2. 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

3. 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

4. 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

5. 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%).

6. 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.

7. 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

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

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

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

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

19. 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.

20. 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.

21. 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.

22. 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.

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

24. 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.

25. 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

26. FB in the nose

27. 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.

28. 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.

29. 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.

30. Rhinolith

31. 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.

33. 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.

34. Oroantral fistula

36. 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.

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

38. 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.

39. 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.

40. Location of CSF leak

41. 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. .

42. THANK YOU