The Nose



The Nose

The nose is a projecting triangular pyramid in the central part of the face and most common organ subjected to trauma.
Anatomy of the Nose
The External Nose
The external nose is supported by bone and cartilage. The bony part is formed mainly by the nasal bones and by the frontal process of the maxillary bone. The cartilaginous portion is formed by several cartilages which support and give shape to the lower part of the nose.
The Nasal Vestibule
Is the entrance of the nasal cavity lined by hair-bearing squamous epithelium (skin) which ends at the mucocutaneous junction at which the nasal cavity begins. This hair is called the vibrissae.

The Nasal Septum

Is the midline partition of the nasal cavity. It is formed by:
Anteriorly ( quadrilateral cartilage.
Posterosuperiorly ( perpendicular plate of ethmoid.
Posteroinferiorly ( vomer.


The external nose The nasal septum.

The Nasal Cavity
Are irregular cavities separated by nasal septum, extending from the vestibule (anterior nares) to the nasopharynx (posterior nares or choanae). The nasal cavity has its axis at right angle to the face. The lining of the cavity is mainly pseudostratified ciliated columnar epithelium with goblet cells (respiratory type).
Boundaries:
Floor: maxilla and palatine bones.
Roof: Nasal bones, cribriform plate of ethmoid and sphenoid bone.
Medially: nasal septum.
Laterally: there is a system of ridges (turbinates), each of which overhangs a groove (meatus). The turbinate is formed from erectile tissue covered by a mucous membrane.
The turbinates are three in number. The superior and middle turbinates are part of the ethmoid bone, whereas the inferior turbinate is a separate bone.
Sup. meathus ( posterior ethmoidal sinuses.
Middle meatus ( frontal, maxillary & anterior ethmoidal sinuses.
Inferior meatus ( nasolacrimal duct.
Blood Supply
1. Sphenopalatine artery (maxillary).
2. Greater palatine artery (maxillary). (External carotid artery)
3. Superior labial artery (facial).
4. Anterior ethmoidal artery (ophthalmic artery).(Internal carotid artery)
5. Posterior ethmoidal artery (ophthalmic artery).
These vessels anatomse forming Keisselbachs plexus in Littles area which is the usual site of epistaxis.
Venous Drainage
Facial + ophthalmic vein ( cavernous sinus.





The lateral nasal wall Blood supply of the nose

Nerve Supply
Sensory: ophthalmic (anterior ethmoidal) and maxillary (sphenopalatine) nerve.
2. Secretory: Vidian nerve (nerve of pterygoid canal) which is formed by the union of the greater petrosal nerve, a branch of the facial nerve (parasympathetic) and the deep petrosal nerve (sympathetic) derived from the sympathetic plexus on the internal carotid artery .
- Greater petrosal nerve (parasymp.) ( Dilates blood vessels + enhances gland secretion.
- Deep petrosal nerve (symp.) ( constricts blood vessels.
3. Oflactory: The olfactory epithelium which is golden/yellowish in colour occupies the cribriform plate, the upper one third of lateral nasal wall (up to superior turbinate) and corresponding part of nasal septum. The oflactory nerves (18-20) on each side ( pass through the cribriform plate to synapse in the oflactroy bulb. Injury to these nerves can open CSF space leading to CSF rhinorrhea or meningitis.
Lymphatic Drainage
Submandibular, retropharyngeal and upper deep cervical chain.
The Paranasal Sinuses
Are air filled cavities located inside the facial bones, lined by an evagination of the mucous membrane of the nose and have communication with the nasal cavity.
Anterior GroupFrontalMiddle meatusMaxillaryAnt. ethmoidalPosterior GroupPost. ethmoidalSup. MeatusSphenoidSphenoethmoidal recess

Maxillary Sinus (Antrum of Higmore)

 This sinus is pyramidal in shape with base towards lateral wall of nose and apex directed laterally into the zygoma. Its roof is the floor of the orbit and its floor lies over the 1st premolar 3rd molar teeth. The ostium of the sinus is situated high in the medial wall (1 cm) and hence drainage is dependent on ciliary action and not gravity.
Frontal Sinus
The sinus is not present at birth but appear at the age of 5 years. The sinus is frontal in location ethmoidal in origin. The frontal sinuses are rarely symmetrical and they are separated by a thin bone. The roof of the orbit forms the floor of the frontal sinus. The frontonasal duct of each sinus opens into the middle meatus.
Ethmoid bone and sinuses
The ethmoid bone is made up of five parts; the perpendicular plate, the horizontal cribriform plate, the crista galli and two lateral labyrinths of cells suspended by the horizontal plate.
The ethmoidal sinuses are multiple air cells (7-15) in number and divided into anterior and posterior groups which drain respectively into middle and superior meatus. They are separated from the orbit by a thin plate of bone known as lamina papyracea.



Maxillary sinus
Maxillary sinus Ethmoid bone and sinuses

Sphenoid Sinus

This sinus occupies the body of the sphenoid bone and drains into the sphenoethmoidal recess. The pituitary gland is located on its roof whereas the lateral wall is in contact with the cavernous sinus, internal carotid artery, and II, III, IV, V and VI cranial nerves. The Vidian nerve passes below this sinus.

