Nose and paranasal sinuses Flashcards
(38 cards)
what important anatomical consideration must be made in management of epistaxis?
that little’s area/kiesselbach’s plexus on the nasal septum receives contribution from branches of BOTH ICA and ECAs, so haemorrhage may be from 1 or a combination of these arteries.
causes of epistaxis?
idiopathic (85%) traumatic, ?nose picking iatrogenic FB inflammatory-rhinitis, polyps neoplastic-malignancies e.g. NP carcinoma, or benign e.g. juvenile angiofibroma.
systemic: HTN-bleed for longer?
coagulopathies e.g. drugs-warfarin, aspirin, haemophilia, von Willebrand disease, liver disease
vasculopathies e.g. wegener’s granulomatosis
hereditary haemorrhagic telangiectasia/Osler-Weber-Rendu disease-AD inherited disorder in which deficient tunica media allows aneurysms to form producing a petechial (non-blanching) rash-lips, tongue, fingertip pads and mucous membranes lining gut and nose, also AV malformations-telangiectases, and worry in pulmonary or cerebral due to STROKE risk. recurrent epistaxis and bleeding from gut can cause Fe deficiency anaemia.
management of epistaxis?
ABCDE approach-are they haemodynamically stable? need initial 1st aid, b.loss assessment, cause evaluation and procedures to stop bleeding.
1st aid-pinch soft part of nose for at least 15 MINS, head forward, spit out any bld in mouth-keep open
?blood loss-measure BP, pulse, pallor, sweating-IV line for fluids/blood, take FBC, clotting profile and X match.
exam-where is bleeding source?-Anterior or Posterior? bleeding from above middle turbinate?-ICA
conservative: cautery-silver nitrate or bipolar diathermy-anterior rhinoscopy if anter. bleed, rigid endoscope if post. bleed, topical adrenaline can help control bleeding before cautery.
nasal packing (merocel-nasal tampon) if cautery fails to control bleed-anterior pack, and posterior if bleeding continues into oropharynx-also consider packing other nostril to increase pressure on bleeding vessel?
inflatable balloon tamponade may be used as alternative method of packing
formal gauze postnasal pack may need GA for insertion, need Abx cover, some packs e.g. ribbon gauze, impregnated with BIPP-can cause iodine toxicity and delirium to develop in elderly patients.
surgical/radiological: following failed packing, can ligate vessels surgically or embolise radiologically:
sphenopalatine
anterior ethmoid-CANNOT EMBOLISE as from ICA
ECA-last resort!
embolise-gelfoam blockage
complications of nasal bone fractures?
septal haematoma
CSF leak with assoc. skull base fracture (rare)
nasal trauma management?
ABC-epistaxis normally self-limiting
examine for septal haematoma
no X-ray needed
if nose deviated consider MUA-local or general, within 2 wks of injury
what do we worry about when performing surgery involving the paranasal sinuses?
orbit damage-orbit is lateral to ethmoid sinus and superior to maxillary sinus, in severe cases sight loss may result from sinus surgery
anterior skull base damage-lies just above sphenoid and ethmoid sinuses, breach can cause CSF leak and in worst cases brain damage.
complications of rhinosinusitis?
periorbital sinusitis (?orbital cellulitis)-can be sight threatening intracranial infection-part. if infective rhinosinusitis involves frontal sinus can spread intracranially, causing meningitis and intracranial abscess.
define rhinosinusitis
inflammation of nose and paranasal sinuses characterised by 2 or more symptoms, 1 of which should be:
either nasal blockage/obstruction/congestion/discharge
anterior/posterior nasal drip:
with or without facial pain/pressure
with or without reduction or loss of smell
and either:
endoscopic signs of polyps, mucopurulent discharge, or middle meatus oedema
and/or:
CT changes-mucosal changes within osteomeatal complex, or sinuses.
viral acute rhinosinusitis/common cold, is defined as?
lasting for less than 3 months, with complete resolution of symptoms-normally resolves within 5 days
causes of viral rhinosinusitis?
rhinovirus
influenza virus
acute rhinosinusitis management?
analgesia if required
nasal decongestants e.g. phenylephrine
if persists longer than 5 days (suggesting bacterial cause) consider topical nasal steorids and oral Abx
how is chronic rhinosinusitis defined?
lasting for 3 mnths without complete symptom resolution
divided into that with and without nasal polyps
why are cystic fibrosis patients prone to developing chronic rhinosinusitis?
due to ciliary impairment-cilia unable to clear mucus
due to this also develop inflammatory nasal polyps-seen in about 40% of CF patients
what must be done in all patients with unilateral polyps?
