Prepared by Dr.

Nowsheen Yasmin;Ew:16
A)what is dangerous area of face?
-triangular area including the tip of the nose and upper part of the lip

Dangerous area of the nose:

-little’s area (anterior inferior part of nasal septum just above the vestibule)
B) Why it is dangerous?
-because this area several vessels supplying the nasal cavity form a vascular [Link]
area is highly [Link] is the commonest site of bleeding from nose.

C)How kisselbaltch plexus is formed?

The vascular plexus of Little's area is known as Kiesselbach's plexus.
Formation:
1) Anterior ethmoidal artery.
2) Sphenopalatine artery.
3) Greater palatine artery.
4) Septal branch of superior labial artery.

[Link] adolescent boy come to you with repeated episodes of profuse nose
[Link] is your diagnosis ?How will you manage the case?
Dx:Nasopharyngeal Angiò fibroma [age:12-20,male(testosterone)]
Management:
Investigation:
1.​ X-ray nasopharynx lateral view
2.​ CT scan (contrast enhanced CT scan of the head)
3.​ Angiography (carotid angiography)
4.​ MRI

Treatment:
1.​ Surgical treatment:Exicision under GA by transpalatal approach,endoscopic &
lateral rhinotomy
2.​ Hormone therapy: Androgen/estrogen therapy
3.​ Radiotherapy,chemotherapy
4.​ Cryo-surgery
 A)Tell the differences between SMR & septoplasty

SMR(submucosal resection) Septoplasty

1.​ after 18years (to avoid nasal 1.​ all age

deformity;ultimately facial
disfiguration)
2.​ Radical surgery 2.​ Conservative surgery
3.​ Most cartilages are sacrificed 3.​ Cartilages are preserved
4.​ Anterior dislocation can be 4.​ Anterior dislocation cannot be
corrected corrected
5.​ Complication-more 5.​ Complication-less
6.​ Revision surgery-difficult 6.​ Revision surgery-easily performed
7.​ Functional benefit-more 7.​ Functional benefit-less

B) How septal haematoma present?

Symptom:
1.​ Bilateral nasal obstruction
2. Pain,frontal headache
3. Headache,septal swelling

Sign:
Smooth rounded swelling in the nasal septum
Palpation:
Soft and fluctuated

C)Give common cause of septal perforation.

[Link] -injury to mucosal flap during SMR
-cauterization of septum with chemical
-Habitual nose pricking
[Link]-septal abscess
-Rhinolith
-Chronic granulomatous condition like Lupus,TB,leprosy
[Link]- prolonged steroid spray,cocaine addiction

Treatment:
●​ Small hematoma can be aspirated with wide bore needle
●​ Large hematoma are incised & drained
●​ Nose is packed on both sides following drainage to prevent re accumulation
●​ Antibiotics (systemic)
DNS :
Congenital
Trauma
Types:
S/S:
-blockage
-bleeding
-breathing problem
-anosmia
-recurrent rhinitis
-recurrent sinusitis
-tonsillitis /adenitis
-Eustatian tube blockage
-headache
-hearing problem

Treatment of DNS:
[Link] symptoms-no treatment
[Link] & septoplasty(safer)

Complication(SMR):
-Bleeding
-Septal hematoma
-Nasal disfigurstion

A)What is the causative organism of Rhinosporidiosis?

-Rhinosporidium seeberi
[man & animals(cow,dogs,horses)]

B)What are the common sites of rhinosporidiosis?

[nose,pharynx,lip,palete,uvula,conjunctiva,epiglottis,larynx,trachea,bronchus,vulva,vagina]
1) Commonly nose and nasopharynx.
2) Extra nasal sites:
a) Lip, palate, uvula, antrum, conjunctival and lacrimal sac.
b) Epiglottis, larynx, trachea and bronchus.
c) Genitals

C) Give the treatment & how you will prevent recurrence of it?
-Complete(wide)excision of the mass with diathermy knife and cauterization of its base
under local anaesthesia or general anesthesia.
-Thorough clearance followed by
• Inj. Dapsone or Inj. Amphotericin B or Inj. Na-stibogluconateIV slowly for 10 days.
Prevention of recurrence
[Link] excision
[Link]-cauterization
[Link] it’s not present- ANS pack
-polypoidal mass,pink to purple, studded with white dots (strawberry),beeds on
touch,blood tinged discharge ,nasal stiffness
Biopsy- sporangia

O. A15 years young boy came to you with recurrent severe epistaxis with
progressive nasal obstruction
A)What si your diagnosis?
-Nasoplarupgeal Angiofibroma

b ) tell the different management approach?

