The nose

Lecture (2) 9/10/2018 د.عماد ناظم الكواز
The Nose

Fracture Nose

Causes:
blunt trauma (external force) as : blow or fall from height, car accident.

Clinical Picture

Symptoms:
History of trauma.
Pain.
Epistaxis.
Nasal obstruction. (Septal hematoma , septal deviation).
Signs
Inspection:
Swelling (oedema, hematoma, surgical emphysema).
Deformity (deviation, depression)
Bruising , black eye, wound .


Palpation:
Tenderness.
Crepitus.

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.

Anterior rhinoscopy:

Clotted blood, lacerated mucosa.
Septal hematoma, dislocated septum.

Investigation:

X-ray is of medicolegal importance. It is less important clinically .

Treatment:

Control of epistaxis if present.
Reduction of fractured bone: depend on timing of presentation:
Early(no oedema): either immediate or within few hours after trauma .
After few hours &before 2weeks (oedema developed): wait for 5-7 days till the oedema subsided then reduce the fracture.
After 2 weeks : wait for 3-6 months then do septo-rhinoplasty.

Note: Reduction of nasal fracture either manual or by instrument.

Fixation of bone
By anterior nasal pack to support the nasal bone from inside.
By plaster of paris to support the nasal bone from outside.

Foreign Body in the Nose

Type of patient:Children & mentally retarded adult.
Type of foreign body: The F.B. may be:
Inorganic(non-vegetable): buttons,beads, plastic from toys, and stones.
Organic(vegetable): rubber, seeds,and nuts.

These are irritant causing inflammatory reaction with nasal discharge.

Clinical Picture
Symptoms
Unilateral nasal obstruction.
Unilateral offensive nasal discharge.
Signs:
Anterior rhinoscopy shows the foreign body or discharge.

Investigation

X ray if the foreign body is radiopaque & not seen by examination.


In a child, unilateral nasal obstruction& offensive discharge is pathognomonic of foreign body.

Complications

Nasal
Early : Inflammation and infection (Rhinitis and sinusitis).
Late : Stone formation ( Rhinolith).

Pulmonary : Inhalation of foriegn body into tracheobronchial tree causing airway obstruction & death.
Alkaline battery is the worst FB as it releases potent alkali causing extensive inflammation and necrosis of nasal mucosa even septal perforation (Emergency).
Treatment
If the child is calm & co-operative : Removal of the FB by probe,hook,forces or forceps.
If the child is irritable ,crying & not co-operative: Removal under general anasthesia with cuffed endotracheal intubation.

Rhinolith

Definition: Hard mass in the nasal cavity.
Cause: Deposits of calcium and magnesium carbonates and phosphates around a nucleus called nidus , Nidus may be organic or inorganic material like F.B or dried blood or pus.
Treatment : Removal under general anasthesia.

Septal Hematoma

Definition: Collection of blood beneath mucoperichondrium of nasal septum ,The condition is more common in children, normally the cartilage takes blood supply from perichondrium so septal hematoma cuts off blood supply to septal cartilage.
Aetiology:
Trauma either surgical (septal surgery) or non-surgical (trauma to the nose).
Blood dyscrasia.
Clinical Picture
Nasal obstruction usually bilateral.
Septal swelling(bilateral)which is red, soft and compressible .


Complications
Septal abscess.
Cartilage necrosis & external nasal deformity (saddle nose).
Septal perforation.
Management
Surgical drainage of hematoma under general anasthesia with nasal packing for 48 hours to prevent recurrence + Systemic antibiotic cover.
Septal Abscess

Definition: Collection of pus beneath mucoperichondrium of nasal septum.

Causes
Complicated septal hematoma.
Following furunculosis.

Clinical Picture

As septal hematoma.
Fever, headache.
Tenderness over nasal bridge.
Symmetrical compressible tender swelling of nasal septum .

Complications

Cavernous sinus thrombophlebitis.
Septal perforation.
Cartilage necrosis & external nasal deformity (saddle nose).


