Nose conditions

Question 1

What is allergic rhinitis

Answer 1

IgE mediated inflammatory reaction of nasal mucosa due to sensitisation to allergen causing histamine release - results in cold like symptoms

Question 2

Causes of allergic rhinitis and different points of year it can present

Answer 2

Dust, mites - more common in winter
Grass, tree, weed pollen - more common in spring/summer
Mould - throughout year
Animal dander - pets

Question 3

Symptoms and clinical signs of allergic rhinitis

Answer 3

Symptoms:
Seasonal / all year around based on cause
Sneezing
Rhinorrhea
Nasal congestion
Nasal pruritis
Post nasal drip
Cough
Bilateral eye itching/redness/puffiness/watery discharge (conjunctivitis)

Clinical signs:
Hypertrophic nasal trubinates
Nasal discharge
BILATERAL eye redness/clear discharge (unilateral in conjunctivtis since localised and not systemic)
Nasal polyps

ATOPY - ECZEMA, ASTHMA ASSOCIATION

Question 4

Diagnosis of allergic rhinitis

Answer 4

Clinical diagnosis

Question 5

Management of allergic rhinitis

Answer 5

Allergen avoidance
Intranasal antihistamine (azelastine) or Non sedating oral antihistamine (cetrizine/loratadine)
Intranasal chromone (sodium cromoglicate) if antihistamine not tolerated

If severe / peristent - daily intranasal corticosteroid (mometasone/fluticasone) during allergen exposure for 2 wks

ENT referral if persistent - allergen testing, structural abnormality

If treatment failure immunotherapy referral - skin prick test and increase allergen exposure over several wks to induce tolerance

Question 6

What are nasal polyps?

Answer 6

Benign swellings of nasal mucosa of paranasal sinuses

Question 7

Risk factors of nasal polyps

Answer 7

Asthma
Aspirin sensitivity
Genetics

Question 8

Symptoms and signs of nasal polyps

Answer 8

Nasal obstruction - struggling to breath through nose/snoring
Nasal discharge
Reduced sense of smell
Cough - from post nasal drip
Seen on examination

Question 9

Diagnosis of nasal polyps

Answer 9

Clinical diagnosis
If not visualised nasal endoscopy referral

IF SYMPTOMS UNILATERAL CT SINUSES - concern of neoplasm

Question 10

Treatment of nasal polyps

Answer 10

1st line - intranasal corticosteroids - continue indefinitely with review every 6 months

Nasal saline irrigation to clear sinuses

Doxycycline if associated chronic sinusitis

2nd line - surgical polypectomy

Question 11

What is acute sinusitis

Answer 11

symptomatic inflammation of paranasal sinuses

Question 12

Cause and risk factors of acute sinusitis

Answer 12

Viral URTI - cause

Risk factors
- allergic rhinitis
- asthma
- smoking
- anatomical variation - deviated septum / nasal polyps

Question 13

Acute sinusitis symptoms and signs

Answer 13

Previous URTI symptoms
INCREASED SYMPTOMS AFTER DAY 5 (double sickening) OR PERSISTENCE SYMPTOMS AFTER 10 DAYS
Nasal blockage
Rhinorrhoea
FACIAL PRESSURE/PAIN
Reduction in smell
Fever
Maxillofacial sinus swelling

Question 14

Acute sinusitis management

Answer 14

DON’T PRESCRIBE ABX IF SX LESS THAN 10 DAYS
Supportive care - paracetamol/ibuprofen, mucolytics, antihistamines, warm face packs

If sx longer than 10 days
high dose nasal corticosteroids - mometasone

Back up abx prescription (pehnoxymethylpenicillin / co-amoxiclav, or doxycycline if penicillin allergy) if worsening symptoms for another wk

Question 15

What is chronic sinusitis

Answer 15

Symptomatic paranasal sinus inflammation for OVER 12 WKS

Question 16

Causes of chronic sinusitis

Answer 16

Less likely infectious, more likely inflammatory cause or multi-factorial

Perhaps bacterial aetiology (staphylococcus aureus, enterobacteriaceae, pseudomonas)

