Dr Deborah Amott ENT Surgeon dhamott@hotmail.com Nasal Congestion Dr Deborah Amott ENT Surgeon dhamott@hotmail.com

Core Presentations By the end of this year, you should be able to perform a competent medical interview, physical examination and suggest a basic investigational plan for a patient presenting with this symptom.

An accurate diagnosis is: 90% History 9% Examination 1% Investigations

Nasal Anatomy

Sinus Anatomy

Function of the Nose 5

Airway Filtration Humidification Warming Smell Function of the Nose Airway Filtration Humidification Warming Smell

What are the symptoms patients will complain of? 6

What are the symptoms patients will complain of? Block: congestion vs. total obstruction uni vs. bilateral Run (‘rhinorrhoea’) React to irritation: itching, sneezing, pain Change in smell (+taste): decreased/absent, foul Facial pressure/pain Bleed (‘epistaxis’)

Each of these can be fixed or variable over time…

General Pathological Processes VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid-base imbalance/auto-immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic: too much vs. too little of an otherwise good thing

Nasal Congestion: DDx Anatomical: Functional Deviation of the nasal septum, hypertrophy of turbinates Choanal atresia Space Occupying Lesions Polyps Tumours: benign vs. malignant Foreign Body Congenital: Meningocoele/menigoencephalocoele, dermoids Functional Infection Rhinitis Sinusitis: acute vs. chronic Facial pain syndromes: migraine, midfacial pain syndrome, paroxysmal hemicrania etc

Anatomy Doesn’t Change…

Anatomical Causes

Septal Deviation

Choanal Atresia

Space Occupying Lesions

Functional Causes

Infections

Rhinitis Nasal congestion Rhinorrhoea Irritation Atopic/Allergic Infectious Irritation Vasomotor Atrophic Medication ….VINDICATE away Rhinitis Rhinorrhoea Irritation

Rhinitis

RhinoSinusitis Acute Bacterial RS Chronic RS Bacterial infection of the paranasal sinuses Symptoms for 7 - 28 days P Facial Pain/pressure/fullness O Nasal Obstruction D Purulent nasal Discharge S Smell: hyposmia/anosmia Ditto, but symptoms lasting for 8-12 weeks. Lack of signs of acute inflammation Requires clinical demonstration of sinus inflammation (endoscopy or imaging) Multiple Causes

Rhinosinusitis

Facial Pain Syndromes If the patients main concern is pain, consider a headache syndrome. Likely the nose? Probably not..

Facial Pain Syndromes If the patients main concern is pain, consider a headache syndrome. Likely the nose? Probably not.. Other nasal symptoms Ache/pressure Location Bilateral Typical triggers No nasal symptoms Pain, not pressure Location Unilateral Typical triggers

Context of a Symptom Symptom itself: acuity, duration, severity, variability, progression, triggers/relievers. Patient: age, sex, race, lifestyle (profession, hobbies, smoking, alcohol, other drugs, other carcinogens/toxins, diet), immune status (Immunosuppressed? Atopic? Autoimmune conditions?), geography. Associated features: what else is changing? Local, adjacent structures Regional Distant organ dysfunction Systemic symptoms

Concerning Features?

Concerning Features Unilateral Symptoms Progressive symptoms Pain is bad, BUT absence of pain ≠ absence of nasty disease Bleeding Crusting Dysfunction of adjacent structures: nasolacrimal duct, orbit, facial sensation or cheek swelling, eustachian tube obstruction, brain

Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

Top 3 Infectious Congenital Traumatic (foreign body) They can’t blow their nose… Infectious Congenital Traumatic (foreign body)

Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

Top 3 Infectious Inflammatory Trauma (foreign body, fall)

Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

Top 3(ish) Infectious Inflammatory Trauma Drugs (Auto-immune)

Top 3? VINDICATE V-vascular I-infectious/inflammatory N-neoplasia D-drugs/degeneration I-idiopathic C-congenital A-anoxia/acid base imbalance/auto immune T-trauma/toxins E-ethyl alcohol, endocrine Genetic

Top 3 Infectious/inflamm atory Neoplasia Degeneration

Examination External view: gross deviation Nasal obstruction Tilt tip Block each nostril separately, ‘sniff in’ Tilt tip Look in: thudicum speculum and pen torch

Investigations Know the question you want to answer. Only order an investigation if the result will affect your management A proper initial clinical assessment and then repeated thorough clinical assessment is always much better than multiple non-targeted tests. Recruit help

Investigation For most, none needed Imaging: options? Biopsy: options? Allergy testing: ‘short cuts’ vs. definitive testing

Investigations: Imaging Plain XRs Ultrasound Computed Tomography Magnetic Resonance Imaging Positron Emission Tomography Nuclear Medicine Scans The weird and wonderful

Investigations: Biopsy Options Fine needle aspiration Incisional: ‘wide needle/core’, punch, shave, scalpel Excisional biopsy Wide local excision (“Halsteadian”, “en bloc”, “R0 resection”)

Intervention Diagnosis OR Symptoms

What’s the Cost-Benefit ratio? Treatment Behavioural: avoid triggers, diet, exercise, sleep, environmental modification, mood management Non-pharmacological treatments: hygiene measures, moisturisers, saline rinsing, dietary supplements etc Pharmacologic: topical, enteral, transcutaneous, injections Interventional Minimal: endoscopic, angiography, etc Maximal: open surgery, radiation etc What’s the Cost-Benefit ratio?

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References