Nasal Anatomy and Obstruction Quiz

Nasal Anatomy

• The nasal cavity is divided into a septum (medial wall) and lateral walls containing three turbinates (inferior, middle, superior).
• Meati are spaces under the turbinates (inferior, middle, superior meatus).
• Turbinates increase surface area for air humidification, warming, and filtration, directing airflow to paranasal sinuses and olfactory region.
• Ostia for drainage include inferior meatus (nasolacrimal duct), middle meatus (drainage of maxillary, frontal, and anterior ethmoids), and superior meatus (drainage of posterior ethmoid and sphenoid sinus).
• Kiesselbach's/Little's area on the anterior septum has anastomosis of internal/external carotid arteries.
• Woodruff's plexus in the posterior nasal cavity involves sphenopalatine artery anastomoses, more common in older patients.

Nasal Obstruction

• Choanal Atresia: Congenital occlusion of the posterior nasal airway (choana) that can cause respiratory distress in newborns. Diagnosis is often made by observing bilateral atresia or unilateral atresia later. Treatment includes emergency airway if bilateral and definitive correction surgically
• Adenoid Hypertrophy: Enlarged lymphoid tissue in the nasopharynx, common in children. Symptoms including nasal obstruction, mouth breathing, snoring, possible eustachian tube dysfunction (OME). Significant nasal obstruction may warrant adenoidectomy.
• Nasal Septal Deviation: Deviation of nasal septum from the midline. Symptoms may include unilateral or bilateral nasal obstruction and epistaxis. Septoplasty may be required for symptomatic patients.
• Turbinate Hypertrophy: Turbinates (nasal conchae) can become hyperplastic due to allergies which lead to bilateral nasal obstruction. Treatment involves medical interventions such as allergies management and topical steroids, or surgical interventions including reducing turbinates.

Nasal Trauma

• Causes include falls, sports injuries, and motor vehicle accidents.
• Septal hematoma is a critical scenario needing urgent drainage to prevent cartilage necrosis and possible saddle nose deformity.
• Fractures may cause deformity, epistaxis, and nasal obstruction, requiring evaluation for other facial fractures.

Rhinorrhea (Nasal Discharge)

• Unilateral vs. bilateral discharge is a key distinction.
• Clear, watery discharge could indicate CSF leak, especially after trauma or surgery
• Purulent or thick discharge suggests an infection (rhinosinusitis).
• Foul-smelling, unilateral discharge may suggest a foreign body, particularly in children.

Rhinitis

• Allergic Rhinitis: IgE-mediated mast cell degranulation causing histamine release and symptoms like nasal obstruction, clear watery rhinorrhea, sneezing, itching, and possible conjunctivitis. Diagnosis can include skin prick testing or serum IgE testing. Treatment utilizes intranasal steroids, oral/topical antihistamines, decongestants, and immunotherapy.
• Non-Allergic (Vasomotor) Rhinitis: Dysregulation of autonomic tone in the nasal mucosa, especially hyper-responsiveness to triggers (like temperature and odor) causing symptoms like nasal obstruction, watery discharge and absence of itching/sneezing. Management includes identifying and minimizing triggers, intranasal steroids, or ipratropium bromide, and in some cases, radiofrequency ablation of turbinates or Vidian neurectomy.

Sinusitis

• Acute Rhinosinusitis: Inflammation of sinuses and nasal mucosa for less than four weeks, often viral, but may be caused by Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis. Symptoms include nasal obstruction, purulent nasal discharge, facial pressure/pain (worse when bending forward), hyposmia, and potentially lasting more than ten days without improvement. Treatment can include supportive care (decongestants, analgesics), watchful waiting, or antibiotics if believed to be bacterial.
• Chronic Rhinosinusitis: Inflammation lasting more than 12 weeks, potentially with nasal polyps, and may involve involvement from bacterial, fungal, or allergic components and anatomical issues such as deviated septum or polyps. Symptoms persistent nasal congestion, postnasal drip, facial fullness, and reduced smell are common. Treatment involves medical therapy (intranasal steroids, saline irrigations, antibiotics, and treatment of allergies or other underlying issues), and occasionally surgical intervention (endoscopic sinus surgery).
• Nasal Polyps: Benign, edematous growths of nasal/sinus mucosa, usually bilateral, grayish, and non-tender often associated with chronic inflammation such as allergic fungal sinusitis. Treatment is typically focused around intranasal corticosteroids.

Epistaxis (Nosebleeds)

• Sites include Kiesselbach's plexus (anterior, common in younger patients) and Woodruff’s plexus (posterior, often more severe in older patients)
• Causes include local trauma, systemic conditions like hypertension, and coagulopathies. Foreign body, dryness, septal deviation, and medications (tamponades) can cause epistaxis
• Management involves stabilizing the patient, identifying the bleeding site (and correcting it with cauterization or silver nitrate), and using packing (anterior or posterior) for persistent bleeding. Ligation, embolizations may be considered in persistent cases. Other systemic factors need to be evaluated as well

Nasal Tumors

• Benign tumors include inverted papilloma, juvenile nasopharyngeal angiofibroma (JNA), and hemangiomas.
• Malignant tumors include squamous cell carcinoma, adenocarcinoma, and esthesioneuroblastoma.
• Diagnostic imaging (CT/MRI) is crucial for staging and determining appropriate management strategies, which may include surgical intervention supplemented with possible radiation or chemotherapy.

Disorders of Smell (Olfactory Dysfunction)

• Anosmia (complete loss of smell)
• Hyposmia (decreased sense of smell)
• Parosmia (distorted smell perception)
• Causes for these include obstructive (nasal polyps, septal deviation, chronic rhinosinusitis) and sensorineural (such as viral infections).