THE NOSE AND PARANASAL SINUSES Dr. Ali A. Muttalib Mohammed Assistant Professor/ Consultant Otolaryngologist Head of ENT Dept, College of Medicine, University of Mosul In charge, Mosul Centre, Iraqi Board of Otolaryngology Undergraduate, The Nose, 2013/2014

Pathology: Causes – Etiology of symptoms 1- Congenital 2- Traumatic Foreign body Accident Iatrogenic 3- Inflammatory Acute: Chronic: Specific: Nonspecific: 4- Neoplastic Benign: Malignant 5- Others

1- Congenital 5- Others Bil. Choanal atresia Deviated septum 2- Traumatic Foreign body Accident: Fracture- Haematoma Iatrogenic: Pack-Haematoma 3- Inflammatory Acute nonspecific: Common cold-Abscess Acute specific: Diphtheria Chronic nonspecific: At. - Hypertrophic Chronic specific: $ – T.B. - Scleroma 4- Neoplastic Benign: Ostioma -papilloma Malignant: Carcinoma - Sarcoma 5- Others Allergy Polyps

Choanal Atresia Congenital atresia of the posterior nares due to persistence of the bucconasal membrane. Choanal atresia is usually unilateral but bilateral cases can occur and these cases are observed at birth because the neonate is obligate nasal breather. The obstruction either composed of bone (most commonly 90%) or membrane (10%).

Clinical Picture Females are commonly affected than males. Bilateral  Neonatal emergency leads to asphyxia because the infant is obligate nasal breather. Unilateral  nasal obstruction and excessive nasal discharge in the affected side which may be not noticed for some years.

Total absence of nasal air flow by mirror test and cotton test. Plastic catheter or probe can’t be passed through the affected side to the nasopharynx. Fibroptic endoscopy Examination

Investigations Contrast radiography by instillation of radiopaque substance in the affected side. CT scan to see the thickness of a bony atresia.

Treatment Bilateral  oral airway  surgical intervention. Unilataral  elective perforation of the occlusion usually prior starting of school.

Trauma to the nose and paranasal sinuses Injury to the nose may result in one or a combination of the following: -Epistaxis. -Fracture of the nasal bone. -Fracture or dislocation of the septum. -Sepal haematoma.

Fracture nasal bone Clinical Picture Usually caused by a blunt trauma to the nose and occasionally by penetrating wounds. Clinical Picture 1. Deformity, bruising, black eye and swelling. 2. Pain and headache. 3. Epistaxis. 4. Nasal obstruction due to septal haematoma or septal dislocation.

Examination It is important to examine the septum for the presence of septal haematoma, especially in children. When present, the haematoma needs urgent drainage; otherwise septal abscess may develop which may result in cartilage necrosis. Investigations X.ray is important medicolegally but of little value clinically.

Treatment -Early (hours): Before swelling appear----- immediate reduction. -Intermediate (Days): When swelling is marked-----Wait 5-6 days till the swelling subside. -Late ( months or years): Septorhinoplasty.

SEPTAL DEVIATION Aetiology and Pathology Generally a few adults have a complete straight septum. Only gross deflections causing symptoms require treatment. Aetiology and Pathology -Trauma: Either birth trauma or external injury. -Developmental errors: The developing septum buckles because it grows faster than its surrounding skeletal framework.

Symptoms -Nasal obstruction which may be unilateral or bilateral. -Recurrent sinus infection due to interference with sinus ventilation and drainage. -Headache due to malventilation of the frontal sinus (vacuum headache). -Epistaxis result from a prominent vessel over a bony spur.

Examination Treatment -External nasal deformity. -The deviation may be S or C shaped. -Signs of sinus infection. Treatment -Mild no Rx. -Symptomatic: septoplasty  Rhinoplasty

Haematoma of the Nasal Septum Collection of blood beneath the mucoperichondrium or mucoperiosteum of the nasal septum. Aetiology 1. Trauma to the nose. 2. Septal surgery. 3. Blood dyscrasia. Clinical Picture 1. Nasal obstruction 2. Septal swelling.

Complications 1. Infection of the haematoma with septal abscess ,cartilage necrosis and perforation. 2. External deformity Treatment The haematoma must be incised and drained followed by application of a pack in the nasal cavity with antibiotic cover.

