Книга_4540_Библиотеки_им_академика_М_И_Перельмана

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208

CHAP TER6 Theear

painful. Other sites of deposition include the olecranon bursa and proximal and distal interphalangeal joints of the ngers. It would be rare for the appearance of tophi to be the presenting symptom in a patient with gout. Small deposits can resolve on ur ic acid- lowering medication, larger deposits may require sur ger y to remove.

bAural fullness

This is the sensation of ‘ear fullness’, or ‘ear pressure’ of ten associated with tinnitus, hearing disturbance, autophony, nasal obstruction, and sore throat. It is often reported in the early stages of Ménière’s disease and idiopathic sensorineural hear ing loss. Ear fullness can be caused by Eustachian tube dysfunction, otitis media with eusion, and chronic otitis media. The underlying mechanisms may involve any part of the ear, from the external audit ory cana l to the inne r ear. Howeve r, in aroun d 10% of patient s no cause can be found. Rarely this can be a symptom of nasopharyngeal carcinoma.

bEar itching

Itching can be a symptom of ear infection, commonly otitis ex terna. Other possible causes include insect bites, cont act allergies, and trauma . Chickenpox is accompanied by red, oozing blisters that cause intense itching. Eczema, contact dermatitis, scabies, and ringworm are other sources of itching.

bPerilymphatic stulas

This is a pathological defect bet ween the air- lled middle ear and the uid- lled inner ear, in either the round window or oval window membranes. The result is leakage of perilymph uid from the semi- circular canals into the middle ear with changes in middle ear pressure transmitted directly to the inner ear. Symptoms include sensor ineural hearing loss, which can be sudden or progressive, vertigo, and tinnitus. It can be a congenital condition, the consequence of middle ear disease such as cholesteatoma, secondar y to tr auma or rapid pressure changes that can occur in SCUBA diving or following middle ear surgery. Denitive diagnosis is by means of surgery with direct visualization of the stula. Symptoms can resolve with bed rest, with sur ger y reserved for those with persistent symptoms.

Chapter7

209

The nose and nasoorbitoethmoid region

Common presentations 210 Common problems and their causes 210 Useful questions and what to look for 213 Examination of the nose 217 Useful investigations 218 Epistaxis (non- traumatic) 219 Nasal frac tures 220 Naso- orbitoethmoid fractures 221 Foreign bodies and infestation 222 Rhinitis 223 Septal problems 226 Tumours of the nose 227 Miscellaneous conditions 228 Anosmia (loss of sense of smell) 229 Rhinorrhoea:‘runny nose’ 230 Nasal congestion 230

210

CHAP TER7 The nose and naso-orbitoethmoid region

Common presentations

Common presentations for the nose/ nasoethmoid region:

• Blockednose

• Crustynose

• Epistaxis

• Injuries

• Irritation/ itchiness

• Loss of smell (anosmia)

• Oensive smell (cacosmia)

• Pain

• Runnynose

• Sneezing

• Swelling.

Common problems and theircauses

Blockednose

Common

• Rhinitis (allergic, vasomotor)

• URTI

• Sinusitis

• Trau m a

• Anatomical variations (e.g. septal deviation, concha bullosa).

Uncommon

• Nasalpolyps

• Side eect of medication

• Rhinitis medicamentosa

• Hormonal changes (e.g. pregnancy, puberty, hormone replacement

therapy, hypothyroidism).

Rare

• Severe GORD, empty nose syndrome

• Tumour (nasal or sinus)/ Wegener’s granulomatosis

• Nasal myiasis.

Crustynose

Common

• Dry environment

• Atrophic rhinitis

• Staphylococcal infection.

Uncommon

• Tumour

• Previous nasal surgery

• Ciliary disease, e.g. cystic brosis

COMMON PROBLEMS AND THEIRCAUSES

• Chronic nose picking

• Basal cell carcinoma

• Vestibulitis

• Perforated nasal septum.

