1. Name of the location of 90% of epistaxis
2. A genetic disorder that forms AV malformations in the skin, lungs, brain etc
3. Name of posterior vascular plexus in the nasal cavity causing posterior epistaxis
4. 1st line treatment for all epistaxis
5. The common brand name for anterior nasal packing
6. Chemical used in cautery sticks
7. Physically scaring complication of posterior nasal packing with foleys catheter
Coming soon..
Acute and Chronic Rhinosinusitis
Objectives
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To know how to diagnose these diseases clinically and to offer acute and long-term management
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To know the complications of these diseases and to be able to start immediate treatment and referral
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To know how to use nasal steroid sprays
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Links with nasal examination and facial pain sessions/resources
Definitions
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Acute rhinosinusitis (ARS) in adults is an acute infection causing sudden onset of two or more of the following: nasal obstruction or rhinorrhoea, +/- loss of smell +/- postnasal discharge.
Facial pain become evident after a few days. It lasts less than 12 weeks but generally only a week or so.
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Chronic rhinosinusitis (CRS) is diagnosed when the symptoms have been present for greater than 12 weeks. Again, diagnosis is made on the presence of nasal obstruction or nasal discharge, +/- reduction in smell, +/- facial discomfort/pressure. Two or more of these must be present for more than 12 weeks to make a diagnosis and the clinician should preferably have seen pus draining from the middle meatus, or nasal polyps, or oedema in the middle meatus too.
Relevant Anatomy
Sinuses are air filled spaces within the bones of the face and skull. Their function is uncertain but many theories exist. Some suggest that they act as a crumple zone, others that they lighten the face and improve resonance of the voice. A plausible theory has it that they produce nitric oxide which is inhaled with air into the lungs where it acts as a smooth muscle relaxant.
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The sinuses are lined with ciliated respiratory epithelium and all mucus created within them is wafted towards the ostium of the sinus and then into a meatus within the nose. The diagram above shows the routes that mucus takes as it is wafted out of each sinus.
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The majority of sinuses open into the middle meatus and drain as shown. The posterior ethmoids open into the superior meatus and the sphenoid sinus opens into the spheno-ethmoid recess. The ethmoid bone is coloured brown in the diagram above.
Acute Rhinosinusitis
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Epidemiology
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10% of population. Most occur in the winter and follow an acute viral infection. Patients with nasal allergy, who are exposed to tobacco smoke, and who live in polluted areas are more likely to suffer with ARS.
Pathophysiology
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An acute viral infection in the nose is the usual trigger for ARS. The infection affects cilia function and causes swelling of mucosa. These combine to cause occlusion of the small sinus ostia and stasis of mucus. In turn this allows for bacterial infection usually from Strep pneumoniae, Moraxella catarrhalis and Haemophilus influenza – the usual respiratory pathogens.
Other infectious organisms can cause ARS such as infections from the upper teeth and fungi. Fungal ARS is managed differently and may require emergency surgical debridement.
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Presentation
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The symptoms of ARS are presented above under definitions. Examination will reveal an oedematous nasal mucosa with secretions that are clear or mucoid. Pus may be seen draining into the postnasal space or oropharynx.
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Immunosuppressed patients may have a fulminant course with rapid deterioration of symptoms and consciousness.
Investigations
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Generally, ARS is a clinical diagnosis. X-rays have no real place in diagnosis but CT scanning is indicated if complications of ARS or CRS are suspected (see below).
If available a nasendoscopic assessment of the middle meatus is valuable and will show draining pus or mucosal oedema. Blood tests have little to offer but will show a raised CRP and a leucocytosis.
Treatment
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For the majority of patients with ARS no treatment is required apart from simple pain relief and a nasal decongestant. The infection is self-limiting.
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If symptoms persist or cause a greater systemic upset, then oral antibiotics are appropriate and are directed at the usual respiratory pathogens. Amoxicillin is a good first choice and should be used for ten days to a fortnight. Nasal decongestants and analgesia should also be used in this situation.
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If complications of ARS are suspected, then systemic treatments are needed alongside investigation and management as outlined below.
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Acute fungal sinusitis requires systemic antifungals e.g. amphotericin B. Emergency surgical debridement is also needed in more aggressive cases.
Chronic Rhinosinusitis
Epidemiology
CRS affects about 10% of the European population and may present in one of two forms: CRS with polyposis and CRS without polyposis. It is more common in smokers and in women.
Pathophysiology
A number of different mechanisms have been adduced to explain the chronic changes in the nasal and sinus epithelium. These include allergies, environmental factors, genetic predisposition or a combination of these.
