Nose Diseases Lecture - جامعة التحدي PDF

DISEASES OF NOSE AND PARANASAL SINUSES presented by Dr WAEL EMHIMMED ABORGIBA OTOLARYNGOLOGY SPECIALIST MASTER DEGREE IN OTOLARYNGOLOGY TRIPOLI UNIVERSITY HOSPITAL  Anatomy of Nose EXTERNAL NOSE It is pyramidal in shape with its root up and the base directed downwards. Various...

DISEASES OF NOSE AND PARANASAL SINUSES presented by Dr WAEL EMHIMMED ABORGIBA OTOLARYNGOLOGY SPECIALIST MASTER DEGREE IN OTOLARYNGOLOGY TRIPOLI UNIVERSITY HOSPITAL  Anatomy of Nose EXTERNAL NOSE It is pyramidal in shape with its root up and the base directed downwards. Various terms used in its description are shown Nasal pyramid consists of osteocartilaginous framework covered by muscles and skin. OSTEOCARTILAGINOUS FRAMEWORK BONY PART Upper one-third of the external nose is bony while tow thirds are cartilaginous. The bony part consists of two nasal bones which meet in the midline and rest on the upper part of the nasal process of the frontal bones and are themselves held between the frontal processes of the maxillae CARTILAGINOUS PART It consists of: Upper lateral cartilages. They extend from the undersurface of the nasal bones above, to the alar cartilages below. They fuse with each other and with the upper border of the septal cartilage in the midline anteriorly. The lower free edge of upper lateral cartilage is seen intranasally as limen vestibuli or nasal valve on each side. Lower lateral cartilages (alar cartilages). Each alar cartilage is U-shaped. It has a lateral crus which forms the ala and a medial crus which runs in the columella. Lateral crus overlaps lower edge of upper lateral cartilage on each side Lesser alar (or sesamoid) cartilages. Two or more in number. They lie above and lateral to alar cartilages. The various cartilages are connected with one another and with the adjoining bones by perichondrium and periosteum. Most of the free margin of nostril is formed of fibrofatty tissue and not the alar cartilage Septal cartilage Its anterosuperior border runs from under the nasal bones to the nasal tip. It supports the dorsum of the cartilaginous part of the nose. In septal abscess or after excessive removal of septal cartilage as in submucosal resection (SMR) operation, support of nasal dorsum is lost and a supratip depression results  Acute and Chronic Rhinitis Acute rhinitis can be viral, bacterial or irritative type. VIRAL RHINITIS Common cold (coryza) Aetiology. It is caused by a virus. The infection is usually contracted through airborne droplets. Several viruses (adenovirus, picornavirus and its subgroups Incubation period is 1–4 days and illness lasts for 2–3 weeks Clinical features. To begin with, there is burning sensation at the back of nose soon followed by nasal stuffness rhinorrhoea and sneezing Treatment. Bed rest is essential to cut down the course of illness. Plenty of fluids are encouraged. Symptoms can be easily controlled with antihistaminics and nasal decongestant Analgesics are useful to relieve headache, fever and myalgia 2 Influenzal rhinitis: Influenza viruses A, B or C are responsible. Symptoms and signs are similar to those of common cold. Complications due to bacterial invasion are common 3 Rhinitis associated with exanthemas. Measles, rubella and chickenpox are often associated with rhinitis which precedes exanthemas by 2–3 days. Secondary infection and complications are more frequent and severe. BACTERIAL RHINITIS Nonspecific infections. It may be primary or secondary. Primary bacterial rhinitis is seen in children and is usually the result of infection with pneumococcus, streptococcus or staphylococcus. Secondary bacterial rhinitis is the result of bacterial infection supervening acute viral rhinitis. Diphtheritic rhinitis. Diphtheria of nose is rare these days. It may be primary or secondary to faucial diphtheria and may occur in acute or chronic form. A greyish membrane is seen covering the inferior turbinate and the floor of nose; membrane is tenacious and its removal causes bleeding IRRITATIVE RHINITIS This form of acute rhinitis is caused by exposure to dust, smoke or irritating gases such as ammonia, formaline, acid fumes, etc. or it may result from trauma inflicted on the nasal mucosa during intranasal manipulation, e.g. removal of a foreign body There is an immediate catarrhal reaction with sneezing, rhinorrhoea and nasal congestion. The symptoms may pass off rapidly with removal of the offendng agent or may persist for some days if nasal epithelium has been damaged. Recovery will depend on the amount of epithelial damage and the infection that supervenes. CHRONIC RHINITIS: Chronic nonspecific inflammations of nose include: 1 Chronic simple rhinitis. 2. Hypertrophic rhinitis. 3. Atrophic rhinitis. 