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‫ باسل محمد نذير سعيد‬.‫د‬
Lecture 1
The Nose
Anatomy of the Nose
1: External nose:
It is a projecting triangular pyramid directed downwards. It has apex, root
connected to the forehead and base perforated by two nostrils.
Bones and Cartilages of the nose:
Nasal bones.
Maxillae.
Frontal bone (nasal process).
Upper lateral cartilages.
Lower lateral cartilages.
Septal cartilage.
The muscles of the nose are a part of facial muscles and are supplied
with facial nerve.
See figure 1.
Fig.1: Anatomy of the external nose.
1
2: Nasal Cavity
A-Nasal Vestibule
It is the entrance to the nasal cavity, lined with skin which is hair
bearing.
B-Nasal cavity proper
They are two cavities separated by the nasal septum, extending from
the anterior nares to the nasopharynx.
The mucosa of the nose is Ciliated Columnar Epithelium with
olfactory epithelium at the roof.
The nasal septum (Medial Wall of the nasal cavity) is composed of the
following:
1-Quadrilateral Cartilage ((Septal Cartilage)).
2-Perpendicular Plate of the Ethmoid bone.
3-The Vomer bone.
4-Nasal Crests of the Maxilla and the Palatine bones.
The Lateral Wall
1- The Inferior Turbinate: is a separate bone attached to the maxilla.
2- The Middle Turbinate.
3- The Superior Turbinate.
The middle and Superior turbinates are parts of the ethmoid bone
Bellow the inferior turbinate is the inferior meatus which receives the
nasolacrimal duct opening. The middle meatus lies bellow the middle
turbinate and receives the openings of the maxillary, frontal and the
anterior ethmoidal sinuses. While the superior meatus receives the
opening of the posterior ethmoidal cells. Above the superior turbinate is
the Sphenoethmoidal Recess which receives the sphenoid sinus ostium.
The Roof of the nose is formed from anterior to posterior from: the nasal
bones, the cribriform plate of the ethmoid bone and sphenoid bone.
The olfactory cleft area is lined with olfactory epithelium (special
sensory epithelium) and occupies the area of the cribriform plate, the
superior turbinate and the corresponding area of the septum.
The floor is formed of the maxilla and the palatine bones.
See figures 3,4 and5.
2
Fig. 2,3,4 &5.
The Blood Supply
The external nose is supplied by branches of the facial, the maxillary and
the ophthalmic arteries. The venous drainage is through the facial,
maxillary and the ophthalmic veins, the latter drains to the cavernous
sinus.
The blood supply to the nasal cavity is coming from the maxillary, facial,
the anterior and the posterior ethmoidal arteries.
Little's area is the anteroinferior part of the nasal septum where
anastomosis of vessels called Kiesselbach's plexus is located and is the
commonest site of bleeding.
See figures 6,7&8.
3
Figures 6,7&8.
Nerve supply
The sensory innervations of the nose is supplied by the trigeminal nerve,
mainly through the maxillary and the ophthalmic divisions.
The olfactory area is supplied by the olfactory nerve.
The nose also has sympathetic supply from the upper deep cervical
ganglion. The parasympathetic supply comes from the geniculate
ganglion of the facial nerve.
4
THE PARANASAL SINUSES
They are Air Filled cavities within the bones surrounding the nose and
have openings or ducts draining into the nose. They are arranged in pairs
and lined with respiratory mucus membrane. They comprise the
maxillary, the frontal, the ethmoid and the sphenoid sinuses.
The Maxillary Sinus
This is the largest Para nasal sinus; it occupies the body of the Maxilla. It
is also called the ANTRUM. It has a roof which is the floor of the orbit, a
base or the medial wall, a floor which is the alveolar process of the
maxilla and an apex.
The ostium is situated high on the medial wall and it opens into the
middle meatus, so the drainage is dependant on the ciliary action of the
mucosa, not on gravity.
The Frontal Sinuses
They are situated in the frontal bone and are divided into two parts by a
septum.
The frontonasal duct of each sinus opens into the middle meatus.
The Ethmoid Sinuses
They are situated in between the nasal cavity medially and the orbit
laterally where a very thin bone (lamina papyraceae) separates it from the
orbit, superiorly the sinuses are bounded by the cranial cavity.
The sinuses are divided into two groups, an anterior group which drains
into the middle meatus and posterior group which drains into the superior
meatus.
