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Neuro & Special Senses > Nose > Flashcards

Nose Flashcards

1
Q

Give four roles of the nose

A
  • Warms and humidifies
  • Removes and traps pathogens
  • Responsible for smell
  • Drains and clears Paranasal sinuses and lacrimal ducts
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2
Q

Name four cartilages associated with the external nose

A

Septal
Lateral
Major Alar
Minor Alar

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3
Q

Describe the blood supply to the external nose

A 
Facial Artery (Angular and Lateral Nasal)
Branches of Maxillary and Opthalmic
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4
Q

The external nose is drained by the facial vein. Why is this relevant?

A

Valveless structure that runs into opthalmic and then cavernous sinus so infection in this region can cause intracranial spread (danger triangle)

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5
Q

What are the three regions of the nasal cavity?

A

Area surrounding external opening - Vestibule
Respiratory region
Olfactory region

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6
Q

What are conchae/turbinates?

A

Bony shelves protruding into cavity (superior, middle and inferior)
Increase SA of cavity and slows air flow down

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7
Q

What are meatuses?

A

4 Pathways between conchae

Inferior - between inferior conchae and floor
Middle - between inferior and middle conchae
Superior - between middle and superior conchae
Sphenoethmoidal - Superoposterior to superior

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8
Q

What structures open up into middle meatus?

A

Frontal, Maxillary and Ethmoid Sinuses

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9
Q

What structures open up into inferior meatus?

A

Nasolacrimal duct

Eustacian tube

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10
Q

What are two gateways of the nasal cavity?

A

Cribriform plate - into Ethmoid bone

Sphenopalantine - Between nasal cavity and Pterygopalantine fossa

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11
Q

The vasculature of the nasal cavity has to be rich. Describe this

A

Internal Carotid - Anterior and Posterior Ethmoidal (branches of opthalmic through cribriform plate)

External Carotid - Sphenopalantine, Greater Palantine, Superior Labial, Lateral Nasal

Anastamose in Little’s Area

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12
Q

Describe the innervation of the nasal cavity

A

Special Sensory - Olfactory

General Sensory - Nasociliary (Opthalmic) and Nasopalantine (Maxillary)

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13
Q

How would a Cribriform plate fracture present?

A

CSF Rhinorrhoea

Anosmia

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14
Q

What are Paranasal Sinuses?

A

Air filled extensions of nasal cavity, lined with pseudostratified epithelium and interspersed with goblet cells

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15
Q

Name four roles of Paranasal SInuses

A

Reduce weight of head
Supports immune defence
Humidifies inspired air
Increases vocal resonance

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16
Q

Describe the anatomy of the Frontal Sinus

A

Triangular shaped within the frontal bone
Drainage into middle meatus
Sensation by Supraorbital (CNV1)

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17
Q

Describe the anatomy of the Ethmoidal Sinus

A

Made up of three

Anterior - into middle meatus
Middle - into middle meatus
Inferior - into superior meatus

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18
Q

Describe the anatomy of the Maxillary Sinus

A

Drains into middle meatus (just below frontal so fluid can enter maxillary)
Maxillary nerve also supplies teeth - referred toothache

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19
Q

Give three broad causes of Nasal Obstruction

A

Anatomical
Nasal lining
Autonomic

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20
Q

Name three anatomical causes of nasal obstruction

A

Septal Deflection
Adenoidal Hypertrophy
Chonal Atresia

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21
Q

Chonal Atresia is a part of CHARGE Syndrome. How would it present?

A

Unilateral - persistent nasal drainage, recurrent sinus infections
Bilateral - RDS or Cyanosis

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22
Q

Name two nasal lining causes of nasal obstruction

A

Rhinitis

Nasal Polyps

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23
Q

Name an autonomic cause of nasal obstruction

A

Vasomotor Rhinitis (increased parasympathetic flow causes engorgement)

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24
Q

Give two causes of watery nasal discharge

A

Allergic

CSF

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25
Q

Give two causes of mucopurulent nasal discharge

A

Bacterial Rhinitis

Foreign Body

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26
Q

Give two causes of bloody nasal discharge

A

Trauma

Neoplasia

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27
Q

How do allergies to dust mites present?

