Книга_4540_Библиотеки_им_академика_М_И_Перельмана

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228

CHAP TER7 The nose and naso-orbitoethmoid region

Miscellaneous conditions

bNasalglioma

A benign polypoid swelling att ached to the septum which presents in infants and children. A CT scan is needed to exclude (rare) intracranial attachment, and biopsy is required to conrm the diagnosis.

bDermoid

A cystic swelling often just above the medial canthus, sometimes with a sinus. As there may be extension of the cyst deep to the nasal bones or orbit, CT is often required.

bNasoalveolarcyst

This causes external attening of the nasolabial fold and aring of the alae nasi. In the anterior nares the cyst extends into the oor of the nose and displaces the inferior turbinate upwards. Be careful these are not dental in origin. Request an OPT. Management is surgical.

bRhinophyma

Here, the sk in becomes thickened and vascular and may produce gross deformity. Shaving/ lasering the excess skin without skin grafting is possible. Irregular areas of epithelium should be sent for histology since basal or squamous cell carcinoma may occur within a rhinophyma.

bVestibulitis

Eczema of the vestibular skin can result from nasal discharge and skin infection. It can aect both nostrils. This may cause crusting, irritation in the anterior nares, and nasal obstruction. Causes include nose picking, overly vigilant cleaning, and inhaled recreational drug. Treatment includes antibiotic and corticosteroid ointments.

bRelapsing polychondritis (atrophic polychondritis/ systemic chondromalacia)

This is a presumed autoimmune disease characterized by inammation and destruction of car tilage. Although the disease usually causes pain and deformity if unrecognized and untreated, it can be life- threatening when the respiratory tract, heart valves, or blood vessels are aec ted. It commonly presents in patients in their late 40s to early 50s although children and young adults may also be aected. Any car tilage may be aected, although in many cases the disease aects several sites, while sparing others. Common sites include the nose, ears, joints, and rib cage. Tracheomalacia and vasculitis can also occur. One sign to look for is a painful, red, and swollen ear. There is no specic test for relapsing polychondritis although inammator y markers (such as ESR or CRP) may be high. Biopsy may help with the diagnosis. Treatment is of ten systemic steroids sometimes with azathioprine or cyclophosphamide.

ANOSMIA (LOS S OF SENSE OFS MELL)

bAnosmia (loss ofsense ofsmell)

Reduc tion in the sense of smell (hyposmia) is relatively common and temporar y. However, total and permanent anosmia is rare and has many causes. Some people may be anosmic for one particular odour— ‘specic anosmia’. Very often no cause for anosmia can be found. Nevertheless this can be an early indication of serious patholog y.

Commonercauses

• URTI (e.g. sinusitis or the commoncold)

• Nasalpolyps

• Head trauma, damage to the ethmoidbone

• Tumours of the front allobe

• MS

• Asthma/ hay fever

• COPD

• Long- term alcoholism

• Cushing’s syndrome

• Stroke

• Epilepsy

• Radiation therapy to the head andneck

• Liver or kidney disease

• Parkinson’s disease

• Alzheimer’s disease

• Primar y ciliary dyskinesia

• Olfactor y esthesioneuroblastoma

• Intranasal druguse

• Smoking

• Pernicious anaemia

• Zinc deciency

• Sarcoidosis

• Chronic atrophic rhinitis

• Paget’s disease ofbone

• Wegener’s granulomatosis

• Primar y amoebic meningoencephalitis.

Presentation

Patients with anosmia may nd food less appetising. It can also be potentially dangerous because it hinder s the detection of gas leaks, res, etc. Occasionally losing an associated sentimental smell memory has been reported to cause feelings of depression. Rarely loss of olfaction may lead to the loss of libido.

Investigations

This can be conrmed using commercially available ‘smell testing kits’. Imaging studies (CT/ MRI) may be required.

Management

This is to treat the underlyingcause.

229

230

CHAP TER7 The nose and naso-orbitoethmoid region

bRhinorrhoea:‘runnynose’

This is a condition in which the nasal cavity is lled with a signicant amount of clear uid. It is a common symptom seen in allergies and URTIs. It also occurs following exposure to cold air/ cocaine or withdrawal from opiate drugs. Additional symptoms include sneezing, nosebleeds, anosmia, and nasal discharge.

Causes

• Exposure to coldair

• Infection (especially common cold and inuenza)

• Allergies (especially pollen, dust, and animals)

• Lacrimation

• Head trauma (CSF rhinorrhoea)

• Opioid withdrawal

• Cystic brosis

• Whoopingcough

• Nasal tumours

• Cluster headaches

• Primar y ciliary dyskinesia.

Management

In most cases treatment is not necessar y. Saline nasal sprays and vasoconstrictor nasal sprays may be used, but prolonged use causes rhinitis medicamentosa. Any identied underlying cause should be managed accordingly.

bNasal congestion

This is not to be confused with the nasal cycle, which is a normal (and usually unnoticeable) cycle of alternating partial congestion and decongestion of the nasal cavit y, often aecting one side and then the other. This is physiological congestion.

Pathological nasal congestion has many causes and can var y signica nt ly. Nasal congestion in an infant can interfere with breastfeeding and

cause respiratory distress. This is because they are obligate nasal breathers.

Causes

• Common cold or inuenza

• Deviatedseptum

• Hayfever/ allergic reaction

• Rhinitis medicamentosa

• Sinusitis

• Nasalpolyps

• Empty nose syndrome

• GORD.

The treatment of nasal congestion frequently depends on the underlying cause. Antihistamines and decongestants may beused.

