Transcript Nose

ANATOMY, PHISIOLOGY and
ILLNESSES of the NOSE and
PARANASAL SINUSES
Head of otolaryngology department
Prof. Alexander I. Yashan
Anatomy of the nose
Line drawing of the key arterial
vessels of the nose.
Computerized axial tomography (CAT) radiograph of the
nose.Coronal section view of the osteomeatal unit.Note
bilateral concha bullosa.
Line drawing of the sagittal view of the lateral nasal wall indicating
the approximate location of the major sensory nerves.
NASAL SEPTUM ANATOMY
NASAL SEPTUM DEFORMITY
(DEVIATION)
NASAL SEPTUM DEFORMITY
(DEVIATION)
• This pathology meets in many people and practically it’s
impossible to meet a person with not deviated partition of
nose. Deformation of nasal septum long time can remain
not noticed and cause not complaints. Only at violation of
the nasal breathing or appearance of other symptoms its
deformity is diagnosed.
• Attend factors
• Traumas of the nose (75 % of cases).
• Inconsistency between growth of nasal septum and nasal
cavity. Nasal septum growths quicker then nasal cavity.
• Congenital deformity (rachitis).
• Compensate deformity (pressure on septum by
hypertrophied nasal turbinates, or by tumor of the nose).
Clinic of Nasal septum
DEFORMITY
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One side or both sides nasal airway
obstruction (heavy breathing through the
nose).
Nasal drainage.
Hyposmia.
Deformation of external nose.
Nose-bleeds.
Diagnostics
•Anamnesis (trauma). General examination of the face
Anterior and posterior rhinoscopia – it is possible to see the
deformity of nasal septum either in cartilaginous or in bone parts or in
both septum parts: S-like, arched, angled-like deformity; ridge or spur of
the septum.
•The anemization of a nasal mucous lining (by a cotton tip applicator
moistened with lidocain+adrenalin 1:10 solution) for best visualization of
deeper departments of the nasal cavity;
•Probing of the nose after anemization by the cotton tip applicator.
•X-ray.
Complications – appears due to
nasal congestion or due to
pathological reflexes:
• Acute and chronic rhinitis (hypertrophy), vasomotor rhinitis;
• Acute and chronic sinusitis (due to deterioration of sinuses
aeration and drainage);
• Acute and chronic otitis media (due to dysfunction of
eustachian tube);
• Acute and chronic pharyngitis (due to breathing through
the mouth);
• Acute and chronic laryngitis;
• Conjunctivitis (due to dysfunction of nasolacrimal canal);
• Reflex disorders of internal organs (bronchial asthma,
asthmatic bronchitis, enuresis, and headache).
Treatment
• Nasal septum deformity is treated by a surgical
method only. Indications for septoplasty are the
nasal congestion and full airway obstruction, or
presence of other complications.
• There are several variants and methods of
operation. The most accepted surgical methods are:
• Radical submucous nasal septum resection (Killian
approach).
• The sparing operations (Voyachec approach):
• a/ mobilization;
• b/ redresation;
• c/ circular resection;
• d/ partial resection
FURUNCLE OF the NOSE
- inflammation of fat glands or hair
follicles, located in entrance of the
nose or on its external surface.
Pathogenic organisms: most
common are staphylococci and
streptococci.
Attend factors
1. Micro trauma of nasal skin (during
self cleaning).
2. Irritation of nasal skins by discharges due to acute rhinitis or sinusitis.
3. General furunclousis.
4. Diabetes or other metabolic
disorders.
Clinic
• Spontaneous pain in the nose especially in the site of furuncle.
• Fever.
• Edema of nasal skin and surrounding tissues.
• General inspection and anterior rhinoscopia
• Cone-shaped infiltrates on one of nostril’s walls or on the
external surface of the nose.
• Painfulness and edema of the external nose and surrounding
tissue: cheek, bridge of the nose, upper lip, eyelids.
• Redness of nasal skin, it is tense and very sensible.
• On a 3-5 day, and sometimes later, in the center of furuncle
appears purulent cavity, with opening on apex. At the beginning
pus is liquid dripping out, forming scab on the furuncle surface
and masking real infiltrate. After removing of scab, thin hole can
be revealed. Then contents of furuncle become jelly-like,
forming shank (grey necrotic masses). It can be removed itself,
either by doctor, or by the patient himself.
• It is categorically banned to squeeze out pus from the
furuncle of nose, as it can result in intracranial
complications (thrombosis of cavernous sinus).
Complications
• Lymphadenitis of cervical lymphatic nodes.
• Thrombosis of facial veins.
