Nose Flashcards
(26 cards)
Functions of the nose?
o Filtration + protection (hairs, mucous blanket with enzymes, lysosomes, nasal cilia – cilia impaired in cystic fibrosis and temporarily by smoking∴ more mucus when stop smoking).
o Humidification + warming/cooling (vascularity of lining, turbinates, secretory glands & nasal cycle; every 1-2 hours each side)
o Olfaction
What are different parts of the nose?
External Nose = nasal bones, upper + lower lateral cartilages, tip, skin (with sebaceous gland).
Nasal Septum
Mucous membrane = ciliated columnar epithelium (i.e. respiratory epithelium) + filled with IgA antigens.
o Mucoperichonrium supplies blood to the cartilage
o Septum rarely straight; deviated 90% of people – may be corrected for cosmetic reasons or blockage of nose
o Quadrilateral cartilage is important in changing shape of nose (rhinoplasty). Note: cartilage has poor blood supply; layer investing the cartilage is only blood source - if have septal haematoma cartilage will die > septal perforation (septal haematoma is common cause of perforation after trauma).
Sinuses - where do they open / drain?
- Maxillary (paired): drains into middle meatus (under middle turbinate)
o Orbit, cheek, teeth - Frontal (paired): drains into middle meatus
o Orbit & anterior cranial fossa - Anterior + middle ethmoids (not paired): drains middle meatus
- Posterior ethmoid: drains into superior meatus
o Ethmoids = lamina papyracea, orbit & ACF - Sphenoid (paired): drains ?
o ICA, optic nerve (CN II), cavernous sinus, CN III, IV V and VI, pituitary gland
Note: lacrimal duct drains into inferior meatus
What is the function of the sinuses?
o Reduce skull weight
o Vocal resonance (sinus infection affects voice)
o Crumple zone: protection of other structures (skull/brain) e.g. sphenoid sinus protects cavernous sinus
Lamina papyracea (paper thin bone) separates the ethmoid sinuses from the orbit; therefore infection easily spreads to eye.
Describe the turbinates and their function
Superior, middle + inferior: pseudostratified columnar ciliated respiratory epithelium
Act as lateral border of nasal cavity (septum is medial border)
Erectile glandular tissue layer
Increase resistance to airflow + regulate temperature + humidity of air before it reaches the lower respiratory tract
Don’t confuse with nasal polyps when examining nose
Blood supply to nasal septum?
o External + internal carotids
o Anterior + posterior ethmoid arteries (branches of internal carotid)
o Sphenopalatine artery (branch of maxillary i.e. external carotid)
o Greater palatine artery (branch of maxillary i.e. external carotid)
o Superior labial artery (branch of facial i.e. external carotid)
Little’s area (Kiesselbach’s plexus)
o Bleeding from nose may be anterior or posterior, however, 90% comes from anterior Kiesselbach’s plexus (where all of the above arteries anastomose & are most fragile – on the lateral surface of the septum)
o Anterior septum in reach of fingers: dries easily + can be cauterised
Venous drainage = facial + ophthalmic veins
Nerve supply to nose?
o Sensory: trigeminal nerve (maxillary)
o Secretomotor: vidian nerve
o Vascular Supply: constriction (sympathetic), dilation (parasympathetic)
o Smell: olfactory nerve (trigeminal for noxious substances e.g. gasoline)
Examination of nose?
Examine nasal cavity (nostrils and nasal septum – thudicums speculum): look for polpys, size of turbinates, bleeding, pus, septal deviation may be seen if inferior).
Metal tongue depressor used to examine nasal airflow (misting test)
Sniff test
Thumb test
Cottle’s manoeuvre: if pull up and out on face and breathing improved, suggests breathing difficulty coming from nose.
Nasendoscopy: Nasal cavity AND POST NASAL SPACE (contains adenoids – if enlarged > breathing difficulties & obstructive sleep apnoea in children - may remove, also contains the Eustachian tube).
Then examine ears, throat + neck (to finish exam: I would do a full ENT examination)
Investigations for nose?
Allergy testing = Skin-prick testing (house dust mite, animals, pollen, control & histamine) and radioallergosorbent test (RAST).
CT scans: Good anatomical detail, good correlation with disease, visualisation of other structures, reformat into coronal, axial, sagittal.