A

Sneezing upon waking (bed acts as resevoir)

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28
Q

What is Cacosmia?

A

Unpleasant smell detected mainly by others

Indicated nasal sepsis

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29
Q

Name two nasal causes of Halitosis

A

Chronic Sinusitis

Post Nasal Drip

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30
Q

Describe the pathophysiology of Allergic Rhinitis

A

IgE mediated inflammation of nasal mucosa due to mast cell degranulation

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31
Q

Describe the acute and late response of Allergic Rhinitis

A

Acute - Stimulation of afferent nerves (sneezing), Increase in nasal secretions 15-20 mins later

Late - 6 to 12h later nasal obstruction

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32
Q

Other than sneezing and nasal obstruction, name two features of Alllergic Rhinitis

A

Mouth Breathing

Halitosis

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33
Q

Allergic Rhinitis may require further investigation to determine allergen. What would these be?

A 
Skin Prick Test (note - surpressed by antihistamines, steroids and TCAs)
Blood IgE (useful if patient is on antihistamines
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34
Q

Name some general advice for house dust mite allergy

A

Special bedding
Soft toys off of bed
Wash bedding weekly
Laminate>carpet

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35
Q

Describe the possible medical managements for allergic rhinitis

A

1) Topical Antihistamines for symptom relief and oral for prevention
2) Nasal Corticosteroids
3) Consider using Corticosteroid and Antihistamine combination (Dimysta) or adding LTRA
4) Short course of oral steroids

Increasing immunological tolerance? Nasal Douching with Saline? Avoiding allergens

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36
Q

Describe a possible surgical management for allergic rhinitis

A

Reduce inferior turbinates to improve airways

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37
Q

Vasomotor Rhinitis presents similarly to allergic but without the positive test. Describe the pathophysiology

A

Imbalance in sympathetic and parasympathetic, increasing vascularity and secretions

Causes - Humidity, temperature, pregnancy, alcohol

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38
Q

How can Vasomotor Rhinitis be managed?

A

Nasal Antihistamines +/- Corticosteroids

Laser treatment or partial turbinectomy

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39
Q

What is Rhinitis Medicamentosa and how is it managed?

A

Reactive vasodilation of nasal mucosa due to prolonged use of topical agents

Substitution of offending drug to one containing a steroid (if established - partial turbinate resection)

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40
Q

What is Hormonal Rhinitis?

A

May be linked to increased oestrohen or hypothyroidism

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41
Q

What is Gustatory Rhinitis?

A

After eating hot and spicy foods, vagus nerve causes nasal vasodilation

Watery rhinorrhoea typically 2h after ingestion

Can be managed with Ipratropium Bromide Spray

42
Q

What are Nasal Polyps?

A

Sac like entities of eosinophil rich oedematous walls, arise from nasal mucosa, most commonly in the clefts of the middle meatus

Considered part of the spectrum of chronic rhinosinusitis

43
Q

Name three associations of Nasal Polyps

A

Asparin Sensitvity
Asthma
CF

44
Q

What is Asparin Sensitivity?

A

Within 20-120 minutes of ingestion - facial flushing, rhinorrhoea and congestion

45
Q

How do Nasal Polyps present?

A 
Nasal airway obstruction
Nasal discharge
Dull headaches
Snoring 
Hypo-osmia
46
Q

How can you distinguish nasal polyps from inferior turbinate?

A

Paler in colour (poor blood supply)

Ability to get between wall and the polyp

47
Q

How are nasal polyps investigated?

A

Rhinoscopy

CT if failing medical therapy/severe disease

48
Q

What Nasal Polyps should you refer to ENT?

A

Unilateral

Children (underlying CF)

49
Q

How are Nasal Polyps managed?

A

Educated on recurrent nature

Then step down to Topical Steroids (if Beclometasone - monitor childs growth

Antihistamines if allergy

If refractory can give a short course of oral steroids

50
Q

What is the gold standard definitive management for Nasal Polyps

A

Endoscopic Sinus Surgery

51
Q

Why is time an important factor in Nasal Injuries

A

After about four hours, swelling obscures diagnosis

52
Q

What are important things to look for OE in a nasal injury?