Physiology of the Nose

Olfaction.
Respiration
Provide an airway for respiration.
Filtration of air.
Humidification and warming of the inspired air.
Vocal resonance.
Collect moisture from the expired air to prevent excessive loss.
produce mucus which is transported by the action of the cilia and contains antibodies which act as a defense mechanism
Nasal Cycle
Nasal mucosa undergoes rhythmic cyclical congestion and decongestion, thus controlling the airflow through nasal chambers. Nasal cycle varies every 2-4 hours.
Physiology of the Paranasal Sinuses
Air conditioning of the inspired air.
Reduce the weight of the skull.
Vocal resonance.
Thermal insulation of the skull base.
Mucus production
Symptoms of Nasal Diseases
Nasal obstruction:
Anatomical abnormality: Congenital choanal atresia or deviated nasal septum.
Abnormality of the mucous membrane: Nasal polyposis or turbinate hypertrophy.
Abnormalities of autonomic control of the mucosa: Vasomotor rhinitis.


II. Nasal Discharge:
Watery clear discharge: Onset of common cold, allergic rhinitis or CSF rhinorrhea.
Mucopurulent:
-Yellow pus: Sinusitis.
-Unilateral foul discharge in a child: FB in the nose.
-Crusts in adults: Atrophic rhinitis.
Thick blood stained discharge: Tumour.
Postnasal mucopurulent discharge: Disease of the posterior group of sinuses.
III. Sneezing: Allergic rhinitis or common cold.
IV. Pain:
Severe local pain: Folliculitis.
Early morning headache: Sinusitis.
V. Epistaxis.
VI. Disturbance of smell:
Anosmia and hyposmia: Complete or partial loss of the sense of smell. It is often described as loss of taste as flavours are largely perceived through the olfactory apparatus. The causes are:
Nasal obstruction from common cold or nasal polyposis.
Vasomotor rhinitis.
Peripheral neuritis particularly following influenza virus.
Atrophic rhinitis.
Trauma: Base of skull fracture involving the cribriform plate.
Cacosmia: The perception of a bad smell. The causes are:
Maxillary sinusitis.
Foreign body in the nose.
Chronic suppurative otitis media. Pus discharge through Eustachian tube.
Parosmia: The perversion of the sense of smell or subjective sensation of non-existing odours (hallucination of smell). Causes:
Functional.
Organic:
Influenzal neuritis.
Epileptic aura.
Drugs: Streptomycin.


Diseases of the Nose
Congenital Anomalies
Choanal Atresia
Congenital atresia of the posterior nares due to persistence of the bucconasal membrane. Choanal atresia is usually unilateral but bilateral cases can occur and these cases are observed at birth because the neonate is obligate nasal breather. The obstruction is either composed of bone (30%) or mixed bone-membrane (70%).
Clinical Picture
Females are commonly affected than males.
Bilateral ( Neonatal emergency leads to asphyxia because the infant is obligatory nasal breather.
Unilateral ( nasal obstruction and excessive nasal discharge in the affected side which may be not noticed for some years.
Examination
1. Total absence of nasal air flow by cold spatula test and cotton test.
2. Plastic catheter(5 or 6 Fr) or probe cant be passed for 3.2 cm through the affected side to the nasopharynx.
3. Fiberoptic endoscopy.
Investigations
Contrast radiography by instillation of radioopaque substance in the affected side. (outdated)
CT scan to see the thickness of a bony atresia.
Treatment
Bilateral ( oral airway (McGovern nipple)( surgical intervention.
Unilataral ( elective perforation of the occlusion usually prior starting of school. (transnasal or transpalatal approaches)


CT scan of choanal atresia Oral airway

Trauma to the nose and paranasal sinuses
Injury to the nose may result in one or a combination of the following:
Epistaxis.
Fracture of the nasal bone.
Fracture or dislocation of the septum.
Septal haematoma.
Fracture nasal bone
Usually caused by a blunt trauma to the nose and occasionally by penetrating wounds.
Clinical Picture
Deformity, bruising, black eye and swelling.
Pain and headache.
Epistaxis.
Nasal obstruction due to septal haematoma or septal dislocation.


Examination
It is important to examine the septum for the presence of septal haematoma, especially in children. When present, the haematoma needs urgent drainage; otherwise septal abscess may develop which may result in cartilage necrosis.
Investigations
X.ray is important medicolegally but of little value clinically.
Treatment
Early (hours): Before swelling appear----- immediate reduction.
Intermediate (Days): When swelling is marked-----Wait 5-6 days till the swelling subside.
Late ( months or years): Septorhinoplasty.



X.ray of fractured nasal bone POP following reduction of fracture

SEPTAL DEVIATION

Generally a few adults have a complete straight septum. Only gross deflections causing symptoms require treatment.
Aetiology and Pathology
Trauma: Either birth trauma or external injury.
Developmental errors: The developing septum buckles because it grows faster than its surrounding skeletal framework.

Symptoms

Nasal obstruction which may be unilateral or bilateral.
Recurrent sinus infection due to interference with sinus ventilation and drainage.
Headache due to malventilation of the frontal sinus (vacuum headache).
Epistaxis result from a prominent vessel over a bony spur.
Examination
External nasal deformity.
The deviation may be S or C shaped.
Signs of sinus infection.
Treatment
Mild no Rx.
Symptomatic: septoplasty
Haematoma of the Nasal Septum
Collection of blood beneath the mucoperichondrium or mucoperiosteum of the nasal septum.
Aetiology
1. Trauma to the nose.
2. Septal surgery.
3. Blood dyscrasia.
Clinical Picture
1. Nasal obstruction
2. Examination reveals smooth rounded swelling of the nasal septum.
Complications
1. Infection of the haematoma with septal abscess ,cartilage necrosis and perforation.
2. External deformity: Saddling
Treatment
The haematoma must be incised and drained followed by application of a pack in the nasal cavity with antibiotic cover to prevent septal abscess.




