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Neurology and Special Senses > Nose and Sinuses > Flashcards

Nose and Sinuses Flashcards

1
Q

What makes up the nose?

A 
Quadrangular Cartilage
Perpendicular plate of the Ethmoid (septum)
Vomer (Septum)
Nasal bones
Maxilla
Palatine bones
Cartilage - minor and major alar, lateral
Fibro-fatty tissue
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2
Q

What vessels supply the nose with blood?

A

Anterior and Posterior Ethmoidal (from opthalmic artery)
Sphenopalatine
Superior Labial
Branch of Greater Palatine

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3
Q

What is Littles/Kiesselbach’s area?

A

Vascular area in anterior 1/3 of septum

Receives supply from all nasal arteries

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4
Q

How can the causes of epistaxis be split up?

A

Local

Systemic

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5
Q

What are the local causes of epistaxis?

A 
Idiopathic (85%)
Trauma
Iatrogenic
Foreign Body
Inflammatory - Polyps, Rhinitis
Neoplastic
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6
Q

What are some systemic causes of epistaxis?

A

Hypertension
Coagulopathies
Vasculopathies
Hereditary Haemorrhagic Telangiectasia/Osler-Weber-Rendu

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7
Q

How is epistaxis managed?

A

First Aid - head forward, pinch nose, ice on forehead/back of neck

Examine - anterior or posterior bleed
Conservative options
Surgical options

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8
Q

What are the conservative management options for epistaxis?

A

Cautery - Silver nitrate/bipolar diathermy
Tranexamic acid
Anterior bleed - anterior rhinoscopy
Posterior bleed - rigid endoscope

Packing - if cautery fails
Initially anterior pack but if continue then posterior pack too

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9
Q

What surgical/radiological options are there for managing epistaxis?

A

Surgical ligation or radiological embolisation of:

Sphenopalatine
Anterior ethmoidal artery (ligated only)
Internal maxillary artery

Last line - external carotid

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10
Q

How can nasal trauma be complicated?

A

Septal haematoma

CSF leak

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11
Q

What is CSF Rhinorrhoea associated with?

A

Basilar skull fracture

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12
Q

How can nasal trauma be managed?

A

ABC - epistaxis normally self limit
Examine septal haematoma
No X-Ray needed
If nose deviated - MUA within 2 weeks, can do septoplasty

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13
Q

What are the 4 paranasal sinuses?

A

Ethmoidal
Sphenoidal
Maxillary
Frontal

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14
Q

What important structures are around the paranasal sinuses?

A

Lamina papyracea - medial wall of the orbit
Anterior cranial fossa
Internal carotid artery

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15
Q

What does the sphenoid sinus drain into?

A

Spheno-ethmoid recess

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16
Q

What do the posterior ethmoid cells drain into?

A

Superior Meatus

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17
Q

What drains into the middle meatus?

A

Anterior ethmoid cells
Maxillary sinus
Frontal Sinus

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18
Q

What drains into the inferior meatus?

A

Nasolacrimal duct

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19
Q

What complications can arise from sinus sugery?

A

Damage to the orbit - Lateral to ethmoid and superior to maxillary sinus

Anterior skull base can be breached –> CSF leak/brain damage

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20
Q

Where can infective sinusitus spread?

A

Orbit –> periorbital sinusitis

Intracranially - esp. if frontal sinus. Lead to meningitis or intracranial abscess

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21
Q

What is Rhinosinusitis?

A

Inflammation of the nose and paranasal sinus characterised by:
2+ symptoms AND
Endoscopic signs or CT changes

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22
Q

What symptoms are characteristic of Rhinosinusitis?

A

Nasal blockage/discharge
Nasal drip - anterior or posterior
Facial pain/pressure
Reduced/loss of smell

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23
Q

What Endoscopic signs and CT changes can be seen in Rhinosinusitis?

A

Endoscopic - Polyps, mucopurulent discharge, oedema in middle meatus

CT - Meatus changes in osteomeatal complex or sinuses

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24
Q

How can rhinosinusitis be characterised?