The Sphenoid Sinuses
These occupy the body of the sphenoid bone and are divided by a septum
into two, each sinus drains into the sphenoethmoidal recess.
See figures 9,10,11 & 12.
5
Figures 9,10,11 &12.
The Physiology of the Nose
The nose has many functions
1-It is an airway passage which moistens and heats the inspired air due to
high vascularity of the mucus membrane which is ciliated columnar
epithelium.
2-The mucus is transported by the action of the cilia and contains
antibodies which act as a defense mechanism.
3-It filters the inspired air from foreign bodies.
4-It adds resonance to sound.
5-Olfaction, the sense of smell.
6
Symptoms and Signs of Nasal diseases
Nasal block
Nasal discharge ((Rhinorrhoea)) and postnasal drip
Bleeding from the nose ((Epistaxis))
Sneezing and itching
Nasal pain, facial pain and headache
External deformity
Disorders of smell …
Anosmia (total loss of the sense of smell)...Hyposmia (decreased the
sense of smell)…Hyperosmia (increased sense of smell)…Cacosmia
(perception of bad smell)
Signs like external deformity, scars, masses and other skin lesions are
readily seen by simple examination.
Examination of the nose is done by using Nasal Speculum and Good
light. This is Called Anterior Rhinoscopy. See fig.13.
Fig.13.
Deviated nasal septum, abnormality of the mucosa, bleeding vessels, and
character of the secretions, nasal masses and polyps.
Postnasal examination is done by Nasopharyngeal Mirror. This is called
Posterior Rhinoscopy.
ENDOSCOPIC EXAMINATION OF THE NOSE IS POSSIBLE BY
USING FLEXIBLE AND RIGID ENDOSCOPES.
Investigations of the nose (Some of them)
X-ray paranasal sinuses
CT scan
MRI scan
Skin prick test for allergy.
7
Lecture 2
‫ باسل محمد نذير سعيد‬.‫د‬
Congenital diseases of the nose
Choanal Atresia:
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- Contrast lateral radiography.
4-CT scan.
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.
Fig.1.
8
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 mucoperichondrium) 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.
Fig.2
Fig.3
9
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.
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
10
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.
Vestibulitis
It is inflammation of the vestibular skin; it is usually secondary to
conditions causing long term or chronic discharge from the nose like
chronic rhinitis. There is excoriation of the vestibular skin and sometimes
painful fissuring and bleeding (epistaxis). See figures 5 &6.
The treatment includes treatment of the underlying cause and topical
antibiotic cream or ointment till subsidence of the condition.
Another form of vestibulitis is the BOIL, which is a staphylococcal
infection of hair follicles. In addition to local treatment; it may need antistaphylococcal antibiotic like cloxacillin.
11
Fig.5&6
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.
12
Acute Rhino sinusitis
The Common Cold or Coryza
It is usually viral infection of the mucus membrane of the nose, which is
accompanied by general inflammation of the nose and sinuses.
Predisposing factors include exposure to cold, fatigue, poor nutrition,
nasal obstruction and chronic nasal and sinus infections.
All ages are affected with higher incidence in children.
Spread of infection is by droplet, dust and eating.
Clinical features
After an incubation period of 1 to 3 days, there is sensation of discomfort
in the nose and attacks of sneezing, chills and low grade pyrexia,
followed by nasal discharge and nasal block which results from
inflammation and swelling of the nasal mucus membrane. The discharge
to start with is watery from increased activity of the glands, and then it
changes to mucopurulent when secondary bacterial infection ensues.
Mucosal swelling results in obstruction of sinus ostia, causing Sinusitis
and associated headache. See fig.7.
Fig.7.
Management
The disease is self limiting and needs supportive measures like good
nutrition and bed rest together with simple analgesics(aspirin or
paracetamol),and local or systemic nasal decongestants (like ephedrine
nasal drops and Actifed tablets or syrup).
Antibiotics are indicated when there are complications like:
acute otitis media, acute tonsillitis, acute sinusitis, and chest infection.
13
Acute Sinusitis
Acute infection and inflammation of Para nasal sinuses
It is usually caused by acute rhinitis but it can be dental in origin (spread
of infection from the teeth).
The commonest sinuses to be involved are the maxillary and the
ethmoids, but all sinuses can be affected and this is called Pan Sinusitis.
Predisposing factors include nasal block from nasal septal deviation,
adenoids, polyps and allergic rhinitis.
Clinical features are similar to those of acute rhinitis (nasal block, nasal
discharge of mucopurulent material) but the symptoms are more severe,
there may be headache and tenderness on pressure on the affected
sinuses. See fig.8.
