Pathology of Nose and Paranasal Sinuses

Question 1

What is the medial wall of the nasal cavity formed by?

Answer 1

The nasal septum

Question 2

What does the nasal septum consist of?

Answer 2

• The perpendicular plate of the ethmoid bone
• Septal cartilage
• Vomer

Question 3

What does the septal cartilage rely on for its blood supply?

Answer 3

The overlying perichondrium

Question 4

Where does the septal cartilages’ blood supply have important clinical implications?

Answer 4

For injuries involving the nasal septum

Question 5

What is the clinical implication for injuries involving the nasal septum?

Answer 5

Septal haemotoma

Question 6

What causes a septal haematoma?

Answer 6

Trauma to the nose leading to buckling of the septum, and shearing of the blood vessels

Question 7

What happens in a septal haemotoma?

Answer 7

Blood collects in the space between the septum and its perichondrium

Question 8

What is the result of blood developing between the septum and its perichondriuM?

Answer 8

It lifts the perichondrium off the cartilage, stripping away its blood supply

Question 9

What does the pressure of the accumulating blood do in a septal haemotoma?

Answer 9

It causes ischaemia of the cartilage

Question 10

What happens if a septal haemotoma is not recognised and drained in a timely fashion?

Answer 10

• Irreversible avascular necrosis of the cartilage can occur
• Infection development in collecting haemotoma

Question 11

What does avascular necrosis of the cartilage cause in a septal haemotoma?

Answer 11

Cosmetic distortion of the nose - saddle deformity

Question 12

What does septal abscess formation increase the likelihood of?

Answer 12

Avascular necrosis of the septum

Question 13

What is sinusitis?

Answer 13

Acute inflammation of the lining of the sinuses

Question 14

How long does sinusitis last?

Answer 14

Under 4 weeks

Question 15

When can sinusitis occur?

Answer 15

Following a viral infection of the nasal mucosae, e.g. a cold

Question 16

What does sinusitis cause?

Answer 16

• Mucosal oedema
• Impedence of ciliary function
• Increase in mucosal secretions

Question 17

When may drainage from the sinuses become obstructed?

Answer 17

If the oedema involves their opening into the nasal cavity

Question 18

What does obstruction of the sinuses cause in sinusitis?

Answer 18

This, combined with increased mucosal secretions, leads to a stagnant pool collection within the sinus

Question 19

What can sometimes happen when a stagnant pool collects in sinusitis?

Answer 19

It can become secondarily infected with bacteria

Question 20

Which sinus is particularly prone to infection?

Answer 20

The maxillary sinus

Question 21

Why is the maxillary sinus the most prone to infection?

Answer 21

Most likely becasue of the location opening high on the medial wall of the nasal cavity

Question 22

What increases the risk of sinusitis?

Answer 22

Conditions which may block the ostia of sinuses

Question 23

Which conditions may block the ostia of sinuses?

Answer 23

• Nasal polyps
• Deviated septum

Question 24

When may a dental infection cause sinusitis?

Answer 24

When it involves the upper teeth

Question 25

How is a diagnosis of sinusitis made?

Answer 25

Based on history and clinical examination alone

Question 26

What are the symptoms of sinusitis?

Answer 26

* Non-resolving cold or flu-like illness that persists for more than a week * Pyrexia * Rhinorrhoea +/- green/yellow discharge * Headahe/facial pain (in area of affected sinus), worse on leaning forward * Blocked nose

Question 27

How is sinusitis managed?

Answer 27

Most cases are self limiting, and can be treated with simple analgesics. They start to improve within 1-2 weeks

Question 28

When may a course of antibiotics be required in sinusitis?

Answer 28

If secondary bacterial infection is suspected

Question 29

What complications can arise from sinusitis?

Answer 29

Orbital cellulitis

Question 30

How may orbital cellulitis occur in sinusitis?

Answer 30

Infections of the air cells of the ethmoidal sinuses may break through the thin medial wall of the orbit, causing orbital cellulitis

Question 31

What is problem with orbital cellulitis?

Answer 31

Spread of infections into the orbit can be potentially sight threatening

Question 32

Why may infections of the orbit be sight threatening?

Answer 32

They may involve the optic nerve

Question 33

How may orbital cellulitus progress?

