Nasal Disorders Comprehensive Overview PDF

Nasal Disorders: Comprehensive Notes 1. Basic Nasal Anatomy 1.​ Nasal Cavity Divisions: ○​ Septum (medial wall) ○​ Lateral wall: Contains three turbinates (conchae)—inferior, middle, superior ○​ Meati: Spaces under each turbinate (inferior, middle, superior meatus) 2.​...

Nasal Disorders: Comprehensive Notes 1. Basic Nasal Anatomy 1.​ Nasal Cavity Divisions: ○​ Septum (medial wall) ○​ Lateral wall: Contains three turbinates (conchae)—inferior, middle, superior ○​ Meati: Spaces under each turbinate (inferior, middle, superior meatus) 2.​ Turbinates (Conchae): ○​ Increase surface area for air humidification, warming, and filtration. ○​ Direct airflow towards the paranasal sinuses and olfactory region (roof of nasal cavity). 3.​ Ostia for Drainage: ○​ Inferior meatus: Nasolacrimal duct opens here. ○​ Middle meatus: Drainage of maxillary, frontal, and anterior ethmoids (via semilunar hiatus). ○​ Superior meatus: Drainage of posterior ethmoid air cells + sphenoid sinus (sometimes drains into sphenoethmoidal recess). 4.​ Blood Supply: ○​ Kiesselbach’s/Little’s area on the anterior septum: Anastomosis of arteries from both internal (anterior/posterior ethmoidal arteries) and external carotid (sphenopalatine, greater palatine, superior labial) systems. ○​ Woodruff’s plexus: Posterior nasal cavity (sphenopalatine artery anastomoses) → more common in older patients, deeper bleeds. 2. Nasal Obstruction 2.1 Choanal Atresia ​ Definition: Congenital occlusion of the posterior nasal airway (choana). ​ Presentation: ○​ Newborns are obligate nasal breathers; bilateral atresia → respiratory distress. ○​ Unilateral often diagnosed later (chronic nasal discharge, obstructed side). ​ Management: ○​ Emergency airway if bilateral (oral airway, possible intubation). ○​ Definitive correction is surgical (e.g., endoscopic perforation of atresia). 2.2 Adenoid Hypertrophy ​ Definition: Enlarged lymphoid tissue in the nasopharynx, common in children. ​ Clinical Features: ○​ Nasal obstruction, mouth-breathing, snoring, possible eustachian tube dysfunction (OME). ​ Indications for Adenoidectomy: ○​ Significant nasal obstruction affecting daily life. ○​ Recurrent otitis media with effusion or chronic middle ear issues. ○​ Suspected contribution to sinusitis or sleep-disordered breathing. 2.3 Nasal Septal Deviation ​ Definition: Deviation of the bony/cartilaginous septum from the midline. ​ Clinical Features: ○​ Unilateral or bilateral nasal obstruction. ○​ Possible predisposition to epistaxis (due to turbulent airflow, mucosal dryness). ​ Management: ○​ Septoplasty if symptomatic (significant obstruction or recurrent epistaxis). ○​ Mild deviations often require no intervention. 2.4 Turbinate Hypertrophy ​ Function: Turbinates warm/humidify air, but can become hyperplastic (e.g., allergies). ​ Clinical Features: ○​ Bilateral nasal obstruction, can fluctuate (e.g., with allergy). ​ Management: ○​ Medical: Treat underlying cause (allergies, dryness); topical steroids, decongestants. ○​ Surgical: Turbinate reduction (e.g., submucosal resection, radiofrequency ablation) if medical therapy fails.  ○​ Avoid over-resection → can lead to “empty nose syndrome.” 2.5 Nasal Trauma ​ Causes: Falls, sports injuries, motor vehicle accidents. ​ Septal Hematoma: ○​ Emergent situation—blood collects between cartilage and perichondrium → cartilage necrosis, risk of saddle nose deformity. ○​ Requires immediate drainage. ​ Fractures: Deformity, epistaxis, nasal obstruction. Evaluate for other facial fractures. 3. Rhinorrhea (Nasal Discharge) ​ Unilateral vs. Bilateral discharge is key. ​ Clear, watery discharge: Could be CSF leak (especially unilateral, post-trauma or post-op). ​ Purulent or thick discharge: Often infectious (rhinosinusitis). ​ Foul-smelling, unilateral discharge: Possible foreign body, especially in children. 4. Rhinitis 4.1 Allergic Rhinitis ​ Pathophysiology: IgE-mediated mast cell degranulation → histamine release. ​ Presentation: Nasal obstruction, clear watery rhinorrhea, sneezing, itching, possible conjunctivitis. ​ Workup: Clinical diagnosis; skin prick tests or serum IgE if uncertain or for allergen identification. ​ Management: ○​ Intranasal steroids (first-line) ○​ Oral/Topical antihistamines ○​ Decongestants (short-term) ○​ Immunotherapy (if severe/refractory) ○​ Allergen avoidance measures 4.2 Non-Allergic (Vasomotor) Rhinitis ​ Pathophysiology: Dysregulation of autonomic (parasympathetic) tone in nasal mucosa → hyper-responsiveness to triggers (temperature changes, strong odors). ​ Clinical Features: Nasal obstruction, watery discharge triggered by environment, no itching/sneezing typical of allergy. ​ Management: ○​ Identify and minimize triggers ○​ Intranasal steroids or ipratropium bromide ○​ Some cases: radiofrequency ablation or surgical reduction of inferior turbinates ○​ Rare cases: Vidian neurectomy for severe refractory vasomotor rhinitis 5. Sinusitis (Rhinosinusitis) 5.1 Acute Rhinosinusitis ​ Definition: Inflammation of the sinus cavities + nasal mucosa 10 days without improvement or biphasic pattern (improvement then worsening), suspect bacterial. ​ Management: ○​ Mild cases: Symptomatic relief (decongestants, analgesics); watchful waiting. ○​ Bacterial suspicion: Antibiotics (e.g., amoxicillin-clavulanate), nasal steroids. ○​ Red Flags (orbital/cerebral complications) → urgent imaging & ENT referral. 