Septal deviation Septal haematoma
Septal Abscess
Is collection of pus beneath the mucoperichondrium or the mucoperiostium.
Aetiology
1. Complication of haematoma.
2. May follow furunculosis, measles or scarlet fever.
Clinical Picture
Nasal obstruction, fever, pain and tenderness over the nasal bridge.
Examination
Symmetrical swelling of the nasal septum.
Complications
1. Cartilage necrosis leading to perforation and external deformity.
2. Cavernous sinus thrombophlebitis.
Treatment
1. Drainage+packing+antibiotics.
2. Plastic surgery for external nasal deformities.

Septal Perforation

Aetiology
Trauma: Nose picking, cautery and septal surgery.
Infection: Acute septal abscess.
Chronic TB and syphilis.
Foreign body.
Malignancy (T /NK cell lymphoma).
Drugs: Cocaine addicts.
Idiopathic.
Clinical Picture
Small perforation leads to whistling. Septal perforation
Large perforation leads to crustation and bleeding.
Treatment
Treat the cause.
Medical: alkaline nasal douche + lubricant ointment.
Surgical closure but with poor success rate.
Foreign bodies in the Nose
They are much more common in children. The F.B. may be organic or inorganic. An inflammatory reaction follows accompanied by nasal discharge.
Aetiology
1. Through anterior nares.
2. Through posterior nares : Food particles may regurgitate to the nose during vomiting.
3. Penetrating wounds.


Clinical Picture
1. Unilateral foul smelling nasal discharge. In a child, unilateral purulent discharge is pathognomonic of foreign body.
2. Epistaxis.
3. Pain.
Investigations
X ray if the foreign body is radiopaque.
Treatment
Removal of the FB by a probe, hook or forces, sometimes G.A. is required.
Rhinoliths
Hard masses in the nasal cavity consist of concretions of phosphate and carbonate salts of calcium and magnesium around a central nucleus called the nidus.
Aetiology
The nidus may be
1. F.B.(exogenous)
2. Dried blood and pus.(endogenous)
Clinical Picture
1. Unilateral nasal discharge.
2. Unilateral nasal obstruction.
3. If it is long standing, it leads to atrophy of the nasal mucosa.
Examination
Probe --- hard mass can be felt.
Investigations
X ray if the foreign body is radiopaque.


Complications
Rhinitis and sinusitis.
Rhinolith formation.
Inhalation into tracheobronchial tree.
Treatment
Removal under G.A.


OROANTRAL FISTULA

A fistula through which the antral cavity communicates with the oral cavity.
Aetiology
Dental extraction of the molar and premolar teeth.
Malignancy.
Penetrating wound.
Fistula following Caldwell-Luc operation.

Clinical Picture

Recurrent foul sinusitis and discharge of pus into the mouth.
Regurgitation of food particles and air into the nose.
Examination
Leakage of air from the fistula when the patient blows with a closed nose and open mouth.
A probe can be passed from the mouth to the antrum.
Treatment
Immediate following dental extraction ( suturing.
Late ( Remove any retained food particles, control infection and then closure using a mucoperiosteal flap.
CSF RHINORRHEA
It is a communication between the subarachnoid space and the nasal cavity.
Aetiology
Trauma: from fracture of the base of the skull involving the cribriform plate or ethmoidal air cells following head injury or nasal surgery (ESS).
Spontaneous: Destructive lesion involving the floor of the anterior cranial fossa as large osteomas or sinonasal malignancies.
Clinical Picture
Watery fluid drips from the nose which increases in bending forward or straining and cannot be sniffed back.
Meningitis.
Examination
Handkerchief test: The fluid associated with rhinitis contains mucus which stiffens a handkerchief while CSF does not.
Nasal endoscope to see the site of the lesion.
Investigations
Identification of glucose in the secretion.
Identification of B2 transferrin is specific for CSF.
Injection of radioactive material into CSF via lumbar puncture.
CT scan of the base of the skull.
Treatment
Medical
Bed rest in head up position.
Systemic antibiotics.
Avoidance of nose blowing and avoidance of nasal packing.
2- Surgical: if no response
Treat the cause.
Closure of the defect by surgery either via frontal craniotomy or endoscopic approach.


Inflammation of the Nose
Skin: Furunculosis.
Mucous Membrane
a. Rhinitis: Acute :common cold (coryza).
Chronic: Hypertrophic.
Atrophic
b. Sinusitis: Acute.
Chronic.
Furunculosis (Nasal boil)
Staphylococcal infection of the hair follicles of the nose due to interference with the vibrissae. Trauma from picking of the nose or plucking the nasal vibrissae is the usual predisposing factor.
Clinical Picture
1. Pain, tenderness, redness and swelling of the tip of the nose.
2. Headache + fever.
Complications
Cavernous sinus thrombophlebitis.
 Septal abscess and cellulitis of the upper lip.
Treatment
Squeezing must be avoided to prevent spread of infection through the valveless facial veins to the cavernous sinus.
Antistaphylococcal antibiotics; Cloxacillin and Flucloxacillin.
Lubrication of the infected area with an ointment like fucidic acid.