Diagnosis is done by the clinical features and aided by radiology ((X-ray
of the Para nasal sinuses)).
Treatment includes rest, antibiotic and nasal decongestants.
Complications of Sinusitis
They are uncommon. They include:
1. Orbital complications
Spread of infection to the eye is usually from the ethmoid sinuses through
the Lamina Papyracea which is very thin bone separating the ethmoid
from the eye.
It is the commonest complication which is mainly in children. See fig.9.
14
Fig.9.
If the condition is early then is treated with hospital admission,
observation and antibiotics. If the situation is severe with abscess then
surgery is needed.
2. Osteomyelitis
It affects diploic bones like the frontal sinus.
It is treated with antibiotics and surgery of no response.
3. Intracranial complications
Meningitis, Cortical venous thrombosis, Cavernous Sinus thrombosis and
Brain Abscess.
Chronic Rhinitis
It refers to the condition where there is chronic inflammation of the nasal
mucus membrane, there are many types, and of them we mention the
followings.
Simple chronic infective rhinitis
It usually arises from recurrent attacks of acute infective rhinitis.
Predisposing factors include conditions causing nasal block, like polyps
and deviated septum, chronic infection of the sinuses, decreased
immunity and environmental pollution.
Clinically the patient complains of nasal obstruction, nasal discharge and
especially post nasal drip.
15
On examination, there is usually congestion and swelling of the mucus
membrane especially of the inferior turbinate, there may be deviated
septum and nasal discharge.
Treatment
Antibiotic treatment.
Short course of topical or systemic decongestants.
Treatment of the underlying cause: correction of deviated septum,
treatment of nasal polyps and sinus surgery for chronic sinusitis.
The hypertrophied turbinate may need reduction of its size either by
cautery or by surgical reduction (turbinectomy).
Atrophic Rhinitis
It is a chronic inflammatory process characterized by atrophic changes of
the mucus membrane and excessive nasal crusting.
The primary idiopathic form is usually affecting females at puberty,
with poor hygiene or living conditions.
The cause is unknown, but many factors are suggested: malnutrition,
vitamin deficiency, iron deficiency, hormonal deficiency (estrogen).
The clinical picture includes young female with nasal block and anosmia,
there is usually bad odour from the nose and this is called ((Ozaena)) and
epistaxis which occurs following the separation of the crusts.
On examination there is excessive crusting in the nose, after removal the
nasal cavity looks wide and patent due to the atrophic changes.
Management
It is usually supportive and local measures. Nasal douching with normal
saline or ordinary water with bicarbonate helps to separate the crusts,
together with application of 25% glucose in glycerol drops and using
Vaseline ointment to sooth the nasal mucosa.
Surgery may be needed and involves airway narrowing procedure like
complete closure of the nostril for a period of one year which helps in the
recovery of the mucus membrane.
Secondary atrophic rhinitis
It usually follows extensive nasal surgery like total inferior turbinectomy
or removal of extensive nasal polyps; it may be caused by chronic
infection in the nose like syphilis.
Treatment is usually symptomatic.
16
Lecture 3
‫ باسل محمد نذير سعيد‬.‫د‬
CHRONIC SINUSITIS
It is long- standing infection of the Para nasal sinuses, with hypertrophic
changes in the mucosa .It may follow an acute attack if not properly
treated or may be insidious in origin. It has been recently defined as
persistent symptoms and signs for 8 weeks, or 4 episodes per year of
acute sinusitis each lasting 10 days with persistent radiological (CT)
findings after proper medical treatment.
Predisposing factors
1- Anatomical abnormalities causing sinus ostium obstruction like
deviated septum, nasal polyps, adenoid hypertrophy and allergic rhinitis.
2- Recurrent acute infections.
3- Ciliary dysfunction.
4- Mucus overproduction or increased viscosity.
5- Dental causes which accounts for about 20% cases of chronic
maxillary sinusitis.
Clinical presentation
SYMTOMS
Nasal obstruction
Nasal discharge which may be greenish-yellow.
Post nasal drip which may lead to chronic sore throat due to chronic
pharyngitis and laryngitis.
Facial pain or Headache.
Smell disorders like anosmia, hyposmia and cacosmia (unpleasant smell).
Epistaxis.
SIGNS
There is usually swelling and congestion of the nasal mucus membrane
with mucupurulent discharge in the nose; there also may be features of
the causative or predisposing factors.
