Congenital and Traumatic diseases of the Nose and Paranasal Sinuses

Dr.Hussein

L.2 Congenital & Traumatic diseases of the Nose and Paranasal Sinuses

Congenital Malformation:

A. Facial cleft:
- Cleft lip: result from failure of fusion of the maxillary process on one
side with the median nasal process; it may be bilateral, or unilateral.
- Cleft palate: result of the failure of the palatine processes to fuse with
each other and with the nasal septum. Bifid uvula and submucous cleft represent
minor degrees.
- Bifid nose.
B.
Dermoid cysts and sinuses: This found in the midline.

C. Aplasia of the sinuses: failure of pneumatization, often of frontal sinus.

D.
Atresia and stenosis of the anterior nares, atresia of the posterior nares
(congenital choanal atresia): due to persistence of the primitive bucconasal
membrane.
Types: 1. Bony, most commonly (90%) mostly thin bone easily perforated.
2. Membranous (10%).
3. Partly bony partly membranous.
Degrees: 1. Complete unilateral atresia, most commonly.
2. Complete bilateral atresia.
3. Incomplete unilateral atresia.
4. Incomplete bilateral atresia.
Pathology:
The partition is covered with mucous membrane, its thickness may vary from
1-10 mm, and females are more commonly affected than males.
Clinical features: 1. Nasal obstruction.
2. Excessive nasal discharge, tenacious.
3. In bilateral atresia may be urgent and
cause death from Asphyxia (the child is cyanosed when he is quite).
Diagnosis:
1. Plastic catheter cannot be passed through the nose to nasopharynx.
2. CT scan.


3. Contrast radiography, when radio opaque substance instilled
into the nose, it does not reach the nasopharynx.
Treatment: Excision of the atretic segment, or perforation.

Trauma of the Nose:

A• Fractured Nasal Bone:
Etiology:
Usually caused by blows to the front or side of the nose due to personal
assault, sport injuries, RTA, personal accidents.
Clinical features:
1. Deformity: external swelling, black eye (periorbital
ecchymosis).
2. Pain.
3.Epistaxis

4. Nasal obstruction.

Diagnosis:
Clinical features and X-ray which is of medicolegal importance with
little clinical value.
Treatment:


1. Early: if the patient is seen early before swelling appears, reduce
immediately.
2. Intermediate; when the swelling is marked, leave until the swelling has
subsided, and give antibiotics and sedatives.
3. Late (7-14 days): after swelling has subsided, reduction under local or
general anesthesia, external splint may be required.
4. Malunion: may require rhinoplasty.
Complications: 1. deviated nose 2. bleeding 3. septal haematoma 4. saddling 5.
CSF leak.
B. Fractures of the middle 1/3 of the face:
Fractures involving that part of the face between the supraorbital
ridge and the upper teeth, along Le Fort's lines of weakness, which may be
unilateral or bilateral, and may involve the paranasal sinuses.

Cerebrospinal Rhinorrhoea:

It is flow of CSF from the nose (CSF rhinorrhea).
Etiology:
1. Traumatic: from fractured base of
skull involving the anterior cranial fossa and tearing of the dura mater.
2. Spontaneous: from destructive lesions.
Clinical features:
1. Watery fluid drips from the nose, the fluid contains no mucous nor albumin,
but contains glucose.
2. Meningitis may follow these drips.
Investigations:


1. Injection of radioactive tracer into the lumbar CSF and wool pled gets placed
in the roof of both nasal cavities.
2. Gamma camera scanning of the head.
3. Simpler method by placing dextostix in the various sites to look for the
glucose in the CSF.
Treatment:

1. Immediate: avoid meningeal infection by systemic ABs, avoid nose blowing, and

avoid any local treatment like packing of the nose.
2. Delayed: if CSF leak persists for more than 4 weeks,
lumboperitoneal shunt to reduce CSF pressure, craniotomy and facial graft if
this fails.

Barotraumatic Sinusitis:

Pathological changes in the nasal mucosa due to lowering of the pressure within
the sinus compared with that of the surrounding atmosphere.
Etiology:

Descent in non-pressurized aircraft in the presence of
obstruction of the sinus ostium, and flying with respiratory tract
infection.
Clinical features:
pain is felt during descent
in the frontal region or the cheek.
Treatment:


Preventive:
avoidance of flying with URTI, polyps, septal deviation.
Symptomatic: analgesia, decongestant nasal drops, treatment of infection.

Septal Deflections and Spurs:
Few adults have a completely straight septum; only gross deviation may lead to
mechanical obstruction.