Acute Rhinitis (Coryza, common cold)
Viral infection of the nasal mucosa by rhinovirus, corona virus or RSV . Transmission occurs by airborne droplets. Increased activity of the normal pathogenic bacteria of the nose can cause secondary infection.
Clinical Picture
Prodormal stage (mucosal ischaemia): Irritation, dryness and sneezing.
Acute stage (hyperaemia): Nasal obstruction, nasal secretion, fever and malaise.
Recovery stage: The discharge become thick, more purulent and the nose become more obstructed. Later the nasal passages are reopened and normal breathing is reestablished.
Treatment
Bed rest and steam inhalation.
Decongestant nasal drops or sprays to promote drainage of secretions.
Analgesics and antihistamines.
Antibiotics are not normally necessary but of value in preventing secondary bacterial infection.
Chronic Hypertrophic Rhinitis (Rhinitis Medicamentosa)
This condition is frequently seen in patients with prolonged and excessive use of nasal decongestant drops (rhinitis medicamentosa).
Aetiology
In this condition after the vasoconstrictor effect of the drops wears off, a rebound increase in mucosal swelling occurs requiring further use of the nasal drops. The ciliary action is lost and the patient therefore uses the drop with increasing frequency to achieve the same effect. Later a chronic nasal obstruction unresponsive to decongestant drops results. It is not recommended therefore that these agents are used for longer than 5 days.
Pathology
The ciliated epithelium changes to stratified squamous or cuboidal epithelium. There is an increase in fibrous tissue and infiltration with round and plasma cells.
Clinical Picture
1. Nasal obstruction, mouth breathing and snoring.
2. Nasal discharge and postnasal drip.
3. Mild headache and anosmia.
Examination
Swelling and redness of the mucous membrane.
Sticky and mucopurulent secretions.
Enlarged inferior turbinate and its posterior end has mulberry like appearance (purple and engorged).
Treatment
Treatment of the cause(i.e : stop decongestant).
Medical: istonic alkaline nasal douche + topical and systemic steroids.
Surgical if no response to medical treatment by reduction of the size of the inferior turbinate by submucosal diathermy (SMD), cryosurgery, laser and turbinectomy.
Atrophic Rhinitis
A chronic inflammation of the nasal mucosa characterized by atrophy of the mucous membrane and underlying bone of the turbinate.
Aetiology
Idiopathic: young females.
Secondary:
Infection: klebsiella ozaenae, chronic rhinitis.
Extensive nasal surgery.
Endocrine imbalance: The disease usually starts at puberty, involves females more than males and tends to cease after meanopause.
Malnutrition: Deficiency of vitamin A,D or iron
Autoimmune disease.
Pathology
The submucosal vessels undergo endarteritis and periarteritis and there is metaplasia of the ciliated columnar epithelium to non-ciliated cuboidal or stratified squamous epithelium with atrophy of the nasal glands.
Clinical Picture
Primary atrophic rhinitis is common in young females at puberty.
Nasal obstruction in spite of wide nasal passages due to lack of normal sensation of airflow.
Epistaxis, anosmia and headache.
Examination
Bad odour (fetor, ozaena) which is not appreciated by the patient who is anosmic( called merciful anosmia).
Wide nasal passages (roomy nose).
Crustation due to ciliary destruction so the nasal secretions are no longer expelled from the nose.
Treatment
Treatment of the cause.
Medical:
Regular cleaning of the nose by alkaline nasal douche which can be made from a powder consisting of equal parts of sodium bicarbonate, sodium binorate and sodium chloride. A teaspoonful of powder can be dissolved in 0.25 liter of warm water and used 2-3X/day.
Crust formation is discouraged by the application of 25% glucose in glycerine.
Local antibiotic ointments to eliminate secondary infection.
Surgical if no response to medical treatment by surgical closure of the nostrils for one year (Young's operation).


RHINOSINUSITIS
Is the inflammatory condition of the mucous membrane lining the sinus. Sinusitis may be open or closed depending on whether the inflammatory products of sinus cavity can drain freely into the nasal cavity or not. A closed sinusitis causes more severe symptoms and is likely to cause complications. Sinusitis could be acute or chronic.


ACUTE RHINOSINUSITIS
Aetiology
Acute rhinitis, common cold and influenza.
Dental infection or extraction (premolars and molars).
Swimming and diving.
Fractures involving the sinus wall.
Bacteriology
Most cases of sinusitis start as viral infections followed by bacterial invasion. The causative bacteria in order of frequency are Pneumococci, H. influenzae and Branhamella catarrhalis. E. coli and anaerobic infection associated with sinusitis of dental origin.
Clinical Picture
One sinus can be affected, but it is more common that the whole sinuses share the infection.
Pain across the infected sinus:
Maxillary sinusitis; this sinus is affected more than other sinuses because of its high ostium. The pain is on the cheek accompanied by a feeling of fullness below the eyes. Pain on the upper teeth may be the first sign of sinusitis.
Ethmoidal sinusitits: the pain is deep behind the eyes. The infection can extend to the orbit across the thin lamina papyracea leading to thickening and swelling of the medial part of the orbit.
Frontal sinusitis: it is usually associated with ethmoiditis. The pain is located above the eyes. It usually starts after waking up and subside later in the afternoon. The pain increases in bending forwards. Infection can cause oedema and puffiness over the upper eyelid.
Sphenoidal sinusitis: it is particularly associated with infection of the posterior ethmoidal air cells. The pain is localized to the vertex of the head and may produce pain over the distributions of the trigeminal nerve because of the close proximity of the nerve to the sinus.
2. Nasal obstruction; because of pus and oedema.
3. Nasal discharge; from the anterior nares in infection of the anterior group of sinuses and from the posterior nares (choanae) in infection of the posterior ethmoidal and sphenoidal sinuses.
4. Pyrexia and malaise.
Examination
1. Tenderness over the infected sinus.
2. The mucous membrane is reddened and oedematous. Pus may be seen in the middle meatus in infection of the anterior group of sinuses or in the postnasal space if the posterior group is infected.
Investigation
1. Radiology
a. X-ray: opacification or a fluid level.
b. CT scan: when complications are expected or when major surgery is anticipated.
2. Bacteriology: by doing antral lavage and sending the pus for C/S (proof puncture).
3. Sinuscopy.