A 
Septal haematoma
Epistaxis/CSF Rhinorrhoea
Septal Deviation
Opthalmoplegia
Facial Anaesthesisa
53
Q

How are nasal injuries managed?

A

Mild - ice and analgesia, review in 5d

Deviation - seen by ENT within 7-10 days

Fracture reduction - 5-10d for adults and 3-7 for children (allows swelling to settle)

54
Q

How could Nasal Foreign Bodies present?

A

Directly after if observed
Nasal obstruction
Foul discharge

55
Q

What are the management options for Nasal FB

A 
Topical anaesthetic and vasoconstrictor in affected nostril 
?Blow positive presure through nose
?Strong Suction
?Thin forceps
? Fogarty balloon

Button batteries should be removed immediately

Refer to ENT after two unsuccessful attempts

56
Q

What is a Septal Perforation?

A

Defect through any part of the cartilagenous/bony septum with no overlying perichondrium/periosteum

57
Q

How does Septal Perforation present?

A

Nasal whistle
Discharge
Congestion
Epistaxis

58
Q

Give four causes of Septal Perforation

A

Nose picking
Trauma
Steroids
Cocaine

59
Q

Describe some early signs of Septal Perforation

A

Bothersome bleeding and crusting

60
Q

How is Septal Perforation managed?

A

Nasal Douching/Emollients
Adjust nasal cannulae if relevant
Surgery if affecting QoL

61
Q

How does a common nasal infection present?

A 
Hyperaemic nasal lining
Nasal Obstruction
Sneezing
Rhinorrhoea
Headache
62
Q

What would you advise patients regarding management of common infective rhinitis?

A

Steam inhalation
Nasal Congestants
Simple Analgesia

May get post nasal drip if glands don’t return to normal

63
Q

What is Nasal Vestibulitis?

A

Excoriation of skin of vestibule (from nose picking, rhinorrhoea, allergy)

64
Q

How would you manage Nasal Vestibulitis?

A

Topical Abx
Steroid based ointments
If persistent with ulceration - BCC/SCC

65
Q

What is Atrophic Rhinitis?

A

Severe crusting in the nasal cavities and atrophy of mucosa and turbinates (often secondary to poor hygiene and malnutrition

Associated with foul odour that patients can’t smell

66
Q

How is Atrophic Rhinitis managed?

A

Douching nose 3-4 times a day
Prolonged Abx based on cultures
Narrow nasal cavities using bone/cartilage

67
Q

What is Nasal Furunculosis?

A

S.Aureus causing hair follicle infection in nasal vestibule often initiated by nose picking)

68
Q

How is Nasal Furunculosis managed?

A

Systemic and Topical Abx (based on swabs)

Don’t squeeze pus - danger triangle

69
Q

How does a Septal Deflection present?

A

Unilateral obstruction typically
Facial Pain
Nasal discharge
Compensatory Hypertrophy of inferior turbinates on opposite side

70
Q

If Septal Deflections are symptomatic, how are they treated?

A

Submucous resection

Septoplasty (repositions septum after removal)

71
Q

Why are Septal Haematomas most common in children?

A

Mucoperichondrium is only loosely adherent to underlying cartilage

72
Q

How does Nasal Haematoma present?

A

Severe nasal obstruction

If not adequately drained - avascular necrosis

73
Q

How are Nasal Haematomas managed?

A

Drained (by aspiration or by formal incision and evacuation)
Nasal packing to prevent recurrence
Abx

74
Q

What is Choanal Atresia?

A

Presence of bony septum between nose and pharynx

Commonly on the right side

75
Q

How is Choanal Atresia investigated?

A

No fogging under nostril

CT

76
Q

How is Choanal Atresia managed?

A

Surgery (Pt may require periodic dilations)

Bilateral - emergency oral airway

77
Q

Name four causes of Epistaxis

A

Trauma
Inflammatory Conditions
Post Op
Vascular Malformations

78
Q

95% of Epistaxis comes from the Anterior Plexus. What is the posterior plexus?

A

Woodruff’s Plexus

79
Q

What is the initial management for Epistaxis?

