It is a pyramidal in shape upper boney pyramid and lower cartilaginous pyramid



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External nose

It is a pyramidal in shape upper boney pyramid and lower cartilaginous pyramid

Boney part consists of upper 1\3 and cartilaginous part consists of lower 2\3

Boney framework consists of

Pair of nasal bone

Frontal process of maxilla

Maxillary process of frontal bone

Cartilages of external nose

Pair of upper lateral cartilages

Pair of lower lateral cartilages(greater alar cartilage)

Part of septal cartilage

Vestibule is part of the nasal cavity just within the the external nose,the vestibular skin contain hair follicles,hair and sebecious glands

Nasal cavity

Divided into two cavities by the nasal septum

It`s ant.openning called ant naris while it`s post. Opening called post.naris which open into nasopharynx

Nasal septum

Formed by

Cartilaginous part anteriorly by quadrilateral cartilage

Boney part posteriorly which formed by

Perpendicular plate of ethmoid

Vomer

Nasal crest of maxilla



Nasal crest of palatine bone

Lateral nasal wall

Within the nasal cavity there are three turbinates (superior,middle and inferior) In the inf.meatus

Opening of nasalcrimal duct

In the mid.meatus

There is bulge called bulla ethmoidalis below it there is Uncinate process between them there is a fissure formed called hiatus similunaris

The following sinuses open in the middle meatus

Ant. Ethmoid air cell and frontal sinus in the anterior part of hiatus simlunaris

Maxillary sinus ostium and sometime accessory ostia open in the posterior part of hiatus simlunaris
Superior and middle turbinate is part of ethmoid bone

Inferior turbinate is a separate bone The air space beneath each turbinate is known as

the meatus of the corresponding turbinate.

i.e each meatus named after the turbinate above it

There are various ducts and sinuses open in the meati

Each turbinate is a cigar-shaed ridges or swellings are attached to the lateral nasal wall ,each is made of bone,superior and middle is part of ethmoid bone while inferior turbinate is a separated bone,

All turbinates are coveres with vascular mucopreriostium and ciliated columnar epithelium.

The space under each turbinate is called a meatus i.e inferior meatus lies under the inferior turbinate etc…In the superior meatus

Posterior ethmoid sinus,sphenoid sinus drain in the sphenoethmoid recess which is a small depression above and behind the superior turbinate

The vascular inferior turbinate contains the second errectile tissue in the body i.e it has the ability to swell and shrink under autonomic nervous system control. Nasal resistance

The nose accounts up to half of the total airway resistance.

The resistance is made by two elements

A is essentially fixed made by bone,cartilage and attached muscle

B is variable made by mucosa

The nasal resistance is high in infants who initially are obligatory nasal breathers

Removal of nasal resistance by tracheostomy reduce the dead space but results in a degree of alveolar collapse


Factors decrease nasal resistance

Exercise


Sympathmymetic

Rebreathing

Atrophic rhinitis

Erect position

Factors increase nasal resistance

Infective rhinitis

Allergic rhinitis

Vasomotor rhinitis

Aspirin

Ingestion of alcohol



Cold air

Supine position

Hyperventilation

Sympthatic antagonists

Factors that influence nasal resistance is nasal cycle

Nasal cycle

Demonstrated in over 80% of adults but it is more difficult to demonstrate in children.

The cycle consists of alternate nasal blockage between passages.

Cyclical changes occur between 4-12 hours;they are constant for each person

Various factors may modify the nasal cycle include

Allergy

Infection



Exercise

Hormones


Pregnancy

Fear


Emotiom

Autonomic nervous symptom vagal overactivity cause nasal obstruction

Drugs the anticholinergic effects of antihistamine can block the parasympthatic activity and produce an increase of sympthatic tone ,hence improve airway
The function of the inferior turbinate is to control the passage of the air through the nose via the nasal cycle,the inferior turbinate is one side enlarged,as and as aresult the air flow through that nostril is restricted.

This reduse the drying effect of airflow and allows for rejuvenation of the nasal lining and cilliary function.

After approximately 4 hours,the turbinate on the other side swells and on previously rested side the turbinate shrinks.

This nasal cycle is a normal physiological mechanism that is present to some extent in all of us but noticed only by some people.

Nasal epithelium is a pseudostratifi ed columnar ciliated mucous

membrane continuous throughout the sinuses. The epithelium contains

goblet cells, which produce mucus, and columnar cells with

mobile cilia projecting into the mucus, beating 12–15 times a second.

