The Nose2

د. باسل محمد نذير سعيد

Lecture 2

Congenital diseases of the nose

Choanal Atresia:
It is congenital obstruction of the posterior nasal orifice ( choana)
It is due to failure of the breakdown of the bucconasal membrane.
It is usually unilateral but bilateral cases occur.
Bilateral cases are observed at birth because the infant has difficulty in breathing and constitutes neonatal emergency.
THE INFANTS ARE OBLIGATORY NASAL BREATHERS.
Unilateral atresia presents as nasal obstruction and on examination a thick secretion is seen in the affected side.
Diagnosis:
1- Failure to pass a soft rubber catheter to the nasopharynx through the affected side.
2- Endoscopic nasal examination.
3- CT scan.
4- Contrast radiography.
See fig.1.

Treatment

In infants with bilateral atresia, perforation of the atresia should be done, followed with regular dilation.
In unilateral cases, similar treatment can be adopted in infants. In adults surgical correction if the atresia can be done through the nose or the palate.


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Fig.1.

TRAUMA TO THE NOSE

Nasal bone Fracture
The nose is liable to trauma because it is the most prominent structure in the face. Fracture of the nasal bone is usually caused by external force, blow and fall from height or assault.
It is presented with pain, swelling, bruises, epistaxis, nasal block, external deformity or deviation. See fig.2.
On Examination, it is important to examine the septum for the presence of septal haematoma, especially in children.
Septal haematoma is accumulation of blood between the mucus membrane(the muco-perichondrium) and the cartilage of the nasal septum. See fig.3.
When present, the haematoma needs urgent drainage; otherwise septal abscess may develop which may result in cartilage necrosis.
Radiography of the nose is usually done and it is of medicolegal importance and it can show the nasal bone fracture.
The correction of nasal bone fracture is needed when there is recent and apparent deformity or deviation of the external nose. This is usually done after 5 to 7 days after the subsidence of edema and good assessment of the nose is possible and before healing of the fracture which makes its reduction difficult.

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Fig.2
Fig.3

EPISTAXIS

It is defined as Bleeding from the nose.
It is usually Anterior bleeding, but it can be posterior or both anterior and posterior bleeding depending on the site and severity of bleeding.
The commonest site of bleeding is Little's area ( the anteroinferior part of the nasal septum)which has high vascularity. See fig.4.


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 Fig.4

CAUSES

A-Local causes:
1-Trauma like fracture nose and nose picking.
2-Upper respiratory tract infections.
3-Acute or Chronic rhinitis.
4-Postoperative.
5-Foreign bodies.
6-Tumours ((benign or malignant)) of the nose and para nasal sinuses like Angiofibroma.

B-Systemic Causes:

1- Hypertension, atherosclerosis and blood vessels abnormalities.
2- Clotting mechanism defects like hemophilia and thrombocytopenia.
3- Anticoagulant drugs like heparin and warfarin.
4-Antiplatelet drugs like aspirin.
5- Hormonal Changes like in pregnancy and puberty.

The cause may be unknown, this is called Idiopathic

MANAGEMENT OF EPISTAXIS
1. Local treatment
If the bleeding is mild and intermittent then pinching of the nose and application of ice on the forehead may be enough to stop bleeding and then local antibiotic cream or ointment is applied locally.
Cautery is done when there is obvious area of dilated vessels and this can be either chemical cautery or electrical cautery.

If the bleeding is severe and not controlled with the above measures, then PACKING of the nose is needed.
Packing can be either anterior OR posterior and anterior packing.

2. Treatment of the underlying cause when present, stop or decrease the dose of the anticoagulant drug, treat sinusitis etc.

3. Resuscitation in case of shock because of the bleeding.

I.V. fluid, blood transfusion may be needed.

4. Other methods to control epistaxis

We may rarely need ligation of the artery to control epistaxis or if facilities are available, embolization of the bleeder under radiographic control may be of great benefit.

Foreign Bodies in the Nose

This is a problem of young children who tend to push objects into the nose. These F.B. can be organic or non organic.
It is manifested by nasal block, discomfort and sometimes if the F.B. is present for long time, there is unilateral foul smelling discharge which is characteristic for F.B.
Management is removal which sometimes needs general anesthetic when the F.B. is deep in the nose and difficult to remove in the uncooperative child.

Rhinoliths

They are calcareous masses which may be unilateral or bilateral in the nasal cavity. They consist of deposits of calcium and magnesium carbonates and phosphates around a nucleus in the nasal cavity. This nucleus may be organic or inorganic material in the nasal cavity like a foreign body.
It is presented with symptoms of nasal block, nasal discomfort and discharge. The rhinolith is evident on examination when it is found hard on probing.
Treatment is removal.









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