Management
Surgical drainage of abscess under general anasthesia with nasal packing for 48 hours to prevent recurrence + Systemic antibiotic.
Rhinoplasty .

Septal Perforation

Defintion: Direct communication between right and left nasal cavities via full-thickness hole in nasal septum.
Causes
Traumatic: nose picking and septal surgery.
Infectious: septal abscess, TB, syphilis.
Malignant.
Irritants: Cocaine addicts.
Ideopathic.

Clinical Features

Asymptomatic.
Whistling due to small perforation.
Large perforation leads to crustation and bleeding.

Management

Asymptomatic: No treatment.
If crustation is a problem: alkaline nasal douche + lubrication by ointment.
Non-surgical closure by Silastic buttons.
Surgical closure have poor success rate.


Oroantral Fistula
Definition: Communication between maxillary sinus and oral cavity.
Causes
Traumatic: either
Surgical:Dental extraction of molar or premolar tooth,antrum operation(Caldwell-Luc operation) most common cause .
Non-surgical :Penetrating injury.
Malignancy : Maxillary tumour erroding the alveolar process.

Clinical picture

Symptoms
Unpleacant tasting discharge & odour.
Reflux of fluid & soft food in to the nose from the mouth.
Recurrent maxillary sinusitis with foul smell nasal discharge due to food particles entering maxillary sinus.
Signs
Fistula is seen through the oral cavity.
Leakage of air while blowing against closed nostrile and open mouth
( Nose Blowing Test).
A probe can be passed from mouth to the antrum (not recommended).

Investigations:

X-ray : Opacity within the antrum ( sinusitis).
Ct scan : Show the site of fistula & presence of sinusitis.


Treatment
Timing of diagosis is crucial.
When the fistula is identified at the time of dental extraction or within hours:Immediate closure is the best management.
Old fistula:
Treat the cause.
Control infection(sinusitis) :Remove retained debris in the sinus.
Closure of fistula with mucoperiosteal flap.

CSF Rhinorrhea

Definition : Communication between subarachnoid space and nasal cavity causing leakage of CSF through the nose .

Origin of leak:

Roof of the nasal cavity (cribriform plate of ethmoid).
Sinuses (frontal , ethmoid &sphenoid).

Causes:

Traumatic( most common).
Surgical: Endoscopic sinus surgery.
Non-surgical trauma :head injury causing fracture of base of skull at cribriform plate.
Neoplastic :tumour erodding the roof of nasal casal cavity or floor of skull.
Congenital defect in the skull base.
Idiopathic of unknown cause.


Clinical Features (Symptoms & Signs)
Unilateral watery nasal discharge.
Clear colourless & increased by straining or bending forward.
Headache dueto decrease CSF pressure.
(Handkerchief test): normally the nasal mucus stiffens a handkerchief while CSF dose not.
Halo or Ring Sign:when bloody CSF placed on a piece of filter paper, the blood will separate out from the CSF (central blood with clear ring).
Intrathecal flourescen + Endoscopic examination .

Complication:

Meningitis.

Investigation

Biochemical analysis of fluid:
Glucose is positive (glucose concentration > 30mg/dL if no blood present).
Beta 2 transferrin(Protein produced by enzymes only in CNS) which is highly sensitive and specific for CSF .

Localisation of leakage site:

CT scan with intrathecal contrust injection (CT Cisternogram).
MRI it require active CSFleakage at time of scan & it is indicated especialy if intracranial pathology is suspected ,

Management

Conservative : Most traumatic cases heal spontaneously:
Bed rest in in semi-sitting head up position.
Avoid straining & nose blowing .
Avoid topical nasal medications&nasal packing.
Prophylactic Systemic antibiotics to prevent meningitis.


Surgical
Surgical closure of the defect either by intracranial approach(craniotomy), or by transnasal endoscopic approach.
Covering the defect by fascial graft or osteoperioseal flap.