The direction of ciliary beats is organized into well-defi ned pathways,

present at birth. These mucociliary pathways ensure drainage of the

sinuses through their physiological ostium into the nasal cavity

المحاضره الثانيه

The middle meatus is of special signifi cance as it contains the ostiomeatal

complex (OMC). This is an anatomical area in the bony

lateral nasal wall comprising narrow, mucosal lined channels and

recesses into which the major dependent sinuses drain. The OMC

acts physiologically as an antechamber for the frontal, maxillary

and anterior ethmoid sinuses. Irritants and antigens are deposited

there and may cause mucosal oedema. As the clefts in the OMC are

narrow, small degrees of oedema may cause outfl ow tract obstruction

with impaired ventilation of the major sinuses

The configuration of the structure of the middle meatus are complex and variable,in disarticulated skull ,the maxillary bone has a large opening in its medial wall,the maxillary hiatus.

In articulated skull this is filled by adjacent bones

1 inferior: maxillary process of inferior turbinate bone

2 posterior:perpendicular plate of palatine bone

3Anterosuperior:lacrimal bone

4superior:UP and Bulla ethmoidalis

So portion of maxillary hiatus is left open these osseous attachment which in life filled wth mucous membrane of

1 Mucous membrane ofMM

2Mucous membrane of maxillary sinus

3 Intervening connective tissue and membranous portion of lateral wall


It is the site for the common pathway of the anterior group of sinuses(frontal,anterior ethmoid,mawillary) structure contribute to this area:

Uncinate process

Thin bony structure runs anterosueriorly to psteroinferioly.it articulate with the ethmoidal process of inferior turbinate,it artly cover the oening of maxillary sinuse

Hiatus similunaris

It is a semilunar groove which leads anteriorly to the ethmoidal infundibulum

Ethmoidal infundibulum

It is a short passage at the anterior end of the hiatus

Frontal sinus,maxillary and anterior ethmoid drain into it

Bulla ethmoidalis

It ia a round prominence formed buldging of ethmoid sinus

Frontal recess

Maxillary sinus

Middle Meats
Middle Meatus

Lies lateral to the MT

Structure important in the MM:

UP

HS



BE

Ethmoid infundibulum

Anterior and posterior fontanelle:

Are membranous areas between the interior turbinate and uncinated process,accessory ostia are found mostly in the posterior fontanelle Arterial supply

external carotid artery- facial artery- superior labial artery nasal branch

maxillary artery- sphenopalatine greater palatine artery

internal carotid artery- anterior ethmoid artery

posterior ethmoid artery

Little`s area or Kiesselbach`s plexus

It is an area in the anterior part of the septum just behind the skin margin contain aggregation of poorly supported blood vessels represents the most important and commonest site of epistaxis

It formed by anastamasis of

*Septal br.of sphenopalatine artery

*Superior labial artery

Greater palatine artery*

*Ant.ethmoid artery
Nerve supply

Autonomic supply either1

Sympthatic

Parasympthatic

Special sence2

By olfactory nerve that supply olfactory mucosa which located in the sup.portion of the nasal cavity

3 sensory supply mainly by branches of trigeminal nerve

Anterior ethmoid nerve from ophthalmic division which has medial branch supply ant.end of the septum and lateral branch supply mid.&sup. Turbinate

Branches from sphenopalatine & greater palatine nerve which supply most of turbinate

4 motor nerves from facial neve for elevate and dilate nasal ala



المحاضره الثالثه

Rhinosinusitis


Rhinitis is defined as inflammation of the lining of the nose,characterized by one or more of the following symptoms

Nasal congestion

Rhinorrhea

Sneezing and itching

The term sinusitis refers to a group of disorder charecterized by inflammation of the mucosa of paranasal sinuses.

Because the inflammation always also involve the nose ,it is now generally accepted that "Rhinosinusitis" is preferred term to desecribe the inflammation of the nose and paranasal sinusesThe ciliated mucosa of the nose and paranasal sinuses are contiguous and it would be rare for one to be affected without the other so the term rhinosinusitis always usedDifferential diagnosis

Polyp

Mechanical factors



NSD

Hypertrophic turbinate

Obstruction OMC

F.B


Choanal atrasia

Tumours..Benign or malignant

Granuloma

CSF Rhinorrhea

Acute rhinosinusitis ARS is acute infection of sudden onset with duration of less than four weeks, 7 days to four weeks as viral rhinosinusitis follow viral URTI and mimic it`s symptoms so five to seven days was recommended perior to an acute bacterial rhinosinusitis.