Epistaxis

Common

• Trau m a

• Sinusitis

• Foreignbody

• Anticoagulant therapy

• Chronic nose picking.

Uncommon

• High altitude

• Hypertension

• Na sal surger y

• Bleeding disorders.

Rare

• Leukaemia/ lymphoma

• Nasal/ sinus tumours/ Wegener’s granulomatosis

• Septal perforation.

Injuries

Common

• Fractures

• Septal haematoma

• Minor injuries

• Foreign bodies (especially in children)

• Lacerations.

Uncommon

• Bites.

211

Irritation/ itchiness

Common

• Allergic rhinitis

• Asthma.

Uncommon

• Fungal infection

• Chronic nose picking

• Tumour (nasal or sinus)

• Nasal myiasis.

212

CHAP TER7 The nose and naso-orbitoethmoid region

Loss ofsmell (anosmia)

Common

• Trauma (skullbase)

• Postvir al.

Uncommon

• Nasal/ sinus tumours

• Nasal polyps

• Post sur ger y.

Oensive smell (cacosmia)

Common

• Atrophic rhinitis

• Sinus infection.

Uncommon

• Fungal infection

• Dental infection

• Tumours

• Psychological.

Pain

Common

• Trau m a

• Infection (abscess)

• Foreignbody

• Facialpain.

Uncommon

• Sinusitis

• Relapsing polychondritis

• Tumour (nasal or sinus)/ Wegener’s granulomatosis

• Nasal myiasis.

Runnynose

Common

• Rhinitis (allergic, vasomotor)

• URTI

• Sinusitis

• Nasalpolyps

• Foreign body (especially in children).

Uncommon

• CSF

• Hormonal changes (e.g. pregnancy, puberty, hormone replacement

therapy, hypothyroidism)

• Migraines/ cluster headaches

• Recreational druguse

• Tumour (nasal or sinus).

Rare

• Churg– Strauss syndrome

• Wegener’s granulomatosis.

Sneezing

Common

• Rhinitis (allergic, vasomotor)

• URTI

• Environmental irritants.

Uncommon

• Rhinitis medicamentosa

• Trau m a

• Opiate withdrawal.

Swelling

Common

• Abscess

• Sinusitis

• Trau m a

• Septal haematoma.

Uncommon

• Nasalpolyps

• Tumour (nasal orsinus)

• Nasalglioma

• Dermoidcyst

• Dentoalveolarcyst

• Rhinophyma.

USEF UL QU ESTI ONS AND WHAT TO LOOKFOR

213

Useful questions and what tolookfor

Blockednose

Askabout

• Pain, bleeding, foulsmell

• Onset:sudden or gradual

• Progression

• Previous episodes

• Unilateral or bilateral

• Histor y of tr auma/ travelabroad

• Childhood history

214

CHAP TER7 The nose and naso-orbitoethmoid region

• Previous treatment:?perennial problem

• Medications applied.

Lookfor

• Foreign body/ infestation

• Nasal deviation

• Septal deviation

• Septal haematoma

• Obstruction:nasal polyps, turbinate hypertrophy, congested

middlemeatus

• Discharge

• Inamed mucosa.

Crustynose

Askabout

• Pain

• Progression

• Unilateral or bilateral

• Previous episodes

• Histor y oftr auma

• History of nose picking

• Histor y of previous treatment

• Medications applied.

Lookfor

• Whether crustiness is dry ormoist

• Signs of infection

• Adjacent tissues (? basal cell carcinoma/ squamous cell carcinoma)

• Foreign body:unilateral nasal vestibulitis ± discharge in children is

almost diagnostic of a foreignbody.

Epistaxis

Askabout

• Previous episodes

• Histor y oftr auma

• How much blood has beenlost

• Unilateral or bilateral

• Nose picking

• Medications.

Lookfor

• CheckBP

• One or bothsides

• Any foreign body, polyps, intranasal tumours

• Signs of infection

• Signs of septal perforation.

