Diseases of nose by Dr. Kavitha Ashok Kumar MSU MAlaysia

Dr. Kavitha Ashok Kumar 7/25/2014 2

Diseases of external nose
Conditions affecting the nasal septum
Infections/inflammation of the nose
Tumoursof the nose and nasopharynx

Congenital: Cleft lip/ palate, meningocoele, dermoid, hemangioma, etc.
Inflammatory
Non-specific: Furuncle,cellulitis
Specific: Rhinoscleroma, TB, syphilis, leprosy, lupus, etc.
Trauma: Facial trauma, surgical trauma
Neoplastic
Benign: Papilloma, rhinophyma
Malignant: Basal cell ca, squamouscell ca.

External nasal skeleton is made of various bones and cartilages
Differential growth rate of these components can give rise to deformed nose
Influenced by
Fetal position in utero
Birth trauma

Bony/ cartilaginous/ both
Hump
Depressed dorsum-Saddle nose
Lateral deformities
Crooked nose-C/ S/ V shaped
Deviated nose
Tip deformities
Alardeformities
‘Frog face’ deformity

Investigations
Radiological: rule out secondary sinusitis
Nasal endoscopy
Preoperative photography
Treatment
Treat associated or secondary rhinitis/ sinusitis
Treat the cause
Surgical treatment: Rhinoplasty/ septorhinoplasty

Acute staphylococcal infection of the hair follicle commonly seen in the nasal vestibule
Etiology of recurrent furuncle:
Nose picking
Diabetes
Immuno-compromised states

Pain on touching the nose especially the tip/ ala
Pus pointing or swelling over the nose or in the vestibule
Purulent discharge if it ruptures
Tenderness of the nasal tip/ ala

Not to squeeze the lesion
Dangerous area of the face—infection can spread along the angular and ophthalmic veins to cavernous sinus
Systemic antibiotics and analgesics
I&D if it becomes an abscess
Management of underlying diabetes, if present.

Facial cellulitis
Abscess of the upper lip
Septal abscess
Cavernous venous thrombophlebitis
Vestibular stenosis-in recurrent forms

Diffuse dermatitis of the nasal vestibule caused by staphlococcusaureus
Etiology:frequentpicking of the nose
Clinical features: red ,painful nose.crustsand scales,fissures
Treatment:cleanthe crusts,ointment.

Thickening and heaped raised lesions of the tip of the nose due to hypertrophy of the sebaceous glands
Typically afflicts white males between 40 and 60 years of age (M:F::12:1)
End result of acne rosaceawhich is actually more common in females

Medical treatment
Treatment of secondary infection and inflammation with antibiotics and steroids
Surgical:
Full thickness excision followed by application of split thickness skin grafts
Partial thickness "decortication" using cryosurgical techniques, chemical peels, dermabrasion, or Argon/CO2 lasers

Most common malignancy of the skin commonly affecting the nose
long-term exposure to sunlight and frequently occur on sun exposed skin, such as the face, scalp, ears, etc.
> White adult population
> Outdoor workers, sailors and the very fair skinned.
>50 years and above

Locally slow growing and mutilating lesion
Lymphatic and distant metastasis-uncommon
Early diagnosis-prevents disfigurement of face
Treatment: Excision and reconstruction
Prognosis-very good on complete removal

Deviated Nasal Septum

C –SHAPED
S SHAPED

•Duplication
•SPUR
•DISLOCATION
7/25/2014 Dr. Kavitha Ashok Kumar 29

•TRAUMA
•DEVELOPMENT ERROR
•HEREDITARY

SIGNS
External examination
Anterior rhinoscopy
Cottle’sTest
SYMPTOMS
Nasal obstruction
Headache
Sinusitis
Epistaxis
Anosmia
External deformity
Middle ear diseases
Anterior ethmoidalnerve syndrome.