 SHAPE \* MERGEFORMAT 

Treatment
1. Treat the cause.
2. Medical
a. Analgesics (e. g : aspirin + codeine).
b. Antibiotics; broad spectrum antibiotics. amoxycillin, augmentin or cefuroxime. If the patient is allergic ( erythromycin or cortrimoxazole. In infection of dental origin metronidazole should be added. The treatment should last for ten days. The new generations of quinolones (Levofloxacin, Moxifloxacin) are recently used and has the advantage of single daily dose.
c. Local decongestants as nasal drops or sprays to shrink the mucosa and assist sinus drainage, e.g. ephedrine, xylometazoline (Otrivin) and naphazoline (Nasophrine). The drops should be installed in head down position and the treatment should last for not more than five days.
3. Surgical: if no response to medical treatment.
a. Maxillary antral lavage (antral wash) as this is the conductor of orchestra. If this sinus infection settles, oedema of the middle meatus disappears and permits adequate drainage of the anterior group of sinuses.
b. Frontal sinus drainage ( trephine (external drainage).


CHRONIC RHINOSINUSITIS

A long standing inflammation of the sinus mucosa and these changes are irreversible. Chronic sinusitis has recently been defined as 12 weeks of persistent symptoms and signs or 4 episodes/year of recurrent acute sinusitis, each lasting at least 10 days, in association with persistent changes on CT scan 4 weeks after adequate medical therapy.
Predisposing Factors
I. Local
1. Local nasal abnormality, e.g. polyps or septal deviation and adenoid hypertrophy.
2. Recurrent acute sinusitis.
3. Dental abscess or root infection.
II. General
1. Immunodeficiency diseases.
2. Mucociliary disorders: Kartageners syndrome.
Pathology
The ciliated epithelium is replaced by stratified or cuboidal epithelium. There is increase in fibrous tissue and infiltration with round and plasma cells.
Bacteriology
It is mixed aerobic and anaerobic infection. Streptococci including the anaerobic ones are common. Proteus, E. coli and pseudomonous are often secondary invaders.
Clinical Picture
Nasal and postnasal discharge which may be mucopurulent.
Nasal obstruction due to swelling of the inferior turbinate and secretions.
Anosmia and cacosmia.
Local pain and Headache are less marked, often described as dullache and the timing is lost.
These purulent secretions can lead to otitis media, pharyngitis and chronic laryngitis.
Examination
Mucopurulent discharge and crusts by anterior rhinoscopy.
Endoscopic examination of the nose is important to evaluate the nose and paranasal sinuses, especially the area of the middle meatus which is the site of the drainage of the sinuses.
Investigations
Radiology: X-ray and CT scan shows thickening of the mucosa lining the sinuses with polyp formation.



Treatment
The principle is to achieve aerations of the sinuses to restore the ciliary ability.
Treat the cause.
Medical treatment
Nasal toilet by alkaline nasal douche.
Antibiotics: augmentin+metronidazole.
Topical steroids (sprays or drops) to reduce mucosal swelling.
Surgical: if there is no response to medical treatment by endoscopic sinus surgery.
SINUSITIUS IN CHILDREN
Aetiology
Congenital: Kartageners Syndrome.
Acquired:
Local causes: adenoids, tonsillar sepsis, F.B. and allergy.
Systemic: low resistance due to overcrowding and malnutrition.
Environmental: low social class, low vitamin supply and lack of ventilation.
Pathology
The ethmoidal and maxillary sinuses are the usual sites. The frontal sinus being poorly developed before 5 years.
Clinical Picture
Nasal discharge, nasal obstruction, snoring and cough.
Tendency to recurrent otitis media.
The general and local features tend to be more pronounced than adults. Oedema of the cheek and eyelids are not uncommon.
Examination
To exclude adenoid hypertrophy, F.B. and tonsillar sipses.
Investigations
1. X ray.
2. Proof puncture under GA.
Treatment
1. Rx the cause
2. Medical: nasal decongestants (1/2 concentration) + antiallergics + antibiotics.
3. Surgical.
Repeated antral wash.
ESS.
Complications of Sinusitis
Routes of Spread
Direct spread; through bony wall as through lamina papyracea from ethmoidal sinusitis leading to orbital complications or through the floor of the anterior cranial fossa to the frontal lobe from frontal sinusitis.
Venous spread; through the facial and superior ophthalmic veins to the cavernous sinus.
Lymphatic spread; to the submandibular and deep cervical lymphnodes.
Perineural spread; through olfactory fibers across the cribriform plate.
Acute
Orbital complications; it is seen most frequently as a complication of ethmoidal sinusitis. These include:
Cellulitis of the eyelids.
Sub-periosteal abscess.
Orbital cellulites.
Intracranial complications; complicate frontal and ethmoidal sinusitis. These include:
Meningitis and encephalitis
Intracranial abscesses (Extradural, subdural and brain abscess).
Cavernous sinus thrombophlebitis Orbital cellulitis
Bony
a. Ostetis ( compact bone ( (maxillary).
b. Osteomylitis ( diploic bone ( (frontal): Pus may form externally under periosteum (Potts puffy tumour).
Respiratory tract complications
Pharyngitis, tonsillitis, otitis media and bronchitis.