4. Rhinitis sicca. CHRONIC SIMPLE RHINITIS AETIOLOGY Recurrent attacks of acute rhinitis in the presence of predisposing factors leads to chronicity. The predisposing factors are: 1 Persistence of nasal infection due to sinusitis, tonsillitis and adenoids. 2 Chronic irritation from dust, smoke, cigarette smoking, snuff, etc. 3 Nasal obstruction due to deviated nasal septum, synechia leading to persistence of discharge in the nose 4 Vasomotor rhinitis. 5 Endocrinal or metabolic factors, e.g. hypothyroidism, excessive intake of carbohydrates and lack of exercise CLINICAL FEATURES 1Nasal obstruction. Usually worse on lying and affects the dependent side of nose. 2 Nasal discharge. It may be mucoid or mucopurulent, thick and viscid and often trickles into the throat as postnasal drip. Patient has a constant desire to blow the nose or clear the throat 3 Headache. It is due to swollen turbinates impinging on the nasal septum 4 Swollen turbinates. Nasal mucosa is dull red in colour. Turbinates are swollen; they pit on pressure and shrink with application of vasoconstrictor drops 5Postnasal discharge. Mucoid or mucopurulent discharge is seen on the posterior pharyngeal wall. TREATMENT 1 Treat the cause with particular attention to sinuses, tonsils, adenoids, allergy, personal habits (smoking or alcohol indulgence), environment or work situation 2 Nasal irrigations with alkaline solution help to keep the nose free from viscid secretions and also remove superfcial infection. 3 Nasal decongestants help to relieve nasal obstruction and improve sinus ventilation. 4 Antibiotics help to clear nasal infection and concomitant sinusitis. Sinusitis and its complication  TUMOURS OF THE NOSE They may be congenital, benign or malignant MALIGNANT TUMOURS Basal cell carcinoma (rodent ulcer) This is the most common malignant tumour involving skin of nose (87%), equally affecting males and females in the age group of 40–60 years. Common sites on the nose are the tip and the ala. It may present as a cyst or papulo-pearly nodule or an ulcer with rolled edges. It is very slow growing and remains confined to the skin for a long time. Lesions which are recurrent, extensive or with involvement of cartilage or bone are excised and the surgical defect closed by local or distant flaps or a prosthesis. Basal cell carcinoma (rodent ulcer) Squamous cell carcinoma (epithelioma). This is the second most common malignant tumour (11%), equally affecting both sexes in 40–60 age group. It occurs as an infiltrating nodule or an ulcer with rolled out edges affecting side of nose or columella Nodal metastases are seen in 20% of cases Early lesions respond to radiotherapy; more advanced lesions or those with exposure of bone or cartilage require wide surgical excision and plastic repair of the defect. Enlarged regional lymph nodes will require block dissection Squamous cell carcinoma (epithelioma)  Melanoma. This is the least common variety. Clinically, it is superficially spreading type (slow growing) or nodular invasive type. Treatment is surgical excision. NASAL DEFORMITIES SADDLE NOSE : Depressed nasal dorsum may involve bony, cartilaginous or both bony and cartilaginous components of nasal dorsum Nasal trauma causing depressed fractures is the most common aetiology. It can also result from excessive removal of septum in submucous resection, destruction of septal cartilage by haematoma or abscess, sometimes by leprosy, tuberculosis or syphilis HUMP NOSE:This may also involve the bone or cartilage or both bone and cartilage. It can be corrected by reduction rhinoplasty which consists of exposure of nasal framework by careful raising of the nasal skin by a vestibular incision, removal of hump and narrowing of the lateral walls by osteotomies to reduce the widening left by hump removal. CROOKED OR A DEVIATED NOSE:In crooked nose, the midline of dorsum from frontonasal angle to the tip is curved in a C- or S- shaped manner. In a deviated nose, the midline is straight but deviated to one side. Usually, these deformities are traumatic in origin. Injuries sustained during birth, neonatal period or childhood but not immediately recognized, will also develop into these deformities with the growth of nose. The deviated or crooked nose can be corrected by rhinoplasty or septorhinoplasty. FRACTURES OF NASAL BONES AND SEPTUM Fractures of nasal bones are the most common because of the projection of nose on the face. Traumatic forces may act from the front or side. Magnitude of force will determine the depth of injury. TYPES OF NASAL FRACTURES 1.Depressed.They are due to frontal blow 2. Angulated. A lateral blow may cause unilateral depression of nasal bone on the same side or may fracture both the nasal bones and the septum with deviation of nasal bridge CLINICAL FEATURES 1. Swelling of nose. Appears within few hours and may obscure details of examination. 2. Periorbital ecchymosis. 3. Tenderness. 