Subacute rhinosinusitis SRS the duration is last for 4- 12 weeks

Recurrent acute infection RARS are defined by four or more episodes per year

Chronic rhinosinusitis CRS occur when the duration of symptoms is greater than 12 weeks

Acute exacerbation of chronic rhinisinusitis AECRS is is sudden worsening of CRS with return to baseline CRS

Signs and symptoms

Rhinosinusitis requires two major factors,or one major and two minor

Major symptoms

Facial pain\ pressure

Facial congestion/fullness

Nasal obstruction

Nasal discharge/purulent/posterior drainage

Hyposmia/Anosmia

Purulence on nasal examination

Fever (acute rhinosinusitis only

Minor symptoms

Headache

Fever (non acute)

Halitosis

Fatigue


Dental pain

Cough


Ear pain/pressure/fullness

Microbiology of acute bacterial rhinosinusitis

Streptococcus pneumoniae 20-43%

Haemophilus influenzae 22-35%

Strep species

Anaerobes

Moraxella catarrhlis

Staphylococcus aureas



Predisposing factors

Either

Local or general



◙ mucosal obstruction ,deviation,polyp

◙ obstruction of the sinus ostea by allergic rhinitis

◙ neighbouring infection especially in children

General factors

◙immunedifficiancy

◙mucocilliary disorder

◙ allergy

Treatment

Medical

1 treatment of infection

Systemic penicilline always effective

If not do culture and sensitivity

2 treatment of pain

Asprin or codien

3 establishment of drainage of sinus

Either local like ephedrine and normal saline or systemic by pseudoephedrine and antihistamine.

Always be aware of Rebound phenomenon on using common nasal decongestant
Surgical operations for chronic sinusitis

█ maxillary sinuses

►antral washout

►►intranasal antrostomy

●Middle meatus antrostomy (endoscopic)

●Inferior meatus antrostomy

►Caldwell-Luc operation

Frontoethmoidosphenoid

►Trephenation of frontal sinuses

►►Intranasal ethmoidectomy

►►►FESS Functional endoscopic sinus surgery

►►►►Transnasal ethmoidectomy

►►►►►external frontoethmoidosphenoidectomy

المحاضره الرابعه

Allergy and Allergic Rhinitis

Atopy is a tendency to develop an exaggerated IgE response while allergy is the clinical resentation of atopic disease in the presence of allergen

Aetiology

A genetic and family history

Environmental factors like exposure to allergen ,air pollution and irritant, occupational allergen like flour, wood dust, latex in surgical gloves,tobacco,detergents and bleach.Food occasionally provoke IgE allergic rhinitis, it may be due to sensitivity to preservatives, some type of food contain histamine like cheese and wine

Drugs like penicilline, asprin, antihypertensive, B-blocker, ACE inhibitor

The allergic responses can be divided into two phases. The first is an acute response that occurs immediately after exposure to an allergen. This phase can either subside or progress into a "late phase reaction" which can substantially prolong the symptoms of a response, and result in tissue damage

Pathogenesis

IgE has a property of binding to high affinity receptor on the mast cell and basophil .the interaction of allergen with IgE initiate secretion of active mediators that cause clinical manifestation,thes mediators either preformed mediators (histamine, proteases, chemokines, heparine); or newly formed mediators (prostaglandins, leukotrienes, thromboxanes



800px-allergy_degranulation_processes_01

Rhinitis if defined clinically by a combination of two or more nasal symptoms

Nasal obstruction…….blocking

Rhinorrhea…………...running

Itching and sneezing

Allergic rhinitis occur when these symptoms are the result of IgE mediated inflammation following exposure to allergen

Classification

Seasonal


Perennial

New classification by ARIA guideline (allergic rhinitis and its impact on asthema)

Mild

Normal sleep



Normal daily activities

Normal work and school

No troublesome symptoms

Moderate or severe

Abnormal sleep

Impairment of daily activities

Problems caused at school and work

Troublesome symptoms


Intermittent symptoms

Less than 4 days/week

Or less than 4 weeks
Persistent symptoms

More than 4 days/week and more than 4 weeks


Co-morbidities

Other conditions associated with allergic rhinitis are asthema,sinusitis,otitis media,sleep disorder,lower respiratory tract infection

Rhinitis and asthma are linked by epidemiological,pathophysiological characteristics and by common therapeutic approach.

█Rhinitis is a risk factor for the development of subsequent asthma ,


█is a frequent cause of asthma exacerbations ,and
█effective rhinitis treatment reduce asthma

So patient with persistent allergic rhinitis should be evaluated for asthma and the converse is true

Clinical presentation

Immediate type allergic symptoms of sneezing ,rhihinorrhea and itching are easily recognized

Perennial allergic inflammation is mainly expressed as nasal obstruction,hyperreactivity and poor sense of smell,the sinus lining is also usually involved so that the picture is of one of a chronic inflammatory rhinosinusutus,in those patient immediate symptom not present and may undergo unnecessary operations for septal deviation or turbinate befor the true nature of the problem is diagnosed properly

Pharmacotherapy

Antihistamine

It relieve running,itching,and sneezing but have little or no effect on blockage

First generation like chlorpheneramine,diphenhydramines should be avoided because of sedation,psychomotor retardation and learning impairment because it cross the BBB and interact with histamine receptors

Second generation antihistamine act with an hour topical ones within 15 minutes

Terfenadine,astemazoleblock potassium channel and cause cardiac arrhythmia, QT prolongation,so care taken not overdose and nor to combine with erythromycin,ketokanazole,grapefruit juice,antiarrythmia .

