General Practitioner Assessment of the Inside and Outside of the Nose. Chris Thomson Otolaryngologist Head and Neck Surgeon

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1 General Practitioner Assessment of the Inside and Outside of the Nose Chris Thomson Otolaryngologist Head and Neck Surgeon

2 Nasal problems are very common in General practice but the nose is a difficult organ to examine!

3 Todays talk Some anatomy Discussion around why the nose is hard to examine and how to get around this Some pointers on history A quick review of some common conditions and my take on managing these Finish with minutes for discussion Please interrupt and ask questions!

4 Anatomy

5 ANATOMY Dunedin Rhinoplasty Course 2011

7 Chris Thomson Specialists at Nine August 2008

8 Chris Thomson November 2004

9 Chris Thomson Specialists at Nine August 2008

10 View with a headlight on a good day

15 ENDOSCOPIC VIEW AT FRONT OF NOSE (NEAR EQUIVALENT VIEW OF AN AUROSCOPE)

16 ORL Surgeons have it easy!

19 Equipment for examination GP

21 Nasal exam in General Practice External Straight? Skin? Lateral wall laxity - does it collapse in inspiration?

22 Nasal exam in General Practice Internal Headlight and thudicums Caudal and proximal septal position State of the mucosa Turbinate size Consider using a decongestant spray Any visible polyps, vessels, FBs etc

23 Can often be difficult to obtain good internal view of the nose in General Practice setting so history becomes all important

24 Patients come to you because their nose is: Blocked Discharging Bleeding

25 History Age of onset of symptoms Unilateral, bilateral or alternating Constant or intermittent Allergic history Exercise, alcohol induced rhinorrhoea Smoking, drug Hx, occupation Sinusitis symptoms (stuffiness and obstruction, hyposmia, PND and facial pressure/pain

26 Common conditions that you encounter in General Practice Adenoid hypertrophy Allergic and vasomotor rhinitis Epistaxis Nasal polyps Septal deviation Nasal fractures Sinusitis Nasal foreign bodies

27 Adenoid hypertrophy Can t see the adenoid so infer from history 2-5 year old children Obstruction is constant and bilateral Often associated with frequent discharge and colds - my son has had a cold all winter Snoring and OSA in younger children

28 Adenoid hypertrophy May coexist with allergic rhinitis in older children Look for tonsillar hypertrophy Treatment is observation or surgery REFER TO SECONDARY CARE IF OSA SUSPECTED or if patient severely troubled by obstruction

29 Allergic rhinitis 6-10 year olds Sneeze, itch, rhinorrhoea Bilateral or alternating nasal obstruction of variable severity and?seasonality Family history and general atopic history

30 Allergic rhinitis - examination Pale oedematous mucosa Watery clear discharge Large inferior turbinates Asthma and eczema Often referred to secondary care with polyps

31 Allergic rhinitis I almost never skin prick unless to prove that patients do not have allergic rhinitis Antihistamines may be useful in very young children but the effect on nasal obstruction is limited TOPICAL STEROIDS ARE THE MAINSTAY OF TREATMENT Compliance is often poor - many secondary referrals are simply a compliance issue

32 Allergic rhinitis -compliance with treatment Poor Often stopped by parents when well Irregular use Poor technique Parental concerns about the word steroid!

33 Allergic rhinitis -when to refer Uncertain diagnosis in a child with significant persistent symptoms despite ADEQUATE treatment? other cause of nasal obstruction Severe nasal obstruction due to AR where turbinate surgery may be indicated to enhance topical therapy

34 Epistaxis in General Practice Common Almost always anterior You can find 90% of bleeding sites in your rooms with a headlight and nasal speculum

35 Epistaxis in General Practice Which side? Anterior or posterior? Drug history Blood pressure Haematology Nose pickers

36 Epistaxis treatment Correct predisposing factors - trauma, dryness,vestibulitis, haematologic, cardiovascular Visualise, vasoconstrict and anaesthetise

38 Cautery pearls Be judicious - dab only small specific areas for 1-2 seconds only, right on the vessel Be careful about heavy bilateral cautery Advise patients that bleeds may still occur in the first week after treatment as the effect may be delayed Advise that treatment may need to be repeated

39 Epistaxis - when to refer If heavy and unstoppable If still recurrent episodes after treatment If no bleeding site visible with a headlight If you don t have experience

41 Nasal polyps

42 Nasal polyps Bilateral constant nasal obstruction Hyposmia Often asthmatic Often easy to see but equally often subtle

44 If you can see polyps Unilateral or bilateral? Start with topical steroids (lifelong) Consider tapering prednisone 60mg od for 1-2 weeks

45 When to refer polyps If they seem to be unilateral If you can t diagnose the cause of nasal obstruction If the polyps have not responded adequately to steroid therapy

46 Nasal fractures seen acutely You have a 2-3 week window before reduction is impractical Swelling can make initial assessment difficult Must exclude a septal haematoma - severe bilateral obstruction - all you can see on both sides of the nose is septum. Severe consequences if missed! Refer if septal or external deformity - ORL should see within 7-10 days

47 Nasal problems in the elderly Epistaxis Vasomotor rhinitis Nasal valve disorders - alar collapse Inferior turbinate hypertrophy

48 Vasomotor rhinits Cause by parasympathetic predominance Causes watery rhinorrhoea and nasal obstruction Mimics allergic rhinitis but patient s age is the clue

49 Vasomotor rhinits Ask about drugs that act on the autonomic system e.g Viagra, cardiac and bladder medications Ask about triggers - exercise, wine, spicy foods, perfumes, cosmetics, air-conditioning Prescribe ipratropium bromide If this fails try levostatin antihistamine spray

50 Inferior turbinate hypertrophy in the elderly Due to loss of tone in the venous sinusoids of the inferior turbinates Patients present with striking nocturnal nasal obstruction - huge impact on sleep quality Try ipratropium Refer for endoscopic inferior turbinate reduction if not response. They are very grateful patients!

51 Flimsy nasal side walls Inherant in some young adults Commoner with age Ask your patient to sniff and watch side wall and internal nose for collapse Try breathe rite strips or internal splints Refer for surgery if troubled by this

54 Sinusitis pearls A very common condition Often self limiting Facial pain is uncommonly a major complaint - think of other causes if it is Sinusitis is very over-diagnosed

55 Sinusitis pearls Consider if a patient has chronic nasal congestion and discharge that has not responded to an adequate trial of nasal steroids Trial a long course of antibiotics for 2-4 weeks (roxithromycin, augmenting, ceclor, doxycycline) Refer to ORL for endoscopy +/- CT scan if no response

56 Nasal foreign bodies - pearls 2-3 year olds or IHC patients Smelly unilateral discharge Only try to remove yourself if absolutely certain of success! Refer disc batteries immediately at any hour of the night!

57 Summary History very important in diagnosis Examination often difficult Try to become familiar with headlight, thudicums and use of a Cottles speculum Refer if uncertain re diagnosis or failure to respond to treatment

58 Q & A

59 Q & A Do you have any useful techniques that you use for nasal examination that you can share with the audience? What problems do you have with nasal examination Do you want the opportunity to sit in on our ORL OPD clinics?

Seasonal Allergic Rhinitis (Hay Fever)

Seasonal Allergic Rhinitis (Hay Fever) Link to prescribing guidance: http://www.enhertsccg.nhs.uk/ear-nose-and-oropharynx Clinical Presentation Link to CKS NICE guidance: https://cks.nice.org.uk/allergicrhinitis