St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Rhinology

Teaching Topics for Mary’s MedicsSteve Lewis

2003/4

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Physiology

• Filtration (hairs/mucus/cilia)• Warming (30C)• Humidification• Olfaction• Vocal resonance

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (outside)

• Bony upper 1/3• Cartilage lower 2/3

• Alar• L Lat• U Lat

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (cavity)

• Septum• Turbinates (x3)• Ciliated epithelium

• Sinus drainage to around middle turbinate

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Use of the bony septum!

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (sinuses)

• Anterior drain to middle meatus– Frontal– Maxillary– Ant Eth

• Posterior drain superior meatus/sphenoethmoidal recess– Post Eth– Sphenoidal

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (sinuses)

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (sinuses)

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (sinuses)

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Anatomy (sinuses)

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Blood Supply

• Very extensive anastamoses• Int Carotid & Ext Carotid branches

• Ethmoidal arteries above MT• Sphenopalatine/Palatine/Labial below MT

• Little’s Area• Kiesselbach’s plexus

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Examination

• Point to yourself!

• Rigid scope (0/30/90)• Flexi ‘scope

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Epistaxis

• ABC– Hx Ex Ix as you go– Basic first aid– Bloods (FBC/G&S/INR/U)– Fluids

– Consider co-morbidity in the elderly

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Epistaxis

• Beavis and Butthead

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Epistaxis

• Find the bleeder and cauterise it• Pack the nose

– merocel uni/bi lateral– BIPP– Foley catheter and BIPP

• Cautery or packing under GA• Ligation of feeding vessels (EC if necessary)

• Antibiotics if pack staying >24hrs• Naseptin when settled

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Trauma

• # Nasal bones (not urgent)– see in 1/52– MUA in 2/52– Rhinoplasty >3/52

• Septal haematoma (URGENT)– prompt drainage– poor cosmetic result possible

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Obstruction

• Congenital/Acquired• Deviated septum• Rhinitis• Polyps• Foreign body• Neoplasia

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Rhinitic Mucosa

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Rhinitis• Allergic (10-20% people)

– Obstruction Type I hypersensitivity– Vasodilatation IgE & Mast Cells– Oedema– sneezing

• Discover and avoid allergen• Prevent swelling/oedema• Stabilise mast cells

– MEDICAL problem with treatment, not cure

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Rhinitis

• Intrinsic (10-15% population)

– Obstruction– Vasodilatation– Oedema– sneezing

• Imbalance of ANS supply to mucosa• PNS overrides SNS• watery rhinorrhoea

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Rhinitis

• Medicamentosa

• OTC decongestants are usually designed for short term use

• Like heroin• Very difficult vicious circle to break free from

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Polyps

• Inflammatory origin most common– neoplastic– CF– idiopathic

• Aspirin/Asthma/Obstruction• Hx Ex Ix• Steroids/Surgery• Recurrence

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Polyps

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Acute Sinusitis

• Inflammation of the MM lining the paranasal sinuses• May be in conjunction with CAUSATIVE FACTOR

• Medical Rx resolves most:

– Analgesia– Decongestants– Steam– Antibiotics

• Surgical Rx includes sinus washout

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Chronic Sinusitis

• Retained secretions– blocked nose– frequent acute episodes– sinofacial pain

• Take careful pain history before diagnosis• Visualise drainage system by CT• FESS

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Nasopharyngeal Carcinoma

• High incidence in those of Eastern origin– Hong Kong boat people (male)

• Associated with:– Dried, salted, smoked fish– EBV– Genetic

• Radiotherapy• Little place for surgery (not curative)

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Foreign Bodies

• Pictures of FBs

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

Cosmetics

• Pictures of septorhinoplasty

• Pictures of facial proportions

• Grades of uglyness

St Mary’s Hospital ENT Department

Founded by Joseph Toynbee in 1851

The End