Transcript Nose and Paranasal Sinuses

A congenital or traumatically acquired bending or bowing of the nasal
septum
Symptoms
Mild forms do not cause
symptoms and have no
pathologic significance
Symptoms
More pronounced degrees of septal
curvature can obstruct nasal breathing
and may also cause olfactory
impairment due to inadequate
ventilation of the olfactory groove.
Deficient nasal airflow can also lead to
paranasal sinus sequelae such as
headaches and recurrent sinusitis.
A large septal spur that comes into
contact with the nasal turbinates can
cause epistaxis

Septal subluxation is a special form in which the anterior
septal margin is displaced from the median plane. This
condition is readily identified by external inspection of the
nasal base.
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Further clinical examination consists of anterior rhinoscopy or
endoscopy.
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The degree of nasal obstruction can be objectively evaluated by
rhinomanometry.
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For medicolegal reasons, olfactory testing should always be
done prior to surgical treatment
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The treatment of choice is surgical straightening
of the deviated septum (septoplasty)
Deformities may be congenital or traumatically
acquired
The most common deformities are a crooked nose,
humped nose, saddle nose, and broad nose, which
may occur separately or in combinations
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Inspection
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Anterior rhinoscopy
Endoscopy
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The treatment of choice is “functional
septorhinoplasty,” with correction of the
nasal septum and external nose
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Nosebleed is a relatively common, usually
harmless symptom that may reflect a
number of diseases of variable severity
1.
2.
3.
4.
5.
6.
7.
8.
Perforation
traumatic
iatrogenic
Inflammatory
spurs or ridges
Foreign bodies
rhinoliths
trauma (including
nose picking)
allergy
acute rhinitis
Traumatic aneurysm
of the internal
carotid
4. Benign neoplasms
5. malignant
neoplasms
1.
2.
3.
1.
2.
3.
4.
5.
6.
7.
Atherosclerosis
Infection
Pregnancy
Diabetes mellitus
Congenital: e.g.,
hemophilia A and B,
Willebrand disease
Acquired: e.g.,
anticoagulant therapy,
Hepatocellular
insufficiency
1.
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1.
Platelet disorders
Congenital
Acquired: uremia,
dysproteinemia, adverse
effects of dextrann and
acetylsalicylic acid (ASA)
therapy Schönlein–
Henoch purpura
Osler disease
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Nosebleed requires a simultaneous,
coordinated protocol of diagnostic and
therapeutic actions
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The diagnostic work-up begins with blood
pressure measurement.
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Except in very minor cases, the Hb should also be
determined, and a coagulation disorder should be
excluded by determining the platelet count,
bleeding time, thromboplastin time, partial
thromboplastin time (PTT), and thrombin time
Bleeding Site
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The nasal cavity is inspected by
anterior rhinoscopy or endoscopy
following decongestion and local
anesthesia of the mucosa.
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In most cases the bleeding site is
in Kiesselbach’s area
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1.
2.
3.
4.
5.
General measures:
The nostrils are compressed against the nasal
septum
the patient is told not to swallow blood running
down the pharynx.
The patient is kept in an upright posture
An ice bag can be placed on the back of the neck
to induce reflex vasoconstriction
An intravenous line should be placed if bleeding
is severe

Mild epistaxis from Kiesselbach’s area can often
be controlled by selective local cauterization