NASAL CONGESTION

cEthmoid sinusitis

This usually occurs with other sinus infections (see E Chapter 3 and E Chapter 9). Patients complain of deep- seated throbbing pain, deep

to the bridge of the nose, bet ween the eyes. The medial orbital walls are paper thin, so orbital cellulitis can rapidly develop. Infection can also ascend into the frontal sinus. Chronic sinus disease in the ethmoid sinuses can

predispose to polyps.

Clinical features

• Headache/ facialpain.

• Sensation of dull, constant pressure over the aectedsinus.

• Symptoms are usually localized over the involved sinus and are of ten

made worse on bending, straining or lyingdown.

• Nasal discharge.

• Halitosis.

• Post- nasaldr ip.

Management ofsinusitis

Antibiotics and, in some ca ses, sinus washout with opening of the draining channels, using functional endoscopic sinus surgery. Ephedrine nasal drops and menthol inhalations may help reduce congestion and improve sinus drainage.

231

Chapter8

233

Thethroat

Common presentations 234 Common problems and their causes 234 Useful questions and what to look for 236 Examination of the throat 238 Useful investigations 240 The infected throat 241 Pharyngeal infections 242 Tonsil (adenotonsil) infections 244 Other types of throat infections 24 6 Chronic adenotonsillar hypertrophy 247 Hypopharyngeal/ upper oesophageal- related problems 248 Miscellaneous conditions involving the throat 251 Dysphagia and aspiration 253 Assessment of dysphagia 254 Cancers of the throat 256

234

CHAP TER8 Thethroat

Common presentations

Common presentations in the throat:

• Acid regurgitation

• Diculty swallowing (dysphagia)

• Foreignbody

• Painful swallowing (odynophagia)

• Snoring

• Sorethroat

• Swellings/ lumps in the throat.

Common problems and theircauses

Acid regurgitation

Common

• Hiatushernia

• GORD

• Medications, spicy foods, acid/ alcoholic drinks.

Uncommon

• Paterson– Kelly syndrome

• Zenker’s diverticulum

• Achalasia

• Oesophageal diverticula

• Oesophagealcancer

• Eosinophilic oesophagitis.

Diculty swallowing (dysphagia)

Common

• Diuse oesophagealspasm

• Hiatushernia

• GORD.

Uncommon

• Paterson– Kelly syndrome

• Zenker’s diverticulum

• Benign strictures

• Retrosternalgoitre

• Achalasia

• Oesophageal diverticula

• Scleroderma

• Webs andrings

• Oesophagealcancer

• Eosinophilic oesophagitis

• Motor disorders.

Foreignbody

Common

• Fish/ rabbitbone.

Uncommon

• Meat/ bread

• Coins/ sharp objects.

Painful swallowing (odynophagia)

Common

• Ver y hot/ cold food ordrink

• Drugs

• Ulcers

• URTIs/ quinsy

• Foreign body (especially sh bones).

Uncommon

• Immune disorders

• Epiglottitis

• Tumours

• Motor disorders.

Snoring

Common

• Physiological (obesity)

• Obstructive sleepapnoea

• Sedative drugs/ alcohol

• Enlarged tonsils/ adenoids

• Retruded mandible.

Uncommon

• Nasalpolyps

• Tumours.

COMMON PROBLEMS AND THEIRCAUSES

235

Sorethroat

Common

• Tonsillitis

• Pharyngitis

• Dental infections

• Foreign body (sh bones).

Uncommon

• Acid regurgitation

• Snoring

• Tumour.

236

CHAP TER8 Thethroat

Swelling/ lump inthethroat

Common

• Tonsillar enlargement ± tonsilloliths

• Swollenuvula

• Foreign body (sh bones).

Uncommon

• Deep neck space abscess

• Papilloma/ leucoplakia

• Tumour

• Globus/ psychogenic.

Useful questions and what tolookfor

Acid regurgitation

Askabout

• Describe symptoms/ treatments

• Globus sensation or burning sensation inthroat

• Dysphagia and frequent throat clearing

• Early morning hoar seness and nocturnalcough

• Postnasaldrip

• At ypical chest pain (may mimic hear t att ack)

• Predisposing factors (obesity, pregnancy, alcohol, smoking)

• Medications (steroids, NSAIDs, antacids)

• Dietar y histor y (spicy foods, acid drinks, caeine).

Lookfor

• Posterior pharyngeal wall erythema

• Congestion and granular changes

• Indirect laryngoscopy if possible.

Diculty swallowing (dysphagia)

Askabout

• Onset

• Where obstruction isfelt

• Intermittent or progressive

• Solids or liquids orboth

• Weightloss

• Vomiting/ regurgitation

• Symptoms of aspiration (coughetc.).

Lookfor

• Swollen/ displacedtonsil

• Lymphadenopathy

• Ulceration

USEF UL QU ESTI ONS AND WHAT TO LOOKFOR

• Tumour

• Anaemia/ cachexia

• Examinechest

• Cr anial ner veexam

• Indirect laryngeal exam or nasopharyngealscope.

Foreignbody

Askabout

• Description ofobject

• Dysphagia, gagging, choking.

Lookfor

• Airway patency

• Locate object.

Painful swallowing (odynophagia)

Askabout

• Onset

• Intermittent or progressive

• Weightloss

• Vomiting

• Symptoms of aspiration.

Lookfor

• Lymphadenopathy

• Ulceration

• Tumour

• Anaemia/ cachexia

• Examinechest.

Snoring

Askabout

• Onset

• Intermittent or progressive

• Sleep deprivation, eect onwor k

• Daytime drowsiness

• Irritability

• Lack offocus

• Decreased libido (if appropriate).

Lookfor

• Enlarged/ displaced tonsils

• Enlargeduvula

• Collarsize

• Obesity

• Retruded mandible

• CheckBP.

237

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