Frontal osteomylitis
Chronic
Mucocele and pyocele: collection of mucous inside the sinus occurs when the ostia became blocked. Pyocele forms when a mucocele become secondary infected. Mucocele occurs most commonly in the frontal followed by the ethmoidal sinuses.

Frontoethmoidal mucocele

Non-Infective Rhinitis
Non-Infective rhinitis is characterized by episodic sneezing, nasal blockage and non-purulent rhinorrhea. Non-Infective rhinitis is classified as allergic when one or more causative allergies can be identified and vasomotor or intrinsic when causative agents can not be found.
ALLERGIC RHINITIS
Is an abnormal reaction of the tissues to certain substances. The causal substances are called "allergens" or "antigens".
Aetiology
Mechanism of allergy: Allergic rhinitis is classified as type I hypersensitivity reaction. Here the mast cells in the nasal mucous membrane become coated with antibodies belonging to the IgE class called the reagins. When the allergen interacts with reagenic antibodies on the mast cell surface, mast cell degranulation occurs. These degranulating cells secrete histamine and other mediators of anaphylaxis. The capillaries become permeable and oedema occurs. Meanwhile, eosinophils infiltrate the tissue and serous alveolar glands are stimulated to produce excessive watery secretion.
Clinical Picture
Seasonal (Hay fever) if the allergen is pollen or molds.
Perennial (non-seasonal) if the allergen is present all year round like house dust mite. House dust mite is found in high concentration in most bedrooms as it feeds on skin scales. Epithelial debris from domestic cats and dogs may also be an important cause of perennial rhinitis.
The symptoms of allergic rhinitis are:
There is a prodromal nasal itching which is soon followed by violent sneezing.
Profuse watery nasal discharge.
Nasal obstruction: Which is bilateral due to mucus, oedema and/or venous stasis of the inferior turbinate.
Itching and watering of the eyes.
Anosmia either intermittent or continuous.
Examination
 The nasal mucosa is thick, pale and oedematous with thin watery mucoid discharge.





Investigations

Skin test using solutions containing various allegens to know the causative one.
Nasal smear which shows increase eosinophil count.
Blood tests can show eosinophilia and allergen specific IgE in the serum.
Treatment
Avoidance of the precipitating factors: Removal of a pet from the house, encasing the pillow with plastic sheet.
Drugs:
Topical steroids: as nasal sprays like beclomethasone, budesonide and mometasone. These are locally acting and not systemically absorbed. A short course of oral steroids as prednisolone is effective in severe seasonal symptoms.
Antihistamines:
First generation (sedating antihistamines) as diphenhydramine (Allermine) and chlorpheniramine (Histadin).
Second generation (non-sedating) antihistamines as loratadine and fexofenadine.
Topical nasal antihistamines as azelastine.
c. Sodium cromoglycate which is a mast cell stabilizer.
Immunotherapy (Hyposensitization): Involve injection of small amounts of antigen to mop up the allergen specific immunoglobulins in the patient. Hyposensitization probably induces a blocking antibodies which intercepts the antigen before it is able to react with IgE bound to the mast cells.

VASOMOTOR RHIMITIS (INTRINSIC RHINITIS)

Episodic nasal obstruction and watery rhinorrhea for which no specific allergen can be identified.
Aetioology
The mechanism appears autonomic imbalance (parasympathetic over activity).
Predisposing factors.
Hereditary.
Infection
Psychological and emotional upset.
Fear ( sympathetic overactivity ( vasoconstriction
Anxiety and frustration ( parasymp. activity ( engorgement of the mucous membrane and excessive secretions from nasal glands.
Endocrine: vasomotor rhinitis is common during puberty and pregnancy.
Drugs: Aspirin, antihypertensive drugs and over use of nasal drops which leads to rhinitis medicamentosa.
Atmospheric conditions as changes in humidity and temperature, fumes and central heating.
Clinical Picture
The symptoms are identical to those of allergic rhinitis.
Nasal obstruction which may alternate from side to side.
Watery rhinorrhea, postnasal discharge and headache can occur.
Sneezing which is paroxysmal in nature especially on getting out from bed.
Postnasal drip.


Examination
The mucous membrane is hyperaemic and hypertrophic. Some times polyps and hypertrophy of the inferior turbinate can be seen.
Treatment
1. Avoidance of the predisposing factors.
2. Medical:
a. When there is little rhinorrhea, the use of topical nasal steroids and antihistamines are the main approach.
b. When there is copious watery discharge, the addition of topical nasal anticholinergics like ipratropium bromide is usually recommended.
3. Surgical:
a. Reduction of the size of the inferior turbinate by submucosal diathermy, cryosurgery or turbinectomy.
b. Nasal polypectomy.

