Download Nasal Congestion Presentation D Amott.

Nasal Congestion
Dr Deborah Amott
ENT Surgeon
[email protected]
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
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:
– 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
Nasal
congestion
Atopic/Allergic
Infectious
Irritation
Vasomotor
Atrophic
Rhinitis
Medication
….VINDICATE away
Rhinorrhoea
Irritation
Rhinitis
RhinoSinusitis
Acute Bacterial RS
Chronic RS
 Bacterial infection of the
paranasal sinuses
 Ditto, but symptoms lasting
for 8-12 weeks.
 Symptoms for 7 - 28 days
 Lack of signs of acute
inflammation
• P Facial Pain/pressure/fullness
 D Purulent nasal Discharge
 Requires clinical
demonstration of sinus
inflammation (endoscopy or
imaging)
 S Smell: hyposmia/anosmia
 Multiple Causes
 O Nasal Obstruction
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
 No nasal symptoms
 Ache/pressure
 Pain, not pressure
 Location
 Location
 Bilateral
 Unilateral
 Typical triggers
 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
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
 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
 Computed Tomography
 Magnetic Resonance Imaging
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
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?
References