ANATOMY OF THE NOSE 1

Congenital Disease of the Nose 5

Nasal trauma 6

Rhino Sinusitis 10

Fungal Sinusitis 13

Complications of sinusitis 15

Allergic Rhinitis 16

Vasomotor rhinitis 21

Nasal Polyps 22

Diseases of the nasal septum 26

Epistaxis 28

Neoplasms of the Nose & Sinuses 30

Symptomatology 34
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A) External nose

1) Nasal bone
BONY FRAMEWORK 2) Frontal process of the maxilla
3) Maxillary process of the frontal bone

CARTILAGINOUS 1) Upper lateral cartilage (ULC)

FRAMEWORK 2) Lower lateral cartilage (LLC)

A) Nasal cavities

▪ Two nasal cavities

NUMBER
“Separated from each other by the nasal septum”
▪ Anterior nasal aperture (anterior naris).
OPENINGS
▪ Posterior nasal aperture (choana) (posterior naris).

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 The roof
1) Nasal process of the frontal bone.
2) The cribriform plate of ethmoid bone.
3) The sphenoid bone.

 Nasal septum (medial wall)

1) Septal (quadrilateral) cartilage: anteriorly.
2) Vomer: posteroinferiorly.
3) Perpendicular plate of the ethmoid: posterosuperior.
4) Nasal crests of the maxilla and palatine bones: inferiorly.

 The floor:
WALLS
1) Separates the nasal cavities from the oral cavity.
2) It is formed by the HARD PALATE.

 The lateral nasal wall → has the following features:

1) 3 turbinates: (INFERIOR – MIDDLE – SUPERIOR)
The pharyngeal orifice of the eustachian tube lies in the nasopharynx one
centimeter behind the posterior end of inferior turbinate.

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2) 3 meati.
◈ Nasolacrimal duct opens in the lateral wall about 3
Inferior meatus
cm from the anterior nares.
◈ Drains
1. Frontal sinus
Middle meatus
2. Anterior ethmoid cells
3. Maxillary sinus

Superior meatus Posterior ethmoid cells open here

Sphenoethmoidal recess: sphenoid sinus drains into this recess medial to the superior turbinate.

Arterial blood supply of nose

 External carotid branches:

1) Sphenopalatine artery.
2) Greater palatine artery.
3) Superior labial.

 Internal carotid artery:

1) Anterior ethmoid artery.
2) Posterior ethmoid artery.

LITTLE'S AREA

DEFINITION  An area located in the anterior part of the nasal septum.

 There is an anastomosis of blood vessels called Kiesselbach's plexus between

the branches of:
MEDICAL 1) Sphenopalatine artery.
IMPORTANCE 2) Greater palatine artery.
3) Superior labial artery.
4) Anterior ethmoid artery.

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Anatomy of the paranasal sinuses

 Air filled cavities within the skull bones and lined with respiratory epithelium
DEFINITION
continuous with the nasal lining.

 4 on each side
▪ Pyramidal in shape within the body of the
1. Maxillary sinus
maxilla.
▪ Occupy the frontal bone
▪ Absent in 10% of population
2. Frontal Sinus
▪ its ostium opens in the medial part of the sinus
NUMBER
floor into the frontal recess.
3. Ethmoid sinuses ▪ 5-15 small air cells within the ethmoid bone.
(anterior & posterior)

▪ The sphenoid sinus is situated in the body of the

4. Sphenoid Sinus
sphenoid bone.

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Nasal Functions
1) Airway: the nose is the natural respiratory airway.
2) Air conditioning.
3) Purification of inspired air.
4) Olfaction.
5) Resonance of the voice.
6) Tear Drainage.

Functions of the paranasal sinuses

1) Increase the surface area for humidification, and air conditioning.
2) Lightening of skull weight.
3) Resonance of the voice.
4) Serves as shock absorption for the floor of head trauma.

1) Choanal Atresia
Congenital Closure of the posterior nasal aperture, due to persistence of the
Bucco-nasal membrane

Definition

Bilateral atresia Unilateral atresia

Severity Fatal Usually pass unnoticed

C/P
▪ Severe airway obstruction ▪ Unilateral nasal obstruction
Characterized
▪ Cyclical cyanosis “as oral ▪ Unilateral glue-like nasal
by
breathing is not developed” discharge

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1) A rubber catheter or colored drops cannot pass to the nasopharynx if

Diagnosis introduced to the nose.
2) CT scan.

