4. Nose.pdf

NOSE AND PARANASAL SINUSES By Dr Reshma Patel WATCH Bates' Physical Examination Videos VOLUME8. NOSE, MOUTH, AND NECK NASAL OBSTRUCTION Aetiology Large adenoids. Suspect if  The soft palate is depressed  The soft palate does not move upwards on saying “Aah”  The patient has nasal speech...

NOSE AND PARANASAL SINUSES By Dr Reshma Patel WATCH Bates' Physical Examination Videos VOLUME8. NOSE, MOUTH, AND NECK NASAL OBSTRUCTION Aetiology Large adenoids. Suspect if  The soft palate is depressed  The soft palate does not move upwards on saying “Aah”  The patient has nasal speech  There are associated large tonsils Allergic rhinitis Foreign body Nasal polyps Recurrent sinusitis Recurrent infections Nasopharyngeal tumours- rare Clinical features Recurrent or constantly blocked nose Patient may breathe through the mouth Severe snoring The patient may have clear nose and breathe well during the day May have deformity of the palate or front of mouth due to mouth breathing Halitosis Complications of mouth breathing Teeth growing inward resulting in malocclusion problems (crooked teeth) Sleep apnoea (obstruction to respiration during sleep) Anoxia Pulmonary hypertension Refer If cannot treat adequately. RHINITIS Is an inflammation of the nasal mucous membrane with resultant nasal congestion, rhinorrhoea and variable associated symptoms depending on aetiology (e.g. itching, sneezing, purulence, anosmia, ozena) ACUTE VIRAL RHINITIS It is associated with coryza (common cold) Aetiology A variety of viruses Clinical features It presents in minor epidemics in winter with sudden onset involving several family members. Watery nasal discharge often with headache Blocked nostrils with sneezing. Sore throat (usually mild) Crusting around the nose of the child. Inflamed nasal mucosa and throat mucus membrane. Management Symptomatic treatment Vitamin B complex and a vitamin supplement- zinc supplement shown to reduce duration of a cold. Encourage fluid and rest Saline nasal drops are if the blocked nose is obstructing sleep or feeding. Vaporizers / humidifiers may be of some use Antibiotics are not indicated (cause are not effective against viruses) Decongestants- Oral N-acetylcysteine has been advocated as a mucolytic agent - sambucus, hydrastis cand. Mother tincure- drainage, Pelargonium sidoides Boost immune system – Echinacea pur MT, Sinupret: (Cowslip (Primula veris/elatior): The active substances of cowslip’s flowers and calyx are mucolytic, anti-inflammatory and combat the disease-causing pathogens, namely, viruses and bacteria. Yellow gentian (Gentiana lutea): The plant part used for medicinal purposes is the root, which contains substances with an anti-inflammatory action.; Black elder (Sambucus nigra): The flowers of the black elder have a mucolytic action; Common sorrel (Rumex species): Its active substances from the leaves and stems also have a mucolytic action and an anti-inflammatory effect. In addition, they support the body’s own defences and exhibit an antibacterial action.; Vervain (Verbena officinalis): The active substances from the leaves and stems also have a mucolytic action, are anti-inflammatory and combat viruses. )  HOMOEOPATHIC REMEDIES Aconite Indicated in the first stages, commencement of illness. Nose is dry and no discharge. The nose is swollen from congestion and is dry and stopped-up. This stoppage changes from side to side with tingling and burning in the nose. There may be sneezing. Better in open air. Arsenicum album Thin, watery, irritating discharge. Constant desire for sneezing. Hay fever. Euphrasia Profuse fluent, bland coryza with much watering from eyes. Eyes burn. Allium cepa Sneezing, burning and itching of nose and eyes. Profuse, clear nasal discharge which is acrid and excoriating. Sneezing when entering a warm room. Fluent coryza with headache, cough with hoarseness. Belladonna Frequent sneezing and tickling in nostrils. Dryness of nose. Fluent coryza from one nostril only. Imaginary odours. Gelsemium Sneezing, fullness at root of nose. Watery excoriating discharge. Sneezing, thin, acrid coryza. Early morning sneezing and streaming of water from nose. Coryza in changeable weather. Kali mur Dull pain in the sinus area. Thick white mucous discharge, congestion in forehead. ACUTE PURULENT RHINITIS It usually results from bacterial super-infection of the common cold. Clinical features Coryza is becoming worse Thick purulent nasal discharge Yellow impetigo like crusts in the nostrils as result of Streptococcus infection Differential diagnosis Foreign body especially if unilateral Syphilis in the new-born (with hepato-splenomegally, peeling of hands