2. THE NOSE AND THE NOSE AND PARANASAL SINUSES PARANASAL SINUSES
Dr. Mohamad S. Aziz
Otolaryngologist
CABMS (ORL-HNS)
ENT Dept, College of Medicine, University of Mosul
Undergraduate, The Nose, 2016/2017

3. Epistaxis
Is bleeding per nose. It is a known disease of unknown aetiology.

4. Epistaxis from Little’s area

5. Aetiology
The two most common causes of epistaxis are idiopathy and trauma.
I. Local causes
1. Idiopathic.
2. Trauma: Direct injury as nose picking or nasal operations.
3. Inflammatory: Acute rhinitis, sinusitis and allergy.
4. Anatomical and structural abnormalities: Septal deviation may disturb air flow and causes turbulence of airflow thereby resulting in mucosal drying and epistaxis.
5. Neoplastic as angioma and carcinoma.
6. Environmental: Airconditioners and industrial fumes.

6. II. Systemic causes
Cardiovascular as hypertension: Here the nasal mucosa is often atrophic and cracks easily which eventually leads to exposure of the arteriosclerotic vessel producing severe bleeding during a hypertensive episode.
Haematologic: Haemophilia, leukaemia and ITP.
Drugs: Aspirin and anticoagulants as warfarin.

7. II. Systemic causes
Diseases of blood vessel as Osler’s disease ( Hereditary haemorrhagic telangiectasia). This is a hereditary disease characterized by the formation of abnormal capillaries in the mucous membrane of the nose. It is treated by radiation, Laser therapy and surgical excision of the mucous membrane of the nose with replacement of a split thickness skin graft.

8. Osler Weber Rendu’s disease

9. Clinical Picture
1. Anterior epistaxis: It is the most common. It arises from Little,s area to the anterior nares and occurs in young and middle aged patients. Here the bleeding is trivial, easy to stop and tends to recur.
2. Posterior epistaxis: Its less common. Arises far back in the nose and may flow back to the pharynx and occurs in elderly hypertensive patients. Here the bleeding is profuse and extremely difficult to stop.

10. Management
A-Arrest of haemorrhage.
R-Resuscitate the patient: A baseline Hb is withdrawn and IV drip is commenced. If necessary plasma and blood transfusion should be given to restore the circulation.
T-Treat the cause.

11. Arrest of the Bleeding by
1-Pressure on the nostrils in a sitting position, the mouth is kept open and swallowing is forbidden. The patient is instructed to breath quietly through the mouth with the head leant forwards.
2-Ice packs on the nasal bridge.
3-Cauterization of the bleeding point: Either chemical cautery using silver nitrate or trichloroacetic acid or electrical cautery. GA is some times required to identify the bleeding point and in children.

12. Correct Incorrect

13. 4. If epistaxis can not be controlled and the bleeding continues a pack may be needed.
a. Anterior packing: Using one inch ribbon gauze impregnated with paraffin or Vaseline. The pack may be left for hours. The first part of the pack is inserted along the floor of the nose as far posteriorly as possible the next layer is placed on top sequentially.

14. . Systemic antibiotics should be used to prevent secondary bacterial infection as sinusitis and otitis media. Sedation is necessary whenever a nasal pack is in situ, not only because the pack is uncomfortable, but the added anxiety of epistaxis may elevate the blood pressure.

15. Anterior pack
Modification from this picture- have both packing ends towards the front

16. b. Postnasal packing: Continued haemorrhage despite an anterior packing is probably a result of bleeding from the posterior branches of the sphenopalatine artery which necessitate the insertion of a postnasal pack.
It is done under GA and prepared from a piece of gause soacked wit paraffin or any antiseptic solution. Tapes are taken anteriorly through each nostril from the posterior pack around the columella. Another tape is tied around the middle of the pack and picked up from the patient mouth.

17. A further anterior pack is placed against the posterior pack
A further anterior pack is placed against the posterior pack. The posterior pack stays in place for 48 hours. Variation of the pack is to use a urinary Foley’s catheter to fill the nasopharynx which can be done without anesthesia.

18. Posterior pack

19. Posterior Pack

20. 5. Surgical Treatment: If despite anterior and posterior packing, the bleeding continues or recurs , surgical intervention is indicated.
a-Submucosal resection of the nasal septum in case of septaal spur to induce fibrosis at Little’s area.
b-Arterial ligation: The appropriate vessel is clipped under GA depending on the area of bleeding.
1. Anterior ethmoidal artery ligation for bleeding from the superior part of the nasal cavity.
2. External carotid artery ligation for bleeding from the inferior part of the nasal cavity.
3. Sphenopalatine ( best) or maxillary artery ligation.
c- Embolization :unfit for surgery

21. Management Protocol
Adapted from Marks SC: Nasal and sinus surgery

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

25. Tumors of the Nose and Sinuses

26. Papilloma Osteoma Chondorma Angioma Fibroma Malignant
Benign
Epithelial CT. Tissue
Papilloma Osteoma Chondorma
Angioma Fibroma
Malignant
Epithelial CT.Tissue
squamous cell Ca Fibrosarcoma 
AdenoCA Angiosarcoma 

27. Papilloma
It arises either from the skin of the nasal vestibule  squamous papillomas or from the respiratory mucosa  inverted papilloma.
A. Squamous papilloma
It is a warty like growth either sessile or pedunculated. It is removed by an elliptical incision and the base is cauterized to prevent recurrence. They can also be treated by cryosurgery or LASER.

