Nose (ENT 4)

Question 1

What is rhinusitis?

Answer 1

Inflammation of nose and paranasal sinuses with 2 or more of:
Nasal blockage / obstruction
Nasal discharge
Facial pain / pressure
Reduction or loss of smell

Question 2

How is rhinusitis defined?

Answer 2

Acute

Chronic (>12wks)

Question 3

What is the management of acute rhinositus (common cold)?

Answer 3

Self limiting

If >5 days, can give intranasal corticosteroids eg mometasone or fluticasone

Question 4

What is acute post viral sinusitis?

Answer 4

Increase in symptoms after 5 days or persistent symptoms >10 days

Question 5

What can be given in allergic rhinosinutis?

Answer 5

Prednisolone 10-20mg/24hr

Question 6

What can cause nasal congestion in a child?

Answer 6

Large adenoids
Choanal atresia - congenital blockage of one / more nasal passage by bone or tissue
Post nasal space tumour eg angiofibroma
FB

Question 7

What can cause nasal congestion in an adult?

Answer 7

Deflected nasal septum
Granuloma eg TB, syphilis
Topical vasoconstrictors eg tricyclics

Question 8

What are red flags for nasal congestion?

Answer 8

Numbness
Tooth loss
Bleeding
Unilateral obstructing mass

Question 9

How does chronic sinusitis with nasal polyps present?

Answer 9

Watery anterior rhinorrhoea
Sneezing
Purulent nasal drip
Nasal obstriction
Sinusitis
Mouth breathing
Snoring
Headachges

Question 10

When do nasal polyps require urgent referral for biopsy?

Answer 10

Single unilateral polyp

May be intranasal pathology eg nasopharyngeal cancer or lymphoma

Question 11

What can polyps be difficult to distinguish from?

Answer 11

Hypertrophic turbinates - the structures in the nose that cleanse and humidify the air

Question 12

What is the medical management of chronic rhinosinusitis with nasal polyps?

Answer 12

Topical steroids to shrink polyps eg betamethasone 0.1% 2 drops / 12 hrs in both nostrils for 2 weeks

Followed by fluticasone 100mcg 2 sprags / 24 hours in both nostrils for 3 months

Consider long term abx eg doxycycline

Question 13

What is the surgical management of chronic rhinosinusitis with nasal polyps?

Answer 13

Endoscopic sinus surgery - watch out for CSF leak in recovery

Dont blow nose until you are better

Question 14

How does a septal haematoma present?

Answer 14

Following trauma

A boggy swelling of septum causing near total nasal obstruction

Question 15

How is a septal haematoma managed?

Answer 15

Refer to ENT for urgent incision and drainage

Question 16

What is the management of a nasal fracture?

Answer 16

Analgesia
Ice
Close skin injury
Reassess 5-7 days post injury once swelling resolved
If manipulation under anaesthesia (MUA) required, perform day 10-14 after injury before nasal bones set

Question 17

What can ethmoid fractures cause?

Answer 17

CSF rhinorrhoea through disrupting dura and arachnoid layers

Question 18

What is the management of an ethmoid fracture?

Answer 18

Conservative
7-10 day bedrest with elevation (15-30 degrees)
\+/- lumbar drain
Avoid coughing, sneezing, nose blowing
Abx and pneumococcal vaccine

Question 19

How does a nasal FB present?

Answer 19

Early purulent unilateral discharge if organic

Question 20

How can a nasal FB be removed?

Answer 20

Ask child to blow nose
or blow into mouth whilst occluding the other nostril
Crocodile forceps to retrieve

Question 21

What can cause septal perforation?

Answer 21

Septal surgery
Trauma
Inhalants eg cocaine
Infection eg TB

Question 22

How does a septal perforation present?

Answer 22

Irritation
Whistle
Crusting
Bleeding

Question 23

What is the management of a septal perforation?

Answer 23

Saline nasal irrigation

Surgical closure through a septal prosthesis (button)

Question 24

How may nasopharyngeal cancer present?

Answer 24

Cervical lymphadenopathy
Nasal symptoms - bleeding, obstruction, discharge
Hearing loss
Cranial nerve palsies (but not I, VII or VIII) due to base of skull extension

Question 25

Describe the usual presentation and cause of hearing loss in nasopharyngeal cancer

Answer 25

Usually unilateral due to conductive deafness from eustachian tube blockage

Question 26

What are some identifiable causes of epistaxis?

Answer 26

* Trauma - nose picking children, fractures * Bleeding disorders * High alcohol intake - low clotting factors * Anticoagulant use * Hypertension * Vasculitis e.g. Wegener's granulomatosis

Question 27

Where is the most common site of epistaxis?

Answer 27

Little's area

Question 28

What is Little's area?

Answer 28

The site of anastomosis of 5 arteries: 1. Anterior ethmoid artery 2. Posterior ethmoid artery 3. Sphenopalatine artery 4. Great palatine artery 5. Superior labial artery

Question 29

What is the step-wise management of epistaxis?

Answer 29

1. Pinch fleshy part for 15 mins whilst sitting up and leading forwards 2. Lidocaine + phenylephrine gauze or spray (uncommonly done but is 2nd step on NICE) 3. Silver nitrate cautery - only if can see bleeding point 4. Pack - Balloon pack/Ribbon pack/Nasal pack 5. Call ENT a. Ligation of sphenopalatine artery b. Posterior packing with urinary catheter

Question 30

How does a septal haematoma cause damage to the septal cartilage?

Answer 30

* Septal haematoma is caused by bleeding under the perichondrium lining the septal cartilage, usually due to trauma * The septal cartilage receives blood supply from overlying mucosa so a haematoma can disrupt blood flow * Damage to septal cartilage can occur within 24 hours and if it is left untreated can lead to irreversible septal perforation and necrosis - saddle-nose deformity

Question 31

What would be seen on anterior rhinoscopy in a patient with a septal haematoma?

Answer 31

Bilateral cherry-red swelling arising from nasal septum