and feet as well as fissures at angles of mouth) Drug abuse e.g. Glue sniffing Management Saline nose drops to help wash out secretions Penicillin VK 3 x daily for 5-7 days, if no response change to Amoxicillin / ampicillin for 7 days Refer If no improvement after 7 days If you suspect a serious cause e.g. Foreign body If there is persistent unilateral discharge If there is unexplained blood stained discharge ALLERGIC RHINITIS It is a very common disorder Aetiology Allergens such as pollen, dust, feathers, eggs, milk, wheat, fruits, certain drugs, moulds and animal danders. Bacteria Insertion of Vaseline in the nostrils or washing the nose with water and soap. Alcohol Hormonal (in Hay fever) - a sex hormonal imbalance may be present e.g. It gets worse with puberty Vasomotor rhinitis which is a reaction to outdoor temperature changes causing a blocked or runny nose Clinical features Recurrent watery nasal discharge Recurrent episodes of blocked stuffy nose Frequent sneezing, conjunctivitis and itchy soft palates with constant desire to clear the throat. Nasal mucosa is swollen and pale greyish Repeated upward rubbing of the nose with back of hand (ALLERGIC SALUTE) to try get rid of the itch. Mouth breathers Management Avoidance of the known allergen Saline nose drops Re-assess patients after the first month. Continue with therapy if there has been definite improvement Average period of treatment is about 3 months Put patients on elimination diet if you suspect that reaction is due to diet. Desensitize the patient- homeopathic mixed allergens Recommend using a neti pot Refer If no improvement to the treatment Nutrients: Bromelain- 1000mg tds between meals- reduces inflammation associated Coenzyme Q10- 30 mg bd- improves oxygenation and immunity Quercetin 400 mg bd, before meals- A bioflavonoid that stabalises the membranes of cells that release histamine Vitamin C with bioflavonoids 3000-10000mg tds- a potent immune-stimulant and anti- inflammatory, use buffered form Zinc 50-80mg daily- do not exceed- boosts immune function (use zinc gluconate lozenges) Herbs Eucalyptus oil- can relieve congestion if used in a steam inhalation Eyebright Hydrasitis tincture- do not use for more than a week at a time on a daily basis, it may disturb normal intestinal flora Turmeric/ curcumin to reduce inflammation Nettle leaf NASAL FURUNCLE It results from an infection of a hair follicle in the nose Aetiology Micro injuries Bacterial infections e.g. Staphylococcal infection Clinical features A small tender, red swelling in the anterior part of the nose. Management Prick the point with a needle Warn the patient not to squeeze or incise the furuncle as this may push the pus into a vein draining into the cavernous sinus Follow up with the patient until the furuncle clears NASAL POLYPS These are pedunculated masses of tissue that consist of oedematous mucosa. They are often very difficult to diagnose Aetiology They are usually a sign of nasal allergy They also result from chronic ethmoiditis Clinical features They are generally multiple and bilateral producing nasal blockage The resultant stagnation of secretion is likely to cause sinusitis Mucoid or purulent discharge They appear greyish in colour and more fleshy Refer If your treatment offers no improvement If it causes breathing difficulties EPISTAXIS Is nose bleeding - it is generally a benign symptom but causes anxiety in patients and relatives Aetiology Local  Rhinitis  Minor trauma  Severe trauma e.g. Fracture  Varicosities or heamangiomas in little’s area (the anterior part of the nasal septum)  Tumours of the nose General  Haematology disorders  Cardiovascular valve disease - https://www.sciencerepository.org/heydes-syndrome-a-forgotten-association_SCR-2021-1-104  Hypertension  Renal disease  Liver disease Fevers  Before onset of measles, mumps and other childhood diseases. Drugs  Chronic Aspirin ingestion  Anticoagulants e.g. Warfarin  Alcohol causes liver damage then bleeding disorders Clinical features Bleeding usually arises from little’s area, and less commonly from far back in the nose from lateral wall- as seen in epistaxis from hypertension. Little’s area is usually red with either fresh clots or old crusts Recurrent Epistaxis should be viewed with concern especially if there is a history of frequency, melena or hematemesis. Management Reassure the patient The patient must sit with his / her head bend slightly forwards and pinch the nostrils firmly for 10 minutes and mouth must be kept open Advice the patient not to blow the nose Follow up the patient to check his / her Hb Treat the cause Nasal packing using Merocel tampon or Calgite