ENDOSCOPIC REPAIR ❖ Excellent visualization, and long-term results.

Treatment
❖ Excellent exposure
TRANS-PALATAL REPAIR ❖ A high success rate
❖ But needs more operative time.

1) Fracture nasal bone

 Direct trauma as
▪ Fall
Cause ▪ Road traffic accident
▪ Sport accidents
▪ Personal assault.

1) History of trauma to the nose

2) Pain: at the time of trauma.
SYMPTOMS

3) Swelling and deformity or deviation of the nose.

4) Skin: cut wounds of nasal skin
5) Epistaxis: due to mucosal tears. It is usually mild and self-limited.
6) Nasal obstruction.
C/P
1) External nasal deformity.
2) External swelling: due to edema and ecchymosis, surgical emphysema
3) Tenderness and crepitus (click sound).
SIGNS

4) Black eye: due periorbital ecchymosis.

5) Associated septal hematoma, fracture, or dislocation → nasal
obstruction.

Investigation  x-ray for medico-legal importance

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NO DEFORMITY No treatment

◈ Before oedema (within the first 6 hours)

▪ Immediate reduction.
Treatment NASAL ◈ After oedema:
DEFORMITY ▪ Delayed reduction after 7 days when edema subsides.

◈ Late cases (malunion):

▪ Rhinoplasty or septorhinoplasty.

2) Foreign Body in the nose

incidence ▪ Usually in children and mentally retarded adults.

▪ Unilateral fetid purulent nasal discharge, sometimes blood- stained

C/P
▪ + Nasal obstruction.
▪ Extraction by forceps or hook.

Treatment

▪ This is done better under General anesthesia.

3) CSF Rhinorrhea

Definition ▪ Leakage of cerebrospinal fluid from the nose.

1) Traumatic most common

2) Idiopathic.
Cause 3) Congenital dehiscence in the cribriform plate.
4) Inflammatory bone necrosis.
5) Tumor erosion.

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1) Unilateral dripping of clear tasteless, watery discharge.

2) It increases by:
▪ Leaning forwards
C/P
▪ Straining
▪ Or by pressure on the internal jugular vein.
3) It does not harden the handkerchief due to low protein content.

1) CT scan and MRI.

investigations 2) Endoscopic examination of the nose after Intrathecal injection of fluorescein.
3) Laboratory analysis of CSF.

(for 2-3 weeks) most of traumatic leaks heal spontaneously

CONSERVATIVE 1) Rest, semi-sitting, No straining.
2) Antibiotics
Treatment

 By fat, fascia, muscle, or cartilage by:

SURGICAL REPAIR 1. Trans-nasal endoscopic approach.
2. Transcranial approach (Neurosurgery).

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4) Oro-maxillary (Oro-antral) Fistula

Definition ▪ Fistula communicating the mouth and the maxillary sinus

1) Traumatic:
▪ After Dental extraction of the upper 2nd premolar, & 1st molar teeth.
▪ After Caldwell-Luc's operation if the Sublabial incision does not heal.

Cause

2) Inflammatory bone necrosis: Osteomyelitis of maxillary sinus.

3) Malignant tumors eroding bony walls of the maxilla.

▪ Unilateral regurgitation of fluids and food from the nose.

C/P ▪ Frothy air comes out from the socket of blowing the nose.
▪ Symptoms of sinusitis.

▪ Immediate suturing of mucosa.

RECENT
▪ Antibiotics.

Treatment ▪ Buccal or palatal flap

OLD
▪ + effective drainage of the sinusitis (ESS).

FAILED REPEATED REPAIR ▪ Dental obturator

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 Inflammation of the mucoperiosteal lining of one or more of paranasal sinuses and or fluid inside the sinuses

Acute Rhinosinusitis Chronic Rhino Sinusitis

DURATION < 12 weeks Persistence > 12 weeks

 Viral.
 Bacterial:  Bacterial:
1. Streptococcus pneumoniae, Hemophilus 1. Aerobic:
C/O influenzae (40-60 %) and Moraxella ▪ Coagulase -ve Staphylococci (most common)
catarrhalis (up to 5%).
2. Anaerobic organisms in 2-20% of cases.
2. Anaerobic organisms from a dental source.
3. Gram -ve organisms → Nosocomial sinusitis.
ROUTES & SOURCE
ETIOLOGY