Test sense of smell, mucociliary clearance, rhinomanometry + nasal provocation tests.
MRI for tumours.
- Plain Sinus X-rays: now rarely done (poor correlation with disease, poor anatomical detail)
What is nasal obstruction?
Constant as opposed to congestion
Variable – allergic or intrinsic rhinitis
Exaggeration of nasal cycle
- Foreign Body
- Physical Obstruction - Septal Deviation
- Acute Rhinitis
- Allergic Rhinitis
- Allergic Rhinitis
- Fungal Rhinitis
- Rhinitis Medicamentosa
- Nasal Polyposis
- Inflammatory Nasal Conditions
- Tumour
What is septal deviation?
- Affected by anteror septal deviation and anterior turbinate hypertrophy
- Often no history of trauma
- Overgrowth of quadrilateral cartilage
What is allergic rhinitis?
Symptomatic disorder of the nose induced after allergen exposure by IgE mediated inflammation of the nasal membranes. Affects 1 in 6, and 1 in 4 adolescents
Risk factors: previous surgery, family history, medical history, asthma / hayfever / eczema
• Symptoms:
o Nasal obstruction
o Rhinorrhoea
o Sneezing
2 or 3 symptoms for more than 1 hour a day for 2 weeks)
What is non-allergic / intrinsic rhinitis?
Ix and Tx?
- Middle aged males > females
- Post nasal drip predominates
- Reactive nasal symptoms – fumes, smoke, temperature, alcohol
- Skin tests negative
- Consider local nasal allergy and nasal polyps
- Treat with steroids, inhaled antihistamine
Ix and Tx of rhinorrhoea?
Investigations:
• Skin prick tests
• RAST/specific IgE
• Mucociliary clearance tests
Tx:
- Allergen avoidance measures - aero-allergens: cats, dogs, HDM, tree, pollens, mould spores
- Occupational: biological, chemical
3. Drugs: o Topical corticosteroids o Systemic cortiocosteroids o Sodium cromoglycate o Antihistamines o Decongestants o Ipatropium bromide – beware of prostate risks of antimuscarinics o Leukotriene receptor antagonists
- Immunotherapy
- Surgery
o Turbinate reduction
o Nasal septal surgery
o FESS
What is nasal polyposis?
Tx?
Swelling of the lining of the nose due to chronic inflammation (e.g. asthma, CF). Contains inflammatory fluid
Can be fungal IgE or non IgE mediated
Causes almost total nasal obstruction, rhinorrhoea, anosmia
If symptoms are unilateral, consider malignancy
Treatment:
o Medical: Steroids, leukotriene receptor antagonists
o Surgery: simple nasal polypectomy, FESS
What is sinusitis?
Inflammatory response involving the mucus membrane of the nose and paranasal sinuses, fluid within cavities and underlying bone
Aetiology is multifactorial – involves the host (genetic, immunity, allergic, systemic) and the environment (infection, trauma, iatrogenic)
Often preceded by viral illness
Classification o Acute < 4 weeks o Subacute - 4-12 weeks o Recurrent acute - 4 or more episodes per year (each episode lasts 7-10 days) o Chronic (>12 weeks)
Management of sinusitis?
Complications of sinusitis?
Identify predisposing factors
- RAST (radioallergosorbent test) and IgE
- SPT
Medical therapy
- Oral/topical nasal steroids
- Antibiotics – oral, IV, nebulised, topical
- Douches – alkaline, saline
- Oral/topical antihistamines
- Leukotriene antagonists
Endoscopic sinus surgery
- complications:
Complications o Orbital cellulitis o Frontal mucocele o Abscess o Septic thrombosis o Osteomyelitis o Meningitis
What is epistaxis?
Occurs in extremes of age
90% from ‘Little’s area’
Commonest admission to ENT ward
Local factors:
o Idiopathic (85%)
o Traumatic – fractures, nose picking
o Inflammatory – vestibulitis, allergy
o Neoplastic – sino-nasal, nasopharyngeal
o Occupational – chromium fumes
o Iatrogenic – previous surgery, steroid sprays
o Endocrine – menstruation, pregnancy
o Systemic – anticoagulants, blood diseases, hereditary haemorrhagic telangiectasia
Management of epistaxis?
