Nese

Question 1

What drains into inferior meatus?

Answer 1

Nasolacrimal gland

Question 2

What drains into middle meatus?

Answer 2

1. Middle- and anterior ethmoidal cells

2. maxillary- and frontal sinus

Question 3

What drains into the superior meatus?

Answer 3

Sphenopalatine foramen and posterior ethmoidal cells. NB. Sphenoid sinus opens above the superior turbinate and a bit posteriorly.

Question 4

How can you check if there is an inflammatory process?

Answer 4

Transillumination test. Check for maxillary sinus inflammation (no light = inflammation). Maxillary sinus can hold up to 15mL in an adult.

Question 5

Acute & Chronic sinusitis - Predisposing factors

Answer 5

1. Blockage of osteomeatal opening by polyp
2. Septum deviation
3. Choncha bullosa(trapped air cell in a turbinate)
4. Mucosal thickening

Question 6

Acute & Chronic sinusitis - definition

Answer 6

Acute < 10 days

Chronic > 3 months

Question 7

Acute & Chronic sinusitis - Symptoms

Answer 7

Symptoms are usually BILATERAL(if unilateral -> think cancer). 
1. Facial pain 
2. Pressure sensation 
3. Decreased smell sensation
4. Mucopurulent discharge 
5. Polyps 
6. Fever
7. Nasal obstruction 
8. Headache
CT-changes - need >2 to set diagnosis

Question 8

Acute & Chronic sinusitis - how to check severity

Answer 8

VAS scale -> gives recommendation on how to treat

Question 9

Acute & Chronic sinusitis - Treatment

Answer 9

1. Functional endoscopic sinus surgery (FESS): Restores osteomeatal meatus physiological state and thus proper drainage of sinuses.
2. Endoscopic sinus surgery (ESS): When there is need to remove excessive tissue(e.g. a polyp).

Question 10

Acute & Chronic sinusitis - Complications

Answer 10

1. Orbital fractures
2. Emphysema
3. Bleeding
4. Blindness
5. CSF leak
6. Meningitis
7. Empty nose syndrome (after surgery, patient still feel congested, however tha nasal passages are clear. Psychosomatic disease? e.g. like fantom leg.
8. Injury to lacrimal gland
   External approach of sinus surgery = Caldwell Luc’s operation.
9. Orbital - cellulitis, abscess
10. CNS - meningitis, abscess
11. Osteomyelitis - cavernous sinus thrombosis (= proptosis, chemosis and optalmoplegia)

Question 11

Rhinitis - Cause

Answer 11

1. Primary allergy -> tx: antihistamines(local or systemic), leukotriene inhibitors “-lukast”, intranasal steroids, nasal decongestants + avoidance of allergen.
2. Infection
3. Hormonal rhinitis (estrogens)
4. Senile rhinitis
5. Vasomotor rhinitis
6. Rhinitis medicamentosa - due to rebound effect when stopping long term anticongestant tx.
7. Atropic rhinitis -> crust and smell really bad. Patient dont know due to “merciful anosmia” - effect. Tx: Young’s operation.
8. Chronic purulent rhinitis -> tx: longterm amoxicillin therapy. If no improvement start to look for signs of immunodeficiency, cystic fibrosis or mucociliary dysfunction.
   ICF - Symptoms of discharge, and head trauma might be in history of patient. Quick test: Beta-2 transferrin + glucose (dipstick test) should be confirmed as they dont appear in nasal secretions. Blood containing CSF - halo sign. Beta 2 transferrin is most specific.

Question 12

Acute Coryza (Common cold) - complications

Answer 12

Risk of acute sinusitis following.

Question 13

Nasal vestibulitis

Answer 13

Carrier of S.pyogenes and their skin becomes infected. Tx: prolonged antiseptic/antibiotic ointment. Systemic flucloxacillin if really bad. In children - look for foreign body.

Question 14

Nose bleed(Epistaxis) - Causes

Answer 14

1. Local trauma (nose picking),
2. Nasal septal deviation
3. Iatrogenic
4. Inflammation
5. Foreign body
6. Environmental factors (cold dry air)
7. Malignancy
8. HTN
9. Blood disorders
10. Ataxia teleangiectasia

Question 15

Young boy with nosebleed, think of:

Answer 15

Juvenile angiofibroma

Question 16

What to do with severe nosebleeds?

Answer 16

Get IV access and cross type blood just for security in case of fluid resuscitation.

Question 17

Blood supply to nose.

Answer 17

1. ICA -> ophtalmic artery -> anterior and posterior ethmoidal arteries. Supplies the anterior and posterior superior nasal cavity and septum.
2. ECA -> Maxillary artery and facial artery.

Question 18

Posterior nose-bleeds

Answer 18

10% - main source: Branches of sphenopalatine artery (Woodruff’s plexus)

Question 19

Anterior nose-bleeds

Answer 19

90% - main source: Kiesselbachs plexus that supply Little’s area. Recieves branches from both ICA and ECA:

Question 20

Anterior nose bleed - Treatment

Answer 20

1. Pinch cartilaginous part of nose (10-12min)
2. Nitrate application sticks for cauterization
3. Sponge hemostatic pack
4. Really severe that dont respond to above mentioned: ANTERIOR PACKING - should be kept for 48h. Hospitalization depend on state of patient.

Question 21

Posterior nose bleed - Treatment

Answer 21

1. Balloon catheter (NB-risk of necrosis)
2. Posterior back + anterior
   - keep posterior one for 72h(anterior for 48h) - Replace always due to risk of infection/sepsis. Still bleed?
3. Arterial ligation
4. Embolization
5. Endoscopic cauteriation(ESPAL)

Question 22

Samter’s triad/Aspirin triad

Answer 22

Bronchial asthma + polyps + aspirin sensitivity

Question 23

Tumors and cancers in nose- M:F ratio

Answer 23

M:F ratio = 2:1

Question 24

Tumors and cancers in nose - Types

Answer 24

1. Osteomas (Gardner syndrome if multiple)
2. Inverted papilloma (malignant potential)
3. Juvenile angiofibroma(adolescent males)
4. SCC (80-85% - usually present late)
5. Melanoma

Question 25

Tumors and cancers in nose - Symptoms

Answer 25

Depends on location: - Blockage on 1 side of nose - Epistaxis (that still persist despite treatment -> if no longer than 2-3 weeks = order MRI) - Rhinorrhea - Prolonged sinusitis (esp unilateral) - Numbness - Swelling - Loose upper teeth/poor dental prosthesis fitting of the elderly indicate maxillary tumor - Severe headache + diplopia might indicate ethmoid air cell tumor - Loose red color vision might follow optic nerve spread. - Most of them are overlapping sites in origin

Question 26

Tumors and cancers - Spread

Answer 26

Spread will tell much about prognosis - Superior and posterior = BAD (Goes to CNS) - Inferior and anterior = BETTER

Question 27

Tumors and cancers - Treatment

Answer 27

Endoscopic surgery or lateral rhinotomy. If scull base is destroyed need help from neurosurgery.

Question 28

Tumors and cancers - Prognosis

Answer 28

5 year survival = 50-70% (depend on type and spread) | - Always do follow up if unilateral inverted papilloma (because of malignant potential)