Management:
Investigation:
1.​ X-ray nasopharynx lateral view
2.​ CT scan
3.​ Angiography
Treatment:
1.​ Surgical treatment:Exicision under GA by transpalatal approach
2.​ Hormone therapy: Androgen/estrogen therapy
3.​ Radiotherapy,chemotherapy
4.​ Cryo-surgery

[Link] symptoms do you expect when there is a foreign body in nose for one
month?
1.​ H/O FB introduction
2.​ Unilateral nasal discharge which is foul smelling
3.​ Occasionally blood stained
4.​
[Link] will you treat it?
1.​ Removal of the FB under GA in case of babies and uncooperative children
2.​ Foreign body hook in case of round object
3.​ Forceps in case of flat object
4.​ Use nasal endoscope to locate the FB

a) Define epistaxis.
-bleeding from inside the nose

B)What are the common causes of epistaxis according ot age group?

Children
1.​ FB
2.​ Nose pricking

Young
[Link]
[Link] Angiofibroma ( in male child of 10-16 age due to
testosterone;Rx:hormone therapy)

Old/Adult:
[Link]
2. Malignancy:nasopharyngeal carcinoma

Very dry and hot atmosphere in desert

C) What are the common sites of epistaxis?

1.​ Little’s area
2.​ Above the level of the middle turbinate
3.​ Below the level of the middle turbinate
4.​ Posterior part of nasal cavity
5.​ Nasopharynx
6.​ Diffuse: both from septum & lateral nasal wall

Extra:
[Link] of epistaxis: sphenopatine artery
[Link] (ANS pack)
-reassurance
-examine the patient
-pinch the nose on the soft part of the nose
-cold compression (with gauze; don’t use direct ice)
-anterior nasal packing
-BP and pulse check
-history taking
- if so profuse bleeding: Ribon pack ointment [Levanol]
-Give packing floor
-if still bleeding- take to OT and do endoscopy and do cauterising under endoscopic
guidance

A)what is furunculosis?
-It is an acute inflammation of the hair follicle of the vestibule of nose
-fever,pain,headache,tenderness(tip of nose)

b)What is its treatment?

1.​ Systemic antibiotic :Flucloxacilline
2.​ Analgesic
3.​ Antipyretics
4.​ Local antibiotic ointments
5.​ Local application of dry heat
6.​ Incision and drainage

C) Why nasal furunculosis is dangerous?

Nasal furuncle is potentially dangerous, because the veins of the nose drain into facial
veins which have no valves & which are connected with cavernous sinus. A spreading
thrombophlebitis of the facial vein can involve the cavernous sinus.
-extracranial and intracranial veins anastomose here

A)What is sinusitis?
Sinusitis / Rhinosinusitis:
It is an inflammation of the mucosa of any or all of the paranasal air sinuses. However, as
this condition is invariably associated with inflammation of the nasal mucosa, hence the
term rhinosinusitis (RS) has been preferred.

B)What are the common causes of sinusitis?

1.​ Acute Rhinitis
2.​ Pharyngeal infection
3.​ Adenoid
4.​ Dental infection involving maxillary sinus

-viral rhinitis
-diving/swimming in contaminated water
-dental infection
-trauma= compound fracture,gun shot wound

C)Name the common bacteria causing sinusitis?

1.​ Streptococcus pneumoniae, pyogen
2.​ Staphylococcus aureus
 3.​ Pneumococcus
4.​ Haemophilia influenza

A)Which age group is usually affected in ethmoidal polyp?

→Young Adults
B)Give differences between antrochoanal &ethmoidal polyp.