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
X-ray of the paranasal sinuses is of limited value in the management of
chronic sinusitis. It may show haziness or opacity of the affected sinuses;
but it is not much specific.
CT scan is an excellent tool to investigate sinus diseases; it shows the
anatomical details of the sinuses and the extension of the disease process.
It shows the anatomy of the area of the middle meatus and the region
called the Osteomeatal Unit which is the area of the drainage of the
17
maxillary, frontal and ethmoid sinuses, and is essential investigation for
endoscopic sinus surgery.
Treatment
1-If acute infection is present; a course of broad spectrum antibiotic is
needed for 2 to 3 weeks; together with short course nasal decongestants
and mucolytics.
2-Treatment of the underlying cause.
3-Surgical intervention may be needed when the situation does not
respond to treatment or recurrent acute attacks of acute sinusitis.
Surgery of the sinuses is now mostly done with endoscopes, where the
procedure is directed to area of the drainage of the sinuses (osteomeatal
unit) to drain the sinuses and improves the ventilation. This surgery is
termed as functional endoscopic sinus surgery.
Other procedures which were previously the main surgeries of the
sinuses, and may have a place in the management of chronic sinusitis are:
1-Antral washout, which is puncturing the maxillary sinus with trocar and
canula through the inferior meatus. This procedure may be diagnostic if
pus comes out of the sinuses and is sent for culture. It is also therapeutic
when the infected material is washed out of the affected sinus and the
natural ostium is opened by the wash.
2-Intranasal antrostomy.
3-Caldwell-Luc operation.
4-External Frontoethmoidectomy.
Allergic Rhinitis
It is defined as hypersensitivity reaction of the nasal mucus membrane to
a variety of stimuli.
It is a common medical problem affecting about 10- 15 percent of the
general population (in western studies).
It can be classified as seasonal allergic rhinitis and perennial allergic
rhinitis; in the seasonal type the symptoms are present mainly in certain
season of the year, but in the perennial type the symptoms are present in
most of the days of the year with possible occasional exacerbations in
some periods.
Etiology
18
Allergic Rhinitis is caused by allergens which are antigens of pollens,
moulds, house dust mites and animal epithelium, which are usually
inhalants. Antigens may also be ingestants like certain foods or drugs.
Allergic rhinitis shows a strong familial predisposition.
Pathology and Pathogenesis
It is type I hypersensitivity reaction which involves IgE, Mast cells and
other cells.
When the antigen comes into contact with the mast cell in nasal mucosa,
it cross links 2 molecules of IgE on the surface of mast cell leading to its
degranulation and release of vasoactive mediators, which are mainly
histamine and prostaglandins.
These mediators are responsible for the pathological changes in the nasal
mucosa, which are swelling excessive discharge and increased vascular
congestion and vascular permeability.
Clinical Picture
The main symptoms of allergic rhinitis are:
Nasal obstruction because of the swelling and congestion of the nasal
mucus membrane.
Nasal discharge which is called Rhinorrhoea.
Sneezing.
Sometimes, itching and watering of the eyes may occur, especially with
inhalant allergens.
On examination, signs like edematous mucus membrane which is usually
pale in color and sometimes bluish discoloration. Thin mucus discharge is
usually obvious in the acute attack. In longstanding cases hypertrophy of
the mucus membrane and even polyp formation may occur.
Investigations
Skin prick test which is a sensitive test to diagnose allergy and to identify
the allergen.
Nasal smear examination which may show eosinophilia.
Certain blood tests which measure the level of IgE in the blood which is
elevated in cases of allergy.
Management
1-Avoidance of the allergen if possible is ideal.
2-Medical therapy
A-Antihistamines: either first generation drugs which have sedative
effects, or second generation ones less sedative side effects.
19
B-Steroids: usually topical steroids in the form of drops or sprays, like
beclomethasone(beconase), budesonide(rhinocort), and
fluticasone(flixonase).
Rarely short course of systemic steroids may be needed.
C- Mast cell stabilizers like sodium chromoglycate, in the form of topical
drops or sprays; they are especially helpful in the prophylaxis.
D- Topical anticholinergic drugs like ipratropium bromide is helpful to
reduce excessive mucus discharge reducing rhinorrheoa.
3- Immunotherapy (hyposensitization).
Non- Allergic Rhinitis
It is also called intrinsic or vasomotor rhinitis.