BIOPSY for histological diagnois
how is the ethmoid sinus separated from the orbit?
by the lamina papyracea
*risk of orbital? cellulitis with extension of ethmoid sinus infection, can be sight threatening, surgical emergency if colour vision affected.
features of orbital cellulitis? what does it commonly result from?
eye pain, followed by eyelid oedema and orbital collection-causing eye proptosis, and opthalmoplegia with reduced eye m.ments.
colour blindness early sign of optic nerve damage-risk of blindness due to nerve tension and septic necrosis
usually infection extension into orbit of ethmoid sinusitis, soft tissues behind orbital septum infected vs. anterior to septum in commoner pre-septal cellulitis. can be infection spread from elsewhere e.g. dental infection via intermediary maxillary sinusitis, distant bacteraemia, direct inoculation from trauma-developing within 72hrs of injury, and occasionally pre-septal cellulitis spread-more common in children-orbital septum not fully developed.
gold standard for orbital abscess diagnosis e.g. following spread of ethmoid sinus infection?
CT scan of sinuses and orbit
management of orbital cellulitis and orbital abscess?
admission to hospital
IV antibiotics e.g. cefotaxime and flucloxacillin
nasal decongestents
urgent surgical drainage of any abscess
why is a CT of the sinuses NOT good for diagnosing nasal polyps, although required if planned surgery or atypical features to hx or examination?
large numbers of asymptomatic patients have sinus changes on CT scanning.
what are nasal polyps?
oedematous mucosal masses, inflammatory if assoc. with chronic rhinosinusitis
most frequently arise from ethmoid cells and prolapse into the nose via the middle meatus (anterior ethmoid sinus, plus frontal and maxillary sinuses drain into middle meatus)
usually bilateral and painless
suspect neoplasia if unilateral and haemorrhage
predisposing factors to chronic rhinosinusitis with or without nasal polyps?
allergy e.g. allergic rhinitis, eczema, asthma
infections-s.aureus, strep pneumonia and fungal infections
immunocompromised host
aspirin hypersensitivity
ciliary impairment e.g. in cystic fibrosis
anatomical abnormalities e.g. septal deviation and abnormal uncinate process leading to narrow infundibulum and osteomeatal complex occlusion
trauma-nasal sinus fracture, surgical-oroantral fistula
atmospheric irritants e.g. smoking, dusts, fumes
FB in nose or sinuses
swimming and diving
hormonal-pregnancy-nasal congestion high due to oestrogen and progesterone effect on nasal mucosal vascularity, and hypothyroidism
symptoms of nasal polyps?
progressive nasal obstruction rhinorrhoea maybe hx of recurrent sinusitis due to ostial blockage hyposmia and anosmia ontological symptoms may occur
management of nasal polyps and chronic rhinosinusitis?
avoid possible allergens topical nasal corticosteroids=mainstay of medical management to improve symptoms and reduce recurrence post surgery-nasal drops. limited risk of systemic absorption with fluticasone and mometasone, both growth monitoring advised in children e.g. CF patients with nasal polyps. antihistamines for allergic rhinitis nasal douche (saline rinsing of nasal passages) oral steroids (1 wk course) in severe cases e.g. in medical polypectomy regimen to treat large polyps, with topical steroids, also may use post surgery oral Abx e.g. doxycycline
surgery-functional endoscopic sinus surgery to improve ventilation/drainage of sinuses
nasal polypectomy
may consider other procedures to improve nasal airways e.g. septoplasty and reduction of inferior turbinates.
what must be excluded in the presentation of a child with a foul-smelling unilateral nasal discharge?
nasal foreign body