COTTLE’S TEST

HEMATOLOGICAL
-Hb
-WBC
-OTHERS
RADIOLOGY
-X Ray -PNS
DIAGNOSTIC ENDOSCOPY

MEDICAL
-EXERCISES
-DECONGESTANTS
SURGICAL
-SEPTOPLASTY
-SUBMUCOSAL RESECTION OF SEPTUM(SMR)

Symptomatic DNS
Grafting material-cartilage/bone
Septalperforation closure.
Surgical access

Steps
INCISION
ELEVATION OF FLAPS
CORRECTION OF DEFORMITY
CLOSURE
ANTERIOR NASAL PACKING

COTTLE’S LINE

INCISION
FREER’S
KILLIAN’S

ELEVATION OF FLAPS
Anterior
Tunnel
Inferior
Tunnel

BEFORE
AFTER

SMR
KILLIAN’S INCISION
FLAP ELEVATED BOTH SIDES
CARTI+ BONY REMOVED
SUPRATIP DEFORMITY
COLLUMELLAR RETRACTION
DORSAL COLLAPSE
SEPTAL PERFORATION
FLAPPING SEPTUM
SEPTOPLASTY
FREER’S INCISION
FLAP ELAVATED ON ONE SIDE
ONLY CORRECTION OF DNS
COMPLICATIONS LESS
RESIDUAL DNS

EARLY
ANAESTHETIC COMPLICATIONS
SEPTAL HEMATOMA / ABCESS
PERFORATION
LATE
SUPRATIP DEFORMITY
COLUMELLAR RETRACTION
SEPTAL PERFORATION
RESIDUAL DEVIATION
ATROPHIC RHINITIS

SEPTAL HEMATOMA
SEPTAL ABCESS

Trauma
Submucosal blood vessel
Chondrocytes die
Infected
abscess

Traumatic
•Surgery / Cautery/ Nose picking
Malignant
•Tumours/ Granuloma
Chronic inflammation
•Wegeners/syphilis/tuberculosis/candida/lupus erythematosus/rheumatoid arthritis.
Poisons
•Industrial/cocaine addicts/topical corticosteroids/topical decongestants
Idiopathic

SEPTAL PERFORATION
Anterior Rhinoscopy
Size:
Small: upto 1 cm
Medium: 1-2 cm
Large: >2cm

REPAIR
SEPTAL BUTTONS

REPAIR
SURGERY

Aetiology: viral--influenza ,coxsackie, reovirus,ECHOvirus and rhinovirus
Pathology: transient vasoconstriction followed by vasodilatation,oedemaand increased secretions
Clinical features:
Irritation—burning sensation---watery nasal discharge 2-3days later—fever,nasalobstruction mucopurulantdischarge
5-10 days-------recovery

Nonspecific:
Chronic hypertrophic rhinitis
Atrophic rhinitis
Rhinitis caseosa(nasal cholesteatoma)
Rhinitis sicca
Allergic rhinitis
Vasomotor rhinitis

Specific:
Lupus vulgarisof the nose
Tuberculosis
Syphilitic rhinitis
Leprosy
Rhinosporidiosis
Rhinoscleroma

Clemens Von Pirquet, ViennessePaediatriciancoined the term allergyin 1906
denoting an altered state of reactivity
to an organic substance
i.e‘allergen’

Is a protein with a size of 2 to 50 micrometer in diameter & molecular weight of 1000 to 40,000 Daltons

Definition: It is an IgEmediated immunological response of the mucosa of nose charecterizedby bouts of sneezing watery nasal discharge, itching and a sense of nasal obstruction

Seasonal allergic rhinitis
March to May(Hay fever) orJuly to September
Prevalence of
pollens of
grasses, flowers,
trees/shrubs

1. Pollens
Weed pollen
Grass Pollen
Timothy Grass
(Phleumpratense)
Cocksfoot
(Dactylisglomerata)
Birch, hazel,
Plane tree ash
and pine
Tree pollens
NETTLE, DOCK &
MUGWORT
FLOWER

Perennial allergic rhinitisThroughout the yearExogenous allergens like house dust, soaps, creams, perfumes, egg, odoursof fish coffee
Commonest is house dust which contains faecesof mites-DermatophagoidesPteronyssinus

