Nasal & Sinus - Upper Respiratory Tract

Upper Respiratory Tract

Nasal & Sinus

·        For Nasal neoplasms, see Cancer of the Nasal Cavity and Paranasal Sinuses (Topic)

·        Warms, cleans and humidifies inspired air.  By back of nose air is 98% humidified and 35 C

·        Anatomy: maxillary, ethmoid, frontal and sphenoid sinuses. Concha and turbinate bones

Nasal obstruction

·        Mechanical:

o  Defect in cartilage or bone

o  Septal deviation. Overtime ® paradoxical obstruction – hypertrophy of turbinate on other side ® bilateral obstruction. Treatment: septoplasty

·        Mucosal:

o  ® Blocked nose, mucoid discharge, ¯smell

o  Vasomotor rhinitis (VMR): there is normally a cycle between one nostril blocked and other

o   cleared. This cycle upset.  Treatment: cauterise turbinates ® reduce venous congestion

o  Allergic rhinitis

o  Polyps: sessile or pedunculated. Usually inflammatory – related to asthma and aspirin sensitivity. Can be idiopathic or secondary to infective sinusitis

o  Treatment: topical steroids (¯allergy, ¯primary polyps, ¯VMR), antihistamines, mast cell stabilisers

Epistaxis

·        Kids: from Little‟s area (= Kiesselbach‟s area). Anterior septum. Naso-palatine plexus. Treatment: cauterise

·        Adults: From further back – septal or lateral wall. In elderly, mortality from severe epistaxis 1% - from secondary effects eg stroke (aspirin common cofactor ® ­bleeding)

Sinusitis

·        See also Acute Sinusitis(Topic)

·        Face pain after cold

·        Maxillary most common presentation, although ethmoid more commonly infected

·        Causes: Strep pneumoniae, Strep pyogenes, H. influenzae, B. catarrhalis

·        Treatment: Amoxil

·        Complications:

o  Orbital cellulitis via orbital periosteum ® optic nerve compression ® compression of ophthalmic artery ® retinal blindness. Need to drain pus and iv antibiotics

o  Sphenoidal and frontal sinusitis can ® cerebral complications (eg cavernous thrombosis)

·        Chronic sinusitis: puss, ¯smell, no pain.  Can be from dental infection

Allergic Rhinitis

·        See also Allergy and Hypersensitivity Disorders Topic

·        Symptoms:  Recurrent or acute

o  Sneezing, blocked or runny nose, itchy watery or puffy eyes, itchy throat

o  May also be epistaxis, snoring, mouth breathing

·        Examination: look at anterior nares for nasal patency, polyps (chronic rhinitis), secretions, oedema

·        Two types:

o  Seasonal Allergic Rhinitis = Hay fever.  Allergy to birch or grass pollen etc. especially rye grass

o  Perennial Allergic Rhinitis: allergy to dust mites, cat dander, moulds, etc

·        Non-drug treatment:

o  Avoid allergen

o  Avoid other irritants: perfume, temperature change, other smoke

·        Drug treatment:

o  Antihistamines: Some can cause sedation, especially if taken with alcohol

o  Decongestants: Vasoconstrictors. Can have stimulant effects (including ­BP). Overuse ® rebound congestion

o  Mast cell stabilisers: Nasal spray.  Slow onset

o  Topical nasal steroids: Slow onset.  Can cause mucosal atrophy ® nose bleeds

o  Desensitisation: Injections of increasing doses of allergen. Expense and takes time (eg up to two years)