For severe epistaxis, the anterior nasal
cavity can be packed with ointmentimpregnated gauze strips
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The most common source of bleeding from the
posterolateral part of the nasal cavity is the
sphenopalatine artery (branch of the maxillary
artery), which can be coagulated or clipped under
endoscopic control
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The main indications for surgery are changes in
the nasal septum such as septal spurs, ridges, and
perforations.
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Treatment consists of straightening the nasal
septum (septoplasty or closing the septal
perforation (e.g., by implanting an auricular
cartilage graft and using local mucosal flap
advancement
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The nasal pyramid is predisposed to
fractures because of its exposed location.
Diagnostic
procedure
Inspection
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Crepitus noted on palpation confirms the
suspicion of a fracture
Imaging
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Further diagnostic measures
include radiographs of the
nose in the lateral projection
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Standard sinus projections to
exclude bony involvement of
the lateral midface
Complications
1.
Subperichondria
l hemorrhage
with hematoma
2.
Septal Abcess
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Lateral midfacial fractures are usually caused by
blunt trauma to the side of the face.
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Affected structures of the bony facial skeleton are
the maxillary sinus, orbit, and the zygoma or
zygomatic arch
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An isolated fracture of the orbital floor with
a partial herniation of the orbital contents
into the maxillary sinus is a special type of
lateral midfacial fracture called a blow-out
fracture
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Facial asymmetry
Limited mouth opening
Diplopia
Sensory disturbances
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1.
2.
3.
4.
Inspection
Swelling
subcutaneous hemorrhage
Asymmetry of the affected facial
Enophthalmos
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Palpation:
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Concomitant soft-tissue swelling can make it
difficult or impossible to palpate sites of bony
discontinuity or displacement
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Sensory testing
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Wisps of cotton can be used to test sensory
function on the healthy and affected sides
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Radiographs
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Whenever a lateral midfacial fracture is
suspected, standard sinus radiographs should be
obtained (occipitomental and occipitofrontal
projections to define the extent of the bony
discontinuity or displacement
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The zygomatic arches may be poorly visualized in
standard projections, and so a “bucket handle”
view should be added when a concomitant
zygomatic arch fracture is suspected
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CT Scans
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be helpful to obtain a more discriminating view of
the fracture and also to exclude an involvement
of the anterior skull base
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Surgical treatment
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is unnecessary for undisplaced, asymptomatic fractures
is indicated for displaced fractures or fractures that are
causing symptoms such as sensory deficits in the
distribution of the infraorbital nerve, diplopia on upward
gaze, enophthalmos, restricted jaw opening, or facial
asymmetry.
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Treatment consists of reduction and fixation of the bone
fragments using miniplates, interosseous wiring, or both
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Central midfacial fractures (Le Fort I-III)
Frontobasal fractures (Escher classification)
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Frontobasal fractures occupy a special place
among skull fractures because they are usually an
“indirectly open” injury that creates a
communication between the cranial cavity and
the environment lead to life-threatening
intracranial complications (e.g., meningitis, brain
abscess)
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Unilateral or bilateral periorbital
hematoma
Dish face: the midface has been separated
from the skull base and displaced inward
Cerebrospinal fluid (CSF) rhinorrhea
Vision loss
Diplopia
Cerebral prolapse
Anosmia
 Glucose test
 β2-transferrin
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Computed tomography
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Axial scans are for evaluating the anterior and
posterior walls of the frontal sinuses and
sphenoid sinus
 Coronal scans more clearly define the ethmoid
roof and cribriform plate
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Testing of hearing and balance
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Olfactory testing
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Every confirmed fracture of the anterior
skull base should be treated surgically in
operable patients, regardless of whether or
not a CSF leak has been detected
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Life-threatening rise of intracranial
pressure due to intracranial hemorrhage
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Bleeding from the nose or sinuses that is
refractory to conservative treatment
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Bleeding from an open skull injury that is
refractory to conservative treatment
Open brain injury
Dural tear from an indirectly open head injury
Penetrating foreign bodies and impalement
injuries
 Early complications (e.g., meningitis,
encephalitis, brain abscess)
 Late complications (e.g., meningitis, brain
abscess, osteomyelitis)
 Orbital complications
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Displaced bone fragments
 Fractures involving the drainage tracts of the
paranasal sinuses (“ostiomeatal unit”)
 Acute or chronic sinusitis at the time of the injury
 Post-traumatic sinus inflammation, mucopyocele
formation
 Supraorbital nerve injury due to an adjacent
fracture