Question 17

Risk factors of chronic sinusitis

Answer 17

Allergic rhinitis
Asthma
Ciliary impairment (e.g. cystic fibrosis)
Aspirin sensitivity (nasal polyp formation preventing drainage)
Smoking
Immunocompromised

Question 18

Symptoms and signs of chronic sinusitis

Answer 18

Nasal blockage
Rhinorrhoea
FACIAL PRESSURE/PAIN
Reduction in smell
Maxillofacial sinus swelling and tenderness
NO FEVER SINCE MORE LIKELY INFLAMMATORY AND NOT INFECTIOUS CAUSE
SX LASTS MORE THAN 12 WKS

Question 19

Chronic sinusitis diagnosis

Answer 19

Clinical
can do ENT referral - they can do CT sinuses

Question 20

Chronic sinusitis management

Answer 20

Supportive management (paracetamol/ibuprofen, mucolytics, antihistamines, warm face packs)
Stop smoking
Nasal saline irrigation
Intranasal corticosteroid for 3 months

no abx
refer if persistent after 3 months

Question 21

What is epistaxis

Answer 21

nosebleed

Question 22

Causes of epistaxis

Answer 22

Trauma - nose picking, nasal fractures, ulcers, perforations
Inflammation - chronic sinusitis, allergic rhinitis, nasal polyps
Topical drugs - cocaine, decongestants, corticosteroids
Systemic drugs - anticoags, antiplatelets (aspirin, clopidegrol)
Tumours
Clotting disorders
Excessive alcohol consumption
Environmental factors - humidity, altitude, temp, cigarette smoke, dust

Question 23

Epistaxis diagnosis investigations

Answer 23

Anterior rhinoscopy

Suspect posterior bleed if unable to visualise or if bleeding began down throat

FBC and coagulation studies

Question 24

Epistaxis management

Answer 24

ADMIT IF SUSPECTING POSTERIOR or if haemodynamically unstable (light headed)

First aid - lean forward slightly and pinch nose cartilage for 15 mins

If bleeding stops topical antiseptic (naseptin)
No blowing nose, heavy lifting, strenuous exercise, lyin supine, alcohol/hot drinks

If bleeding doesn’t stop, nose cautery or nose packing

Question 25

What is nose cautery and steps

Answer 25

Done in epistaxis if bleeding point is visualised Topical anaesthetic (lidocaine) with vasoconstrictor spray Wait 3-4 mins Apply silver nitrate stick lightly to bleeding point for 3-10 seconds until grey colour develops Dap cauterised area with cotton bud Apply topical antiseptic (naseptin) for 10 days to prevent infection

Question 26

What is nose packing and steps

Answer 26

If nose cautery fails (last step due to complications) or bleeding point not visualised in epistaxis Anesthetise topically with lidocaine and vasocontrictor spray Wait for 3-4 mins Pack affected nostril whilst pt is sitting upright and forward

Question 27

Complications of nose packing

Answer 27

Sinusitis Septal haematoma/abscess Pressure necrosis (rare) Toxic shock syndrome (rare)

Question 28

Presentation of nasal fracture

Answer 28

Nasal deformity Nasal obstruction Painful palpation Swelling Discolouration Epistaxis

Question 29

Diagnosis and management of nasal fracture

Answer 29

No need for XR Clinical diagnosis Assess for MUA (manipulation under anaesthesia) Refer if gross displacement, compound (broken through skin so increases chance of infection), uncontrolled bleeding, CSF rhinorrhea (clear straw like discharge), septal haematoma (collection of blood has to be drained surgically)

Question 30

How to tell if bump in nasal fracture is septal haematoma

Answer 30

Boggy on palpation = haematoma If hard - displaced bone or cartilage

Question 31

Nasal foreign body presentation

Answer 31

Visualisation Nasal discharge - unilateral Halitosis Epistaxis Septal perforation Ingestion/aspiration of foreign body

Question 32

Nasal foreign body management

Answer 32

Only attempt if confident, if not refer Topical vasoconstrictor to reduce swelling Mother's kiss (hold one side of nose and blow into mouth) Balloon catheter (inflate and withdraw) Suction catheter Magnet