Citrizine,fexofenadine,and desloratidine not block potassium channels even at supranormal dose

Desloratidine is exception that affect on nasal blockage

Topical corticosteroid

Are the most effective treatment of rhinitis especially if started prior to allergen exposure it reduce the relative risk of asthma exacerbation by 50%

Side effects are minor include epistaxis and nasal irritation

Sodium cromoglicate

It is weakly effective against all rhinitis but safe means it is useful for small children less than four years for whom a topical corticosteroid is not available


Decongestants

Used topically reduce nasal obstruction but increase rhinorrhea,regular use for more than few days result in rhinitis medicamentosa

Systemic decongestant are relatively ineffective with side effects like hyperactivity,insomnia in children and hypertension in adult
Ipratropium bromide

Response in patients who do not response to topical corticosteroid alone


Systemic corticosteroid

Used to unlock the nose at start of treatment or for sever symptoms,used for few days Depot injection not recommended because they are not if side effects occur


Antileukotriens LRA

Recently been licensed in rhinitis it can also be helpful in polyposis


Nasal douching

Immunotherapy



المحاضره الخامسه

Epistexis
Epistaxis is the commonest otolaryngologic emergency, affecting up to

60% of the population in their lifetimes, with 6% of cases requiring

medical attention.

The nasal cavity is extremely vascular. Terminal branches of the external

and internal carotid arteries supply the mucosa of the nasal cavity

with frequent anastomoses between these systems

The anterior nasal septum is the site of a plexus of vessels called Little’s or

Kiesselbach’s area, which is supplied by both systemsThe maxillary sinus ostium serves as the dividing line between

anterior” and “posterior” epistaxis. Anterior bleeding is usually easier



to access and is therefore less dangerous. Posterior epistaxis is more

difficult to treat because visualization is more difficult and blood is often swallowed, making it more difficult to gauge the amount of

blood loss The term “posterior bleeding” is all too often used incorrectly to

label bleeding that cannot be visualized with a head lamp. It transpires

in many cases that endoscopic examination shows the bleeding to be

located high on the septum Primary No proven causal factor

Secondary Proven causal factor

Childhood <16 years

Adult >16 years

Anterior Bleeding point anterior to piriform aperture

Posterior Bleeding point posterior to piriform aperture

Aetiology:

A idiopathic---------from little`s area

B Trauma

Nose picking

F.B

Maxillofacial trauma

Itrogenic

C infection acute or chronic.viral or bacterial

D Inflammatory

Rhinosinusitis

Nasal polyp

E Neoplasm

Benign angiofibroma, papilloma

Malignant sq.cellcarcinoma,adenocarcinoma, lymphoma

F Drug induced

Cocaine abuse

Rhinitis medicamentosa medicamentosa,asprin,anticoagulant.chloramphinicol,immunosuppressant,alcohol

G inhalant

Tobacco

H endocrine

2 General

A atherosclerosis

B bleeding disorder

A coagulopathy

1inhereted coagulation factors deffeciancy like factor vii,factor ix

2acquired :anticoagulant,liver disease,vitamin k defficiancy

B platelate disorders

thrombocytopenia

●●platelate disfunction

congenital like vonwillbrand disease

►► acquired like leukemia,uremia,drugs as asprin & NSAID

C blood vessel disorders

congenetal----osteogenesis imperfecta

●●acquired-----amyloid,vasculitis,vit.K defeciancy

D hyperfibrinolysis

congenital------αantitrypsin deficiency



●● acquired------malignant DIC
Management

Initial Assessment

The amount of blood loss should be estimated (the physician should

ask about whether the patient has lost enough to soak a handkerchief,

a facecloth, or a towel; the last would indicate a significant loss), and

over what period (a regular minor bleed can cause anemia). A clinical

assessment of the patient’s cardiac status and circulating blood volume

should include looking to see if the patient is pale, sweating, or cool,

or has tachycardia; any of these findings would indicate significant

hypovolemia. A reduction in blood pressure is often a late sign, particularly

in young people, who can maintain blood pressure until the

circulatory volume is critical.

