HEENT Nasal and Sinus Disorders

Normal respiratory functions of the nose

1. Warms air (conchea, septum)

2. Humidifies air completely before it passes beyond the nose

3. Partially filters via turbinate, septum, and pharyngeal wall, traps in mucus coating and transports via cilia

Nose function raises air temp to within

1 degree F of body temp

Keisslebach’s plexus is a common area for

epistaxis = arteries or veins get dry or brittle, bleed easily

Nose function is very effective at filtration; nothing larger than

6 micrometers will enter the lungs

“Coal miner’s lung” can come from

particles greater than 5 micrometers entering the lungs; cigarette smoke particles 0.3 micrometer and can get to alveoli

Anterior vs Posterior epistaxis

Anterior Epistaxis = Kiesselbach venous plexus MC source

Posterior Epistaxis = Sphenopalatine artery branches and Woodruff’s plexus MC site (may cause bleeding in both nares & the posterior pharynx)

Epistaxis etiology

Nasal trauma, rhinitis, alcohol/cocaine use, antiplatelet meds, HTN may prolong

Epistaxis risk factors

 HTN, nasal neoplasms

Epistaxis presentation

Bleeding out of one or both nostrils, bleeding into oropharynx

Epistaxis dx

Assess location of bleeding, anterior vs posterior

Epistaxis tx - anterior

Local pressure for 10 min.

Review Meds: ASA, Warfarin, Dabigatran- possible instigators

Oxymetazoline NS

Premarin cream for recurrent anterior bleeds

Epistaxis tx - posterior

Immediate ENT Referral, nasal packing

Other instigators of epistaxis may be

local trauma

HTN

extreme dryness

atrophic rhinitis

foreign body

Nasal fracture etio

fracture of nasal bones, septum, or turbinates

etio: trauma

Nasal fracture presentation

Swelling, tenderness, black eyes, nasal bleeding, nasal congestion

Nasal fracture dx

x-rays, CT

Nasal fracture tx

Splinting and realignment by hand or surgery

Surgery right away or after edema goes down

Nasal septum deviation etio

congenital, trauma, can get worse w/ age

Nasal septum deviation presentation/symptoms

Obstruction of one or both nostrils

Nosebleeds

Snoring, preference for sleeping on a certain side

Awareness of nasal cycle

Nasal septum deviation dx

speculum/endoscopy

Nasal septum deviation tx

Septoplasty

Decongestants

Antihistamines

Corticosteroid NS

Complications: 

compensatory turbinate hypertrophy on non occluded side; 

predispose to secondary disorders like rhinitis, sinusitis; nasal septal 

hematoma

Nasal foreign body etio

Most common in children

Button batteries- if suspected/known = urgent referral, radiographs might be helpful if suspected but not visualized

Nasal oreign body presentation

Classically presents with epistaxis associated with unilateral, mucopurulent and foul smelling discharge, nasal obstruction

-mouth breathing

can also be largely asymptomatic

Nasal foreign body dx

Direct visualization with otoscope or endoscopy

Nasal foreign body tx

Remove via positive pressure technique or instrumentation

Positive pressure technique: having patient blow nose while occluding nose opposite of foreign body

Instrumentation: hemostat, forceps

Nasal polyps etio

Allergic rhinitis most common cause, may be seen with CF

Nasal polyps presentation

Pale, boggy mass on the nasal mucosa. May have findings associated with allergic rhinitis

Nasal polyps dx

Most are incidental findings but if large, they can cause obstruction or anosmia

Nasal polyps tx

Intranasal corticosteroids are most effective

Surgical removal may be needed if medical therapy unsuccessful

Chronic sinusitis etio/physio

Inflammation of the nasal cavity and paranasal sinuses for at least 12 consecutive weeks

etio = S. aureus is most common bacterial cause, Aspergillus is most common fungal cause, Mucormycosis is second most common fungal cause

RF = tobacco smokers

Chronic sinusitis presentation

Chronic obstruction, congestion (pain/pressure), mucopurulent nasal drainage, hyposmia, mucosa typically damaged, thickened and cilia spotty throughout sinus mucosa

Chronic sinusitis dx

CT

Biopsy or histology is diagnostic test of choice

Chronic sinusitis tx

Usually nasal issues -Allergies, polyps, turbinate disorders

Refer to ENT

Stop tobacco use

Abx if bacterial with ENT follow up

Amoxicillin, Augmentin, Doxycycline, Levo

Acute sinusitis etio/patho

Inflammation of the nasal cavity and paranasal sinuses, 1-4 weeks

Patho: same as in acute rhinosinusitis, usually URI precedes

Etio: mostly viral, very few actually bacterial

In order of frequency: Maxillary > ethmoid > frontal > sphenoid

Acute sinusitis presentation

in one or both nares, purulence, dental/facial pain, unilateral sinus tenderness, initial improvement but then worsening symptoms

10 days to 4 weeks of symptoms

Acute sinusitis dx

Acute sinusitis tx

Decongestants, antihistamines, analgesics, corticosteroid nasal spray

Abx if prolonged symptoms

antibiotics if bacterial cause, Amox, Augmentin, Doxy, Levofloxacin

Barosinusitis etio

Negative air pressure in one or more sinus cavities

Etio: acute forms with rapid change in ambient pressure (diving, URI, nasal blowing, high altitude), chronic forms with obstruction of usually maxillary sinus ostia

Barosinusitis presentation

Chronic sinus pain

Barosinusitis dx

Barosinusitis tx

Pain relief

Counsel: Avoid flying, diving, etc.  during periods of 

allergic/viral rhinitis or sinusitis

Benign tumor or masses in the nose

can be inverted papillomas = MC lateral nose wall/squamous papilloma

less common is hepangiomas = juvenile nasal angiofibroma

Malignant tumor or masses in the nose

rare = < 1%

malignancies in the nasal cavity typically present with nasal obstruction, congestion, proptosis, visual changes, diplopia, facial pain or numbness, and bleeding

late stages = cranial nerve palsies 2ndary to invasion of the skull base.