Traits Antro-coanal Polyp Ethmoidal Polyp

age common in children & adolescents common in adults

aetiology infection allergy or multifactorial

number single Multiple

involved site unilateral bilateral

extension grows backward to the coana, may mostly grow anteriorly

hang down behind the soft palate

recurrence uncommon common

treatment FESS polypectomy (FESS)

Cold Well Luc operation if Intranssal,extra nasal or
recurrence transantral ethmoidectomy

x-ray unilateral opacity of the maxillary bilateral antral haziness due to

antrum as well as nasal cavity associated maxillary sinus
[Link] cells are also
hazy

C) How will you treat Ethmoidal polyp?

Conservative
1.​ Antihistamine
2.​ Control of allergy
3.​ Short course steroid (topical nasal, systemic)
Surgery
1.​ Polypectomy
2.​ Intranasal ethmoidectomy
3.​ Extranasal ethmoidectomy
4.​ Transantral ethmoidectomy
5.​ Functional endoscopic sinus surgery(FESS)

Q. a) What is acute rhinitis?

-acute inflammation of the mucosa of nasal cavity
-inflammation of the mucous membrane of nose
b) How it present?
Symptoms
1.​ Anosmia
2.​ Nasal obstruction
3.​ Headache
4.​ Discharge of greenish crust
Sign
1.​ Foul smelling discharge from the nose
2.​ Greenish crust
3.​ Epistaxis and ulceration
4.​ Turbinates are atrophied

-nasal stiffness
-rhinorrhoea
-Sneezing
-LGF
c) What is your management?
Investigation:
1.​ X-ray PNS OM view
2.​ Pus for culture and sensitivity
3.​ CBC
Treatment:
1.​ Avoidance of allergen
2.​ Antihistamine
3.​ Sympathomimetic drug :Pseudoephedrine,phenylephrine
4.​ Steroids
5.​ Sodium cromoglycate
6.​ Anticholinergics
7.​ .
8.​ Immunotherapy
-bed rest
-plenty of fluid
-anti histamine
-nasal decongestant

Q. a) A60 yesrs old man come to you with posterior epistaxis .What is your
suspicion?
-nasopharyngeal carcinoma

B)How will you treat the case?

1.​ Radiotherapy
2.​ Radical block dissection of cervical lymph nodes
3.​ In N2a,N2b and N2c contra lateral neck dissection is needed
4.​ Chemotherapy

a) What is SMR?
SMR: It is the operation to correct the nasal septal deviation by submuco-perichondrial
resection of deflected septal cartilage and bone.

B)What are the indications of SMR? Tell the common complication o f

SMR. Give differences between SMR and septoplasty
Indication:
1) Symptomatic septal deviation (persistent obstruction).
2) DNS with nasal polyp.
3) DNS with sinusitis.
4) Epistaxis due to DNS.
5) Approach to pituitary & vidian neurcetomy.
6) Septal cartilage as grafting material for reconstructive surgery.
-as a part of rhinoseptoplasty

Complications of SMR operation:

1) Bleeding.
2) Septal haematoma.
3) Septal abscess.
4) Septal perforation.
5) Depression of the nasal bridge.
б)Retraction of columella.
7)Persistence of deviation.
8) Flapping of nasal septum.
9) Nasal synechiae.
10) Toxic shock syndrome.
-synechia with lateral wall

a)What are the Para-nasal sinuses?

[Link] group
1.​ Frontal sinus
2.​ Maxillary sinus
3.​ Anterior and middle group of ethnically air cells
[Link] group
1.​ Posterior ethmoidal air cells
2.​ Sphenoid air sinus

b)What are the sinuses open into middle meatus?

-Maxillary & frontal air sinus

Inferior meatus- nasolacrimal duct

Superior meatus- posterior group of ethmoidal air sinus

C)tell the function of PNS

1)Air conditioning.
2) Resonance of voice.
3)Act as thermal insulators to protect the delicate structures in the orbit & the cranium from
variations of intranasal temperature.
4)Lighten the skull bones by air containing bony chambers.
5)Extended surface for olfaction.
6)Increase surface for teeth eruption.
7)Provide local immunological defense against microbes.
8)Act as buffers against trauma & thus protect brain against injury, e.g., frontal, ethmoid &
sphenoid sinus.