Obtaining intravenous access, checking for and correcting any

clotting abnormalities, and taking blood for “group and save” and/or

crossmatching may be required. In our unit patients admitted via the

emergency department can be “fast-tracked” to the otorhinolaryngo- logic emergency unit if stable This practice helps avoid

unnecessary and counterproductive nasal packing in the emergency

department as well as transfer of patients before they are fit enough to

travel.
The clinician must remember that epistaxis is frequently idiopathic

but can be a manifestation of a possible underlying pathology

). Your patient should undergo further investigation

First aid measures include asking the patient to apply constant firm

pressure over the lower (non-bony) part of the nose for 20 minutes and

to lean forward with the mouth open over a bowl so that further blood

loss can be estimated. Otherwise, blood dripping postnasally will be

swallowed, and the next warning sign of a serious loss could be several

hundred milliliters of blood being vomited up.

It is important to establish both the site and the cause
The philosophy of this approach can

be summarized as follows:

1. Establish the site of bleeding.

2. Stop the bleeding.

3. Treat the cause.

Headlamp Examination Using Local Anesthesia—

Initial Overview

The key to controlling most epistaxis is to find the site of the bleeding,

and although chemical cautery with silver nitrate can be used, bipolar

diathermy is more effective for stopping the bleeding. Protection from

blood contamination is important. A plastic apron for both parties is

helpful in order to avoid staining of clothes, and eye protection is advisable

if there is active bleeding because some patients have a reflex to

blow away any fluid dripping down the upper lip, which can create a

bloody aerosol. Once the clots have been sucked out, the nasal airway

should be inspected, initially with a headlamp and then, if the bleeding

point cannot be located, with an endoscope Epistaxis in Children

Young children usually bleed from a vessel just inside the nose at the

mucocutaneous junction on the septum, and the bleeding invariably

stops spontaneously. In children with epistaxis in whom no prominenvessel can be seen, the regular local application of a cream can help,

but petroleum jelly (Vaseline) alone does not.

As many as 5% to 10% of children with recurrent nosebleeds

may have undiagnosed von Willebrand’s disease. Children

who have leukemia or are undergoing chemotherapy often have

epistaxis associated with thrombocytopenia. Older children, adolescents,

and adults often bleed from Little’s area or a maxillary spurt

Epistaxis in Adults

The caudal end of the septum, where several branches of the external

and internal carotid anastomose in Little’s area or Kiesselbach’s plexus,

is the most common site of bleeding in adultsLess commonly bleeding,

comes from further back on the septum, and a septal deviation

may make it difficult to visualize Some patients with

seasonal allergic rhinitis complain of more nosebleeds in the hay fever

season, and topical nasal steroids aggravate the bleeding in approximately

4% of users. Many people believe that a nosebleed signifies a

release of pressure and may herald a stroke, and it is important for the

clinician to address these anxieties for the patient. Although many

patients are found to be hypertensive during nosebleeds, few remain so on follow-up. The association between hypertension and epistaxis is

disputed.

Many clinicians report that hypertension is not related to

Nosebleed

However, nosebleeds in patients with hypertension

are more likely to lead to admission and to be associated with

comorbidity.
In over-anticoagulated

patients, fresh frozen plasma, clotting factor extracts, and vitamin K

help. Vitamin K takes more than 6 hours to work, however, and it can

delay anticoagulation for 7 days after warfarin is started.

. Tranexamic cyclocapron

acid, an antifibrinolytic agent, has not been shown to help.

But other litriture advice to give it Scott brown) Tranexamic

acid has been shown to reduce the severity and risk of rebleeding in epistaxis at a dose of 1.5 g

three times a day. These drugs do not increase fibrin deposition and so do not increase the risk of

thrombosis. Preexisting thromboembolic disease is a contraindication.

Other drugs associated with bleeding are aspirin, which interferes with

platelet function for up to 7 days, clopidogrel, and nonsteroidal antiinflammatory

drugs.27,28 In patients who do not have a history of a

bleeding disorder or undergoing anticoagulant therapy, routine clotting

studies do not add to the management.22,24 There is a higher incidence

of epistaxis in patients with a high alcohol intake, even when there is

no laboratory evidence of a coagulation abnormality.29,30

Topical Treatment

Topical Treatment

A randomized controlled trial of silver nitrate cautery with topical

antiseptic nasal carrier cream versus topical alone showed both to be

effective

Use of cold pack is advisable although hot water irrigation 50c has been proposed as an alternative to packing
Cautery

Most anterior epistaxis can be controlled with identification of the

bleeding point and cautery using a headlamp. The vast majority of

posterior bleeding sites can be identified by endoscopy without the use

of general anesthesia After cautery the patient should be advised against blowing the

nose for about 10 days to allow the area to heal. A greasy antiseptic barrier cream should be applied several times daily for 2 weeks to

prevent the eschar from drying and coming off with a resulting rebleed.

The ointment should not be placed directly on the area treated but is

best placed inside the rim of the nostril with the tip of the finger, and

milked up” by massaging the nostril rims, and then sniffed up. This



advice can also be given to patients with a crusted septal area from

picking or excessive drying.
Nasal Packing

If a bleeding point cannot be found, ideally the nose is packed with an

absorbable hemostatic agent that produces minimal mucosal trauma.