1. Nasal. 2. Dental. 3. Trauma. ---

OF INFECTIONS
1. Anatomical variations 1. Inadequate treatment of acute sinusitis.
▪ That narrow the ostia of the sinuses 2. Local predisposing factors
▪ E.g. Septal deviation. ▪ E.g., Septal deviation.
PREDISPOSING 2. Systemic diseases 3. Systemic:
FACTORS ▪ →  in mucociliary clearance. ▪ Poor immunity e.g., DM or prolonged
▪ Including cystic fibrosis & Kartagener corticosteroid therapy
syndrome. ▪ Environmental factors e.g., smoking or
3. Patients with immunodeficiency. pollution.

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Acute Rhinosinusitis Chronic Rhino Sinusitis

 General: ❶ Vacuum headache
1) Fever. ▪ Characteristic for frontal sinusitis.
2) Anorexia. ▪ The cause may be due to closure of the sinus ostium helped by
3) Headache. congestion of the head due to lying position with absorption of
4) Malaise the air from within the sinus cavity.
▪ This pain is:
 Local: - Maximal in the morning
1) Facial pain - ⇊ Gradually over the day.
2) Nasal obstruction - Erect position during the daytime gradually relieves the ostial
3) Nasal & postnasal discharge obstruction leading to headache release.
SYMPTOMS

C/P  muco-purulent or purulent. ❷ Facial pain.

4) Hyposmia, anosmia. ⮱ A localized dull aching pain over the affected sinus.
❸ Nasal obstruction.
❹ Nasal & Postnasal discharge.
▪ Anterior Nasal discharge: Muco-purulent or purulent.
▪ Postnasal discharge: Mucopurulent with irritative cough.
▪ May be fetid in dental maxillary sinusitis.
❺ Symptoms of descending infection:
▪ Otitis media – Pharyngitis – Laryngitis - Bronchitis.
❻ Symptoms of septic focus:
▪ Low grade fever – Headache - Rapid fatigue - Arthritis.

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Acute Rhinosinusitis Chronic Rhino Sinusitis

❶ Tenderness & redness over affected sinus.  By nasal endoscopy:
❷ Postnasal mucopurulent or purulent discharge 1. Congested edematous nasal mucosa over turbinates.
❸ Anterior rhinoscopy: 2. Mucopurulent or purulent discharge.
▪ Swelling & congestion of nasal mucosa 3. Nasal polyps may be present in middle meatus “in
SIGNS

C/P ▪ Mucopurulent or purulent discharge chronic ethmoiditis”.

❹ Endoscopic examination:
▪ Reveal origin of purulent discharge.
▪ Provide information about nature of
ostiomeatal obstruction.
❶ CT scan ❶ CT scan “Gold standard for diagnosis of chronic sinusitis”.
INV.
❷ Culture & sensitivity test of the discharge ❷ Culture & sensitivity test of the discharge.
❶ Antibiotics. ❶ Systemic antibiotics.
MEDICAL

❷ Analgesic anti-inflammatory drugs for pain & edema. ❷ Nasal decongestants.

TREATMENT

❸ Vasoconstrictors (systemic or local). ❸ Alkaline nasal wash.

❹ Anti-histamines. ❹ Intranasal steroid spray may benefit.
 Surgical Drainage:
SURGICAL

▪ Indicated after failure of medical treatment or threatening complications.

▪ Achieved with Functional Endoscopic Sinus Surgery (FESS).

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Non-invasive Invasive
Description Absent hyphae within the mucosa. Presence of hyphae within the mucosa.

Occurs in Immune-competent patients. 1. Acute invasive:

1. Allergic fungal sinusitis: (AFS) in immune-compromised
Types 2. Fungus ball (mycetoma). 2. Chronic invasive:
3. Superficial mycosis In immune-competent

Non-invasive Fungal Sinusitis

▪ It is suggested to be an IgE mediated sinonasal inflammation in response to fungal antigen, associated with accumulation of
allergic mucin in the sinuses.