Presentation
The symptoms required to make a diagnosis of CRS are listed above under definitions. Endonasal examination is very helpful and probably essential in establishing a diagnosis and will show changes in the middle meatus, mucosa swelling, polyposis or pus trails coming from the sinuses.
It is noteworthy that CRS is rarely a painful condition and even patients with massive polyposis don’t usually complain of pain.
Investigation
This is largely a clinical diagnosis in Primary Care but endoscopic evaluation is required for a definitive diagnosis. For those without access to endoscopy the main differential for CRS is the situation where a patient has rhinitis plus non-sinogenic pain (i.e. two different conditions in the same person)
Rhinitis is common and produces nasal blockage, discharge, and loss of smell. Put these together with facial pain from, say, facial arthromyalgia (temporomandibular pains) and it is tempting to make a diagnosis of CRS.
The challenge for the clinician in these situations is to be open to the possibility of dual pathology and to treat each separately.
CT scanning is not very helpful in diagnosing CRS as about 40% of a normal population will have radiological signs of mucosal abnormality even though they don't have symptoms of CRS. CT is used in surgical planning.
Treatment
CRS is treated by avoidance of environmental irritants and allergens, stopping smoking, long-term nasal steroid sprays and nasal douching with saline solutions. With proper adherence and good technique this almost always reduces symptoms to a satisfactory level.
Nasal steroid sprays need to be used in a particular way: looking downwards towards the floor and every day.
In cases of nasal polyposis oral steroid can be used for a short period. These will very effectively reduce the size of polyps and patients can them change to topical steroid sprays.
Three months of low-dose macrolide antibiotic such as Erythromycin can also be very effective if other medical management fails.
Failing medical management, surgery is planned to improve nasal airflow, remove polyps and open up the normal sinus outflow tracts. More can be read about the surgical management of sinus disease at out endoscopic sinus surgery page in the procedures section.
Complications of sinusitis
Complications are rare but serious. In essence, the infection within the sinus can spread outside the sinus via direct or haematogenous spread. In either case, it helps if you are familiar with the anatomy of the sinuses when thinking about complications. The most significant complications are listed here:
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Orbital subperiosteal abscess
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Intracranial abscess – usually in frontal lobe
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Osteomyelitis – aka Pott’s puffy tumour
Intracranial abscesses are dealt with in collaboration with neurosurgeons.
Orbital complications
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Infection can easily spread through the lamina papyracea of the ethmoids bone into the orbit, especially in children. Once inside the orbit it causes a variety of problems depending upon in which part of the orbit they arise and how extensive they are.
Chandler’s classification is a way to categorise orbital complications of sinus disease according to their severity.
By far the most common complication that we see in ENT is a subperiosteal orbital abscess. In this, pus collects under the periosteum of the medial wall of the orbit (over the lamina papyracea) and causes an increase in orbital pressure with proptosis of the globe, diplopia, and loss of vision in extreme circumstances.
S. pneumonia, H. influenza and S. aureus are common pathogens. CT scanning is used to diagnose the problem.
Treatment is by draining the abscess which is generally done by making an incision between the eye and the nose, dissecting down to bone and then elevating periosteum posteriorly until the abscess is found and drained. In adults, the abscess can be drained from inside the nose using the endoscopic sinus surgery techniques used for chronic sinus disease.
Osteomyelitis
This usually presents as a firm pitting lesion under the skin of the forehead. This is an important complication as intracranial complications may occur. CT scanning will confirm the underlying disease.
Treatment is by surgery for the underlying sinus disease (either endoscopic or via open incision) and by intravenous antibiotics.
Intracranial Abscess
This is an uncommon complication of sinus disease and can present with very few symptoms or signs. It is important to bear it in mind in any patient with sinusitis who is not making the progress that one would expect while on intravenous antibiotics.
A headache, drowsiness, inattention, declining mental status are important features to watch for. Hemiparesis and speech disorder will make the diagnosis more obvious.
CT scanning with contrast will show the classic rim-enhancing lesion in most recent onset cases. There may be a zone of brain oedema. MRI is more sensitive in diagnosing the problem.
Management of the abscess takes into account a number of features. Small abscesses can be aspirated for diagnosis and appropriate antibiotics given. Larger abscesses can be excised or aspirated.
Empiric management with antibiotics is appropriate while culture and sensitivity are awaited and the drug of choice will be decided by local protocol. Penicillin G is commonly prescribed as is Metronidazole. Vancomicin, imipenem and cefotaxime are also used.
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