Nasal Polyps

 Are pedunculated portions of oedematous mucosa of the nose and paranasal sinuses which are attached to the nasal mucosa by a narrow pedicle. Nasal polyps originate in the region of the ethmoidal sinuses and middle turbinate and project into the nasal cavity. They tend to be bilateral and multiple. In unilateral nasal polyp, antrochoanal polyp, neoplasia and meningocele should be exluded.
Aetiology
Allergic and VMR.
Chronic rhinosinusitis.
Mixed infection and allergy
Cystic fibrosis.
Nasal polyps are found in association with bronchial asthma and aspirin intolerance.
Pathology
They are round, smooth glistening yellow or pale structures. Polyps show oedematous hypertrophy of the sub-mucosa with intercellular serous fluid.
Clinical Picture
Nasal polyps are more common in adult males. Any child with nasal polyps should be regarded as having cystic fibrosis until proved otherwise.
Nasal obstruction which is usually bilateral.
Nasal discharge which could be mucoid or purulent.
Postnasal drip and anosmia.
Examination
The polyp is pale, glistening, not tender and moves backwards when probed. These features differentiate the polyp from turbinate hypertrophy.
Investigations
X-ray of the sinuses
CT scan if endoscopic ethmoidectomy is to be performed.
Skin test to diagnose and treat allergy.
Treatment
I. Control of the predisposing factors.
II. Medical: is useful in small polyps by topical nasal steroids. A patient with more extensive polyps is usually best treated with systemic steroids.
III. Surgical: Endoscopic intranasal polypectomy.



Antrochoanal Polyp
Arises from the lining of the maxillary sinus which become oedematous and project from the maxillary ostium to enlarge posteriorly to the nasopharynx. It tends to be single and unilateral.
The polyp tends to be dumb-bell in shape with a constriction where they pass the ostium of the sinus. Therefore, it has two compartments; maxillary and nasal portions.
Aetiology
It is unknown but faulty development of the maxillary sinus ostium (large or accessory ostium) is a possible factor.

Clinical Picture

The polyp is common in adolescent and young adult males.
Unilateral nasal obstruction: The obstruction is greater in expiration than inspiration due to ball-like effect of the polyp.
Nasal and postnasal discharge.
Examination
Anterior rhinoscopy may be normal or some times the stalk of the polyp can be seen.
Posterior rhinoscopy to visualize the polyp.
Nasal endoscopy.
Investigations
X-ray and Ct scan of the paranasal sinuses shows opacification of the affected antrum.
Treatment
Endoscopic removal of the polyp including the maxillary portion because it has a high incidence of recurrence. In recurrence a caldwell-Luc operation can be performed to clear the maxillary sinus.


Antrochoanal polyp


Epistaxis
Is bleeding per nose. It is a known disease of unknown aetiology.
Aetiology
Local causes
Idiopathic.
Trauma: Direct injury as nose picking or nasal operations.
Inflammatory: Acute rhinitis, sinusitis and allergic disorders.
Anatomical and structural abnormalities: Septal deviation may disturb air flow and causes turbulence of airflow thereby resulting in mucosal drying and epistaxis.
Neoplastic as angioma and carcinoma.
Environmental: Airconditions and industrial fumes.
II. Systemic causes
Cardiovascular as hypertension: Here the nasal mucosa is often atrophic and cracks easily which eventually leads to exposure of the arteriosclerotic vessel producing severe bleeding during a hypertensive episode.
Haematologic: Haemophilia, leukaemia and ITP.
Drugs: Aspirin and anticoagulants as warfarin.
Diseases of blood vessel as Osler,s disease ( Hereditary haemorrhagic telangiectasia). This is a hereditary disease characterized by the formation of abnormal capillaries in the mucous membrane of the nose. It is treated by radiation, Laser therapy and surgical excision of the mucous membrane of the nose with replacement of a split thickness skin graft.

Clinical Picture

Anterior epistaxis: It is the most common. It arises from Little,s area to the anterior nares and occurs in young and middle aged patients. Here the bleeding is trivial, easy to stop and tends to recur.
Posterior epistaxis: Its less common. Arises far back in the nose and may flow back to the pharynx and occurs in elderly hypertensive patients. Here the bleeding is profuse and extremely difficult to stop.
Management
ART
A Arrest of haemorrhage.
R Resuscitate the patient: A baseline Hb is withdrawn and IV drip is commenced. If necessary plasma and blood transfusion should be given to restore the circulation.
T Treat the cause.
Arrest of the Bleeding by:
Pressure on the nostrils in a sitting position, the mouth is kept open and swallowing is forbidden. The patient is instructed to breath quietly through the mouth with the head leant forwards.
Ice packs on the nasal bridge.
Cauterization of the bleeding point: Either chemical cautery using silver nitrate or trichloroacetic acid or electrical cautery. GA is some times required to identify the bleeding point and in children.
If epistaxis can not be controlled and the bleeding continues a pack may be needed.
Anterior packing: Using one inch ribbon gause impregnated with paraffin or vaseline. The pack may be left for 24-48 hours. The first part of the pack is inserted along the floor of the nose as far posteriorly as possible other layer is placed on top sequentially. Systemic antibiotics should be used to prevent secondary bacterial infection as sinusitis and otitis media. Sedation is necessary whenever a nasal pack is in situ, not only because the pack is uncomfortable, but the added anxiety of epistaxis may elevate the blood pressure.