A
  • A to E assessment
  • Lean forward and pinch nose for 10-20 minutes (ice pack on back of neck)
  • Spit out any blood (it is an emetic)
80
Q

How should refractory Epistaxis be managed?

A

IV Access (clotting, fbc, g+s)

  • ?Anticoag reversal
  • Cautery (with NO, Naseptin afterwards)
  • Nasal Packing and Admission (local anaesthetic, vasoconstrictor, rapid rhino)
81
Q

How are posterior Epistaxis managed?

A

Double balloon catheter

82
Q

What post Epistaxis advice would you give the patient?

A

Naseptin cream (not if peanut allergic)

Avoid: Hot drinks, blowing nose, heavy lifting and lying flat for 24-48h

83
Q

When should you refer an Epistaxis?

A

Under 2y - NAI

Recurrent - ?Leukaemia?Nasopharyngeal Ca?HHT

84
Q

What is Sinusitis?

A

Inflammation of the membranous lining of the sinuses (may also implicate rhinitis)

Acute - 7-30d
Subacute - 4 to 12 weeks
Chronic - >90d
Recurring - >3 episodes in a year, each lasting atleast 10 days

85
Q

What indicates Bacterial Sinusitis?

A

Worsening symptoms beyond 5d, or persisting beyond 10d

86
Q

Give five risk factors for Sinusitis

A 
URTI
Allergy
Polyps
CF (Kartageners, Youngs)
Smoking
87
Q

What is Samter’s Triad?

A

Aspirin Sensitivity
Rhinitis
Asthma

88
Q

How would you palpate for the sinuses?

A

Frontal - upwards beneath medial supraorbital ridge
Axillary - against anterior wall below infraorbital margin
Ethmoidal - medial orbit

89
Q

How could you percuss the Sinuses for Sinusitis?

A

Technically difficult as the area is very small

Dullness indicates infection

90
Q

How can you transilluminate for SInusitis?

A

Frontal - place under supraorbital ridge and look for reddish glow
Maxillary - patients mouth open but lips sealed around torch

91
Q

Describe the pathophysiology of Acute Sinusitis

A

Normally viral causing blockage and then a secondary bacterial infection
Strep Pneumoniae, Haemophilus Influenza, Moraxella Catarrhalis
Normally involves maxillary sinus

92
Q

How does Acute Sinusitis present?

A

Non resolving cold
Biphasic
Pain/Pressure over affected sinuses - worse on leaning forward
Unresponsive to nasal decongestants

93
Q

Sinusitis is a clinical diagnosis. How should it be aimed to be managed?

A

Reassure it will take a little longer to settle
Simple analgesia and intranasal decongestants
Warm face packs
Irrigation with warm saline

94
Q

When should you treat sinusitis with Abx?

A

<10d if severely at risk

>10d - Deferred 5d Pen V (or co amoxiclav if systemic) only after a trial of 2 weeks nasal steroid

95
Q

Who should you refer with sinusitis?

A

Severe
High risk
Suspicious unilateral symptoms

96
Q

Name two complications of sinusitis

A

Meningitis

Orbital Cellulitis

97
Q

Chronic Sinusitis can be infective/inflammatory/structural in aetiology. How does it present differently

A

Not as florid as acute
Dull ache
May have middle ear fluid
Loss of smell is more common

98
Q

Apart from acute exacerbations, how is Chronic Sinusitis managed?

A

Dental Hygiene
Smoking Cessations
8-12 weeks nasal steroids
Antihistamines if allergic aetiology

If refractory still consider function endoscopic sinus surgery

99
Q

What is Fungal Sinusitis?

A

Associated with immunocompromised or diabetics
Associated with high humidity
Can involve orbit

100
Q

How is Fungal Sinusitis investigated?

A

Serum IgE
CT
Microbiology

101
Q

How is Fungal Sinusitis managed?

A

Surgical debridement
Steroids
Antifungal

102
Q

What is Barosinusitis?

A

Pressure changes disrupt gas and mucous exchange leading to accumulation

Pain on returning to sea level, congestion and occasional epistaxis

Managed the same as acute sinusitis

Neuro & Special Senses (12 decks)

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