USEF UL QU ESTI ONS AND WHAT TO LOOKFOR

Injuries

Askabout

• When it occurred

• Mechanism ofinjury

• Neck/ headinjur y

• Progression of symptoms since time ofinjury

• Other injuries.

Lookfor

• Other injuries

• CSF leakage

• Intercanthal distance

• Vision, diplopia

• Na sal deviation, septal haematoma

• Lacerations.

Irritation/ itchiness

Askabout

• Known precipitants, travelabroad

• Any discharge

• Unilateral or bilateral

• Previous episodes

• Concurrent symptoms (sneezing, irritation, itchy eyes)— rhinitis

• Medications applied.

Lookfor

• Signs of congestion

• Foreign body/ infestation

• Nasal polyps.

215

Loss ofsmell (anosmia)/ oensive smell (cacosmia)

Askabout

• Constant or intermittent

• Sudden or gradual

• Histor y oftr auma

• Headaches

• Nasal discharge/ bleeding

• Obstruction.

Lookfor

• Discharge

• Foreignbodies

• Nasalpolyps

• Intranasal tumours

• Basal skulltrauma.

216

CHAP TER7 The nose and naso-orbitoethmoid region

Pain

Askabout

• Type/ site ofpain

• Histor y oftr auma

• Swelling

• Discharge

• Loss ofsmell.

Lookfor

• Signs ofinjur y

• Infection (skin, septum, sinuses).

Runningnose

Askabout

• Watery orthick

• Clear or coloured (blood, mucus,pus)

• Unilateral or bilateral

• Previous episodes, seasonal, diurnal variation

• Concurrent symptoms (sneezing, irritation, itchy eyes)— rhinitis

• Histor y oftr auma

• Other symptoms (sneezing, irritation, itchyeyes)

• PMH of atopy, asthma, previous treatments, medications.

Lookfor

• Conrm present

• Signs of congestion

• Foreignbody

• Nasalpolyps

• Mucous retentioncysts

• Intranasal tumours.

Sneezing

Askabout

• Known precipitants

• Discharge

• Previous episodes, number of bouts perday

• Other symptoms (irritation, itchyeyes)

• Medications applied.

Lookfor

• Signs of congestion

• Foreignbodies

• Nasalpolyps

• Conjunctivitis.

EXAMIN ATION OF THENOSE

Swelling

Askabout

• How long/ progression

• Histor y oftr auma

• Painful/ painless

• Discharge

• Loss ofsmell.

Lookfor

• Signs of injur y, septal haematoma

• Internal/ external component

• Solid/ cystic

• Surface characteristics (normal mucosa/ haemorrhagic/ pus)

• Abscess.

Examination ofthenose

The structure of the nose is related to its function:the large surface area of mucosa over the turbinates humidies, warms, and lters particles from the air. The roof of the nose contains specialized neuroepithelium to provide the sense of smell. Normal air ow uctuates slightly through each nostril (nasal c ycle).

Thorough examination of the nose requires special equipment:

• Headlamp.

• Na sal mirror and tongue spatula:it may be necessary to anaesthetize

the oropharynx with topical anaesthesia prior to examining the postnasalspace.

• Thudichum’s speculum:this is useful to view the anterior – inferior

nasal septum including Little’sarea.

Position the patient in a chair slightly higher than your own. Ask the patient to remove any glasses.

Externalnose

• Examine the skin for lesions or scarring.

• Note any redness, discharge, crusting, or oensivesmell.

• Palpate the nasal bones and lateral car tilages, looking for asymmetr y,

mobility, or other abnormality.

• Have the patient tilt their head back to allow you to inspect the

columella and alar cartilages.

Internalnose

• Examine the appearance of the na sal mucosa, including colour,

texture, and hydration.

• Check for inammation, position of the septum, and presence of

polyps (insensitive to touch).

• Aforeign body, usually accompanied by an oensive unilater al

discharge, may be seen inside the nose of a child. Infestation israre.

217

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