28. B. Inverted Papilloma (transitional cell papilloma, Ringertz tumour )
It arises from the lateral wall of the nose and occasionally from the nasal septum. They expand the containing bone but do not infiltrate. Extension to the ethmoidal and maxillary sinus is common.

29. Pathology
It is histologically benign but has a great tendency to recur. It is named so because microscopically neoplastic epithelium is seen to grow towards underlying stroma rather than on the surface (transitional type of epithelium).
There is a coincidental malignancy (synchronous malignancy) in 15% of cases and malignant transformations of the tumour occur in about 8%.

30. Clinical Picture
Mostly seen between years with male predominance. The usual presentations are unilateral nasal obstruction and recurrent attacks of sinusitis.
Examination
It arises from the lateral wall of the nasal cavity and it is always unilateral. It presents as red or grey mass simulating simple nasal polyp.

31. Investigations
1. Radiology: X.ray and CT scan.
2. biopsy.
Treatment
Adequate local excision (medial maxillectomy) by lateral rhinotomy approach.

33. Osteoma
I. Localized Compact Osteoma: it is most frequently found in the frontal sinus, but may be seen in the ethmoidal region.
Clinical Picture
They are frequently silent.
If the frontonasal duct is obstructed, it leads to frontal mucocele.
Displacement of the eye.
Pressure on the floor of the anterior cranial fossa leads to CSF rhinorrhea and intracranial infection.

34. Investigations
Radiology: X.ray and CT scan.
Treatment
Asymptomatic: observation.
Symptomatic: external frontoethmoidectomy.

35. II. Fibro-osseous Dysplasia: This disease commonly involves the maxilla and mandible. It represents an arrest of the maturation of bone formation at the stage of woven bone. It is divided into two types: the multiple polyostotic lesion and the monostotic lesion.
Multiple polyostotic lesion which is a systemic disease involving several bones.
Monostotic lesion which is localized to the maxilla and ethmoidal bone.

36. Fibrous dysplasia

37. Clinical Picture
It presents as a painless swelling around the orbit or the cheek. This swelling become apparent during childhood and increases in size, but often ceases to expand after 20 years.
Investigations
Radiology by CT scan.
Treatment
1. Asymptomatic  observation as the lesion tends to slow in progression during puberty.
2. Big (symptomatic)  surgical resculpturing (shaving)

39. Angioma
I. Capillary: the commonest site is the nasal septum and here it is called a bleeding polyp of the septum.
Clinical Picture
Epistaxis and on examination a pedunculated friable red lesion is seen which bleeds easily on touch.
Treatment
Excision with an adequate margin of the normal mucosa to prevent recurrence.
II. Cavernous: which may involve the whole tip of the nose.

40. Bleeding polyp of the septum

41. Cavernous Haemangioma

43. Squamous Cell Carcinoma
A rare tumor involving mainly the maxillary and ethmoidal sinuses.
Aetiology
Unknown, but hardwood and nickel workers are more liable to develop this tumour. .

44. Clinical Picture
The average at presentation is 60 years.
1. Unilateral nasal obstruction.
2. Blood stained discharge.
3. Toothache or loosening of the teeth.
4. Extension to the orbit  proptosis and diplopia.
5. Facial swelling and skin involvement.

45. Examination
Fleshy polyp
Investigations
Radiology: CT and MRI.
Biopsy through intranasal antrostomy.
Metastasis
Deep cervical lymph nodes and retropharyngeal lymph nodes
Treatment
Combination of surgery and DXT.

46. Squamous cell carcinoma of the maxillary sinus

47. Sinonasal tumors: Classification
1- Benign:
A- Epithelial: -Papilloma -Inverted papilloma Adenoma
B-Non-epithelial: -Hemangioma -Ostioma -Fibrous dysplasia
-Chondroma nZeurofibroma
2- Intermediate:
A-Epithelial: -Ameloblastoma
B-Non-epithelial: -Giant cell tumor
3- Malignant:
A-Epithelial: -Squamous cell ca –Adenoid cystic ca
-Melanoma – Olfactory neuroblastoma
–Mucoepidermoid tumor –Anaplatic ca
B-Non-epithelial: -Osteosarcoma –Angiosarcoma –Rhabdomyosarcoma -Fibrosarcoma
Reda Kamel, M.D.

48. Sinonasal tumors: Symptoms:
1-Benign:
Nasal
Extension
Expansion
2-Malignant:
Erosion
Lymph nodes
Metastasis
Reda Kamel, M.D.

49. Sinonasal tumors: Symptoms:
A- Nasal:
Obstruction
Discharge
Headache
Pain
Bleeding
Bad odor
Reda Kamel, M.D.

50. Sinonasal tumors: Symptoms:
B- Extension:
Medial:nasal
Inferior:oral
Lateral:orbital, fossa
Superior:cranial
Anterior:sublabial
Posterior: nasopharynx
Reda Kamel, M.D.

51. Sinonasal tumors: Investigations Endoscopy CT & MRI Biopsy
Reda Kamel, M.D.

52. THANK YOU