or Ribbon gauze is usually performed to stop bleeding. If patient bleeds at the back - refer. Refer If drip is needed If bleeding is recurrent If there is abnormal bleeding anywhere in the body If you suspect foreign body or tumour If bleeding fails to respond to the treatment FOREIGN BODIES Anything small to enter the nose could become a foreign body Three type of foreign body Insects Vegetable matter Non-vegetable matter Clinical features Its common in small children It is usually detected by parents soon after insertion Often detected late when there is unilateral purulent, offensive discharge or blood stained nasal discharge. Blocked nostril, usually unilateral Other features include epistaxis, halitosis and nasal obstruction Management Clear the nose from any secretion by gentle suction Try hard nose blowing in adults Try dental wax stuck on orange stick Soft objects may be removed with crocodile forceps Refer If nothing works If there is any difficulty breathing FRACTURED NOSE Clinical features Most blows cause swelling, suspect fracture if there is:  Swelling and discolouration of the skin and subcutaneous tissue covering the nasal bone and in surrounding area.  Epistaxis especially if persistent  Deformity may or may not be present  Deformity is usually deviation of the nose towards one side  Crepitus of the nasal bones  Obstruction to air passages  Pain  The nose will look or feel crooked.  Diagnosis of displaced nasal fracture is the clinical diagnosis. Management Treat epistaxis and any associated injuries Refer If you suspect fractured nose SEPTAL HAEMATOMA This is a haemorrhage between the layers of the nasal septum. Aetiology Trauma Associated with a fracture Clinical features Haematoma carries risk of cartilage necrosis which can result with septal perforation. Severe complete nasal obstruction with boggy nasal septum swelling. Refer If suspect septal haematoma SEPTAL DEVIATION It is the common cause of nasal obstruction Aetiology Developmental Trauma Clinical features Nasal obstruction Septal deformity is usually obvious on examination. Management If mild the no treatment If severe then refer for surgery SEPTAL PERFORATION Aetiology Trauma e.g. MVA, Boxers Surgery Syphilis Chemicals TB Tumours Clinical feature Often there are no symptoms Epistaxis and crusted mucus Occasionally whistling on inspiration and expiration Refer If you suspect this condition SEPTAL ABSCESS Aetiology Infections Trauma Clinical features Pyrexia with tender and a blocked nose Septal swelling Complications Septicaemia Meningitis Cavernous sinus thrombosis Pressure necrosis ORBITAL CELLULITIS Aetiology It follows ethmoid or frontal sinusitis Clinical features Proptosis (the eyeball projects forwards) The eyeball is unable to move Loss of visual acuity Periorbital swelling with evidence of sinusitis Refer If suspect this refer stat CAVENOUS SINUS THROMBOSIS Is a very rare, typically septic thrombosis of the cavernous sinus, usually caused by bacterial sinusitis. Aetiology Complication of sinusitis, nasal furuncle, otitis media and cholesteatoma Clinical features Sign resembling orbital abscess and are usually bilateral Refer This is serious, refer stat SINUSITIS SINUSITIS An inflammation of the paranasal sinuses due to viral, bacterial, or fungal infection or allergic reactions. ACUTE SINUSITIS This refers to the acute inflammation. Aetiology Poor drainage of the sinuses e.g. Polyps, deviated nasal septum Allergic rhinitis Overuse of nasal decongestants Infection Clinical features The mucous membrane is inflamed, oedematous and forms pus. The sinus ostia is blocked Symptoms are mild except when there is infection Pain or headache usually referable to a particular sinus, felt bending forward and pain being worse in the morning Maxillary sinus pain often referred to the upper incisor and canine teeth Nasal obstruction usually unilateral Nasal discharge- may be intermittent Halitosis Post nasal drip often causing sore throat and cough, cough worse at night because of the post nasal drip. Purulent discharge may be seen under the middle turbinate bone There may be purulent post nasal drip Cough of post nasal drip may be the only symptoms Pyrexia with sinus tenderness  Maxillary- tenderness over the cheek just lateral to the alae nasal  Ethmoid sinusitis- tenderness medial to the canthus of the eye, a slight redness around the inner canthus may be diagnostic.  