- ABC
- Blood tests
- Nasal examination
‘Epistaxis ladder’
- Simple measures e.g. ice, sedation
- Cauterised using silver nitrate (chemical burn) or electric
- Anterior nasal packing
- Posterior nasal packing
- Surgical management (endoscopic SPA ligation) – gold standard
- Radiological embolisation of vessels
Rhinoplasty?
Rhinoplasty • Cosmetic and functional reasons • Understanding nasal anatomy • Facial proportions o Nasofrontal angle = 115-130 degrees o Nasolabial angle = 90-120 degrees
NHS - must be functional reasons / breathing
Rhinoplasty?
Cosmetic and functional reasons
NHS - must be functional reasons / breathing
Understanding nasal anatomy - facial proportions
Nasofrontal angle = 115-130 degrees
Nasolabial angle = 90-120 degrees
Passmed - nasal polyposis?
Around in 1% of adults in the UK have nasal polyps. 2-4x more common in men, not commonly seen in children or the elderly.
Associations: asthma* (particularly late-onset asthma) aspirin sensitivity* infective sinusitis CF Kartagener's syndrome Churg-Strauss syndrome
Features: nasal obstruction, rhinorrhoea, sneezing, poor sense of taste and smell
Unusual features which always require further investigation include unilateral symptoms or bleeding.
Tx: all patients with suspected nasal polyps should be referred to ENT for a full examination, topical corticosteroids shrink polyp size in around 80% of patients
*asthma, aspirin sensitivity + nasal polyps = Samter’s triad
How is epistaxis classified
Causes?
Split into anterior and posterior bleeds
Anterior often has a visible source of bleeding and usually occurs due to an insult to the network of capillaries that form Kiesselbach’s Plexus (little’s area)
Posterior haemorrhages tend to be more profuse and originate from deeper structures. They occur more frequently in older patients and confer a higher risk of aspiration and airway compromise.
Most cases tend to be benign and self-limiting, they may be an indicator of serious pathology. Most common cause is trauma to the nose- can range from the insertion of foreign bodies, nose picking and nose blowing.
Bleeding can also indicate platelet function disorders such as thrombocytopaenia, splenomegaly, leukaemia, Waldenstrom’s macroglobulinaemia and ITP- as these tend to be congenital, they often present earlier in life.
In adolescent males, juvenile angiofibroma is a benign tumour may bleed as it is highly vascularised. If the nasal septum looks abraded or atrophied, inquire about drug use. This is because inhaled cocaine is a powerful vasoconstrictor and repeated use may result in obliteration of the septum.
In the elderly, hereditary haemorrhagic telangiectasia may cause prolonged nasal bleeding.
Granulomatosis with polyangiitis (Wegener’s) and pyogenic granuloma may also present with nosebleeds.
management of epistaxis?
If haemodynamically stable, bleeding can be controlled with first aid measures: 1. sit with torso forward and mouth open- avoid lying down unless feel faint - decreases flow to nasopharynx and allows pt to spit out any blood in mouth, also reduces the risk of aspirating. 2. pinch the cartilaginous (soft) area firmly + consistently for at least 15 minutes and breathe through mouth.
If first aid measures successful, consider topical ANTISEPTIC e.g. Naseptin (chlorhexidine + neomycin) to reduce crusting and the risk of vestibulitis. Cautions to include peanut, soy or neomycin allergies - Mupirocin is a viable alternative. Admission and follow up care may be considered in patients if comorbidity (e.g. coronary artery disease, or severe HTN), an underlying cause is suspected or if <2 years (as underlying causes such as haemophilia or leukaemia are more likely in this age group).
If bleeding does not stop after 10-15 minutes of continuous pressure: consider cautery or packing.
Cautery should be used if the source of the bleed is visible and cautery is tolerated- it is not so well tolerated in younger children! Packing may be used if cautery is not viable or the bleeding point cannot be visualised. If the nose is packed in primary care, the patient should be admitted to hospital for review.
Haemodynamically unstable or compromised: admit to ED- control bleeding with first aid measures in the interim. Pts with a bleed from an unknown or posterior source (i.e. the bleeding site cannot be located on speculum, bleeding from both nostrils or profuse) should be admitted to hospital.
Self-care advice: avoid blowing or picking nose, heavy lifting, exercise, lying flat, drinking alcohol or hot drinks. Same applies for patients who have just been cauterised, as any strain on the nostril may induce a re-bleed.