It is a form of chronic rhinitis similar to allergic rhinitis in its clinical
presentation but negative history of allergy and negative allergic test.
It is thought to be caused by imbalance of the autonomic nervous supply
to the nose (overactivity of the parasympathetic supply) and hyper
reactivity of the nasal mucosa to external environmental factors, like
change in humidity or temperature or exposure to environmental
pollution.
Clinical Picture:
These can be 2 types, the first group is manifested mainly by excessive
nasal discharge(rhinorrhoea), and the second type is manifested mainly
by nasal block.
Treatment
Avoidance of the irritants like cigarette smoke is clearly helpful.
Medical treatment is either nasal steroids and antihistamines which is
helpful if the presentation is mainly nasal block. Topical anticholinergic
drugs like ipratropium bromide is helpful in the rhinorrhoea group.
Surgery is indicated if there is co-existent septal deviation or hypertrophy
of the turbinate.
Deviated Nasal Septum
Some mild form of septal deviation is common in the general population
and this needs no treatment, only those cases of gross deviation of the
nasal septum and causing symptoms and complications need treatment.
Etiology
20
1-One theory suggests that the nose may be compressed during birth
(birth moulding theory).
2-Trauma.
Clinical presentations
Nasal obstruction, it can be unilateral or bilateral.
Epistaxis.
Symptoms of associated complications, like nasal discharge and pain
(facial pain or headache), when there is sinusitis.
The deviation may in the form of sharp angulation called (spur) or
smooth curve.
Investigations
X-ray of the sinuses or CT scan if available may be needed when there is
suspicion of sinusitis.
Treatment
Surgery is needed to correct the deviated septum.
The operation is called septoplasty which entails minimal resection of
the septal cartilage and repositioning of the septum in the midline.
21
Septal Perforation
It is defined as a direct communication between the right and left nasal
cavities via a hole in the septum.
Causes:
1- Iatrogenic (post septal surgery), is the commonest cause.
2- Traumatic, as in chronic nose picking.
3- Chronic inflammatory conditions like syphilis, tuberculosis and
atrophic rhinitis.
4- Chronic exposure to irritants, like in cocaine addicts.
5- Malignant diseases in the nose.
Clinical Picture:
The perforation may be asymptomatic and the condition is diagnosed
accidentally.
The symptoms may be irritating crusts in the nose, bleeding when the
crust separates and whistling sound in the nose when the perforation is
small.
Management
If the perforation is asymptomatic, no treatment is required.
Nasal douching is recommended when bleeding and crusting is a problem
and application of a lubricant ointment like vasaline.
Non surgical closure using a silastic prosthesis ( biflanged buttons).
Surgical closure may be done for symptomatic perforations and these
have poor outcome.
Oroantral Fistula
It is a communication between the maxillary sinus and the oral cavity.
It occurs most frequently through the alveolar border following dental
extraction, especially of the first upper molar teeth. It may also follow
Caldwell- Luc operation when the incision line breaks down. It can be
malignant in origin( maxillary sinus malignancy).
It usually presents with recurrent maxillary sinusitis when food particles
enter the sinus cavity.
Management:
1- Immediate closure when the fistula is identified at the time of
dental extraction is the best treatment.
2- Treatment of infection in case of sinusitis.
3- Removal of any retained foreign body like tooth root.
4- Delayed closure of the fistula.
22
Cerebrospinal fluid (CSF)leak
It is also called CSF rhinorrheoa, it is a communication between the
subarachnoid space and the nasal cavity. The most common causes are:
1- traumatic as in head injury, is the most common etiology. The
commonest site of the leak is the area of the cribriform plate of the
ethmoid bone.
2- Iatrogenic, like post surgical.
3- Tumors.
4- Hydrocephalus.
5- Idiopathic.
The diagnosis can be suspected when there is clear fluid discharge from
the nose after head injury or nasal surgery, and this fluid is collected for
analysis of glucose( it has high glucose content about 2 thirds that of the
serum). Beta 2 transferrin estimation by electrophoresis is pathognomonic
for CSF.
Estimation of the site can be done by endoscopic examination of the nose
combined with intrathecal fluorescein injection.
CT scan is extremely important in the localization of the fistula.
Sometimes isotope study may be needed.
Treatment:
1- Prophylactic antibiotic is needed to prevent meningitis.
2- Treatment of the underlying cause if possible.
3- Closure of the defect by surgery which is either via craniotomy or
endoscopic approach.
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.