Q A 10 years old boy present with history of repeated epistaxis what is your
diagnosis? Give the outline of treatment of acase of epistaxis.
Dx:Nasopharyngeal angiofibroma
Management of a case of epistaxis:
[Link] bleeding by
1.​ Compression (pressure on the bleeding vessel for 7-10minutes)
2.​ Cold compression
3.​ ANS packing
4.​ PNS packing
5.​ Cautery
6.​ Ligation of Maxillary artery/ external carotid
[Link] treatment
1.​ Antibiotics
2.​ Analgesic
3.​ Sedative
4.​ Antihistamine
[Link] of causative factor

a)What are the common FB of nose in children?

1.​ Organic :flies,mosquitoes,lice, maggots
2.​ Inorganic:paper,button,seeds,chalk
b)How you manage a case of FB in nose?
●​ Removal of the FB under GA is case of baby and uncooperative patient
●​ FB hook in case of round object
●​ Forcep in case of flat object
●​ Use nasal endoscopy to locate the FB

c)What is Rhinolith?
-stone formation in the nasal [Link] deposition of calcium & magnesium salt
-deposit of salts of calcium,magnesium and phosphate around FB -calculus

a)Give aetiology of nasal polyp?

1.​ Chronic rhino sinusitis
2.​ Asthma
3.​ Aspirin intolerance
4.​ Cystic fibrosis
5.​ Bacterial of fungal infection
6.​ Young syndrome
7.​ Nasal allergy with sinus infection
8.​ Kartagener syndrome
b)What are hte usual presentation of Ethmoidal polyp?
Symptoms:
1.​ Multiple polyp
2.​ Nasal stiffness leading to total nasal obstruction
3.​ Partial or total loss of sense of smell
4.​ Headache due to associated sinusitis
5.​ Sneezing & (runny nose)watery nasal discharge due to associated allergy
Signs:
1.​ On anterior rhinoscopy: smooth,glistening,grape like masses often appear pale in
colour ,maybe sessile or pedunculated
2.​ Polyp multiple or bilateral
3.​ On probing- insensitive to touch, does not bleed on touch,mobile soft in
consistency,so smooth surface
c)What are the surgical management of antrochoanal polyp?
1.​ Polypectomy
2.​ Intra nasal ethmoidectomy
3.​ Extranasal ethmoidectomy
4.​ Transantral ethmoidectomy
5.​ FESS( functional endoscopic sinus surgery)-common
-if FESS not available then (not done nowadays)
•polypectomy followed by antra’s wash out
•Cald-Well-Luc operation (indication:Removal of FB,excision of dentigenous cyst,repair of
oro-a real fistula) (done in adult above 14yrs of age)

[Link] present with pinkish polypoidal mas with nasal obst which is pain
sensative & bleeds on touch. what is your diagnosis? How you will treat thecase?

1.​ Antro-choanal polyp

2.​ Rhinosporidiosis

Q. A 30 years old female come to you with anosnia & nasal discharge. After
examination greenish crust has been found in roomy nasal [Link] is
your diagnosis & how you will manage this case?

Q. A 30 yrs old lady come to you with mucopurulent nasal discharge & Headache.
X-ray PNS O/M view showing haziness in both maxillary antrum.
What is your diagnosis &plan of treatment?

a) Name the arteries anastomose in little's area?

b)Which is called artery of epistaxis ?
c)Give surgical impotence of little’s area?

a)Which sinus infection is more common?

b)Why is it common ?
c)Tell the clinical feature and treatment of acute maxillary sinusitis.

a)What are the parts of nasal septum?

b)How bony part is formed?
c)What is little's area?

Q. a) What are the causes of septal deviation.

b) How it present& what are the surgical management of septal deviation?

A)Aetiology of acute sinusitis?

B)How will you diagnose a case of acute sinusitis?
a Define polyp.
b)What are the types of nasal polyp?
c) Give five differences between antrochoanal and ethmoidal polyp

a)What is littel's area?

b)How kisselbatch plexus is formed?
c) Tell the procedure of anterior nasal packing.