A

Acute or Chronic

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25
What is Acute Rhinosinusitis (ARS)?
<12 week complete resolution of symptoms viral or non viral
26
What is Chronic Rhinosinusitis (CRS)?
12 without complete symptom resolution With or without polyps
27
What commonly causes Viral Acute Rhinosinusitis (common cold)?
Rhinovirus or Influenza virus Normally resolve within 5 days
28
What causes Non Viral Acute rhinosinusitis?
Strep Pneumoniae, H Influenzae, Moraxella Catarrhalis Last longer than 5 days
29
How is viral acute rhinosinusitis managed?
Analgesia if req. Nasal decongestants - no more than 5 days Warm compress
30
What predisposes people to chronic rhinosinusitis?
``` Allergy Infection - S aureus, strep pneumoniae, fungal Ciliary impairment - CF Anatomical abnormality - septal deviation, abnormal uncinate process etc. Immunocompromised Aspirin hypersensitivity Atmospheric irritants Hormonal issues Trauma Swimming, Foreign body ```
31
What is a nasal polyp?
Abnormal mass found in the nose
32
What are polyps associated with chronic rhinosinusitis due to?
Inflammation
33
When do nasal polyps require biopsy?
Worrying signs if bilateral Any unilateral polyp
34
How does chronic rhinosinusitis present?
Facial pain - worse on bending forward Nasal discharge - thick and purulent Nasal obstruction - mouth breathing Post nasal drip - chronic cough
35
How is chronic rhinosinusitis diagnosed?
Skin prick test - allergy suspected | Radiology - CT (not diagnostic as asymptomatic patients can have changes). Plain X-ray has no use
36
How is chronic rhinosinusitis managed?
Symptomatic management Conservative - avoid allergens, nasal douching Medical - Antihistamines, topical steroids (beclametasone, budesonide), oral steroids (1 week if severe), oral antibiotics Surgical - Nasal polypectomy (high recurrence), functional endoscopic sinus surgery (improve ventilation/draining of sinuses), septoplasty and turbinate reduction (improve airway)
37
What is allergic rhinitis?
IgE mediated hypersensitivity reaction in the mucous membranes of the nasal airways
38
How can allergic rhinitis be cyclical?
Seasonal - summer hayfever | Perennial - seasonal exacerbations
39
What are some common allergens associated with allergic rhinitis?
Pollen Mould House dust mites Animal epithelia
40
Describe the pathophysiology of allergic rhinitis
IgE mediated inflammation of nasal mucosa. Allergen detection stimulate: Release of prostaglandin D and leukotrienes Mast cell degranulation - release of histamine
41
How does allergic rhinitis present?
Bilateral symptoms worse on waking - congestion - itchy nose - sneezing - clear/yellow discharge - Posterior nasal drip - Watery red eyes nasal mucose swollen and grey on examination
42
How is allergic rhinitis scored?
``` ARIA score (allergic rhinitis and its impact on asthma) Duration of symptoms - intermittent and persistent Severity of symptoms - mild, moderate to severe ```
43
What would be classified as mild allergic rhinitis?
Normal daily activities and sleep | No troublesome symptoms
44
How would you investigate allergic rhinitis?
Diagnosis from history Skin prick test and IgE testing via ELISA - specific allergens RAST blood test - if skin prick test not possible
45
How is allergic rhinitis managed?
Conservative - allergen avoidance, nasal douching PRN - topical nasal antihistamines (if >5yo) Reg. preventative - cetirizine (non drowsy anti histamine) Nasal blockage - topical nasal steroids (careful!) Topical nasal decongestants for 1 week max Desensitise - gradual exposure to increasing amounts of allergen
46
Where can epistaxis occur?
Anterior - 95% commonly from kiesselbach's plexus Posterior - normally in elderly, profuse bleeding and airway risk
47
What is important to know about nasal packing?
Leave in for 2/3 days Need to give amoxicillin as well - bad for culturing bacteria Complications include: - anosmia - clot aspiration - posterior migration of pack leading to airway obstruction - perforation of septum
48
What are some causes for nasal trauma?
Car accident Sports injuries Falls - elderly Child abuse
49
How would you assess nasal trauma?
Look for other facial injuries and possible head trauma - Rhinorrhoea - Epistaxis - Septal Haematoma - Septal deviation - Ophthalmoplegia - Facial anaesthesia
50
How would you investigate nasal trauma?
No need for imagine - fractures are a clinical diagnosis Just start management
51
How is nasal trauma managed?
If no significant swelling/deformity - simple analgesics Deviation --> refer to ENT within a week - allow time for swelling to go down Laceration - Abx Septal haematoma - incision needed
52
When/where should you refer nasal trauma?
