د. باسل محمد نذير سعيد Lecture 1 The Nose Anatomy of the Nose 1: External nose



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د. باسل محمد نذير سعيد

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.
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.


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.





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.
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.



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.

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.

Lecture 2

د. باسل محمد نذير سعيد
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.
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.


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.
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.


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 anti-staphylococcal antibiotic like cloxacillin.
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.

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.



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.

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.

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.
Lecture 3

د. باسل محمد نذير سعيد



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 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

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.

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

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.


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.

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.

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 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.

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.

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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