4. Nasal deformity. Nose may be depressed from the front or side, or the whole of the nasal pyramid deviated to one side. 5. Crepitus and mobility of fractured fragments. 6. Epistaxis. 7. Nasal obstruction due to septal injury or haematoma. 8. Lacerations of the nasal skin with exposure of nasal bones and cartilage may be seen in compound fractures DIAGNOSIS Diagnosis is best made on physical examination. X-rays may or may not show fracture Patient should not be dis missed as having no fracture because X-rays did not reveal it. X-rays should include Waters’ view, right and left lateral views and occlusal view. TREATMENT Simple fractures without displacement need no treatment; others may require closed or open reduction. Presence of oedema interferes with accurate reduction by closed methods Therefore, the best time to reduce a fracture is before the appearance of oedema, or after it has subsided, which is usually in 5–7 days. It is difficult to reduce a nasal fracture after 2 weeks because it heals by that time. Healing is faster in children and therefore earlier reduction is imperative. 1 Closed reduction Depressed fractures of nasal bones susained by either frontal or lateral blow can be reduced by a straight blunt elevator guided by digital manipulation from outside. Laterally, displaced nasal bridge can be reduced by firm digital pressure in the opposite direction. Impacted fragments sometimes require disimpaction with Walsham or Asch’s forceps before realignment. Septal fractures are also reduced by Asch’s forceps. Septal haematoma, if present, must be drained Simple fractures may not require intranasal packing. Unstable fractures require intranasal packing and external splintage External nasal splinting to support and protect the nasal reduction. 2. Open reduction. Early open reduction in nasal fracture is rarely required. This is indicated when closed methods fail. Certain septal injuries can be better reduced by open methods. Healed nasal deformities resulting from nasal trauma can be corrected by rhinoplasty or septorhinoplasty FOREIGN BODIES IN NASAL CAVITY AETIOLOGY They are mostly seen in children and may be organic or inorganic. Pieces of paper, chalk, button, pebbles and seeds are the common objects. Pledgets of cotton or swabs may be accidentally left in the nose CLINICAL FEATURES Patient may present immediately if the history of foreign body is known If overlooked, the child presents with unilateral nasal discharge which is often foul smelling and blood stained If a child presents with unilateral, foul-smelling nasal discharge, foreign body must be excluded.” ENDOSCOPIC VIEWO OF NASAL FOREIGN BODIES AND REMOVAL TREATMENT Pieces of paper or cotton swabs can be easily removed with a pair of forceps. Rounded foreign bodies can be removed by passing a blunt hook (a eustachian catheter is a good instrument) past the foreign body and gently dragging In babies and uncooperative children general anaesthesia with cuffed endotracheal tube is used Foreign bodies lodged far behind in the nose may need to be pushed into the nasopharynx before removal A nasal endoscope is very useful to locate the foreign body and carefully remove it COMPLICATIONS A foreign body left in the nose may result in: 1. nasal infection and sinusitis. 2. rhinolith formation. 3. inhalation into the tracheobronchial tree. Facial paralysis Causes of facial paralysis Central Brain abscess Pontine gliomas Poliomyelitis Multiple sclerosis Intracranial part (cerebellopontine angle) Acoustic neuroma Meningioma Congenital cholesteatoma Metastatic carcinoma Meningitis  Intratemporal part Idiopathic – Bell palsy – Melkersson syndrome Infections – Acute suppurative otitis media – Chronic suppurative otitis media – Herpes zoster oticus – Malignant otitis externa.Trauma – Surgical: Mastoidectomy and stapedectomy – Accidental: Fractures of temporal bone Neoplasms – Malignancies of external and middle ear – Glomus jugulare tumour – Facial nerve neuroma – Metastasis to temporal bone (from cancer of breast, bronchus),  Extracranial part Malignancy of parotid Surgery of parotid Accidental injury in parotid region Neonatal facial injury (obstetrical forceps) Systemic disease Diabetes mellitus Hypothyroidism Uraemia Polyarteritis nodosa Wegener’s granulomatosis Sarcoidosis (Heerfordt’s syndrome) Leprosy Leukaemia Demyelinating disease Epistaxis Bleeding from inside the nose is called epistaxis. It is fairly common and is seen in all age groups—children, adults and older people. It often presents as an emergency. Epistaxis is a sign and not a disease per se and an attempt should always be made to find any local or constitutional cause. CAUSES OF EPISTAXIS They may be divided into: 1.Local, in the nose or nasopharynx..1 2. General. 3. Idiopathic. A. LOCAL NASAL CAUSES 1.Trauma. Finger nail trauma, injuries of nose, intranasal surgery, fractures of middle third of face and base of skull, hard-blowing of nose, violent sneeze. 