1.
2.
3.
4.
5.
Define the paradoxical cyanosis.
Name four common nasal deformity.
Where is the common site of epistaxis in
old age?
What is the most definitive sign for nasal
fracture?
Name six common symptoms for
frontobasal fracture.
Inflammations of the External Nose, Nasal Cavity,
and Facial Soft Tissues
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Folliculitis: the disease is confined to the
hair follicles.
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Furuncle: the infection spreads to deeper
tissues and forms a central core of purulent
liquefaction.
Symptoms
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Nasal furuncles present as painful,
tender, erythematous swellings
about the nasal tip and nares
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Antibiotic that is active against staphylococci:
1.
2.
Dicloxacillin sodium , Cephalexin and so on
Combined with the local application of an
antibiotic-containing ointment
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Inadequate treatment or manipulations of the
nasal furuncle itself can result in:
Hematogenous spread to intracranial structures
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Causative organisms are beta-hemolytic
group A streptococci
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Less common pathogens are streptococci
of other groups, Staphylococcus aureus,
and gram-negative rods (e.g., Klebsiella
pneumoniae)
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High fever
Feeling of tension in the soft tissues
Rapidly by broad areas of erythema and
swelling, which are sharply demarcated
from unaffected skin
The tissue is warm to the touch, and small
blisters occasionally form
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The treatment of choice is the parenteral
administration of penicillin
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Acute rhinitis (common cold) is the most
prevalent infectious disease
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Rhinoviruses and coronaviruses comprise
almost half of the causative organisms of
acute viral rhinitis
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Dry stage
 Malaise (lethargy, headache, fever) and local
discomfort in the nose and nasopharynx (burning,
soreness).
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Catarrhal stage

Watery, initially serous nasal discharge and nasal
obstruction due to mucosal swelling, which
mainly involves the turbinates.
Bacterial
Superinfection
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Viral damage to the epithelium promotes bacterial
colonization, which alters the consistency of the clear
nasal discharge, causing it to become mucopurulent.
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Treatment consists of supportive measures to
relieve nasal obstruction and prevent sinusitis and
other sequelae by the use of decongestant nose
drops
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Antibiotics may also be prescribed in patients
with bacterial superinfection or paranasal sinus
involvement
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Nonspecific chronic rhinitis can develop due to
anatomic changes (e.g., marked septal deviation,
septal spur) or other lesions of the nasal cavity
(polyps, tumors) and nasopharynx (adenoids)
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Environmental factors such as sustained extreme
temperatures or air pollutants can also bring on
this condition
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1.
2.
3.
Patients present clinically with:
Obstructed nasal breathing
Mucous nasal discharge
Frequent throat clearing and occasional
hoarseness
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The most important step is to eliminate the
cause by removing chronic irritants from
the environment or by surgically correcting
any intranasal pathology (e.g., septoplasty)
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Tuberculosis
Sarcoidosis
Rhinoscleroma
Actinomycosis
Syphilis
Wegner
Granulomatosis
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1.
2.
3.
Fungal infections
Aspergillosis
Mucormycosis
Rhinosporidiosis
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Triggered by an immediate, IgE-mediated
reaction of the immune system to any of a
number of foreign substances, particularly pollens
and animal allergens.
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Mainly by pollens
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Disappear at the end of the pollen season
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Is caused by year-round allergen exposure
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The predominant causative allergens are house
dust, pet dander, and molds
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The disease may also be caused by certain foods
(e.g., strawberries, nuts, eggs, fish) as well as
occupational exposure to allergens (e.g., bakers
and hairdressers)

1.
2.
3.
4.
The clinical manifestations:
Obstructed nasal breathing
Sneezing attacks
Watery nasal discharge
Itching of the nose and eyes (conjunctivitis)
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Detailed allergy history (do the symptoms present yearround or only during contact with certain animals or
plants).
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Seasonal allergic rhinitis, a bluish-purple
discoloration of the mucosa.
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Perennial rhinitis, the mucosa is bright red and
shows inflammatory changes.
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Careful allergy testing is necessary to identify the
antigens involved.
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The best treatment strategy is to avoid contact
with the allergen or eliminate allergenic irritants
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Pharmacologic treatment
1.
2.
3.
Mast-cell stabilizers
Local and systemic H1 antihistamines
Local steroids
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Immunotherapy or hyposensitization therapy
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Surgical options
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Resembles allergic rhinitis in its clinical
features, but there is no evidence that the
patient has been previously sensitized.
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Neurovascular autonomic disturbances in
regulating the tonus of the nasal mucosal
vessels
 Obstructed nasal breathing
 Watery nasal discharge
 Sneezing
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The history shows that the symptoms are related
to a temperature change, the consumption of hot
liquid or alcohol, or less specifically to “emotional
stress.”
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Medical therapy includes
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
Antihistamines
corticosteroid-containing nasal sprays
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In the Kneipp system of therapy, ice-cold water is
sniffed up the nose as a way of “training” the
neuroautonomic regulation of the blood supply to
the nasal mucosa
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For intractable vasomotor rhinitis is
surgical reduction of the turbinates a
septoplasty should be performed.
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Characterized by pronounced dryness of
the nasal mucosa.
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Severe cases, especially with secondary
bacterial colonization, are marked by a
fetid nasal odor that is not perceived by the
patient due to degeneration of the
olfactory epithelium.
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Primary atrophic rhinitis is unknown
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Secondary forms
1.
2.
3.
Extensive prior tumor resection
Excessive use of nose drops drug abuse (cocaine)
Previous radiotherapy for nasal and sinus
tumors
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Conservative:
 Symptomatic measures (saline “nasal douche,”
soothing mucosal ointments).
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Surgery :

