1. CALENTAMIENTO GLOBAL Y CONTAMINACIÓN ATMOSFÉRICA
1.2. CALENTAMIENTO GLOBAL Y EMISIONES ANTRÓPICAS
and judo when he has repeated injuries
to his nose?
Key concepts
⦁ Bilateral nasal discharge is often the result of allergy rather than an adenoid problem. ⦁ Treat allergy medically.
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answers
Clinical cases
CASE2.5– Child with nasal obstruction and snoring
A1: Whatisthelikelydifferentialdiagnosis?
Rhinitis, commonly allergic, or physical obstruction due to adenoid hypertrophy
A2: Whatadditionalfeaturesinthehistorywouldyouliketoelicit?
Determine whether the nasal obstruction fluctuates from side to side and whether it is seasonal or continuous. Seasonal symptoms and fluctuating symptoms are more likely to be allergic in origin. Continuous symptoms are either due to a perennial allergy (house dust mites or pets) or enlarged adenoids. Ask whether obstructive apnoea is present at night, as this is much more common in children aged under 4 years. Other nasal symptoms include sneezing attacks, or clear or mucoid running nasal discharge. Older children and adults may complain of postnasal drip, changes in the sense of smell and facial pain. Asthma and rhinitis often coexist.
A3: Whatshouldonelookforintheexamination?
Watch the child in the clinic. If a child is breathing through his or her nose, the adenoids cannot be hypertrophied. Adenoid hypertrophy causes permanent nasal obstruction and these children sit with their mouths open. It is important to examine the tonsils because large tonsils may cause mouth breathing. The tip of a child’s nose turns up easily to help when looking at the mucosa. A purple colour suggests allergy. Place a metal spatula under the nose and observe the misting pattern to ensure both nasal cavities are patent.
A4: Whatinvestigationswouldbemosthelpfulandwhy?
Undertake allergy testing if history and examination suggest rhinitis.
A5: Whatarethetreatmentoptions?
If the child has an obvious allergic rhinitis, confirmed on skin prick testing, the standard treatment is avoidance of the allergen, if at all possible, followed by medical treatment. Surgery has little part to play. If there is no sign of rhinitis then adenoidal hypertrophy is likely, and these may be removed surgically. The risks of surgery should not be underestimated and primarily involve bleeding. This may occur immediately or 10 days post-operatively. The patient and parents should be warned about a change in voice after the nasal blockage has resolved.
CASE2.6– Adolescent with nasal trauma
A1: Whatisthelikelydifferentialdiagnosis?
Nasal trauma leading to nasal and septal deviation
A2: Whatadditionalfeaturesinthehistorywouldyouliketoelicit?
A3: Whatshouldonelookforintheexamination?
Examine the bony pyramid of the nose and make sure that this has not been fractured – this is best performed by looking at the seated patient from behind and noting any nasal deviation. Look at the cartilaginous septum to see whether this is displaced at either side. Turn the tip of the nose up to see whether the front part of the septum has been dislocated outwards.
A4: Whatinvestigationswouldbemosthelpfulandwhy?
Undertake allergy testing on all patients who have bilateral nasal obstruction because many will have an allergic rhinitis. It is rarely necessary to undertake any other investigations.
A5: Whatarethetreatmentoptions?
Do not advise nasal surgery except for manipulation of a fracture when the risk of re-injury is high. Surgery should not be undertaken until 18 years of age because the nose is still growing and surgery may adversely affect the growth plates. Avoid septal surgery if the child plays a contact sport.
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OSCE Counselling cases
OSCECOUNSELLINGCASE2.5– A mother asks whether their cat should
be removed if this causes allergic
rhinitis
Frequently children are not concerned about their nasal symptoms but the parents are. The cat may be more important to the child than the symptoms. Cats should be excluded from bedrooms. If the child is severely disturbed by the symptoms it may be necessary to re-house a pet. A cat must go if it causes severe asthma.
OSCECOUNSELLINGCASE2.6– What advice should you give to a boy
who wants to continue playing football
and judo when he has repeated injuries
to his nose?
Stress that surgery on the septum makes the structure weaker and more prone to further damage. Should another injury occur cosmetic deformity could be extreme and exceptionally difficult to correct. The septum can be corrected at any time, because nasal obstruction is not a life-threatening condition.
reVision panel
⦁ Full rhinological history and examination are always necessary as allergy often co-exists with other rhinological complaints and needs treating.
⦁ Childhood non-traumatic nasal blockage is typically due to allergy or enlarged adenoids. ⦁ Allergic rhinitis is treated with allergen avoidance and, if unsuccessful, medical therapy. ⦁ Septal surgery is not advised in childhood and should be delayed until after 18 years of age.