Mladina’s classification of septal deformities:

Type 1: is characterized by a vertical, unilateral ridge in the region
of the nasal valve, but without a direct contact with the valve, hence not
compromising it’s function.
Type 2: is characterized by a vertical, unilateral ridge that is in
contact with the nasal valve area, thus compromising it’s function.
Type 3: is characterized by a unilateral vertical ridge, next to the
head of the middle turbinate i.e. at the junction of the quadrangular cartilage
and the perpendicular plate of ethmoid bone.
Type 4: is characterized by bilateral vertical ridges, one in the
valvular region on one side, and the other in the region of the middle turbinate
on the contra lateral side of the nose (S – shape septum).
Type 5: is characterized by an almost flat septum on one side or
deviated and a basal, horizontal spure on the other side.
Type 6: is characterized by a deep horizontal gutter in the basal
segment of the anterior septal region on one side and a ridge formed from a wing
of intermaxillary bone on the contra lateral side.
Type 7: is characterized by a combination of more than one type, so
called: crumpled septum.
Type 6: is characterized by a deep horizontal gutter in the basal segment of
the anterior septal region on one side and a ridge formed from a wing of
intermaxillary bone on the contra lateral side.
Type 7: is characterized by a combination of more than one type, so
called: crumpled septum.


Anterior cartilaginous: types 1,2,6
Posterior bony:
types 3,4,5
Vertical deformity:
types 1,2,3,4
Horizontal deformity:
types 5,6

Etiology:

1. Trauma is the commonest cause.
2. Errors of development produce either bending or spurs.
3. Compression of the nose during birth.
Pathology:
Deflections may
involve cartilage and/or bone, either simple or sigmoid (double bend).
Spurs: are isolated thickenings found at the junction of the bone and cartilage,
which may impede drainage of sinuses and lead to sinusitis, and epistaxis due to
vessels on their convex side.
Clinical features:
1. Nasal
obstruction.
2. External deformity.
3. Pressure headaches: result from contact of the deflected septum with
structures of the lateral wall of the nose.
4. Nose bleeding.
Treatment: 1. No treatment is required in minor degrees.
2. Submucous resection (SMR), or septoplasty.


Haematoma of the Septum:
Collection of blood beneath mucoperichondrium of the septum.
Etiology:
1.
Traumatic, nearly always, either because of blovvs or fails, or operations
like SMR.
2. Sometimes rarely blood dyscrasias. Clinical features:
1. Nasal obstruction, usually bilateral.
2. Septal soft swelling.
Complications:
1. Septal abscess due to secondary
infection of the haematoma.
2. Cartilage necrosis and saddling of the nose.
3. Permanent thickening of the septum due to fibrosis.
Treatment:

1. Simple aspiration in small haematoma.

2. Incision and drainage is more effective with insertion of drainage tube.
3. Nasal packing to prevent recurrence of haematoma.
4. Antibiotics and sedatives.


Septal Abscess:
Occur due to secondary infection of haematoma, or
spontaneously following measles or scarlet fever, furuncolosis.
C clinical features:.
1. Pain may be severe and throbbing.
2. Nasal obstruction.
3. Pyrexia.
4. Septal swelling.
Complication:
1. Cartilage necrosis and saddling of the
nose.
2. Meningitis and cavernous sinus thrombosis.
Treatment:
Incision and drainage with systemic antibiotics.

Perforation of Septum:

Etiology: -

A. Traumatic:

1. Septal operations.
2. Pick ulcers; result from picking of the septum.
3. Chronic perforation, which is an occasional condition
4. Snuff takers perforation in cocaine addiction.
5. F.Bs. placed through the septum like safety pins. B.Pathological:
1. Lupus.
2. Syphilis involves the bony septum.
3. Haematoma or abscess.
4. Malignant granuloma (Wagener's granuloma).
5. Rhinitis sicca and rhinitis caseosa.
6. Pressure from F.Bs. or rhinoliths.
C. Idiopathic:


Clinical features:
1. Irritation in the nose and crusts formation.
2. Epistaxis.
3. Whistling.
4. Pain and foeter.
Investigations:
1. Serological test for syphilis.
2. ESR.
3. Biopsy.

Treatment:

1. Alkaline douche, glucose
25% in glycerin to separate crusts.
2. Chlorhexidine cream 0.5% is applied.
3. Silver nitrate may be used in bleeding.

4. Closure of the perforation.
Foreign Bodies in the Nose:
Etiology:
More common in children, either through the anterior nares, or food through the
posterior choanae, or penetrating wounds. The F.Bs. may be organic or inorganic,
papers, beads, buttons, or cotton pieces.
Clinical features:
1. History of introduction of a F.B. may be not obtained.
2. Unilateral nasal discharge, foul smelling.
3. Nose bleeding.
4. Pain.
5. Sneezing.
Treatment:
Removal of the F.B. through the
anterior nares, which might be done under G.A. in young children.


Rhinoliths
Nasal concretions are formed around the F.B., blood, mucous may be
friable or hard, and it is radopaque in x-ray.
Treatment:
Removal, through anterior nares under G.A...... .