• Thrombosis of cavernous sinus of brain is
the most serious complication of the
furuncle. It appears due to spreading of
inflammatory thrombosis from facial veins to
the cerebral sinuses (through anastomosis
between angular vein - the branch of facial
vein and ophthalmic vein – from cavernous
sinus).
Treatment
• 1. Greasing of a skin by antiseptics ointments, or ointments with antibiotics
and corticosteroids.
• 2. Surgical incision of furuncle (after appearance of purulent apex) with
draining by rubber band.
• 3. Anti-inflammatory drugs.
• 4. Antibacterial therapy (antibiotics - better passing through blood brain
barrier).
• 5. Physical therapy procedures (fonoforesis with ointments) at the end of
disease.
• Patients with the furuncle of nose must be treated in hospital.
• Care of patient
• Progressing edema of patient’s face soft tissue has to disturbance medical
personal, as well as changes of consciousness and septic sings: fever
with chills and sweating all over, strengthening of headache, appearance
of meningeal signs, dizziness, and vomits. Appearance of such
pathological sings indicates on development of intracranial complications.
• Prophylaxis
• 1. Tempering of organism.
• 2. Medical treatment of acute rhinitis.
• 3. Medical treatment of endocrine diseases (diabetes).
RHINITIS (COLD) is inflammation of nasal mucus lining
Acute and Chronic rhinitis
• ACUTE RHINITIS (COMMON COLD)
• is the most frequent human disease. An average adult suffers a
common "cold" two to three times per year, more often in
childhood and less often the older he gets as he develops more
immunity. The common "cold" is caused by any number of
different viruses, some of which are transmitted through the air,
but most are transmitted from hand-to-nose contact. Once the
virus gets established in the nose, it causes release of the body
chemical histamine, which dramatically increases the blood flow
to the nose, causing swelling and congestion of nasal tissues,
and stimulating the nasal mucosa to produce excessive
amounts of mucus.
• Acute rhinosinusitis: sudden in onset, lasting up
to 4 weeks. Symptoms resolve after treatment.
• Subacute rhinosinusitis: acute rhinosinusitis that
progresses 4 to 12 weeks. Symptoms eventually
may be less severe than in the acute phase and
still resolve after treatment.
• Recurrent acute rhinosinusitis: symptoms and
physical findings of acute rhinosinusitis, lasting 1
to 4 weeks. More than four episodes per year,
with intervening symptom-free interludes.
Pathogenic organisms:
• viruses (adenoviruses, rhinoviruses) - at the beginning of the
disease (1-3 days);
• staphylococci and streptococci;
• bacteria.
• Acute rhinitis is very contagious disease. The spreading way is
mainly air-drop, but contact transmission (through hands,
crockery, objects) is possible too. The incubation period is 1-3
days. The bacterial super infection often joins to the viral
infection (mainly gram positive cocci flora). The immunity to
viruses lasts out only short time after convalescence so it’s
possible to have reinfection of same virus.
Attend factors
• Cooling of the organism;
• Breathing with heated or dry air;
• Other defects in the nose and throat (allergy, septum deformity)
• Low general resistance of organism;
• Stresses.
Diagnosis of Acute Rhinosinusitis,
Major and Minor Factors
Major Factors
Facial pain/pressure
Facial congestion/fullness
Minor Factors
Headache
Fatigue
Nasal obstruction/blockage
Halitosis
Nasal discharge/ purulence/
discolored postnasal drainage
Dental pain
Hyposmia/anosmia
Purulence in nasal cavity on
examination
Fever
Cough
Earpain/ pressure/
fullness
Clinic
can be divided in three stages:
• 1. „Dry stage” lasts from few hours to few days. At the beginning of disease
there is easy indisposition. Dryness and tickling in the nose, sneeze, easy
pain in the throat and feeling of head compression can be marked.
Progressing nasal congestion begins in the first stage and continues in
second and third stages. The mucous lining of the nasal cavity gets a purplered color and acutely infiltrates.
• 2. Stage of serosous excretions is characterized by abundant watery
excretions from the nose. The patient also suffers from full nasal obstruction,
headache, sub febrile temperature, and hyposmia. The nasal discharge is
thin and plentiful, it irritates the skin around the nose. Then discharges
become more tick. Second stage lasts 2-4 days.
• 3. Stage of mucous-purulent excretions. In this stage the quantity of
excretions diminishes, they become mucus and purulent (adding of bacterial
infection) . This stage lasts 2-4 days.
• In next 6-12 days (eventual phase) the symptoms of “lowering” infection can
appear – causing the inflammation of throat and larynx, that shows up pain
in a throat, hoarse of voice, cough and others like that.