5.2 Chronic Rhinosinusitis ​ Definition: Inflammatory condition >12 weeks, with or without nasal polyps. ​ Etiology: May involve bacterial, fungal, or allergic components; often structural issues (deviated septum, polyp). ​ Clinical Features: Persistent nasal congestion, postnasal drip, facial fullness, reduced smell. ​ Management: ○​ Medical therapy: Intranasal steroids, saline irrigations, antibiotics (longer courses), treat comorbidities (allergies). ○​ Surgery (Endoscopic Sinus Surgery) for refractory cases or to correct anatomical obstructions. 5.3 Nasal Polyps ​ Definition: Benign edematous growths of the nasal/sinus mucosa. ​ Clinical Features: ○​ Usually bilateral, grayish, and non-tender. ○​ Associated with chronic inflammation (e.g., allergic fungal sinusitis, aspirin-exacerbated respiratory disease). ​ Management: ○​ Intranasal corticosteroids (mainstay). ○​ Oral steroids for severe flare. ○​ Endoscopic sinus surgery if large or medical therapy fails. ​ Note: Polyps are painless (unlike an antrochoanal polyp in children which can cause unilateral obstruction). 6. Epistaxis (Nosebleeds) ​ Sites: 1.​ Kiesselbach’s Plexus (Little’s area) → anterior epistaxis, more common in younger patients. 2.​ Woodruff’s Plexus (posterior bleeds) → older patients, often more severe. ​ Causes: 1.​ Local trauma (nose picking, foreign body, dryness), septal deviation. 2.​ Systemic: Hypertension, coagulopathies, medications (antiplatelets/anticoagulants). 3.​ Tumors (especially in older patients or recurrent unilateral bleeds). ​ Management: 1.​ Stabilize patient (vitals, IV access if heavy bleed). 2.​ Identify bleed site: If visible → cauterize (silver nitrate). 3.​ Nasal packing (anterior or posterior) if unclear or persistent. 4.​ If bleeding persists: Consider arterial ligation (e.g., sphenopalatine artery) or endovascular embolization. 5.​ Control systemic factors (HTN, coagulopathy). 7. Nasal Tumors ​ Benign: Inverted papilloma, juvenile nasopharyngeal angiofibroma (JNA), hemangioma, etc. ○​ Juvenile nasopharyngeal angiofibroma: Adolescent males, epistaxis + nasal obstruction, highly vascular → be cautious with biopsy. ​ Malignant: Squamous cell carcinoma, adenocarcinoma, esthesioneuroblastoma. ○​ Present with unilateral nasal obstruction, epistaxis, possible facial swelling or orbital involvement in advanced disease. ○​ Imaging (CT/MRI) essential for staging; management often surgical + possible radiation/chemotherapy depending on type. 8. Disorders of Smell (Olfactory Dysfunction) ​ Anosmia: Complete loss of smell. ​ Hyposmia: Decreased sense of smell. ​ Parosmia: Distorted smell perception. ​ Causes: ○​ Obstructive: Nasal polyps, septal deviation, chronic rhinosinusitis. ○​ Sensorineural: Post-viral (e.g., COVID-19), head trauma affecting olfactory nerves, neurodegenerative conditions. ​ Evaluation: Clinical assessment; formal smell tests are not widely standardized. ​ Management: ○​ Address structural causes (polyps, sinusitis). ○​ Olfactory training (smell exercises). ○​ Limited proven therapy for sensorineural anosmia. 9. High-Yield Considerations 1.​ Nasal Obstruction: Always consider age (infants → choanal atresia, children → adenoid hypertrophy, adults → septal deviation, polyps). 2.​ Rhinitis: Distinguish allergic (sneezing, itching, watery discharge) from non-allergic vasomotor (triggered by temperature changes, no itch). 3.​ Acute Sinusitis: Usually viral; suspect bacterial if persistent >10 days or “double-worsening.” 4.​ Chronic Sinusitis: Evaluate for polyps, structural issues (CT scan). Prolonged medical therapy ± endoscopic surgery. 5.​ Epistaxis: Kiesselbach’s area in anterior bleeds (common in younger). Posterior bleeds (Woodruff’s plexus) can be severe in older patients—may need posterior packing or arterial ligation. 6.​ Tumors: Unilateral nasal obstruction, recurrent bleeds, or facial swelling → urgent imaging and ENT referral. Juvenile nasopharyngeal angiofibroma in adolescent males is highly vascular. 7.​ Smell Disorders: Common post-viral (e.g., COVID-19). Rule out mechanical causes like polyps. Olfactory training can help. In Conclusion Nasal disorders include anatomical variations (septal deviation, turbinate hypertrophy), inflammatory conditions (rhinitis, sinusitis), obstructive lesions (polyps, adenoid hypertrophy, choanal atresia), bleeding issues (epistaxis), and neoplastic causes. Assessment involves history, physical exam (rhinoscopy, endoscopy), and usually imaging (CT sinuses). Management may range from medical therapy (topical steroids, antibiotics, immunotherapy) to surgical interventions (septoplasty, endoscopic sinus surgery, polypectomy, tumor resection) depending on disease severity and underlying etiology. By Abdulaziz Alnufaei - B18