St Mary’s Hospital ENT Department Founded by Joseph Toynbee in 1851 Rhinology Teaching Topics for Mary’s Medics Steve 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) –ObstructionType I hypersensitivity –VasodilatationIgE & 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