Various nonabsorbable packs have been used, but their insertion is

uncomfortable, as is their presence once in position. The insertion of

a pack can cause local mucosal trauma and complicate localization of

the bleeding point The insertion of a nasal pack has

conventionally meant that the patient has to be admitted, although one

study discharged 46 of 62 patients whose nasal airways had been

packed, with outpatient follow-up arranged for 48 hours later If anterior packing fails, a posterior balloon may have to

be placed and inflated in the postnasal space. An anterior pack is then

placed, and gentle traction used to pull the balloon forward against the

anterior pack this arrangement is held by placement of a clip over the

catheter anteriorly as it emerges through the anterior pack The morbidity and physical discomfort

associated with nasal packing includes pain, hypoxia, alar necrosis, and

toxemia, and is well described in the literature; Packing not only traumatizes the nasal lining but also can

cause cardiorespiratory complications and local infection.
The role of prophylactic systemic antibiotics in patients who have

nasal packs is not well established. If the patient does not experience rebleeding within 12 to 24

hours, the packs should be removed

removal.” Endoscopic sphenopalatine

artery ligation (ESPAL; see later) has replaced the need for

posterior nasal packs, oLigation od sphenopalatine arteryLigation of ant ethmoid artery

Ligation of posterior ethmoid artery

Ligation of external carotid artery

Angiography and embolization

Septal surgery

When epistaxis originates behind a prominent septal deviation or vomeropalatine spur, septoplasty

or submucosal resection (SMR) may be required to access the bleeding point. Some authors have

advocated septal surgery as a primary treatment for failed packing. The rationale is that by

elevating the mucoperichondrial flap for septoplasty or SMR, the blood supply to the septum is

interrupted and haemostasis secured. Cumberworth et al. showed a strategy involving SMR and

repacking to be more effective and economic than ligation in patients who had failed with packing.

Embolization

Embolization under angiographic guidance has been shown to control severe epistaxis in between
المحاضره السادسه

Nasal obstruction



Nasal Breathing Function

During normal nasal breathing, air passes through the anterior nares

over the nasal mucosa to the nasopharynx, with resulting humidification,

cleansing, filtering, and warming of the air but without the sensation

of obstruction. These functions are influenced by changes in the

natural environment, normal physiologic reflexes, normal anatomic

variations, and pathologic conditions

Nasal Septal Deviation

Nasal septal deviation is an asymmetric bowing of the nasal septum

that may compress the middle turbinate laterally, narrowing the middle

meatus Bony spurs are often associated with septal deviation,

which may further compromise the ostiomeatal unit. Nasal septal

deviation is usually congenital but may be a posttraumatic finding in

some patientslife in utero onwards there are many risks of nasal trauma in which the septum

is involved. Therefore, in adulthood a straight septum is more the exception than the rule A straight septum is the exception rather than

the rule.
Cleft lip and palate are two of the most common congenital conditions in which the septum is

involved, not only because the basal support of the septum is missing, but also because surgical

closure at a very young age causes scar formation that inhibits further development of the

surrounding structures

Septal trauma is very common. It may occur at any stage of life. Often a septal deformity is the

only sign of trauma, which previously went unnoticed or was forgotten
so the causes of septal deviation

Trauma

Minimal with caecerian section

Moderate with normal vertex presentation

Severe with persistant occipitoposterior position

Genetic

Can be divided to

Spur……sharp angulation occur at junction of vomer with septal cartilage usually result of vertical compression force

Deviation…….c or s shape involve cartilage and bone

Dislocation….lower border of septal cartilage displaced from its medial position into one of the nostril
The symptoms and signs accompanying septal deviation may be nasal blockage, dryness,

crusting, bleeding, itching, rhinorrhoea, anosmia, headache and cosmetic complaints

examination

First, the mucosa is inspected for swelling, vulnerable

blood vessels, secretions, pus, crusts, atrophy and dysplasia. Congestion of the mucosa can mask

or accentuate pathology related to the skeleton, such as septal deviations, spurs and crests. In

order to observe these properly, decongestion by adrenaline or similar is strongly recommended In rhinomanometry, two graphs are produced, one representing the relationship between the

pressure and flow in the right half of the nose and the other in the left half of the nose Acoustic rhinometry is a means of measuring the cross-sectional area of the nose

INDICATIONS FOR SEPTOPLASTY

Nasal obstruction, crusting, rhinorrhoea, post-nasal discharge, recurrent sinus pressure or pain,

epistaxis, headache, snoring and sleep apnoea
In septoplasty four general principles