• If in an inflammatory process spreads to paranasal sinuses, pain in the area
of their projection appears (brow, bridge of the nose, cheeks). If inflammation
spreads to the Eustachian tube, fullness in the ear and hearing loss appear.
Complications
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• Acute sinusitis.
• Acute otitis media.
• Acute pharyngitis.
• Acute laryngitis.
• Acute tonsillitis
• Pneumonias and others like that.
• Furuncle of the external nose.
• Possible transition in chronic rhinitis.
Medical Treatment
• At the beginning of disease his development can be stopped by
means sudorific medication (hot mustard baths on feet, for
children - paraffin “socks”). Decongestants drops in the nose
(0,1 % solutions of naphthyzin, galazolin, sanorin, rhinozolin).
These medications improve the nasal breathing, save
permeability of opening between paranasal sinuses and nasal
cavity, and reduce mucous lining edema of the Eustachian
tube.
• The term of decongestants drops administration must not
exceed a 1 week. More prolonged use of these medications
can develop the medicinal rhinitis.
• Antihistamines and decongestants help relieve the symptoms of
a "cold," but time alone cures it. In persons with headache
analgesics are prescribed (paracetamol, analgil, ascofen and
others like that). Medications in the aerosol packing are used:
ingalipt, cameton; and also inhalation of hot air and irrigation of
nasal cavity by antiseptic solutions (decoctions of medical
flowers and leafs - 10 g on 200 the ml boiled water). Physical
therapy procedures are also applied.
Rhinitis in newborns
• is always heavy disease, as their protective mechanism is not
enough developed. Babies carry difficulty of the nasal breathing
heavier, than senior children, as, except for violation of
breathing, a cold hinders still and pectoral feeding.
• This disease presents a special danger to babies. The nasal
meatuses in infants are very narrow, and nasal obstruction is
very likely to follow even a minor swelling of the mucosa.
• Apart from disorders due to the absence of nasal respiration,
such as excitability, broken sleep, etc., nasal obstruction may
often lead to emaciation of the baby, which is unable to suck at
the breast normally
• Clinic
• The temperature of body is often high. There can be meningeal
symptoms, quite often the violated function of the digestion
system is observed (vomits, diarrhea). At the heavy cases the
inflammation of pharyngeal tonsil can occurred (adenoiditis).
Other complications are the inflammations of ear, throat, lungs
and others like that.
Medical Treatment Rhinitis in
newborns
• Decongestant drops in the nose (0,01-0,05
% solution of adrenalin, nazivin, rhinozolin)
to maintain the nasal cavity passability
during breast-feeding. Before feeding the
secretion from the nasal cavity is sucked
by a bulb.
• Prophylaxis
• Out contact of child with virus infect
patient.
CHRONIC RHINITIS (CHRONIC COLD)
is chronic unspecific inflammation of nasal mucus lining.
• Reasons
• Repeated attacks of acute rhinitis.
• The prolonged action of external harmful factors
(dust, gases, overheated air and others like that).
• Infection lesion located near to the nose
(adenoids, sinusitis, tonsillitis, carious teeth).
• Nasal septum deformity.
• Disease of internal organs (hearts, stomach,
kidneys and others like that).
• Deep damages of mucous lining due to acute
infectious diseases (scarlet fever, diphtheria and
others like that).
• Constitutional inclination.
Chronic catarrhal rhinitis.
• Its symptoms are basically the same, though not so marked
as those of acute rhinitis. Patients complain of nasal
obstructions and nasal discharge. The obstruction is not
constant and is worse on lying down. When the patient turns
in bed, the upper nostril opens up and the lower nostril
closes. The discharge may be abundant or poor; sometime it
may be mucus, sometime – purulent; may be postnasal
discharge. Although there can be dryness, hyposmia,
headache, disorders of sleep.
• Rhinoscopia reveals the diffuse edema of nasal mucous
lining and its diffuse redness. In some cases the inferior
turbinate may be so congested and swollen that is
impossible to see deeper parts of the nose. To make visible
inner parts of nasal cavity it’s necessary to do anemization
of mucous lining by application of 0,1 % adrenalin solution .
Chronic hypertrophy rhinitis
• is more common in males. The principle deference of this
disease from catarrhal rhinitis is the development of fibrous
tissues in the submucosal layer of the nose, particularly over
the inferior turbinate. The disease is characterized by diffuse
or limited hyperplasia of mucous lining. This fibrous tissue
contracts in different places (mostly on inferior turbinate) so
mucus surface becomes irregular. Patients suffer from the
abundant nasal secretion and obstruction, headache and
hyposmia. Excretion from the nose is mainly mucus, and it
becomes purulent when pathogenic organisms change.
