharynx, most common reason is adenoid hypertrophy (“adenoid facies” - long face due to mouth open with developing skeleton)
3 - inflammatory nasal polyp (also go looking for them in the other side; bilateral polyps are better as this suggests allergic rhinosinusitis, unilateral polyp may suggest inflammatory reaction to underlying tumour)
4 - mass in maxillary sinus (probably primary malignant neoplasm)
Functional causes of nasal congestion
Infections Rhinitis (e.g. infectious, atopic, irritation, vasomotor, atrophic, drugs including cocaine, heroine, speed, long term nasal decongestant use)
Rhinitis
Clinical triad of nasal congestion, rhinorrhoea and nasal irritation (itching and sneezing)
Rhinitis medicamentosa
Nasal congestion caused by longterm decongestant use
Atrophic rhinitis
“Crusting” in the nose - block, stuffy, dried, smelly (mucus and bacteria)
Consider AI rhinitis (e.g. sarcoidosis, ??)
Acute bacterial rhinosinusitis
Symptoms for 7-28 days Diagnosis clinical: at least 2 of, one of which must be P or O P - facial pain/pressure/fullness O - nasal obstruction D - purulent nasal discharge S - smell: hyposmia/anosmia
Chronic rhinosinusitis
Symptoms lasting 8-12 weeks
Lack of signs of acute inflammation (facial pressure but not so much pain)
Requires clinical demonstration of sinus inflammation (via endoscopy or imaging)
Multiple causes
Facial pain syndromes - likely the nose
Other nasal symptoms (e.g. discharge, difficulty breathing through nose, etc)
Ache/pressure
Location (maxillary, bridge, potentially retro-orbital)
Commonly bilateral
Typical triggers
Systemic symptoms (e.g. fever)
Changes with head position (headache worse with head forward)
Worse with respiratory symptoms/during hayfever season
Facial pain syndromes - probably not
Lack of nasal symptoms Pain, not pressure Location Unilateral Typical triggers (menstrual cycle, stress, musculoskeletal problems with neck)
Gate theory for pain
Operative pain gives the patient other pain to focus on
6 weeks later comes back
Concerning features
Head and neck cancers don’t cause weight loss until end stage
Small but frequent bleeding
Unilateral symptoms
Progressive symptoms
Crusting
Dysfunction of adjacent structures (e.g. nasolacrimal duct, orbit, facial sensation or cheek swelling, eustachian tube obstruction, brain)
Wegener’s granulomatosis
If untreated 100% mortality
With age, tip of nose droops, cartilage droops - nasal obstruction
Can intervene surgically or just leave it
Imaging
Most likely CT (MRI has soft tissue benefit - can figure out exactly what is going on)