Answer 33

May track back further to involve intracranial structures

Question 34

What is an epistaxis?

Answer 34

A nosebleed

Question 35

Describe the prevalence of epistaxis

Answer 35

Very common

Question 36

How are epistaxis usually managed?

Answer 36

*Often minor*, so usually self-treated with simple first-aid measures, by pinching in front of (not on) the bony bridge of the nose, and applying a cold compress

Question 37

What is the arterial supply of the nasal cavity from?

Answer 37

Mainly from branches of the maxillary artery

Question 38

What branches of the maxillary artery supply the nasal cavity?

Answer 38

* Sphenopalatine * Greater petrosal

Question 39

What % of nosebleeds come from the sphenopalatine artery?

Answer 39

10%

Question 40

Why can nosebleeds from the sphenopalatine area be particularly problematic?

Answer 40

Blood in this vessel tends to be at higher pressure, and as it is posteriorly located in the nasal cavity, harder to reach to stop the bleed

Question 41

Other than branches of the maxillary artery, what contributes to the nose's rich blood supply?

Answer 41

Ethmoidal branches from the opthalmic artery, and a branch of the facial artery

Question 42

What is the opthlamic artery a branch of?

Answer 42

The internal carotid artery

Question 43

What forms Little's area?

Answer 43

Anastomoses of the opthlamic artery (ethmoidal branches), facial artery, greater petrosal, and sphenopalatine artery

Question 44

What is Little's area also known as?

Answer 44

Keiselbach's Area or Plexus

Question 45

What is Little's Area?

Answer 45

A cartilaginous part of the septum

Question 46

What % of nosebleeds originate from Little's area?

Answer 46

90%

Question 47

When may nosebleeds occur?

Answer 47

Spontaneously, or with very minor trauma to the nose

Question 48

What may sometimes be the cause of nosebleeds?

Answer 48

Underlying systemic causes; * Abnormal coagulation * Connective tissue disorders

Question 49

What can happen is serious nosebleeds occur?

Answer 49

Can potentially risk significant blood loss, and rarely even death

Question 50

How is a serious nosebleed managed?

Answer 50

1. Applying simple compression and leaning forwards 2. Cauterise a visible bleeding point using silver nitrate 3. Anterior packing using nasal tampons 4. Posterior packing 5. Surgical intervention

Question 51

What do nasal tampons do?

Answer 51

Expand within the nasal cavity, and tamponade the area of bleeding

Question 52

What surgical interventions are taken in a serious nosebleed?

Answer 52

* Embolism * Ligation of blood vessels

Question 53

What should be monitored in severe epitaxis?

Answer 53

* ABCs * Blood tests to check Hb levels and clotting

Question 54

What should happen regarding underlying systemic consequences in severe epitaxis?

Answer 54

They should be sought and treated

Question 55

What are nasal polyps?

Answer 55

Benign, fleshy swellings arising from nasal mucosa

Question 56

Do nasal polyps usually affect one or both sides of the nasal cavity?

Answer 56

Both

Question 57

Describe the appearance of nasal polyps

Answer 57

Pale or yellow in appearance, or flesh coloured and reddened

Question 58

Who are nasal polyps most common in?

Answer 58

Those over 40 years

Question 59

What are the symptoms of nasal polyps?

Answer 59

* Blocked nose and watery rhinorrhea * Post nasal drip * Decreased smell and reduced taste

Question 60

What might suggest a tumour instead of a polyp?

Answer 60

Unilateral polyp, with or without blood-tinged secretion

Question 61

How are nasal polyps treated?

Answer 61

Nasal spray, to reduce size

Question 62

How do you differentiate between a nasal polyp and a turbinate?

Answer 62

Polyps are mobile if poked, and can't be felt, whereas turbinates are immobile and painful if poked

Question 63

What is rhinitis?

Answer 63

Inflammation of the nasal mucosal lining

Question 64

What are the common causes of rhinitis?

Answer 64

* Simple acute infective rhinitis * Allergic rhinitis

Question 65

What causes simple acute infective rhinitis?

Answer 65

Common cold

Question 66

What causes allergic rhinitis?

Answer 66

Hayfever

Question 67

What are the symptoms of rhinitis?

Answer 67

* Nasal congestion * Rhinorrhoea * Sneezing * Nasal irritation * Postnasal drip