Seasonal
Paroxysmal sneezing
Watery Nasal discharge
Nasal obstruction
Itching
Perennial
Frequent colds
persistently stuffy nose
Loss of smell
Postnasal drip
Chronic cough
Hearing impairment

Nose
transverse crease on nose
pale, oedematous nasal mucosa
turbinates are swollen
thin, watery/ mucoid discharge
Ears
retracted T M
Serous otitis media

Investigations
1.Blood -TC, DC, AEC
2.Nasal smear for eosinophils
3.Nasal provocation tests
4.Skin test (Prick/ Scratch/ Intradermaltests)
5.Radioallergosorbenttest
Antigen (radioactive) + Pt’s serum (Contains IgE)
Radioactive IgEcomplex (Measured)

a. Avoid possibly known allergen
b. Drugs
1. Antihistamines
2. Sympathomimetic drugs
3. Corticosteroids
Oral/Local/Injection
4. Mast cell stabilizer (2% Sodium chromoglycate nasal spray)
c. Immunotherapy

Vasomotor rhinitis
Rhinitis medicamentosa
Endocrinal rhinitis
a. Thyroid dysfunction
b. pregnancy
c. Honeymoon Rhinitis
Drug induced rhinitis
a.Contraceptive pills
b. Antihypertensives
c. Neostigmine

Definition
It is a clinical condition due to imbalance of autonomic nervous system
Epidemiology
Common in emotionally unstable persons( Women of 20 to 40 years)

Nasal Obstruction, Rhinorrhoea
Postnasal drip, Head ache, fatigue
Signs
Enlargement of turbinates
Mucosa is dusky red in color (Mulberry like appearance)

Physical exercise
Tranquillizers
Decongestants
Surgical treatment
Cauterization of turbinates
submucosaldiathermy
Cryosurgery
Surgical resection of turbinates
VidianNeurectomy( Malcomson1959) in intractable rhinorrhoea

Atrophy of nasal mucosa & turbinate bones.
• Excessive drying, crusting and infection
Klebsiellacolonization
Types:
Primary:Causeis not known Theories proposed :
Hereditary,Endocrinal,Racial,Nutritionaldef,Infective, Autoimmune.
Secondary:in Syphilis,TuberculosisLeprosy,Lupus.

Metaplasiafrom ciliated columnar to squamous
Type 1;Endarteritis & periarteritisdue to chronic inflammation
Type 2;Vasodilatation of capillaries

Nasal block, epistaxis
(Merciful) anosmia
Choking when detached crusts slips from the nasopharynxto oropharynx
Atrophic pharyngitis& laryngitis
O/E
Greenish/grayish black crusts,
Roomy nasal cavity
Shrivelledturbinates.

Nasal douche
3-4 times per day for 2-3 months,then1-2 times per day indefinitely
280ml of water + 28.4gm(1tsp)Sodium bicarbonate +1tsp sodium diborate+ 56.7gm(2tsp) sodium chloride
Drops of 25% glucose in glycerin locally
Local antibiotics
Oestradiolspray
Placental extract
Rifampicin600mg daily / Streptomycin
Oral KI

Narrowing:
Young’s operation; Modified young’s Lautenslager’soperation, Submucousinjof Teflon,Cancellousbone graft.
Transplant:Witmack’sprocedure,
Nerve destructive:Ganglion nerve blocks, Dr. Kavitha Ashok Kumar 7/25/2014 71

Crust formation seen in patients who work in hot dry surroundings
Confined to anterior1/ 3rd Nose
Treatment
Correction of occupational surroundings,
Local application of ointment,
Nasal douche. Dr. Kavitha Ashok Kumar 7/25/2014 72

Mostly affects males
Nose filled with offensive,cheesymaterial
Secondary to chronic sinus infection
Treatment-Removal of debris, drainage of sinus. Dr. Kavitha Ashok Kumar 7/25/2014 73

Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.