• On rhinoscopia in common cases the nasal cavity is filled by
abundant, thick, viscid, yellowish discharges. After
cleaning (by blowing patient's nose) the mucosal lining
looks congested, swollen and deep in colour. The
turbinates are enlarged and hypertrophied particulary the
inferior one, so it hampers to inspect the inner parts of nasal
cavity. Surface of mucous lining is irregular, pitted and
looks mulberry-shaped or mulberry-shaped
diagnostic
• The anemization probe is used. The nasal lining is
smeared by vasoconstrictor solutions (adrenalin,
naphthyzin and others like that). In patients with
catarrhal rhinitis the nasal lining become thinner and
nasal breathing becomes better; in patients with
hypertrophy rhinitis the hypertrophy places do not
change and breathing either not becomes better, or
get better only in insignificant measure.
• Chronic hypertrophy rhinitis can complicate by
appearance of polypes, especially when allergy
present, so chronic polipous rhinosinusitis can
develop. In rare cases malignant growth can occur, so
a morphological examination is needed.
Chronic atrophy rhinitis
• is more common in females. Atrophy of nasal mucous lining is main
characteristic of this disease. Mucous membrane loses some of its
mucous glands also it sheds (теряет) ciliated epithelium and in many
places it undergoes metaplasia turning into squamous stratified
epithelium. The disease is often accompanied by diminished mucous
secretion which tends to dry into crusts, but has no bad smell (in
contrast to ozaena). The olfactory nerves become atrophic.
• Symptoms. A young female patient suffers of constant dryness in
the nose and nasopharynx. Another common complaint is a feeling
of foreign body in the nose or dull pressure at the nasal root.
Paradoxical to the wide nasal meatuses, nasal obstruction appears
due to the crusts accumulation on the surface of turbinates and nasal
septum. After self removing of this crusts the little bleeding can occur.
The headache, hyposmia or anosmia (full or partial loss of smell)
can present. In may cases the atrophic process spreads to the
pharynx and larynx, so dryness of the throat can occur.
• On rhinoscopia the reduction or absence of secretion and formation
of crust in the nose can be observed. The nasal cavity fills with
yellowish or green crusts or scabs. After removal of the crusts, the
nasal passages are seen to be very wide and in anterior rhinoscopy
offer a clear view of the posterior wall of the nasopharynx. The nasal
mucous membrane appears dry, very thin, and pale (not red).
Medical Treatment
• This may be local or general. Above all, the underlying
cause of disease should be found out and should be
eradicated, if possible. Liquidation of inflammation focus,
that can be located near to the nose or alongside should
be done (medical treatment of carious teeth, chronic
tonsillitis, adenoids, chronic sinusitis and others like that).
The presence of any nasal deformity should be eradicated.
Physician should advise patients to avoid the harmful
factors of external environment (even to change the
unhealthy job), to eliminate smoking of tobacco, drinking
and to keep to a diet. If necessary, medical treatment of
internal diseases is administrated (hearts, stomach, kidney,
and others like that). If allergy present, the expose of
allergen is needed to avoid the contact with it. Antiallergic
medical treatment is prescribed. Antihistamines and
decongestants help relieve the symptoms of a "cold". In
cases with fever, antibiotics may have to be used after
culture and sensitivity test of the nasal discharge have
been done.
Chronic catarrhal rhinitis.
• Local treatment consists of prescribing astringent and vasoconstrictor drops.
Decongestants drops or sprays in the nose (0,1 % solutions of naphthyzin,
galazolin, sanorin, rhinozolin, and so on) and anti-inflammatory prescription
nasal sprays (argyrols, polydexa, izofra) is prescribed, with duration no
more than 1 week. These medications improve the nasal breathing, save
permeability of opening between paranasal sinuses and nasal cavity, and
reduce mucous lining edema of the Eustachian tube.
• For thinning secretions, especially for older persons, more fluids drinking
(eliminating caffeine, and avoiding diuretics - fluid pills) may be recomended.
Mucous-thinning agents such as guaifenesin (Humibid, Robitussin) may also
thin secretions.
• Irrigating of the nasal cavity by sodium chloride solution (a 1 tea-spoon on a
1 glass of water), can be advised. The patient breathes in the nose the
heated solution from the tea-pot spout, or from the built palm. Nasal
irrigations may alleviate thickened secretions. These can be performed two
to four times a day either with a nasal douche device or a Water Pik with a
nasal irrigation nozzle.