Anterior Nasal Pack
Postnasal packing: Continued haemorrhage despite an anterior packing is probably a result of bleeding from the posterior branches of the sphenopalatine artery which necessitate the insertion of a postnasal pack.
It is done under GA and prepared from a piece of gauze soaked with paraffin or any antiseptic solution. Tapes are taken anteriorly through each nostril from the posterior pack around the columella. Another tape is tied around the middle of the pack and picked up from the patient mouth. A further anterior pack is placed against the posterior pack. The posterior pack stays in place for 48 hours. Variation of the pack is to use a urinary catheter to fill the nasopharynx which can be done without anesthesia.
Surgical Treatment: If despite anterior and posterior packing, the bleeding continues or recurs, surgical intervention is indicated.
Submucosal resection of the nasal septum in case of septaal spur to induce fibrosis at Little,s area.
Arterial ligation: The appropriate vessel is clipped under GA depending on the area of bleeding.
Anterior ethmoidal artery ligation which is useful for bleeding that originate from the superior part of the nasal cavity.
External carotid artery ligation for bleeding from the inferior part of the nasal cavity.


Posterior nasal pack

Tumors of the Nose and Sinuses
BenignEpith.
CT. Tissue
PapillomaOsteomaChondormaAngiomaFibromaMalignantEpith
CT.TissueSquamous cell CA.FibrosarcomaAdeno CAAngiosarcomaPapilloma
It arises either from the skin of the nasal vestibule ( squamous papillomas or from the respiratory mucosa ( inverted papilloma.
a. Squamous papilloma
It is a warty like growth either sessile or pedunculated. It is removed by an elliptical incision and the base is cauterized to prevent recurrence. They can also be treated by cryosurgery or LASER.
b. Inverted Papilloma (transitional cell papilloma, Ringertz tumour)
It arises from the lateral wall of the nose and occasionally from the nasal septum. They expand the containing bone but do not infiltrate. Extension to the ethmoidal and maxillary sinus is common.
Pathology
It is histologically benign but has a great tendency to recur. It is named so because microscopically neoplastic epithelium is seen to grow towards underlying stroma rather than on the surface (transitional type of epithelium).
There is a coincidental malignancy (synchronous malignancy) in 15% of cases and malignant transformation of the tumour occurs in about 8%.
Clinical Picture
Mostly seen between 40-70 years with male predominance. The usual presentations are unilateral nasal obstruction and recurrent attacks of sinusitis.
Examination
It arises from the lateral wall of the nasal cavity and it is always unilateral. It presents as red or grey mass simulating simple nasal polyp.
Investigations
1. Radiology: X.ray and CT scan.
2. biopsy.
Treatment
Adequate local excision (medial maxillectomy) by lateral rhinotomy approach.



Inverted Papilloma
Osteoma
Localized Compact Osteoma: it is most frequently found in the frontal sinus, but may be seen in the ethmoidal region.
Clinical Picture
They are frequently silent.
If the frontonasal duct is obstructed, it leads to frontal mucocele.
Displacement of the eye.
Pressure on the floor of the anterior cranial fossa leads to CSF rhinorrhea and intracranial infection.
Investigations
Radiology: X.ray and CT scan.
Treatment
Asymptomatic: observation.
Symptomatic: external frontoethmoidectomy.


Osteoma of the paranasal sinuses

Fibro-osseous Dysplasia: This disease commonly involves the maxilla and mandible. It represents an arrest of the maturation of bone formation at the stage of woven bone. It is divided into two types: the multiple polyostotic lesion and the monostotic lesion.
Multiple polyostotic lesion which is a systemic disease involving several bones.
Monostotic lesion which is localized to the maxilla and ethmoidal bone.
Clinical Picture
It presents as a painless swelling around the orbit or the cheek. This swelling become apparent during childhood and increases in size, but often ceases to expand after 20 years.
Investigations
Radiology by CT scan.
Treatment
1. Asymptomatic ( observation as the lesion tends to slow in progression during puberty.
2. Big (symptomatic) (surgical resculpturing (shaving).




Fibrous Dysplasia

Angioma

Capillary: the commonest site is the nasal septum and here it is called a bleeding polyp of the septum.
Clinical Picture
Epistaxis and on examination a pedunculated friable red lesion is seen which bleeds easily on touch.
Treatment
Excision with an adequate margin of the normal mucosa to prevent recurrence.
Cavernous: which may involve the whole tip of the nose.

Squamous Cell Carcinoma

A rare tumor involving mainly the maxillary and ethmoidal sinuses.
Aetiology
Unknown, but hard wood and nickel workers are more liable to develop this tumour.
Clinical Picture
The average at presentation is 60 years.
1. Unilateral nasal obstruction.
2. Blood stained discharge.
Toothache or loosening of the teeth.
Extension to the orbit ( proptosis and diplopia.
5. Facial swelling and skin involvement.
Examination
Fleshy polyp
Investigations
Radiology: CT and MRI.
Biopsy through intranasal antrostomy.
Metastasis
Deep cervical lymph nodes and retropharyngeal lymph nodes
Treatment
Combination of surgery and DXT.



Malignant Granuloma (midline, non-healing granuloma)
Wegeners Gran: Systemic, autoimmune disease characterized by vasculitis.
Rx:1. High dose of steroid.Immunosuppressants a. cyclophosphamide.
b. azathioprine.2.Stewarts Granuloma: limited to the skull, is variant of T-cell lymphoma.
Rx: local DXT.












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( Rhinoplasty.

Air Fluid Level in Maxillary Sinus

Normal

Bilateral Maxillary, Unilateral Ethmoid RS

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