Depending on the site
Unilateral/ bilateral
Pansinusitis
Multisinusitis
Maxillary/ frontal/ ethmoidal/ sphenoidal
Depending on whether the sinus is draining or not
Open type
Closed type
Depending on the pathology
Suppurative
Non-suppurative

Rhinogenic-Commonest (85%)
Usually after viral rhinitis (Flu)
Any form of rhinitis
Dental (Maxillary)
Root abscess, dental procedure, etc.
Trauma
RTA, Swimming and diving, FB, barotrauma, etc.
Iatrogenic-nasal packing, septal surgery
Hematogenous-Rare

Mucosal odema of MM
Any form of rhinitis: Viral, bacterial, Irritant, allergic, VMR, atrophic, etc. (environmental factors play role)
Mechanical (anatomical) obstruction of nose/ MM
DNS, spur, polyp, hypertrophic turbinate, any mass, FB, nasal packing, etc.
Pathological mucous
Thick mucous (mucoviscidosis, cystic fibrosis)
Primary mucociliary dysfunction
Others: Poor general health, immunodeficiency states, DM, nutritional def., etc,

Str.Pneumoniae
B-hemolytic streptococcus
H.influenzae
Stap. Aureus
Klebsiella pneumoniae
Others

Obstruction to sinus ostium/ meatus
Stasis of secretions (serous-mucinous): Non-suppurative
Secondary bacterial invasion: Suppurative
Severity and resolution depends on
Open/ closed. May drain creating accessory opening.
Organism virulence
Host resistance
Treatment received

Acute inflammatory changes: Hyperemia, odema, acute infl. infliterate.
Increased activity of the mucous glands
Severe suppuration
Mucosal destruction
Empyema
Bony destruction
Complications

Constitutional symptoms: Fever, malaise, lethargy
Headache/ facial pain: Dull ache, postural/diurnal.
Max: Facial, forehead
Frontal: Forehead, “Office headache”
Ethmoid: Between the eyes, may > with eye movement
Sphenoid: Vertex, occipital
Nasal discharge
mucous/ mucopurulent/ purulent/ blood stained
Anterior/ postnasal
Nasal obstruction
Cheek/ lid congestion, swelling

Fever
Tenderness
Cheek swelling
Lid edema: in ethmoid and frontal
Inflamed nasal mucosa especially the meatus
Discharge in MM/ SM as on anterior/posterior rhinoscopy
Signs of complications

Endoscopicappearance of acute infective sinusitis, with pus exuding from under the right middle turbinate and down into the middlemeatus.

Clinical diagnosis
Diagnostic nasal endoscopy (DNE)
Radiological
X-ray PNS
Water’s view (Occipetomental)
Caldwel view (Occipetofrontal)
Lateral view
Base skull view (Submento-vertical)
CT scan: indicated in impending complications
C/S: rarely done

Postural test
Transilluminationtest
X-Rays PNS
CT Scan
Pus swab

CT –Coronal views centered on OMC
Investigations (cont…)

CT
Coronal CT shows the inflammatory changes in the right frontal recess and anterior middle meatus(star).

Antibiotics
Nasal decongestants (Topical/systemic)
Anti-inflammatory analgesics
Medicated steam inhalation
Mucolytics
Hot fomentation

If not responding to medical treatment
Impending or manifest complications
Depends on the sinus involved

Acute maxillary: Antral washout/ endoscopic MMA
Acute frontal: Frontal trephination/ endoscopic frontal recess clearance
Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy
Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy

Chronic sinusitis
Acute sinusitis or acute exacerbations of chronic sinusitis may give rise to following complications:
Orbital
Intracranial
Osteomyelitis
Septic focus for other infections

Spiking fever
Lid odema, facial/orbital swelling
Proptosis, reduced vision, reduced extraoccular movt.
Severe headache and hyperirritable
Projectile vomiting
Meningeal signs
Hypothermia
Altered sensorium

Common in acute ethmoiditis or frontal sinusitis
Direct spread/ ostitis/ thrombophlebitic
Odema of the lids
Subperiosteal abscess
Orbitial cellulitis
Orbital abscess
Superior orbital fissure syndrome: Deep orbital pain, frontal headache, progressive paralysis of extraoccular movements
Blindness

A patient with acute ethmoiditis threatening vision.