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invasive Fungal Sinusitis

Acute (fulminant) invasive Chronic (indolent) invasive

fungal sinusitis fungal sinusitis
▪ Immuno-compromised patients as on ▪ Commonly the patients are non-
Occurs in
- Cancer chemotherapy. - AIDS. - Uncontrolled diabetes. atopic immune-competent.
1. Aspergillus species as:
Causative Aspergillus
▪ Aspergillus fumigatus → Aspergillosis (COMMONEST)
Organisms IS THE MOST COMMON PATHOGEN
2. Mucor species as: Rhizopus Oryza → Mucor mycosis
Usually unilateral, like acute bacterial sinusitis
with rapid deterioration of the general condition Insidious onset
C/P 1. Acute onset, rapid progressive course, and lethal in short time. Slow progressive course
2. Necrosis of the nasal mucosa which becomes covered with (weeks to months).
blackish crusts (eschar).
▪ Extension to:
1. The palate (gangrene).
Complications ---
2. Orbit (proptosis, and blindness).
3. Intra-cranial cavity (cranial nerve affection, coma).
1. CT scan: It shows the extension of disease.
Investigations
2. Biopsy of the mucosa & special staining: intramucosal hyphae,
1. Wide surgical debridement of the necrotic tissues.
TTT 2. Systemic antifungal: Amphotericin B (nephro-toxic & hepato-toxic).
3. Control of the predisposing factor.

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 Spread of infection beyond the mucosal lining of the paranasal sinuses.


A. Orbital infections:
1. Pre-septal cellulitis
2. Sub-periosteal abscess
3. Orbital cellulites
4. Orbital abscess
5. Superior orbital fissure syndrome
1) EXTRA-
6. Orbital apex syndrome
CRANIAL
B. Descending infections:
1. Otitis media.
2. Pharyngitis, Laryngitis & Bronchitis.
C. Septic focus:
1. Arthritis
2. Nephritis
1. Osteomyelitis
2) CRANIAL 2. Mucocele
3. Pyocele
1. Extra-Dural abscess.
2. Sub-Dural abscess.
3) INTRA-
3. Meningitis.
CRANIAL
4. Cavernous sinus thrombo-phlebitis.
5. Frontal lobe abscess

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❶
 It is an Ig-E mediated hypersensitivity inflammation of the nasal
Definition
membranes.
 A symptom complex that consists of any combination of the
following:
Characterized A. Sneezing.
by B. Nasal congestion.
C. Nasal itching.
D. Rhinorrhea
Types Intermittent (seasonal) - Persistent (perennial).
Severity Mild - Moderate - Severe
A) Inhalants: House dust mite (commonest), molds, pollens,
Allergens B) Food allergy: Eggs, strawberry, etc.
C) Drugs

❷
In susceptible individuals..
1) Allergic  Exposure to certain allergens → allergic sensitization with production
sensitization of specific IgE which coats the surface of mast cells in the nasal
mucosa.
 When allergen re-inhaled, it binds to the IgE on mast cells, →
immediate and delayed release of chemical mediators.
2) Early or  Mediators, including leukotrienes and prostaglandin D2 which ultimately
immediate → the symptoms of rhinorrhea:
phase
- Nasal Congestion - Sneezing - Itching
reaction
- Redness - Tearing - Swelling
- Ear Pressure - Postnasal Drip -

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Over 4-8 hours, these mediators through a complex interplay of events →

the recruitment of other inflammatory cells to the mucosa such as
neutrophils, eosinophils, lymphocytes, and macrophages

3) Late phase Continued inflammation for hours or days with
reaction less sneezing and itching and more congestion & mucus reproduction

▪ Systemic effects, including fatigue, sleepiness, and malaise, may occur
from this response.
▪ These symptoms often contribute to impaired quality of life.

1. Sneezing (very characteristic symptom for allergies)

2. Runny nose, nasal congestion
3. Itchy ears, eyes, and palate
4. Post-nasal drip
5. General facial features
Allergic shiners Allergic salute
dark circles around the eyes horizontal nasal skin crease
Symptoms

Related to Due to
VD & nasal congestion Frequent itching & rubbing

▪ Turbinate mucosa may be:

- Swollen (boggy)
Signs - Have a pale, bluish-gray color.
▪ Nasal mucus:
- Thin and watery secretions are frequently associated with AR.

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❹
- Standard work-up in allergy.
- Skin prik test to detect possible causative allergen

Skin Sensitivity
tests

Nasal Challenge - A spray of the suspected allergens applied into the nose causing
test sneezing and rhinorrhea
- Total IgE
Blood test
- Radio Allegro Sorbent Test (RAST), test specific Ig E levels

 The biggest offenders are dust, pets, pollens, molds

1) Pollens - it is usually seasonal
- Vacuum cleaner.
- Change air conditioning filters.
- Face masks during housecleaning.
2) Dust
- Wash bedding in hot water.
- Polyester, not foam or feather pillows.
- Plastic cases on mattresses and pillow.
3) Molds, Pets - Avoid contact with pets

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 Indications: For the sneezing, scratchy throat, itchy eyes.