1 Incision

2 Exposure

3Mobilization and straightening

3 fixation
Nasal polyp

It is around ,smooth,translucent,soft,yellow or pale structure results from prolapsed lining of ethmoid sinus
Aetiology
1 bernouilli phenomenon

If there is constriction the pressure will drop result in prolapse of mucosa
2 polysaccride changes in ground substance
3vasamotor imbalance when patient is not atopic
4 infection
5 allergy 90% or more of polyps have eosinophil and threr is association with asthema,and the nasal finding mimic allergy(rhinorrhea,sneezing &nasal obstruction

Incidence

It is a disease of adult, male predominance.
If present below 2 year think of meningocele
If present below 10 year think of cystic fibrosis
Any child with nasal polyps should be regarded as having cystic fibrosis until proved otherwise
Unilateral nasal polyp need histopathological study

Sign and symptoms

Polyp seen by anterior rhinoscopy occasionally seen normal externally

Mouth breathing due to nasal obstruction which is constantly present but of varying degree depending on the size of polyp

Watery rhinorrhea

Post nasal drip

Anosmia

Hyponasal voice

Hypertelorism may develop if patient develop polyp befor fusion of facial bone


Management

Anteroir rhinoscopy is enough to diagnose nasal polyp

Plain x-ray

CT scan

Nasal polyp treated either medically by short course of systemic steroid or intranasal steroid(betamethasone) or steroid nasal drops for one month this depend on the extent of the polyposis

Surgical treatment

1 simple polypectimy

2 intranasal ethmoidectomy which done endoscopically

3 external ethmoidectomy

Antrochoanal polyp

Antrchoanal polyps are a separate entity,this polyp has two components,a solid nasal one and a cystic maxillary one

It is less common arise from maxillary antrum and prolapsed through the ostium of the sinus to the nasal cavity and nasopharynx

It is common in adolescence

Ther is no place of medical treatment in antrochoanal polyp Septal haematoma

It is due to collection of blood beneath the mucoprechondrium of the nasal septum this collection interfere with the vitality of the cartilage ,the cartilage remain viable for 3 days more than 3 days the chondrocyte die lead to absorption of the cartilage

Clinical pictures

Nasal obstruction---complete bilateral nasal obstruction

Discomfort

Septal swelling soft red in colour
Complication

Septal abcess

Cartilage necrosis

Nasal saddle deformity

Treatment

Simple aspiration ---if haematoma is small
Incision and drainage
Packing to obliterate dead space with or without quilting suture
Systemic AB

Septal abcess

*Mostly due to trauma 75%
*Infective –measle,scarlet fever,furenculosis,AIDS.

*Complicate ethmoid and sphenoid sinus infection
Complication

Spread infection to orbit,meningies,brain,cavernous sinus

Clinical pictures

Sever pain

Septal swelling

Nasal obstruction

Pyrexia

Treatment

Immediate drainage

Systemic AB

Reconstruction of the defect in the acute phase will reduce growth impaction
Fracture nasal bone

Treatment of nasal fractures was first recorded 5000 years ago during the early Pharonic period in

Ancient Egypt
Delays in management can result in significant cosmetic

and functional deformity that is often a cause for subsequent medicolegal action The prominence and delicate structure of the nose make it vulnerable

to a broad spectrum of injurywhich accounts for why it is the most

frequently fractured facial bone.

Sports, falls, and assaults are the

usual mechanisms responsible for the majority of nasal fractures, with

alcohol consumption being an important contributing factor in many

cases. Males are affected approximately twice as often as females

in both the adult and pediatric populations, with a peak incidence

occurring during the second and third decades of life

Deformity, swelling, epistaxis, and periorbital ecchymosis are signs that

are suggestive of nasal fracture, whereas bony crepitus and nasal segment

mobility are diagnostic
Pathophysiology

Understanding the process by which nasal fractures occur and how

injuries to key areas of support can alter appearance and function are

essential to appropriate treatment. Variables such as force, impact direction,

nature of the striking object, patient’s age, and other host factors

will influence the pattern of injury to both the bony and cartilaginous

components of the nose.
The cartilaginous portions of the external nose are able to absorb

a greater amount of force without fracture as compared with the bony

components,


Pattern of fracture

Nasal fractures can be subdivided into three broad categories that characterize the patterns

of damage sustained with increasing force. This classification has some practical utility as each

category of fracture requires a different method of treatment
CLASS 1 FRACTURES

Class 1 fractures are the result of low–moderate degrees of force and hence the extent of

deformity is usually not marked. The simplest form of a class 1 fracture is the depressed nasal

bone. The fractured segment usually remains in position due to its inferior attachment to the upper

lateral cartilage which provides an element of recoil. The nasal septum is generally not involved. In the more severe variant, both nasal bones and the septum are fracturedClass 1 fractures tend not to cause gross lateral displacement of the nasal bones and may not

even be perceptible. Deformity generally results from a persistently depressed fragment, which is

often due to impaction of the flail segment beneath the residual nasal bone. In children, these

fractures may be of the ‘greenstick’ variety and significant nasal deformity may only develop at

puberty when nasal growth becomes accentuated
Class 2 fractures are the result of greater force and are often associated with significant cosmetic

deformity. In addition to fracturing the nasal bones, the frontal process of the maxilla and septal

structures are also involved. The ethmoid labyrinth and adjacent orbital structures remain intact.

