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Dr Deborah Amott ENT Surgeon

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Presentation on theme: "Dr Deborah Amott ENT Surgeon"— Presentation transcript:

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

2 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.

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

4 Nasal Anatomy

5 Sinus Anatomy

6 Function of the Nose 5

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

8 What are the symptoms patients will complain of?
6

9 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’)

10 Each of these can be fixed or variable over time…

11 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

12 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

13 Anatomy Doesn’t Change…

14 Anatomical Causes

15 Septal Deviation

16 Choanal Atresia

17 Space Occupying Lesions

18 Functional Causes

19 Infections

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

21 Rhinitis

22 RhinoSinusitis Acute Bacterial RS Chronic RS
Bacterial infection of the paranasal sinuses Symptoms for 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

23 Rhinosinusitis

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

25 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

26 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

27 Concerning Features?

28 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

29 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

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

31 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

32 Top 3 Infectious Inflammatory Trauma (foreign body, fall)

33 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

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

35 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

36 Top 3 Infectious/inflamm atory Neoplasia Degeneration

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

38 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

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

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

41

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

43 Intervention Diagnosis OR Symptoms

44 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?

45 ?

46 References


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