Squamous cell M/C

Hormonal/environmental rhinitis etio

 dusty workplace, (major problem when cannot change exposure or wear mask) toxic fumes at work, wood stove, irritants with hobbies, factories nearby etc.

Hormonal/environmental rhinitis tx

 Saline NS, Corticosteroid NS, try to adjust environmental factors if able

Drug-induced rhinitis patho

Cocaine abuse, anticholinergic meds, overuse of oxymetazoline NS, Reserpine, beta blockers, Hydralazine, OCPs, ACE inhibitors, PDE-5 inhibitors (Viagra)

nonallergic & noninfectious

Drug-induced rhinitis tx

Noninfectious, change offending med

Atrophic rhinitis etio

anatomical deformity of nasal septum, turbinates exacerbated by conditions

Usually in elderly

OMC (ostiomeatal complex) is a

complex drainage system; flow vs obstruction

lack of flow = drainage can cause pain, pressure, then lead to infection

Atrophic rhinitis presentation

Dry nose, frequent anterior nosebleeds

Atrophic rhinitis dx

Atrophic rhinitis tx

Premarin cream- estrogen cream, corticosteroid nasal spray

Medicamentosa Rhinitis definition

non-allergic form of rhinitis that is caused by prolonged use of topical nasal decongestants

Aka rebound congestion

Medicamentosa Rhinitis tx

Change medication

Counseled to not exceed 3 days of nasal decongestant management 

Vasomotor rhinitis etio/patho

nonallergic & noninfectious dilation of the blood vessels

Patho: Imbalance of ANS activity in elderly

Often confused with allergic rhinitis (AR), which is uncommon in elderly

Vasomotor rhinitis presentation

Chronic dry nasal mucosa, clear rhinorrhea

Vasomotor rhinitis dx

Vasomotor rhinitis tx

None very satisfactory

Saline nasal spray, corticosteroid NS, Azelastine NS, Ipratropium NS, Avoid contributing meds (caution anti-cholinergics)

Bacterial rhinitis (ABRS) etio/patho

Bacteria infects sinus cavity; much less common than viral

Patho: Impaired sinus drainage: MC d/t complication of viral infection.

Also mechanical obstruction of nose, dental infections, impaired mucociliary clearance, smoking

Etio:  S. pneumoniae, H influenzae, M. catarrhalis

More apt to be ethmoid sinusitis causing a rhinosinusitis

In order of frequency: Maxillary > ethmoid > frontal > sphenoid

Bacterial rhinitis (ABRS) presentation (maxillary, ethmoid, frontal, sphenoid)

Erythema or edema over involved area, purulent drainage in nose or posterior pharynx.

Maxillary MC check pain or pressure that can radiate to upper incisors.

Ethmoid: Tenderness to high lateral wall of nose

Frontal: Pain around eyes and forehead

Sphenoid: Mid head tenderness

Acute rhinosinusitis: Facial pain or pressure worse/localized with bending down & leaning forward, purulent nasal discharge, nasal congestion or obstruction, HA, fever <4 weeks.

Bacterial rhinitis (ABRS) dx

Clinical criteria for bacterial cause: Persistent symptoms that last 10 or more days w/o improvement, a biphasic pattern where symptoms initially improve then worse

Bacterial rhinitis (ABRS) tx

Amox, Augmentin, Doxycycline for 5-7 days

Viral rhinitis etio

 Common cold, symptomatic inflammation of the nasal cavity and paranasal sinuses

Acute = <4 weeks

Primarily due to ARS

Etio: Rhinovirus, influenza, parainfluenza,

Viral rhinitis presentation

Erythematous, engorged nasal mucosa w/o intranasal purulence

Symptoms: Nasal congestion & obstruction, clear rhinorrhea, hyposmia. Associated cough, HA, malaise

Viral rhinitis dx

Viral rhinitis tx

Supportive management: symptoms are self-limited, roughly 7-10 days Decongestants to promote sinus drainage, analgesics, antihistamines, mucolytics, intranasal glucocorticoids, analgesics, and saline irrigation may also be used Manifestations: Eustachian tube dysfunction, acute rhinosinusitis

Allergic rhinitis etio

Inflammation of nasal mucosa due to allergen

Pollen, mold, dust etc.

Etio: IgE mediated, mast cell histamine release due to allergens

MC Rhinitis 

allergic rhinitis presentation

Edematous, pale or violaceous boggy turbinates with cobblestone mucosa

Allergic “salute”, allergic “shiners”

May have avascular polyps originating in ethmoid sinuses and extending into nasal airway

Symptoms: Nasal mucosal edema, congestion, rhinorrhea

allergic rhinitis dx

allergic rhinitis tx

Antihistamines, Decongestants, systemic/topical, nasal corticosteroid sprays

Referral for immunotherapy

-Intranasal corticosteroids- most effective pharmacologic therapy for allergic rhinitis and polyps