Frontal sinusitis- tenderness over the supra orbital ridge Always exclude sinusitis in children when they complain of headache Complications Osteomyelitis Meningitis or brain abscess Chronic otitis media Chronic sinusitis Pneumonia Orbital cellulites CHRONIC SINUSITIS Aetiology The same as for acute sinusitis Clinical features The mucous membrane lining becomes thickened and sometimes polyps develops Halitosis Nasal and post nasal discharge Sometimes nasal obstruction Pain is uncommon Chronic cough usually worse in the morning. Management Saline drops frequently in fairly large volumes 3-6 drops Can use Sodabic nose solution: 1 teaspoon of salt and 1 teaspoon of bicarbonate of soda in 500ml luke warm water. Inhale small quantities every 4-6 hours.  It is better than normal saline  It dissolves pus to create thinner and more manageable sinus discharge.  Warm compresses or ice packs to help with pain  Neti pot- nasal irrigation with saline water  Vapourizer- add few drops of eucalyptus oil  Eliminate sugar salt and dairy from diet Nutrients for sinusitis: Acidophilus- replaces good bacteria in colon, important if antibiotics are prescribed. Flax seed oil- reduces inflammation Bromelain- 1000mg tds between meals- reduces inflammation associated Coenzyme Q10- 30 mg bd- improves oxygenation and immunity Quercetin 400 mg bd, before meals- A bioflavonoid that stabalises the membranes of cells that release histamine Vitamin C with bioflavonoids 3000-10000mg tds- a potent immune-stimulant and anti-inflammatory, use buffered form Vitamin B Complex- aids in healthy immune system Zinc 50-80mg daily- do not exceed- anti-viral, boosts immune function (use zinc gluconate lozenges) Colloidal silver- natural antibiotic Garlic- 2 capsules tds- immune stimulant, antibiotic Herbs Eucalyptus oil- can relieve congestion if used in a steam inhalation Eyebright Hydrasitis tincture- do not use for more than a week at a time on a daily basis, it may disturb normal intestinal flora Turmeric/ curcumin to reduce inflammation Nettle leaf Olive leaf extract/Echinacea - antibacterial and antiinflammatory Refer If there is a need for antibiotics If orbital cellulites and cavernous sinus thrombosis develops. If sinusitis is associated with dental infection If no improvement with your treatment **Remedies: Manual Of Clinical Homeopathy by Moiloa Pg:41 -43 Read : wyethia helenoides TUMOURS OF THE MAXILLARY SINUS It is the most common malignant tumour of the nose and paranasal sinuses. Aetiology Chronic abuse of snuff or smoking Clinical features Unilateral nasal obstruction Epistaxis Pain and swelling of the cheek Unilateral offensive nasal discharge Swelling and ulceration of the palate Watering eye due to involvement of the nasolacrimal duct Proptosis and diplopia Lymphadenopathy Management Refer  FRACTURED MANDIBLE / MAXILLA Aetiology Trauma Clinical features Marked oedema and bruising Check for loose teeth as these occur commonly at fracture site Trismus or any loss of ability to open mouth should be viewed as a fracture Inability to clench teeth (bite on a spatula) Diagnose a fracture if there is:  A step in the alveolar margin  Any bony tenderness Diagnosis Confirm by X-ray Palpate the area of injury, insert a gloved finger into the patient’s mouth between the cheek and teeth, and palpate the alveolar margin in the suspicious area:  If tenderness is on the cheek side only, it is soft tissue injury  If there is bony tenderness along the gum, then is a fracture Refer If you suspect fracture HOMOEOPATHIC REMEDIES FOR NOSE AND PARANASAL SINUS DISORDERS Refer to K&K and Moila pg 41-44 Aconite At the commencement when the patient feels that he is catching cold, dry state and no discharge. The nose is swollen from congestion; and is dry and stopped up and this stoppage is apt to change from side to side with tingling and burning in nose and throbbing frontal headache; may be sneezing also, better in open air. There might be fever also Ars Alb For winter colds with thin, watery excoriation discharge with feeling of nose being stopped up. Sneezing does not relieve the throbbing frontal headache. Ars Iodide After meals is indicated, when burning in nose and throat is marked. Allium cepa Profuse discharge of bland water from eyes with burning water from the nose indicates this remedy. Terrible laryngeal cough may also be present in some cases. Belladonna Headache worse from motion or lying down; dull pain in frontal sinuses, cerebral excitement and swelling in throat are the chief symptoms If recovery from catarrh has been impeded by fresh exposure with pain over the eyes (right side) and face flush. Merc Sol The discharge is thicker and acrid in character and is fully established and is aggravated in damp weather. Also when the discharge is thin and watery from damp, with soreness and rawness in the nose and throat. Euphrasia Burning watery discharge