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:-
- Nasal obstruction: unilateral
or bilateral- commonest cause of unilateral in children is foreign bodies of the nose.
- Rhinorrhoea: could be watery
due to flue or upper respiratory infection or mucus due to sinusitis.
- Facial pain: due to sinus infection.
- Nose bleed: that will be discussed
later.
- Headaches: mainly due to sinusitis
but other causes may be investigated.
- Snoring: due to nasal and post
nasal obstruction 50% chance that improving the nasal airway will cure the snoring.
- changed sense of smell: Anosmia
total loss of sense of smell mainly due to URTI. Cacosmia is a bad smell mainly due to sinusitis.
- 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.