 Effects:
- Will have little effect on nasal congestion.
- But may have drying effect.
1) Antihistamines  Types:
A. Sedating: old 1st generation
B. Non-sedating: 2nd and 3rd generation
C. Topical: less effective than local steroids
 Indications: For congestion and rhinorrhea.
 Types:
A. Topical:
- But long-term use may cause rebound vasodilation (rhinitis
2) Decongestants
medicamentosa)
B. Systemic: e.g., Pseudoephedrine.
- Working as alpha blockers.
- Have some general side effects
 Types:
A. Topical nasal steroids:
Examples Beclomethasone, fluticasone, budesonide
Make the nasal mucosa an inhospitable site
Effect
for mast cells
1. Blocks synthesis of both leukotrienes and
3) Steroids
Mechanism prostaglandins
2. Prevents influx of neutrophils

NB Systemic absorption is negligible

B. Systemic steroids:
- Especially with nasal polyps.
- Course for 2 weeks.
 Indications: In cases of persistent moderate and severe allergy.
4)
 Repeated therapy to limited allergens.
Immunotherapy
 Mechanism: elevate IgG and suppress IgE antibodies.

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 Although allergic rhinitis is a medical condition, adjunctive surgery may be offered to

alleviate obstructive symptoms in appropriate individuals.
▪ Partial turbinectomy procedures
▪ In cases with medically resistant turbinate hypertrophy

1) Inferior
turbinate
reduction
maneuvers

2) ESS  for cases with nasal polyps

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Definition ▪ Abnormal reaction of the nasal mucosa to non-allergic factors.

Mechanism ▪ Parasympathetic overactivity causing VD and increased secretions
1. Environmental factors:
▪ Dust.
▪ Tobacco.
▪ Temperature.
▪ Humidity changes.
2. Endocrine factors:
Aetiology ▪ Pregnancy.
▪ Hypothyroidism.
3. Drugs:
▪ Anti-hypertensive.
▪ Contraceptive pills.
▪ Rhinitis medicamentosa
4. Emotional and stress.
1. Rhinorrhea: Bilateral watery nasal discharge
Clinical Pictures
2. Nasal obstruction: Bilateral, alternating, and intermittent
Laboratory Studies ▪ Negative tests for allergy
1. Anti-cholinergic (Ipratropium nasal spray or oral) for rhinorrhea
Medical 2. Decongestants: (oral or systemic) temporary relieve nasal
obstruction

TTT A) Inferior turbinate reduction maneuvers:

▪ Partial turbinectomy procedures.
Surgical ▪ In cases with medically resistant turbinate hypertrophy.
B) Posterior nasal nerve neurectomy:
▪ To alleviate rhinorrhea in resistant cases.

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❶
 Benign semitransparent nasal lesions that arise from:
A. The mucosa of the nasal cavity (mainly from the middle meatus), or
B. Paranasal sinuses.
 They are fluid filled sacs composed of:
▪ An edematous tissue..
▪ With infiltrating cells, including mast cells, eosinophils, lymphocytes, and plasma cells
▪ Surrounded by a ciliated airway epithelium

❷
The pathogenesis of nasal polyposis is unknown.

 It is the ultimate manifestation of chronic inflammation in the nose.

 Nasal polyps are not a disease, but a physical finding with a number of causes and
associated conditions.

 The following conditions are associated with multiple benign polyps:

- Allergic rhinitis
- Allergic fungal sinusitis (AFS) - Polyps in 85% of patients with AFS
- Chronic rhinosinusitis
- Bronchial asthma - In 20-50% of patients with polyps
- Nonallergic rhinitis with eosinophilia syndrome (NARES): 20% of patients
- Cystic fibrosis (CF)
- Primary ciliary dyskinesia
- Aspirin intolerance

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❸
1. Small polyps may not produce symptoms
2. Nasal airway obstruction, and rhinorrhea
3. Hyposmia or anosmia
Symptoms
4. Postnasal discharge
5. Dull headaches, snoring
6. Obstructive sleep symptoms and chronic mouth breathing.