reduce the nasal cavity by the submucous
implantation of cartilage grafts.
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Occurs mainly during pregnancy and is
believed to be caused by estrogen-induced
swelling of the mucosa with nasal airway
obstruction.

This disease occurs mainly as a side effect
from the long-term use of decongestant
nose drops
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Antihypertensive drugs
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
Beta-blockers,
Angiotensin-converting enzyme (ACE) inhibitors
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Oral contraceptive
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Clinical
symptoms consist of obstructed nasal breathing, dry
mucosa, and occasional olfactory disturbances.
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Intranasal anatomic changes such as:


Septal deviation
Septal spurs
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Chronic inflammation
Allergy
Trauma
Neoplasms
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The common pathogenic mechanism is impaired
ventilation of the ostiomeatal unit
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Chronic sinusitis frequently affects the
maxillary sinus and ethmoid cells
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Pain (from feeling of pressure to persistent
or recurrent headaches)
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Nasopharyngeal drainage (postnasal drip)
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Obstructed nasal breathing
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Rhinoscopy
Endoscopy
Imaging studies
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Conservative treatment options

Appropriate antiallergic therapy

Sinus surgery

The modern surgical treatment of chronic
sinusitis is performed intranasally under
endoscopic or microscopic control.
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Genetic causes
Chronic irritation of the mucosa, like that
occurring in chronic rhinitis or sinusitis
In response to allergic rhinitis and
acetylsalicylic acid (ASA) intolerance
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Nasal polyps are rarely observed in
children.

Most occur in a setting of cystic fibrosis.
 Obstructed nasal breathing
 Hyposmia or anosmia
 Headache
 Snoring
 Rhinophonia clausa
 Frequent throat clearing
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Spread to the lower airways can lead to laryngitis
with hoarseness and bronchitic symptoms.
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Rhinoscopic or endoscopic evaluation
Computed tomography
Allergy tests
Olfactory testing
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Conservative measures
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

Use of corticoid containing nasal sprays
Systemic antihistamines
Systemic steroids

Surgical treatment

The prognosis is guarded even with modern
surgical techniques most meticulous
ablative sinus surgery cannot prevent a
recurrence
Adhesions due to
 Postinflammatory
 Post-traumatic
 Postoperative


The most common site of occurrence is the
frontal sinus, followed by the ethmoid
cells, maxillary sinus, and sphenoid sinus.
Frontal Sinus

Presents as an isolated, tense
swelling over the anterior wall
of the frontal sinus

It may also cause inferolateral
displacement of the orbital
contents
Maxilla

Swelling in the cheek area
with upward displacement of
the orbital contents
Ethmoid

Proptosis, limited ocular
movements, and diplopia may
also occur, depending on the
location of the mass.

Computed tomography

MRI

The treatment of choice is surgical removal
of the mucocele

1.
2.
3.
4.
5.
6.
They occur with highest frequency in children
under 6 years of age
Orbital edema
Periosteitis
Subperiosteal abscess
Orbital cellulitis
Orbital apex syndrome
Cavernous sinus thrombosis

Osteomyelitis occurs mainly as a
complication of frontal sinusitis
Symptoms

The patient presents clinically with
a tender, doughy, erythematous
swelling over the forehead

Cranial CT scans

The treatment of choice is surgical
eradication of the affected bone under
antibiotic coverage
Intracranial
Complications



Epidural, subdural and
intracerebral abscesses
Meningitis
Sinus Thrombosis and
Thrombophlebitis
1.
2.
3.
4.
5.
What is so serious regarding nasal
foliculitis?
Name the common symptoms of sinusitis.
When orbit shift to the inferolateral the
mucocel perhaps is located in …. sinus.
Name the causes of sinonasal polyposis.
Subdural abscess is more common when
the ….. Sinus is involved.