from eyes and bland thin discharge from the nose. Justicia Adhatoda It stands between Allium cepa and Euphrasia Lachrymation, with coryza, profuse, fluent, with constant sneezing; loss of smell and taste; coryza with cough. Pulsatilla Is indicated in the advanced stages of a cold. The discharge is thick, yellow, mucopurulent and bland. This is relieved by cool air and aggravated by warmth; or when catarrh results from cold and the patient can neither smell nor taste, Pulsatilla cold plus sneezing requires Cyclamen. Hydrastis Is similar to Pulsatilla, but there is more burning, rawness and constant desire to blow, when cold has settled at the back of the nose and throat. Camphora It should be given in the first and initial stage of cold, when nose is stopped up and dry, and the inspired air feels cooler than usual. It is really indicated before Aconite. Gelsemium This remedy can break up a cold. It is indicated when there is congestion in the head, hot fever, and chilliness. The patient is dull and weak, and chill runs up and down the back with a watery, excoriating, or bland discharge from nose along with sneezing. Cold brought by warm weather. Nat mur Colds with watery, transparent discharges causing blister like eruptions about mouth and nose, which burst and leave thin crusts and scabs. Entire loss of taste or smell exists (sinusitis). The complaints are worse on going into open air, and on exertion; great dryness of posterior nares, watery, clear, frothy discharge from nose. Calc carb Purulent discharge foetid, thick yellowish, making lip sore, slimy discharge through the day, with sensation of stoppage; stoppage worse in the morning. Smell dull, like rotten eggs Arum triph Discharge of burning, fluid, excoriating nostril, upper lip corners of mouth. Constant boring and picking at nose and lips Hepar sulph Nose swollen and red, sensitive to touch, blowing the nose causes whizzing and snapping in the ear and a raw feeling inside of nose; feverish and sensitive to cold air; wants to be covered, even when hot. When fluent coryza suddenly stops and is followed by hoarseness and croupy cough. Kali Bich A sense of tight pressure at the root of nose, and dull heavy headache in forehead, better from pressing tightly the bridge of the nose, discharge is excoriating nose and lips. Yellowish ropy and stringy discharge. Worse in warm, better in cool temperature Lachesis Profuse discharge of thin, watery slime, soreness of nostril and lip; preceded for few days by a feeling of soreness, rawness and scraping in the throat. Violent headache in forehead, when the discharge suddenly dries up. Phosphorus Frequent alternation of fluent and dry coryza; obstruction often in the morning; or discharge from one and stoppage the other nostril; sneezing causes pain in throat or head and constriction of chest. Fauces feel raw and burning and appear dry and glistening. Hoarseness and bronchial catarrh. Smell and taste gone. Nux vom Ordinary cold at the commencement; when dry or fluent only through the day and stopped up at night; tingling in nose, scraping in throat; heat in head and pain in forehead; hot and feverish and chilly on moving. Smell as of old cheese; sulphur or cider. Constipation of new born children Arg nit Discharge of pus with clots of blood. Chilliness, lachrymation and stupefying headache. Violent itching of nose. Cuprum Affection of frontal sinuses, with pain in forehead, worse over left eye and root of nose, worse for motion, better when lying. Nose feels stuffed, and yet sometimes discharge yellow and again watery matter. Silica Secretion tough, slimy, purulent; stoppage in the morning followed by hacking of thick, green-yellow, foetid masses after getting up. Acrid water from nose making it sore and bloody. Chronic inflammation of tonsils and swelling of sub-mandibular glands Sulphur Slimy, acrid discharge with burning pain in eyes and upper lip; dryness of nose like parchment and a feeling of stiffness of the nose followed by discharge of thick, bloody slime and then again dryness with sneezing. Inclination to draw the phlegm down through posterior nares. On blowing the nose the ears feel obstructed, or feels as if air were entering the ears. The interior nose is sensitive to the inhalation of air in a warm room, not in open air. BIOTHERAPY Tissue salts: ferrum phos- first stage, fever and congestion, pain in sinus area, flushed face, rapid pulse, throbbing pains Kali mur-dull pain, white thick mucus discharge, congestion in forehead Nat mur- nasal obstruction with watery discharges, loss of sense of smell. Inflammation of sinuses with sensation of beating hammers in head