1. Polyps appear as smooth, gray, glossy lesions hanging from a narrow

stalk.
2. They are soft, mobile, and nontender to palpation.
3. They are frequently multiple, bilateral, and vary in size.
4. Mostly seen by endoscopy in the middle meatus, if extensive may be
visible by anterior rhinoscopy
Physical 5. Middle ear effusion if polyps cause eustachian tube block
signs

❹
1. Polyps in children with chronic sinusitis.
2. Allergic rhinitis.
3. Cystic fibrosis.
4. AFS.

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❺
▪ CT scan is the standard imaging technique.
▪ For:
Imaging Studies
A. Diagnosis
B. Define the extension to nasal cavities, sinuses, and beyond.

Multiple polyps arising from the

ethmoid sinuses and middle meatus

▪ In short term use.

Oral steroids
▪ Are the most effective medical treatment for nasal polyposis.

▪ Effectively relieve symptoms and increase the nasal airflow.

Topical nasal ▪ It is used either as the primary treatment or as secondary
steroid sprays
treatment immediately following oral steroids or surgery.

▪ It includes:
Endoscopic Sinus 1. Removal of the polyps.
Surgery (ESS) 2. Opening of the involved sinuses.
To decrease the recurrence rate
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❼
▪ Polyposis recurrence is not uncommon following treatment with
medical or surgical therapy.
Recurrence
▪ Recurrence involve affection by many factors in the disease,
patient and surgery.

Antrochanal Polyps

▪ Single polyp arising from the maxillary sinus

▪ Protruding into:
Definition - The nasal cavity
- & Posteriorly into the nasopharynx through the choana (posterior
nasal aperture)
Epidemiology ▪ More common in young adults and children
▪ Unilateral nasal blockage, nasal discharge.
Symptoms ▪ If large in the nasopharynx → it can cause obstructive sleep
symptoms
Diagnosis

▪ It is seen usually with rigid or flexible nasal endoscopy:

- As smooth grey, glistening soft nasal polyp arising from the
Signs
middle meatus.
- It can be seen behind the palate in the nasopharynx
Investigation ▪ CT scan of nose and sinuses
▪ Endoscopic sinus surgery for:
- Removal of the polyp.
Treatment - Widening the maxillary ostium
- Clearing the maxillary sinus
▪ Cald Well Luc`s operation may be done for multiple recurrences.

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1) Deviated Nasal Septum (D.S.)

1) Traumatic.
Cause
2) Developmental.

C shaped S shaped Spur or sharp angulation

To one side i.e., bilateral deviation Usually at the inferior part of
the septum

Types

1) Nasal obstruction: Persistent unilateral or bilateral.

2) Facial pain.
SYMPTOMS 3) Epistaxis: due to angulation of vessels over spur or drying of
mucosa.
C/P 4) Hyposmia due to misdirection of air.

1) Deviation: of the nasal septum in form of C- or S- shape or

SIGNS spur.
2) Anterior dislocation of caudal edge of nasal septum.

 Surgical correction
▪ When deviated septum causes symptoms or
INDICATIONS
Treatment complications.
▪ Submucous resection
METHODS
▪ Septoplasty

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2) Septal Hematoma

▪ Collection of blood between the mucoperichondrial layer and the septal cartilage.

Definition

1) Septal incision & drainage of hematoma

Treatment 2) Then anterior nasal pack to avoid recollection.
3) Antibiotics and anti-inflammatory drugs.

3) Septal Abscess

Definition ▪ Collection of pus between mucoperichondrium and septal cartilage

1) Aggressive broad-spectrum antibiotics.
Treatment
2) Incision and drainage (on one side).

4) Septal Perforation

Definition ▪ A hole in the nasal septum connecting the two nasal cavities.

Site ▪ May be anterior or posterior

size ▪ Varies from small to big perforation

▪ If symptomless no interference.
▪ Nasal douching with alkaline nasal wash to separate crusts.
▪ Closure by silastic button obturator.

Treatment

▪ Surgical closure by mucosal flaps or grafts for symptomatic small perforation.