2. Infections (a) Acute: Viral rhinitis, nasal diphtheria, acute sinusitis. (b) Chronic: All crust-forming diseases, e.g. atrophic rhinitis, rhinitis sicca, tuberculosis, syphilis septal perforation, granulomatous lesion of the nose, e.g. rhinosporidiosis. 3. Foreign bodies (a) Nonliving: Any neglected foreign body, rhinolith. (b) Living: Maggots, leeches. 4. Neoplasms of nose and paranasal sinuses. (a)Benign: Haemangioma, papilloma. (b) Malignant: Carcinoma or sarcoma. 5. Atmospheric changes. High altitudes, sudden decompression (Caisson disease). 6. Deviated nasal septum. LOCAL NASOPHARYNGEAL CAUSES 1. Adenoiditis. 2. Juvenile angiofibroma. 3. Malignant tumours. B. GENERAL CAUSES 1.Cardiovascular system. Hypertension, arteriosclerosis, mitral stenosis, pregnancy (hypertension and hormonal). 2.Disorders of blood and blood vessels Aplastic anaemia, leukaemia, thrombocytopenic and vascular purpura, haemophilia, Christmas disease, scurvy, vitamin K deficiency and hereditary haemorrhagic telangectasia. 3. Liver disease. Hepatic cirrhosis (deficiency of factor II, VII, IX and X). 4. Kidney disease. Chronic nephritis. 5. Drugs. Excessive use of salicylates and other analgesics (as for joint pains or headaches), anticoagulant therapy (for heart disease). CLASSIFICATION OF EPISTAXIS ANTERIOR EPISTAXIS When blood flows out from the front of nose with the patient in sitting position. POSTERIOR EPISTAXIS Mainly the blood flows back into the throat. Patient may swallow it and later have a “coffee-coloured” vomitus. This may miss diagnosed as haematemesis. MANAGEMENT In any case of epistaxis, it is important to know: 1.Mode of onset. Spontaneous or finger nail trauma. 2. Duration and frequency of bleeding. 3. Amount of blood loss. 4. Side of nose from where bleeding is occurring. 5. Whether bleeding is of anterior or posterior type. 6. Any known bleeding tendency in the patient or family. 7. History of known medical ailment (hypertension, ,mitral valve disease, cirrhosis and nephritis). 8. History of drug intake (analgesics, anticoagulants). GENERAL MEASURES IN EPISTAXIS  1. Make the patient sit up with a back rest and record any blood loss taking place through spitting or vomiting 2. Reassure the patient. Mild sedation should be given. 3. Keep check on pulse, BP and respiration. 4. Maintain haemodynamics. Blood transfusion may be required. 5. Antibiotics may be given to prevent sinusitis, if pack is to be kept beyond 24 h. 6. Intermittent oxygen may be required in patients with bilateral packs because of increased pulmonary resistance from nasopulmonary reflex 7. Investigate and treat the patient for any underlying local or general cause FIRST AID Most of the time, bleeding occurs from the Little’s area and can be easily controlled by pinching the nose with thumb and index finger for about 5 min. This compresses the vessels of the Little’s area. In Trotter’s method patient is made to sit, leaning a little forward over a basin to spit any blood and breathe quietly from the mouth. Cold compresses should be applied to the nose to cause reflex vasoconstriction. CAUTERIZATION This is useful in anterior epistaxis when bleeding point has been localized. The area is first topically anaesthetized and the bleeding point cauterized with a bead of silver nitrate or coagulated with electrocautery. ANTERIOR NASAL PACKING In cases of active anterior epistaxis, nose is cleared of blood clots by suction and attempt is made to localize the bleeding site If bleeding is profuse packing should be done use a ribbon gauze soaked with liquid paraffin. About 1 m gauze (2.5 cm wide in adults and 12 mm in children) is required for each nasal cavity. First, few centimetres of gauze are folded upon itself and inserted along the floor and then the whole nasal cavity is packed tightly by layering the gauze from floor to the roof and from before backwards. Packing can also be done in vertical layers from back to the front). One or both cavities may need to be packed. Pack can be removed after 24 h, if bleeding has stopped. Sometimes, it has to be kept for 2–3 days; in that case, systemic antibiotics should be given to prevent sinus infection and toxic shock syndrome POSTERIOR NASAL PACKING It is required for patients bleeding posteriorly into the throat. A postnasal pack is first prepared by tying three silk ties to a piece of of gauze rolled into the shape of a cone A rubber catheter is passed through the nose and its end brought out from the mouth ENDOSCOPIC CAUTERIZATION Using topical or general anaesthesia, bleeding point is localized with a rigid endoscope It is then cauterized with a malleable unipolar suction cautery or a bipolar cautery procedure is effective with less morbidity and decreased hospital stay The procedure has a limitation when profuse bleeding does not permit localization of the bleeding point Thank you