Part III

Nasal Anatomy and Disease

Development:

Anatomy:

Histology:

            Respiratory epithelium:

Lower 2/3 of the nose.

Ciliated columnar epithelium.

            Olfactory Epithelium:

                        Upper 1/3 of the nose.

                        Non-ciliated columnar epithelial  responsible for smell and connected with

Olfactory nerve to the brain.

Blood supply:-

 External carotid artery à  maxillary artery à  sphenopalatine and greater palatine artery                                                      facial artery à superior labial artery

  Internal carotid artery: à Anterior + posterior ethmoidal artery

Remember Kiesselbach's plexus of vessels which forms of these 5 arteries in the front of the nose in an area called Little's area, which is the main cause of nose bleed.

Investigation of nasal disease

History:-

1. Nasal obstruction: unilateral or bilateral- commonest cause of unilateral in children is foreign bodies of the nose.
2. Rhinorrhoea: could be watery due to flue or upper respiratory infection or mucus due to sinusitis.
3. Facial pain: due to sinus infection.
4. Nose bleed: that will be discussed later.
5. Headaches: mainly due to sinusitis but other causes may be investigated.
6. Snoring: due to nasal and post nasal obstruction 50% chance that improving the nasal airway will cure the snoring.
7. changed sense of smell: Anosmia total loss of sense of smell mainly due to URTI. Cacosmia is a bad smell mainly due to sinusitis.
8. Family history of atopy: usually accompanied by bronchial asthma and allergic rhinitis eczema is part of the manifestation.

Examination:-

                        Good light source.

Inspection:

                        Nasal scar.

                        Nasal deformity.

Anterior rhinoscopy:

                        Using thudicum speculum to open the nose.

Examine:

                                    Canodal septal dislocation.

                                    Nasal vestibule.

                                    Inferior tunbinate.

                                    Nasal cavity.

                                    Nasal septum.

Then examine the throat and post nasal space.

Endoscopy: rigid endoscopy 0 degrees or 30 degrees to examine nasal cavity under L.A.

Investigation:-

            Haematology: full blood cound ESR.

            PRIST (plasma radio immune sorbent test)                                                                                            Measure plasma level of IgE in total.

            RAST (radio allergo sorbent test).

                        Measure IgE specific allergens.

            Mucociliary clearance test:

Check ciliary motility by Saccharine clearance test normal time is 20 minutes from the nose to the tongue.

                        If delay in clearance then ciliary disease should be suspected.

Radiology:

                        Plain X-ray:

                                    Occipito mental

                                    Occipito frontal

                                    Lateral

                                    Sub mento vertical

                                    Oblique

                        CT  scan: Best for sinus disease

MRI: not as good as C.T to show bone diseases.

Diseases of the nose:

Congenital:

            Cleft lip, bifid nose (nose divided into 2 halves).

            Hypertelorism (Crouzon's disease) with wide separation of the eyes.

            Congenital choanal atresioa:

                        Due to persistent bucconasal membrane.

                        Types:

                                    Unilateral

                                    Bilateral

                        Clinically:

Bilateral Urgent treatment should be done due to asphyxia as

                                                     New born baby is only nasal breathe.

                        Treatment:

                                    Perforation of the membrane of the bone.

Acquired:

1.      Traumatic:

                        Nasal ± facial trauma

                        Nasal bone fracture ± septal deviation:

            Aetiology:

                        Direct hit to the nose by a fist

                        RTA

            Clinically:

                        External nasal deformity.

                        Nasal obstruction.

                        Black eyes.

                        Other facial fractures:

                                    Zygoma.

                                    Maxilla.

                                    Mandible.

            Complications:

                        Septal haematoma à abscess à  perforation

                        Eye complications: like haematoma in the eye and eye infections.

                                    Covernous sinus thrombosis (rare).

            Treatment:

                        Nasal manipulation (reduction).

                        Septorhinoplasty later or septoplasty if the deformity persists after 6-12

months.

2.      Inflammatory:-

Furunculosis: staphylococcal remember the dangerous areas of the face as the

  Infection could spread into the cavernus sinus.

            Erysipelas: streptococcal

            Rhinitis:

                        Acute

                        Chronical

            Acute:

                        Viral: Influenza, RSV.

                        Bacterial: Streptococci, pneumococci.

                        Treatment:

                                    Viral: vaccine?

                                    Bacterial: antibiotics.

            Chronic:

                        Non-specific:

                                    Simple chronic: delay resolving of acute attack

                                    Hypertrophic rhinitis (Medicamentosa) due to excessive use of

nasal decongestant drops like ephidrean.

