What is littles area?
Also called kiesselbachs plexus, a highly vascularised area on the nasal septum
Causes of epistaxis (local/systemic)
Local: Idiopathic (85%), traumatic, iatrogenic, foreign body, inflammatory (rhinitis, polyps), neoplastic
Systemic: hypertension, coagulopathies, vasculopathies, Hereditary Haemorrhagic Telangiectasia
Management of epistaxis
First Aid - pinch soft part of nose, head forward, spit out blood in mouth
Examination - locate source of bleed, anterior or posterior?
Cautery - silver nitrate or bipolar diathermy
Nasal packing - initially anterior pack, then posterior
Surgical - ligation of sphenopalatine, anterior ethmoid, external carotid (last resort)
Common causes of Nasal trauma
Assault
Sports
Falls
RTAs
Complications of nasal bone fracture
Septal haematoma leading to avascular necrosis and deformity
CSF leak with associated skull base fracture
Management of nasal bone fracture
ABCs
Examine for septal haematoma
If deviated nose consider manipulation under anaesthetic within 2 weeks of injury
Structures at risk during paranasal sinus surgery
Lamina papyracea (medial wall of orbit) - lateral to the ethmoid sinus. Loss of colour vision or loss of sight
Anterior cranial fossa - lies just above sphenoid and ethmoid sinus, can be breached and cause CSF leak or brain damage
Site of drainage of sphenoid sinus
Sphenoethmoidal recess
Site of drainage of posterior ethmoid sinus
Superior meatus
Site of drainage of frontal sinus
Middle meatus
Site of drainage of maxillary sinus
Middle meatus
Site of drainage of anterior ethmoid cells
Middle meatus
Site of drainage of nasolacrimal duct
Inferior meatus
Define rhinosinusitis
Inflammation of the nose and paranasal sinuses characterised by two or more symptoms, 1of:
Nasal blockage/congestion or discharge
Facial pain/pressure
Reduction or loss of smell
AND 1 of:
Endoscopic signs of polyps, mucopurulent discharge/oedema in Middle meatus
CT Changes
Define Acute and Chronic Rhinosinusitis
Acute = 12 weeks, without complete resolution. Divided into CRS with polyps and CRS without polyps
Viral ARS causes
Rhinovirus
Influenza virus
Resolution of symptoms within 5 days
Non viral ARS causes
Persistence of symptoms after 5 days, caused by super added bacterial infections:
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Predisposing factors to ARS
Allergy
Ciliary impairment
Management of ARS
Analgesia if required
Nasal decongestants
If persists for five days consider topical nasal steroids and oral antibiotics
Predisposing factors to CRS
Allergy Infections Ciliary impairment eg. Cystic fibrosis Anatomical abnormalities eg. Septal deviation Immunocompromised host Aspirin hypersensitivity Hormonal eg. Pregnancy, hypothyroidism Trauma Foreign body
Investigations of CRS
Skin prick test if allergy suspected
CT sinuses
Management of CRS
Conservative - avoidance of allergens
Medical - antihistamines, topical nasal steroids, oral steroids (severe), oral antibiotics
Surgical - nasal polypectomy, functional endoscopic sinus surgery to improve ventilation/drainage
What is allergic rhinitis?
IgE mediated type 1 hypersensitivity reaction in the mucous membranes of the nasal airways.
Allergic reaction leads to mast cell degranulation to release histamine. Increases capillary permeability leading to congestion, oedema, rhinorrhoea, sneezing and irritation
Allergens include pollens, moulds, house dust mites
How is allergic rhinitis classified?
By duration:
Intermittent = symptoms 4 days a week, more than 4 weeks
By severity:
Mild = normal daily activities, normal sleep, no troublesome symptoms
Moderate - severe = impairment of daily activities and sleep
Investigation of allergic rhinitis
Skin prick test for specific allergens
Treatment of allergic rhinitis
Conservative - allergen avoidance
Medical - antihistamines, topical nasal steroids
Immunotherapy
Cause of peri orbital cellulitis
Direct spread of pus from the ethmoid sinus through Lamina papyracea, or from thrombophlebitis of mucosal vessels in any of the sinuses
Symptoms of peri orbital cellulitis
Pain Oedema of eyelids Proptosis Reduced eye movements Reduced colour vision
Investigation and treatment of periorbital cellulitis
Investigation - test colour vision (red/brown), CT Scan
Management - IV antibiotics, nasal decongestants, urgent surgical drainage of any abscess
Describe the blood supply to the nose
ECA - superior labial artery, sphenopalatine artery, greater palatine artery
ICA - anterior ethmoidal , posterior ethmoidal