Anosmia
Definition & DDx
Complete loss of the capacity to smell Endocrine/Metabolic
- Alcoholism
Anatomy & Risks - DM
Nasal obstruction/URTI - Hypo/hyperadrenalism
- Septal deviation - Vit B12 def
- Allergic Rhinitis - Zinc def
- Bacterial/viral infection e.g., - Malnutrition
influenza, COVID
Toxins/Others
Trauma - Smoking
- Foreign body - Drugs
- Nasal surgery - Radiation
- Base of skull fracture - Toxin exposure
- Nasal fracture
Investigations
Neoplastic - Anterior rhinoscopy
- Nasal polyps - Sensory testing
- Juvenile Nasopharyngeal - Imaging to rule out
Angiofibroma neoplasms/fractures/congenital
abnormalities
Nasal Obstruction
Definition & DDx Symptoms & Complications
Acute nasal blockage lasts <12wks - Difficulty breathing through the
nose
Anatomy & Risks - Nasal congestion
Common causes - Runny nose
- Viral infection e.g., influenza, - Sneezing
rhinovirus - Reduced sense of smell
- Allergic rhinitis
o Sneezing/itching/runny Investigations
nose/congestion - Depending on suspected
- Rhinosinusitis underlying cause, may include
o Facial pain/nasal imaging studies/allergy testing
discharge/congestion
- Nasal polyps Treatment/Management & Side effects
o Obstruction/reduced sense - Antihistamines/antibiotics/nasal
of smell/runny nose spray
- Septal haematoma - Surgical intervention
o Obstruction/pain - Lifestyle changes e.g., avoiding
- Tumours allergens, using humidifier
,Allergic Rhinitis
Definition & DDx
Inflammatory condition of nasal mucosa
DDx
- Sinusitis
- Nasal polyps
- Deviated nasal septum
- Common cold
Anatomy & Risks
IgE-mediated response to environmental allergens
- Pollen/dust mites
Can be seasonal, year-round or occupational
Symptoms & Complications
- Nasal pruritus
- Sneezing
- Rhinorrhoea
- Nasal congestion/bilateral obstruction
- Post-nasal drip
- Associated with allergic conjunctivitis
o Eye redness/puffiness
o Watery eye discharge
Investigations
- Skin prick tests to identify allergen if unknown
Treatment/Management & Side effects
- Avoid triggers
- Nasal irrigation with saline
- Short course of nasal decongestants e.g., oxymetazoline
o Do not use for long periods
o Increasing doses required to achieve same effect
o Rebound nasal mucosal hypertrophy may occur on withdrawal
- Intra-nasal / PO antihistamines
- Regular intranasal steroids if initial measures ineffective
- Oral steroids if severe and affecting QoL
- ENT referral if:
o Red flags
o Refractory cases
o Allergen testing
, Rhinosinusitis
Definition & DDx Anatomy & Risks
Inflammation of nose and paranasal Diagnosis requires ≥2 symptoms, with one
sinuses of:
- Commonly caused post-infective - Blockage/obstruction/congestion
Predisposing factors - Discharge (ant/post-nasal drip)
- Nasal obstruction Most common infectious agents
- Recent local infection e.g., rhinitis, - Strep. Pneumoniae
dental extraction - H. influenzae
- Swimming/diving - Rhinoviruses
- Smoking
Symptoms & Complications
- Nasal blockage/obstruction/congestion
o Obstruction in chronic sinusitis
o Due to mucosal hypertrophy and discharge
- Nasal discharge
o Purulent discharge in sinusitis
- Facial pain/heaviness
o Worse when sitting forward
- Reduced olfaction
- Headache
- Ear pain
- Sore throat
- Cough
Complications
- ‘Double-sickening’ = initial viral cause worsens due to 2º bacterial infection
Investigations
- Cultures if bacterial sinusitis suspected
- CT for evidence of sinus inflammation/obstruction
- Nasal endoscopy
Treatment/Management & Side effects
- Nasal saline irrigation
- Analgesia
- Intranasal corticosteroids
o High dose 14/7 if Sx ≥10 days
- Abx guided by culture results
o PenV = 1st line
o Co-amoxiclav if systemic upset