Anterior cranial fossa and cavernous sinus closely related
Meningitis
Extradural abscess
Subdural abscess
Frontal lobe abscess
Cavernous sinus thrombophlebitis, etc

“Acute sinusitis especially in a child should be treated adequately to prevent consequent chronic sinusitis or other more severe complications which may be even fatal”.

HISTOLOGICALLY BENIGN, LOCALLY
AGGRESSIVE NONENCAPSULATED
VASOFORMATIVE NEOPLASM SEEN
EXCLUSIVELY IN MALE ADOLESCENTS.

MACROSCOPY
WELL CIRCUMSCRIBED .LOBULATED
PURPLE RED MASS
COVERED WITH INTACT MUCOSA
APPEAR DECEPTIVELY AVASCULAR

TWO MAIN CELLULAR COMPONENTS
FIBROUS STROMA
BLOOD VESSEL CHANNELS --RICH
DISTINCT LACK --SMOOTH MUSCLES
ELASTIC FIBRES

JUVENILE --OCCURS 10 TO 25 YR
NASAL BLOCK --UNILATERAL
EPISTAXIS --80 PERCENT
FACIAL SWELLING
PROPTOSIS
OCULAR SYMPTOMS

PLAIN X-RAY --ANT.BOWING OF THE POSTERIOR WALL OF MAXILLARY SINUS(HOLMAN-MILLER’S SIGN)
CT-SCAN --BONY INVOLVEMENT
MRI --SOFT TISSUE—INTRA CRANIAL SPREAD
ANGIOGRAPHY --FEEDING VESSEL

1.ENDOSCOPIC INTRANASAL
2.OPEN ACCESS
# TRANSPALATAL
# MIDFACIAL DEGLOVING
# LATERAL RHINOTOMY
INTRACRANIAL APPR. --SURGERY
--RADIATION
EMBOLISATION
RECURRANCE-30-40%

Most common in southern states of China Taiwan and Indonesia
Etiology
Genetic
Abnormality in chromosome 1 to6, 9,11,13,14,16,17,22, and X
Viral -Epstein Barr virus
Environmental –smoking, airpollution
Dietary –Nitrosamines from dry salted fish

Pathology
Squamouscell carcinoma ( 85%)
Graded in to well, moderately, poorly differentiated
Lymphoma (10%)
Rhabdomyosarcoma, Malignant salivary tumour, malignant chordoma(5%)
Clinical features
Age –4thto 5thdecades of life
Male : female -3:1
Symptoms
Neck mass, hearing loss, Nasal obstruction, epistaxis, cranial nerve palsies, weight loss

Signs –
proliferative/ulcerative/ infiltrative
Unilateral serous otitismedia
Rhinolaliaclausa
Squint and diplopia(CN -VI)
Opthalmoplegia(CN –III, IV, VI)
Facial pain and reduced cornialreflex (CN –V)
Blindness (CN –II)
Jugular Foramen Syndrome (CN -IX, X, XI)
Collet–Sicardsyndrome (CN –IX, X, XI, XII)
Horner’s syndrome (cervical sympathetic chain)
Trotter’s triad
Cervical Neck Nodes
Distant metastasis

Investigations
Endoscopy and biopsy
FNAC
MRI Scan
CT Scan
Serology for Epstein Barr virus
Positron emission tomography (for residual or recurrent disease after treatment)
Treatment
Irradiation
Systemicchemotherapy
Radicalneck dissection
Overallsurvival is 50 to 80%

Diseases of nose by Dr. Kavitha Ashok Kumar MSU MAlaysia

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Diseases of nose by Dr. Kavitha Ashok Kumar MSU MAlaysia