Septal Abscess Is collection of pus beneath the mucoperichondrium or the mucoperiostium. Aetiology 1. Complication of haematoma. 2. May follow furunculosis, measles or scarlet fever. Clinical Picture Nasal obstruction, fever, pain and tenderness over the nasal bridge. Examination Symmetrical swelling of the nasal septum.

Complications 1. Cartilage necrosis leading to perforation and external deformity. 2. Cavernous sinus thrombophlebitis. Treatment 1. Drainage+packing+antibiotics. 2. Plastic surgery for external nasal deformities.

Septal Perforation Aetiology -Trauma: Nose picking and septal surgery. -Infection: Acute septal abscess. Chronic TB and syphilis. -Foreign body. -Drugs: Cocaine addicts. -Malignancy. -Idiopathic.

Clinical Picture -Small perforation leads to whistling. -Large perforation leads to crustation and bleeding. Treatment -Treat the cause. -Medical: alkaline nasal douche +ointment -Surgical closure but with poor success rate.

Foreign bodies in the Nose They are much more common in children. The F.B. may be organic or inorganic. An inflammatory reaction follows accompanied by nasal discharge. Aetiology 1. Through anterior nares. 2. Through posterior nares : Food particles may regurgitate to the nose during vomiting. 3. Penetrating wounds

FB in the nose

X – ray if the foreign body is radiopaque. Clinical Picture 1. Unilateral foul smelling nasal discharge. In a child, unilateral purulent discharge is pathognomonic of foreign body. 2. Epistaxis. 3. Pain. Investigations X – ray if the foreign body is radiopaque. Investigations X – ray if the foreign body is radiopaque. Complications Rhinitis and sinusitis. Rhinolith formation. Inhalation into tracheobronchial tree.

Complications -Rhinitis and sinusitis. -Rhinolith formation. -Inhalation into tracheobronchial tree. Treatment Removal of the FB by a probe, hook or forces, sometimes G.A. is required.

Rhinoliths Hard masses in the nasal cavity consist of deposits of phosphate, and carbonate of calcium and magnesium around a central nuclear called the nidus. Aetiology The nidus may be 1. F.B. 2. Dried blood and pus.

Rhinolith

Clinical Picture 1. Unilateral nasal discharge. 2. Unilateral nasal obstruction. 3. If it is long standing, it leads to atrophy of the nasal mucosa. Examination Probe --- hard mass can be felt. Investigations X - ray Treatment Removal under G.A.

OROANTRAL FISTULA A fistula through which the antral cavity communicates with the oral cavity. Aetiology -Dental extraction of the molar and premolar teeth. -Malignancy. -Penetrating wound. -Fistula following Caldwell-Luc operation.

Oroantral fistula

Clinical Picture -Foul sinusitis and discharge of pus into the mouth. -Regurgitation of food particles and air into the nose. Examination -Leakage of air from the fistula when the patient blows with a closed nose and open mouth. -A probe can be passed from the mouth to the antrum.

Treatment -Immediate following dental extraction  suturing. -Late  Remove any retained food particles, control infection and then closure using a mucoperiosteal flap.

CSF RHINORRHEA Aetiology -Trauma: from fracture of the base of the skull involving the cribriform plate or ethmoidal air cells . -Spontaneous: Destructive lesion involving the floor of the anterior cranial fossa. Clinical Picture -Watery fluid drips from the nose which increase in bending forward or straining and cannot be sniffed back. -Meningitis.

Examination -Handkerchief test: The fluid associated with rhinitis contains mucous which stiffens a handkerchief while CSF does not. -Nasal endoscope to see the site of the lesion. Investigations -Identification of glucose in the secretion. -B2 transferrin is specific for CSF. -Injection of radioactive material into CSF via lumber puncture. -CT. scan of the base of the skull.

Location of CSF leak

Treatment 1. Medical -Bed rest in head up position. -Systemic antibiotics. -Avoidance of nose blowing and avoidance of nasal packing. 2- Surgical: if no response -Treat the cause. -Closure of the defect by surgery either via craniotomy or endoscopic approach. .

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