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❶
 Nose bleeding & it is either:
▪ Anterior bleeds (nasal)
Based on where the bleeding originates
▪ Or posterior bleeds (postnasal)

Little's area Commonest site of epistaxis

- Represents a region in the anteroinferior third of the nasal septum where the Kiesselbach’s
plexus forms on the septum

1) Idiopathic: most common cause of epistaxis

▪ > 70% of bleeds occur anteriorly and arise from the Little's area.
2) Hereditary: hemorrhagic telangiectasia
Local causes 3) Trauma.
4) Inflammatory.
5) Neoplasms.
6) Septal deviation, spur, perforation.

1) Venous hypertension
2) Arterial hypertension
General 3) Blood Diseases
causes 4) Fevers
5) Deficiency diseases
6) Toxins

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1) Side: unilateral or bilateral

2) Site: anterior or posterior
History 3) Duration.
4) Recurrencies.
5) Medical history (general illness, blood disease).

1) Anterior bleeds (> 90% of bleeds) → arise from the Little's area.
2) Posterior bleeds (arise further back in the nasal cavity)
 Characters:
▪ Usually more profuse
Nasal ▪ Often of arterial origin.
examination
3) Epistaxis originating from below middle turbinate
 Usually, comes from SPHENOPALATINE ARTERY.
4) Epistaxis originating from above middle turbinate
 Usually, the source will be the ethmoidal arteries.

1) Vital data:
Pulse Temperature BP

General ▪ Low in shock

Rapid in shock High in fevers
examination ▪ High in hypertension

2) Systematic examination: to detect general causes of epistaxis.

3) Hess test (by sphygmomanometer): +ve in purpura.

❹
➲ For the most cases, laboratory studies are not needed for first time or infrequent recurrences with a good
history of nose picking or trauma to the nose.

LABORATORY ▪ CBC, Bleeding and clotting times and INR

BIOPSY ▪ for suspicious lesions

RADIOLOGICAL ▪ CT help diagnose certain cases

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❺
1) Control of shock (if present)
2) First aid measures:
▪ Patient is sitting and leaning forward.
▪ Direct pressure by squeezing the nostrils together for 5-10 minutes.
▪ Local vasoconstrictor drops may be placed in the affected nostril.
3) Cauterization of bleeding point (either chemical or electrical).
4) Anterior and posterior nasal packing.
5) Surgical Treatment by:
▪ ligation of the bleeding vessel.
▪ Treatment of the cause e.g., septoplasty.
▪ Selective angiography and embolization.
6) General treatment: Rest - Vitamin K - Vitamin C.
7) Causal treatment after control of bleeding

1) Hemangioma.
Benign 2) Osteoma.
3) Inverted papilloma.

Malignant Squamous cell carcinoma

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Inverted papilloma

BEHAVIOR ▪ Locally destructive tumor

ORIGIN ▪ From the epithelial lining of the nose

SEX ▪ Males > females (5:1)

▪ The proliferating epithelial cells grow into the

BEHAVIOR
underlying stroma, (inverting)

PATHOLOGY SITE ▪ Arises from the lateral nasal wall

MALIGNANT TRANSFORMATION ▪ 5%

RECURRENCE ▪ Common after surgery

SYMPTOMS ➲ Unilateral nasal obstruction, discharge, and epistaxis.

C/P
SIGNS ➲ Unilateral polypoidal fleshy reddish grey nasal mass.

CT SCAN & MRI ➲ To assess tumor extension to sinuses.

INVESTIGATIONS
BIOPSY ➲ To confirm the diagnosis.

TREATMENT Wide surgical excision

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 ENT NOSE

Squamous Cell Carcinoma

The commonest malignant tumor of the nose and sinuses

SEX & AGE ➲ Most commonly males > 40 years.

➲ Most commonly:-
1) The lateral nasal wall
SITE
2) The maxillary
3) The ethmoidal sinuses.

➲ Exposure to:-
PREDISPOSING 1) Formaldehyde
FACTORS 2) Nickel
3) Wood dust.

1) Obstruction
2) Epistaxis
NASAL
3) Offensive nasal discharge
4) Ulcerating friable nasal mass

1) Persistent dental
2) Loose teeth
ORAL
3) Palatal swelling and ulceration
4) Oro-antral fistula
MANIFESTATIONS
1) Proptosis
2) Diplopia
ORBITAL
3) Vision loss
4) Epiphora

1) Facial paresthesia
FACIAL
2) Cheek swelling

NECK Enlarged upper deep cervical lymph nodes

1) CT scan and MRI.

INVESTIGATIONS 2) Biopsy.
3) Metastatic work-up: Chest X-ray, abdominal ultrasound and bone scan.