Definition & DDx
Complete loss of the capacity to smell Endocrine/Metabolic
- Alcoholism
Anatomy & Risks - DM
Nasal obstruction/URTI - Hypo/hyperadrenalism
- Septal deviation - Vit B12 def
- Allergic Rhinitis - Zinc def
- Bacterial/viral infection e.g., - Malnutrition
influenza, COVID
Toxins/Others
Trauma - Smoking
- Foreign body - Drugs
- Nasal surgery - Radiation
- Base of skull fracture - Toxin exposure
- Nasal fracture
Investigations
Neoplastic - Anterior rhinoscopy
- Nasal polyps - Sensory testing
- Juvenile Nasopharyngeal - Imaging to rule out
Angiofibroma neoplasms/fractures/congenital
abnormalities
Nasal Obstruction
Definition & DDx Symptoms & Complications
Acute nasal blockage lasts <12wks - Difficulty breathing through the
nose
Anatomy & Risks - Nasal congestion
Common causes - Runny nose
- Viral infection e.g., influenza, - Sneezing
rhinovirus - Reduced sense of smell
- Allergic rhinitis
o Sneezing/itching/runny Investigations
nose/congestion - Depending on suspected
- Rhinosinusitis underlying cause, may include
o Facial pain/nasal imaging studies/allergy testing
discharge/congestion
- Nasal polyps Treatment/Management & Side effects
o Obstruction/reduced sense - Antihistamines/antibiotics/nasal
of smell/runny nose spray
- Septal haematoma - Surgical intervention
o Obstruction/pain - Lifestyle changes e.g., avoiding
- Tumours allergens, using humidifier
,Allergic Rhinitis
Definition & DDx
Inflammatory condition of nasal mucosa
DDx
- Sinusitis
- Nasal polyps
- Deviated nasal septum
- Common cold
Anatomy & Risks
IgE-mediated response to environmental allergens
- Pollen/dust mites
Can be seasonal, year-round or occupational
Symptoms & Complications
- Nasal pruritus
- Sneezing
- Rhinorrhoea
- Nasal congestion/bilateral obstruction
- Post-nasal drip
- Associated with allergic conjunctivitis
o Eye redness/puffiness
o Watery eye discharge
Investigations
- Skin prick tests to identify allergen if unknown
Treatment/Management & Side effects
- Avoid triggers
- Nasal irrigation with saline
- Short course of nasal decongestants e.g., oxymetazoline
o Do not use for long periods
o Increasing doses required to achieve same effect
o Rebound nasal mucosal hypertrophy may occur on withdrawal
- Intra-nasal / PO antihistamines
- Regular intranasal steroids if initial measures ineffective
- Oral steroids if severe and affecting QoL
- ENT referral if:
o Red flags
o Refractory cases
o Allergen testing
, Rhinosinusitis
Definition & DDx Anatomy & Risks
Inflammation of nose and paranasal Diagnosis requires ≥2 symptoms, with one
sinuses of:
- Commonly caused post-infective - Blockage/obstruction/congestion
Predisposing factors - Discharge (ant/post-nasal drip)
- Nasal obstruction Most common infectious agents
- Recent local infection e.g., rhinitis, - Strep. Pneumoniae
dental extraction - H. influenzae
- Swimming/diving - Rhinoviruses
- Smoking
Symptoms & Complications
- Nasal blockage/obstruction/congestion
o Obstruction in chronic sinusitis
o Due to mucosal hypertrophy and discharge
- Nasal discharge
o Purulent discharge in sinusitis
- Facial pain/heaviness
o Worse when sitting forward
- Reduced olfaction
- Headache
- Ear pain
- Sore throat
- Cough
Complications
- ‘Double-sickening’ = initial viral cause worsens due to 2º bacterial infection
Investigations
- Cultures if bacterial sinusitis suspected
- CT for evidence of sinus inflammation/obstruction
- Nasal endoscopy
Treatment/Management & Side effects
- Nasal saline irrigation
- Analgesia
- Intranasal corticosteroids
o High dose 14/7 if Sx ≥10 days
- Abx guided by culture results
o PenV = 1st line
o Co-amoxiclav if systemic upset