23
Nasal Polyps
They are of 2 main types
1-Ethmoidal polyps
2-Antrochoanal polyp
Ethmoidal Polyps
They are round; smooth, soft, translucent yellow or pale glistening
structures. Polyps arise from the nasal and sinus mucosa, particularly the
middle turbinate, the middle meatus and the ethmoids. They are mucosa
full of edematous fluid produced by tissue inflammation and are
frequently bilateral.
Nasal polyps are more common in men and the incidence increases with
age.
The predisposing factors of nasal polyposis are thought to be infection,
allergy and other factors.
Nasal polyposis is found in association with bronchial asthma and aspirin
intolerance.
Cystic fibrosis in children causes nasal polyposis in this age and should
be suspected in any child with nasal polyps.
Clinical picture
Polyps produce nasal block, nasal discharge, hyposmia or anosmia. On
examination polyps are readily seen in the nasal cavity as painless
masses.
Patients with long standing nasal polyposis may have deformity of the
external nose ( broadening of the nose).
Management
About half of cases respond to local intranasal steroids. If there is no
good response after about one month of treatment, then surgery is needed,
which can be either simple polypectomy or removal under endoscopic
guidance. If endoscopic approach is adopted, the CT scan od the
paranasal sinuses is needed.
The condition tends to recur, so maintenance treatment with topical
steroid drops or spray is usually needed.
Antrochoanal Polyp
It is usually Unilateral and it arises from the maxillary sinus (the antrum)
and it prolapses through the maxillary ostium into the nasal cavity and it
goes to the posterior choanal opening and nasopharynx when increased in
size.
Clinically is manifested by nasal block which is usually unilateral. On
examination it may be seen by anterior rhinoscopy, and it needs
24
examination of the post nasal space by mirror or endoscope to see the
polyp.
Management
The treatment is surgical (Polypectomy), and is now done with the aid of
endoscope.
If there is recurrence after several removals, then Caldwell-Luc operation
may be needed. In this operation the anterior wall of maxillary sinus is
opened and stripping of the hypertrophied sinus mucosa is done.
Tumors of the Nose
1. Benign Tumors
Osteoma:
They are benign bony tumors containing mature bone. They occur, in
order of frequency, in the frontal, ethmoid and the maxillary sinuses.
These tumors are excised surgically if they are symptomatic.
Papilloma:
this tumor can be classified into 2 types
a-Squamous Papilloma
It is a wart like lesion usually arising from the skin of the Nasal
Vestibule.
Treatment is excision.
b- Inverted papilloma
This tumor is also called transitional cell papilloma or Ringert's tumor.
This rare tumor arises from the lateral wall of the nose and may extend to
the maxillary and ethmoid sinuses.
Clinical picture: this tumor is slowly growing and it causes unilateral
nasal obstruction of long duration. Sometimes there is Epistaxis because
the tumor is soft and friable. On examination, a pale and fleshy polypoid
mass is seen in the nasal cavity.
Investigations:
X-ray, CT and MRI scans are usually needed to identify the extent of the
mass and biopsy is needed to confirm the diagnosis.
Note: any unilateral nasal mass should be suspected and sent for
histopathology.
Treatment
Adequate local excision.
Recurrence and malignant transformation are problems of this tumor.
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2. Malignant Tumors
They are rare tumors
The commonest primary malignant tumor of the Sino nasal region is:
Squamous cell carcinoma.
The patient may complain of nasal obstruction, numbness of the cheek
(infraorbital nerve involvement), orbital symptoms such as proptosis and
cranial nerve involvement
Investigations
CT and MRI scans, biopsy is needed to confirm the diagnosis.
Treatment
Combination of surgery, radiotherapy and chemotherapy.
Bad prognosis.
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Angiofibroma
This is a rare vascular tumor which arises from the lateral wall of the
nasopharynx.It is almost exclusively found in boys and presents at
puberty.
This tumor is pathologically composed of vascular and fibrous elements.
It is benign, but it extends locally and infiltrates the surrounding
structures with pressure effects and deformity.
Symptoms and signs
Nasal obstruction and epistaxis are the main symptoms. Facial deformity,
proptosis, trismus, cranial nerve involvements are signs of extensive local
spread.
A dusky red mass is seen in the nose and nasopharynx. NO BIOPSY,
profuse bleeding will result.
Investigations
CT scan to show the extent of the tumor.
Angiography to show its blood supply and allows preoperative
Embolization to reduce the blood loss at surgery.
Treatment is surgical excision.
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