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 ENT NOSE

Combined surgery & postoperative radiotherapy

CANCER MAXILLARY SINUS ▪ Partial or total maxillectomy

▪ Cranio-facial resection for tumors

TREATMENT CANCER ETHMOID SINUS
extending to ethmoid cavity

ORBITAL EXENTERATION ▪ If the tumor invades the orbit

RADICAL NECK DISSECTION ▪ In presence of lymph nodes involvement

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 ENT NOSE

1) Nasal obstruction
 CAUSES:

1) CONGENITAL ◈ Congenital choanal atresia.

2) DEVELOPMENTAL ◈ Deviated septum.

1) Foreign body.
2) Accidental trauma:
▪ Fracture nasal bones and associated fracture of septum.
3) TRAUMA
▪ Septal hematoma.
3) Operative trauma:
▪ Hematoma after septal operation.

◈ All inflammations (rhinosinusitis):

4) INFLAMMATORY ▪ Acute or chronic
▪ Specific, or nonspecific.

5) ALLERGY ◈ Allergic rhinitis & vasomotor rhinitis.

6) POLYPS ◈ Sinonasal polypi & antrochoanal polyp.

7) TUMORS ◈ Benign & malignant tumors.

1) Adenoids enlargement in children.

8) CAUSES IN THE
2) Nasopharyngeal angiofibroma (Benign tumors).
NASOPHARYNX
3) Malignant tumors.

 Causes of unilateral nasal obstruction:

CONGENITAL ▪ Unilateral choanal atresia ▪ Antrochoanal polyp.
INFLAMMATORY ▪ Unilateral Rhinosinusitis.
TRAUMA ▪ Foreign body ▪ Nasal diphtheria.

TUMORS ▪ benign and malignant DEVIATED SEPTUM ▪ To one side

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 ENT NOSE

2) Nasal obstruction
 TYPES:
MUCOPURULENT
➲ Acute or chronic rhino sinusitis.
& PURULENT

BLOOD ➲ Epistaxis

1) Allergic rhinitis.
2) Vasomotor rhinitis
WATERY 3) Early acute rhinitis.
4) Excessive secretions of lacrimal glands.
5) CSF rhinorrhea.

▪ Cleft palate
1) CONGENITAL
▪ Short palate

2) TRAUMATIC ▪ Oroantral and oronasal fistulae

▪ Syphilitic perforation of the hard palate

FLUID AND FOOD 3) INFLAMMATORY
▪ Osteomyelitis
(NASAL
REGURGITATIONS) 4) NEUROGENIC ▪ Post-diphtheritic, bulbar, & pseudobulbar palsy

5) NEUROMUSCULAR ▪ Myasthenia gravis

6) MALIGNANT ▪ Erosion of the palate

CAUSES OF UNILATERAL NASAL DISCHARGE UNILATERAL FETID NASAL DISCHARGE

1) Unilateral purulent or mucopurulent discharge: 1) Foreign body of the nose.
Unilateral rhinosinusitis. 2) Nasal diphtheria.
2) Unilateral watery discharge: CSF rhinorrhea. 3) Unilateral sinusitis of dental origin.
3) Unilateral regurgitation of water and food: 4) Malignant tumors of nose and sinuses.
Oroantral and oronasal fistulae.
4) Unilateral blood: Epistaxis.

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 ENT NOSE

3) Olfactory disorders

A Anosmia causes

1) Collapsed alae nasi.

2) Allergic rhinitis.
1) In the nose 3) Bilateral nasal polypi & hypertrophy of the turbinates.
4) Atrophic rhinitis.
5) Peripheral neuritis after influenza or exposure to gases.

2) Cranial causes ▪ Fracture skull base involving cribriform plate.

3) Intracranial ▪ Compression of the nerve tract by brain tumors and abscess.

B Hyposmia

DEFINITION ▪ Diminished sense of smell

CAUSES ▪ Those like anosmia

C Cacosmia

DEFINITION ▪ Patient himself perceives bad smell

▪ Maxillary sinusitis of dental origin.

CAUSES
▪ Foreign body in the nose.

D Parosmia

▪ Hallucination of smell
DEFINITION
▪ It is a perversion of the sense of smell (i.e., patient smells non-existing odors).

▪ Functional: Psychosis.
CAUSES
▪ Organic: Influenzal neuritis - Epileptic aura - Hysteria

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