ENT - marked deviation, epistaxis not stopping or septal haematoma Neuro - rhinorrhoea Max fax if facial fractures/anaesthesia
53
What would widened inter-cantal distance suggest?
Nasoethmoidal fracture which needs surgical repair?
54
How does septal perforation present?
``` Nasal whistling sound Discharge Congestion Infection Epistaxis ```
55
What can cause nasal perforation?
``` Nose picking Untreated septal haematoma Iatrogenic - intubation Malignancy Ulcers Cocaine sniffing Intranasal steroid sprays ```
56
How are septal perforations managed?
Symptomatic: - nasal douching - reduce crusting and bleeding - nasal emollients Surgical options if quality of life severely affected
57
How do nasal foreign bodies present?
Witnessed event - at time Later - hx of nasal obstruction or persistent unilateral offensive discharge
58
When should nasal foreign bodies be referred to ENT?
History of prolonged unilateral discharge FB in posterior position Child uncooperative BUTTON BATTERIES REQ. IMMEDIATE ATTENTION
59
How would you get out a nasal foreign body?
Topical anaesthetic and vasoconstrictor spray - reduce swelling - Positive pressure blown through nose - parents blow into mouth while unaffected nostril obstructed - Nasal speculum and hook/forceps - Suction - Pass narrow balloon catheter past FB, inflate and retract
60
What are some differentials for nasal obstruction with discharge?
``` Rhinitis - infective, allergic, non-allergic, rhinosinusitis Rebound congestion FB Septal deviation, perforation, haematoma Occlusion of nasal valve Hypertrophy of turbinate/adenoids Polyps Neoplasm CSF rhinorrhoea ```
61
When does nasal obstruction with discharge require urgent investigation?
Unilateral | Blood tinged
62
What is rhinitis?
Mucosal swelling Increased volume and viscosity of secretions Impaired ciliary function
63
What is req. to diagnose rhinitis?
>=2 of: - Discharge - Sneezing - Nasal itching - Congestion
64
What are the 3 categories of allergic rhinitis?
Seasonal - hayfever Persistent - dust mites/pets Occupational - flour, wood dust
65
How can allergic rhinitis be classified?
Intermittent - symptoms <4 dyas per week + <4 weeks Persistent >4 days pw and >4 weeks
66
What is the acute phase response in allergic rhinitis?
Sneezing followed by secretions
67
What is the late phase response in allergic rhinitis?
6-12 hours after you get nasal congestion
68
What risk factors are associated with allergic rhinitis?
Atopy Smoker - active or passive Air pollution Family Hx of atopy
69
When does each type of pollen tend to affect people the most?
Tree - Spring Grass - late spring - early summer Weed - early spring - early autumn
70
What are some causes of non allergic rhinitis?
``` Vasomotor Hormonal NARES - non-allergic rhinitis with eosinophilia syndrome Occupational Gustatory Drug induced ```
71
What happens in vasomotor rhinitis?
Vascular engorgement and watery rhinorrhoea Associated with weather changes and stress Nasal mucosa bright red/purple
72
How is vasomotor rhinitis managed?
Humidified air 1 Topical antihistamines 2 Topical steroids
73
When is hormonal rhinitis seen?
Increased oestrogen: - Pregnancy - Menstruation - Puberty Hypothyroidism
74
What is NARES and how is it managed?
Eosinophilic reaction without evidence of allergy Steroid nasal spray
75
What can cause occupational rhinitis and how is it managed?
Metal salts Animal dander Wood dust Avoid trigger Topical antihistamines/steroids
76
What causes gustatory rhinitis? How is it managed?
After eating spicy foods Can be caused by other food Use ipatropium bromide nasal spray
77
What causes drug induced rhinitis? How is it managed?
Rebound congestion after topical decongestant use Many other drugs also cause rhinitis Stop drug - 7-21 days to resolve. Use topical steroids in this time
78
How is non-viral rhinosinusitis managed?
Topical nasal steroids - not for duration of illness Oral abx - little evidence: 1 Phenoxymethylpenicillin 2 Co-amoxiclav
79
What is aspirin sensitivity associated with?
Rhinosinusitis Polyps Asthma
80
Where a polyps commonly seen?
Clefts of middle meatus
81
How do polyps appear on examination?
Sac like entities Pale - poor blood supply, become fleshy and red over time (squamous metaplasia) Not sensitive to touch Yellowish grey Can get between them and side wall of nose Grape like structures Nasal bridge may appear widened
82
What do very large polyps appear like?
Grow down into oropharynx Visible with tongue depressor
83
How are polyps managed?
Topical nasal steroid drops | Can do surgical options as with chronic rhinosinusitis

Neurology and Special Senses (28 decks)

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