Class 3 fractures are the most severe nasal injuries encountered and usually result from high

velocity trauma. They are also termed naso-orbito-ethmoid fractures and often have associated

fractures of the maxillae. The external butresses of the nose give way and the ethmoid labyrinth

collapses on itself. This causes the perpendicular plate of the ethmoid to rotate and the

quadrilateral cartilage to fall backwards. These movements cause a classic, ‘pig-like’ appearance

to the patient, with a foreshortened saddled nose and the nostrils facing more anteriorly, like the

snout of a pig. There is also telecanthus, which may be exaggerated further by disruption of the

medial canthal ligament from the crest of the lacrimal bone
Management

Look after • details of how the injury was sustained;

nasal obstruction;

change in appearance;

epistaxis;

hyposmia;

watery rhinorrhoea;

visual disturbance;

diplopia;

epiphora;

altered bite;

loose teeth;

trismus


Examination deviation, depression, step deformities;

mobility, crepitus, specific areas of point tenderness;

generalized swelling;

skin lacerations;

septal fracture/haematoma/abscess/perforation;

mucosal lacerations


Investigation The need for nasal x-rays is controversial and in many places it is actively discouraged. Unlike

other fractures, nasal x-rays are not required in order to make the diagnosis or aid subsequent

reduction.
Treatment

A very significant number of patients do not

require any active treatment.
Many do not have a nasal fracture and, in those that do, the fracture

may not be displaced.

Soft tissue swelling can produce the misleading appearance of a deformity

which disappears as the swelling subsides. Reassurance is all that these patients require and

some may heed suggestions to avoid further trauma. Topical vasoconstrictor drops are helpful to

alleviate congestion and obstructive symptoms. A reexamination about five days later is prudent

where there is uncertainty about the need for reduction.

A large number of patients will have a preexisting nasal deformity caused by a previous incident

Manipulation of the nose will, at best, only return it to its most recent appearance. Patients that fall

into this category are probably better advised to consider a formal rhinoplasty when everything has

settled down some months later.

The indications for surgical intervention in the acute phase are significant cosmetic deformity and

nasal obstruction caused by a septal haematoma

As a general rule, primary care physicians should refer all patients to ENT departments for

evaluation if there is any deformity or significant nasal obstruction. Patients with a suspected

septal haematoma should be seen urgently at the first possible opportunity

Reduction of a fractured nose can be performed under local or general anaesthesia. Local

anaesthesia has the advantages of reduced cost and convenience
Local anaesthetic can be used as a combination of external infiltration with internal application of

topical preparations. Lignocaine is injected along the nasomaxillary groove, infraorbital nerve in its

foramen and around the infratrochlear nerve.
Within the nose, sprays, injections, pastes or packs

coated with local anaesthetic are all acceptable, using combinations of cocaine, lignocaine,

adrenaline and phenylephrine.
The general principle of fracture reduction is to mobilize the fragments first by increasing and then

decreasing the degree of deformity

Ashe and Walsham forceps

Splints or packs may be necessary, depending on the stability of the reduction and the surgeon's

preference. A splint or plaster applied to the nasal bridge maintains, to some extent, the position of

the nasal bones and prevents accidental displacement. Splints are usually kept in place for about

seven days. It is advisable to refrain from contact sports for at least six weeks

All class 1 and most class 2 fractures can be reduced

with these techniques.

indications for open reduction:17

bilateral fractures with dislocation of the nasal dorsum and significant (preexistent or recent) septal



deformity;

infraction of the nasal dorsum;



fractures of the cartilaginous pyramid, with or without dislocation of the upper laterals

For depressed tip or flail lateral fractures that are unstable despite closed reduction techniques, Kirschner

(K) wires can be used

The external wire can be covered by dressings or plaster to protect the

wires from disruption and the patient from injury. The wires are removed after two weeks
Management of the nasal septum

Septal fracture is often missed and is a major reason for poor functional and cosmetic results

Septal reduction can sometimes be performed with Ashe's forceps, but often requires a Killian or

hemitransfixion incision, elevation of mucosal flaps to expose the cartilage and bone fragments,

and replacement and/or removal of cartilaginous and bony fragments, as in a standard

septoplasty


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