• In patients with diffuse swelling of the nasal mucous membrane the
injections of glucocorticoid solutions (dexamethazone, hydrocortisone est.)
in the inferior turbinate (once in 2-3 days) are effective.
• Also the physiotherapeutic procedures should be prescribed (endonazal
electrophorus of calcium chloride or zinc sulfate, ultrasonic therapy, UShF,
appliques of dirt).
Chronic hypertrophy rhinitis.
• Conservative treatment, as a rule, has only temporal effect in
such patients. The injections of glucocorticoid solutions in the
inferior turbinate are useful. If they are not effective after 3-4
times, more vigorous surgical procedures are performed.
Places of hyperplasia of mucous lining are removed by
means of:
• Chemicals (chemiocaustics) – solutions of silver nitrate,
chromic or trichloracetic acids (10 %) are applied to
pathological tissue.
• Galvanocautery – cauterization with a special instrument pointed electrocauter.
• Criodestruction (by liquid nitrogen).
• Resection of part of the inferior turbinate by surgical
instruments (nasal scissors, conсhotom, nasal snare (петля)).
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Chronic atrophy rhinitis.
The treatment of those patients may only be symptomatic, it aims to irritate nasal mucous
membrane to increase production of mucus. It relieves dryness and crusting in the nose by
alkaline douches with subsequent application of iodine glycerol solution, ointments or menthol
oil. The nose may also be cleansed of crusts by warm alkaline spray. Below are the formulae of
the alkaline solution and some of the drops and ointments commonly used:
Rp. Jodi puri 0.05-0.1 ""
Kalii jodati 0.2
Glycerini
Aq. destill. aa 5.0
01. Menthae pip. gtt. 1
DS. Five drops in each nostril twice a day
#
Rp. Mentholi crystallisati 0.1
01. Provincialis 20.0
DS. Five drops in each nostril twice a day
#
Rp. Natrii bicarbonici 60.0
Natrii biborici 30.0
Natrii chlorati 10.0
01. Menthae pip. gtt. V
M. f. pulv.
DS. One teaspoonful in a glass of water for a nasal douche
enzymes (0,001 g tripsin on 50 ml isotonic solution) or mineral waters (“Glade of cvasova”,
“Borgom” and others like that. ). After cleaning conduct instilyatsii vegetable butters with
tocoferolom and retinolom; useful butters of sea-buckthorn and wild rose. Appoint electroforez
nicotine acid or potassium of iodide on the area of neck or nose and navcolonosovih bosoms.
Enough effective there is in the conditions of warm moist climate.
Neurovegetative form of
vasomotor rhinitis
• describes a nonallergic "hyperirritable nose" that
feels congested, blocked, or wet.
• The mucosa of the nose have an abundant supply
of arteries, veins, and capillaries, which have a
great capacity for both expansion and
constriction. Normally these blood vessels are in
a half-constricted, half-open state. But when a
person exercises vigorously, his/her hormones of
stimulation (i.e., adrenaline) increase. The
adrenaline causes constriction or squeezing of
the nasal mucosa so that the air passages open
up and the person breathes more freely.
Attend factors
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Frequent acute inflammatory processes of
upper airways;
Violation of the vegetative nervous
system;
Nasal septum deformity;
The prolonged foreign body in nasal
cavity;
The protracted supercooling of organism;
Digestive apparatus disorders.
VASOMOTOR RHINITIS
• „Rhinitis" means inflammation of the nose
and nasal mucosa. "Vasomotor" means
blood vessel forces. Two forms are
distinguished:
• Neurovegetative;
• Allergic.
Clinic.
• Vasomotor rhinitis is characterized by intermittent attacks with
very brief and sometimes long periods of relief. The attacks,
very violent at times, are accompanied by prolonged
paroxysms of sneezing, nasal obstruction and profuse,
mostly watery, discharge from the nose or postnasal drip.
Many patients have additional symptoms of lacrimation,
itching of the eyes, nasal interior and hard palate, and
headache.
• Rhinoscopia.
• Turbinates may be enlarged.
• Edema of nasal mucous lining.
• Mucus-watery or foamy excretions in nasal meatuses a
generous amount.
• Bluish or cyanotic color of nasal mucous lining with white or
gray spots on it (Voyachec spots).
• In the intervals between the attacks, all morbid symptoms may
utterly disappear, so there may be no rhinoscopic sign at all.
But in protracted cases, the swelling of the nasal mucosa may
become stable or turn into hyperplasia, as in chronic rhinitis.
Sinusitis