                                    Atrophic rhinitis:

Atrophy of nasal mucosa due to its degeneration of the mucosa and it becomes infected with coccobacillus forming a crust, nose bleed and foul smell.

                                    Treatment: Nasal douch - Glucose 25% with glycerine, antibiotics.

                        Specific:

                                    Syphilis:

                                                Congential

                                                Acquired

                                                            Primary

                                                            Secondary

                                                            Tertiary

                                                Treatment:

Penicillin, I.V for up to 3 weeks

                                    Others:

                                                T.B, sarcoidosis, fungal infection.

Paranasal sinusitis.

Acute sinusitis: maxillary, frontal, ethmoidal, sphenoidal.

                        Maxillary

                                    Aetiology:

                                                Rhinogenic 90%

                                                Dental 10%

                                    Clinically:

                                                Pain

                                                Nasal obstruction

                                                Discharge

                                    Investigation:

                                                Plain X-ray

                                                C.T  scan

                                    Treatment:

                                                Painkillers, Antibiotics, surgery.

Chronic sinusitis:

                        From acute sinusitis complication.

                                    Treatment: varies from medical to surgical steroids and

antibiotics are the main medical treatment. FESS (functional enodoscopic sinus surgery) is the main line of surgical treatment all done with keyhole surgery through the nose.

            Complications of sinus diseases:

Rare nowadays

            Extracranial:

Osteosmyelitis caused by frontal sinusitis.

                                    Treatment:

IV antibiotics.

                                                Surgery.

                        Orbital complications:

                                    Periorbital oedema.

                                    Orbital cellulitis.

                                    Optic neuritis.

                                    Treatment:

I.V antibiotics

Drainage of abscess.

                        Others:

                                    Tonsillitis, pharyngitis, laryngitis, otitis media.

Intracranial:

                        Extradural, subdural and brain abscess.

                        Meningitis.

                        Cavernous sinus thrombosis.

3.      Neoplastic

            Benign:

                        Papilloma, adenoma, fibroma, osteoma, angioma.

            Malignant:

                        Skin: BCC, squaemous cell carcinoma

                        Inside the nose:

                                    80% SCC.

                                    10%:    Adenocarcinoma, "hardwood worker", adenoid

cystic carcinoma.

5% transitional cell carcinoma

others:

            Malignant malanoma.

Olfactory neuroblasyoma

            Lymphoma.

            Metastasis from GI system.

                        Clinically:

                                    Diagnosis is usually late.

                                    Nasal obstruction.

                                    Toothache, difficulty in fitting denture.

                                    Proptosis, epiphora, diplopia.

                                    Cranial nerve involvement.

                        Investigation:

                                    CT scan

                        Treatment:

                                    Radiation pre or post operatively or for advanced cancers.

                                    Tumour limited to the nose à lateral Rhinotomy.

                                    Maxillary sinus à partial or total maxillectomy.

                                    Ethmoid tissues à craniofacial approach.

4.      Nose bleed (epistaxis)

                        Anterior: front of the nose.

                        Posterior: back of the nose.

            Classification:

                        Local: idiopathic traumatic, neoplastic.

                        General: coagualation Problems, drugs related aspirin and warfarin.

                        Leukaemia.

                        Blood vessel abnormality: Osler's disease.

            Site of nose bleed:

                        Anterior: Little's area

                        Posterior: mainly due to sphenopalatine artery bleed.

            Treatment: immediate

                        Anterior:

Pressure to the nose.

                                    Ice pack.

                                    Cautery with AgNO3.

Posterior: usually in hypertensive patient.

            Admission to the hospital with packing to the nose.

            ± Catheterisation to the postnasl space, sedation.

            Treat coagulation problems if present

Surgery for resistant cases:

            EUA (examination under anaesthesia) packing

Ligation:

            External carotid artery

            Sphenopalatine artery.

            Ethmoidal artery.

5.      Allergic rhinitis:

Define: common problems related to type I allergic reaction mediated by

IgE immunoglobulin.

Pathology: IgE has an affinity for mass cells with allergens it degranualtes

releasing histamine, leukotrine and prostaglandins.

Allergens:

                                    Pollen: House dust mites and moulds.

                                    Animals:

                                    Feathers:

Clinically: runny nose, sneezing and obstruction

Examination: shows pale hypertrophy of inferior turbinates with nasal

discharge.

Investigation: skin test.

Treatment: treat the cause if possible, steroid spray, antihistamine tablets

or spray.