Transcript T6 Nasal Obstruvtionx

KAU Rabigh School
of Medicine
Department of Otolaryngology, Head and Neck Surgery
Tutorial 6
By Razan A. Basonbul, MBBS
NASAL OBSTRUCTION
Objectives
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Definition
Differential diagnosis
History
Examination
Investigation
Common issues:
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Mucosal Swelling
Septal deviation
Collapse of nasal valves
Nasopharyngeal obstruction:
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Adenoids
Choanal atresia
Nasal polyps
Cephalocele
Tumors, JNA
Definition
• Nasal obstruction is the sensation of reduced air flow either
through one nostril (unilateral) or both nostrils (bilateral).
There are four main subdivisions:
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Mucosal swelling
Septal deviation
Collapse of the nasal valves
Nasopharyngeal obstruction
Differential Diagnosis
KITTENS Method
(K) congenital
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Neurogenic tumors.
Conginital
Nasopharyngeal cysts.
Teratoma
Choanal atresia.
Nasoseptal
deformaties
Infectious & Idiopathic
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Infectious Rhinitis
Rhinoscleroma
Chronic Sinusitis
Adenoid Hyperplasia
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Endocrine
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Diabetes
Hypothroidism
Pregnancy
Neurologic
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Vasomotor rhinitis
Toxins & Truma
Tumor ( Neoplasia)
Nasal & septal
Fractures
Medicatios side
effects ( Rhinitis
medimentosa)
Synechia
Environmental
irritants
Septal Hematoma
Foreign bodies
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systemic
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Granulomatous
diseases
Vasculitis
Allergy
Cystic fibrosis
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Papillomas
Nasal Polyps
Hemangiomas
Pyogenic
granulomas
Juvenile
nasopharyngeal
angiofibromas
Malignancy
History
• Character of Nasal Obstruction:
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Onset and duration.
Constant VS intermittent.
Unilateral VS Bilateral.
Associated mouth breathing, Snoring, anosmia/hyposmia/taste
disturbance
• Tearing ( Nasolacrimal Duct Obstruction or Allergy).
• Contributing Factors:
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Toxin and Allergen exposure.
Known Drug Allergies
Medications
Hx of Asthma
Rhinosinusitis
Sleep Disturbance
Facial Trauma or Surgery
Common Drugs that cause Nasal
Congestion
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Antihypertensive, Asprin
OCP
Chronic Nasal Decongestants
Cocaine, Marijuan
Tobacco
Antithyroid Medication
• Associated Symptoms and signs:
• Allergic component:
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Sneezing
Itching
Watery eyes
Clear Rhinorrhea
• Sinus Involvement:
• Facial Pain
• Headaches
• Acute Infection:
• Fever
• Malaise
• Purulent or odorous nasal
discharge
• Pain
• H&N:
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Sore throat.
Postnasal drip
Cough
Ear complaints
Halitosis
Ocular pain
hoarseness
Examination
• External Nasal Exam:
• External deformities: ( firmness, tenderness on palpation)
• Nasal flaring
• Nasal airflow
• Anterior Rhinoscopy/ Nasal endoscopy:
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Examine twice ( with and without topical decongestion)
Quality of turbinates ( hypertrophic, pale, blue)
Quality of nasal mucosa, Septum.
Osteometal complex obstruction
Foreign body, Nasal Masses, Choanal opening
• Quality of Nasal Secretions:
• Purulent and thick ( infectious)
• Watery and clear ( Vasomotor rhinitis, Allergy)
• Salty and clear ( CSF leak)
• H & N exam:
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Facial Tenderness
Tonsil and adenoid hypertrophy
Cobblestoned posterior pharynx
Cervical lymphadenopathy
Otologic exam
Investigations
• Allergy Evaluation
• CT/MRI of Paranasal Sinus:
• CT is Indicated if Obstruction secondary to;
• Nasal Masses
• Nasal Polyps
• Work up for Chronic rhinosinusitis
• MRI is preferred if;
• Suspected Tumors
• Intracranial involvement
• Complicated rhinosinusitis
• Biopsy:
For any mass suspecious of malignancy, avoid biopsy of vascular neoplasms
or encephaloceles.
• Ciliary Biopsy and mucociliary Clearance Tests:
Electron microscopy and ciliary motility studies for ciliary defects.
• Nasal secretion protien, Glucose or B2-transferrin:
For CSF leak.
• Culture and Sensitivity:
Direct Nasal Swabs or Surgically obtained cultures may be indicated
of r complicated acute rhinosinusitis and resistant chronic
rhinosinusitis.
• Pulmonary Function test:
Considered if suspected coexisting reactive airway disease process.
Nasal obstruction
Children
Adults
*Large Adenoids
*Deviated Nasal Septum
*Choanal Atresia
*Rhinitis, Sinusitis
*Rhinitis
*Polyps
*Postnasal space tumors
(angiofibroma)
*Granuloma ( wegner’s)
*Foreign body
*Topical vasoconstrictors
Refer to ORL urgently:
Refer to ORL in the same day
if: Unilateral obstruction ±
foul or bloody discharge.
Numbness, tooth
pain, bleeding,
unilateral obstruction,
tumor suspected
Mucosal swelling
• Autonomic rhinitis
Clear mucus production is the primary problem with less nasal
obstruction. This is due to over activity of the glands in the nose. It is
not common and usually occurs in the over 60s.
• Rhinitis medicamentosa
Overuse of some decongestant nasal sprays (Otrivine, Sinex).
These can help decongest the nose for a few hours if you have a cold
but should not be taken for more than a 5 days as they damage the
lining of the nose.
• Chronic infection
It is associated with a mucky discolored production of green mucus
through the day.
• Idiopathic rhinitis
Where neither allergy nor infection can be found yet the lining of the
nose is swollen.
Turbinate Hypertrophy
Turbinate Hypertrophy
With lower two showing management with coblation
Septal deviation
• Septum is bent or deviated over to one side and this blocks
the air passage of the nose.
• Septal deviation may be associated with a visibly deformed
nose and a history of nasal trauma although it is not necessary
as the cartilage may bend and deform as the nose grows.
• Nasal obstruction is the predominant symptom, usually on
one side. However, if other symptoms are present other
disease processes must be excluded.
• Management depends on the severity of nasal obstruction.
Surgery to correct the deformity can be undertaken if the nose
is blocked or unsightly.
Deviated nasal septum
Septal Hematoma
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Occurs following Trauma, Drugs as ASA or Idiopathic.
• Management by: Drainage and pressure Dressing..
Collapse of the nasal valves
• Normally on breathing in through the nostrils there is a small
amount of collapse of the nostrils. Often this collapse stops if
the mucosal swelling is treated.
• Occasionally the problem is primarily due to a ‘floppy’ valve or
side wall of the nose collapsing.
• Treatment using external nasal splints can sometimes be help
at night. Surgery is an option in case of bothersome issue.
Nasopharyngeal obstruction
Adenoids :
• Most common cause of nasal obstruction in children
• reaching maximum size between the age of 3-5 years old and
then reduce in size often by the age of 7 and can hardly be
seen by the late teens.
• Snoring alone is not an indication for adenoid removal but if
the child also develops apnea (stops breathing for more than
10 seconds regularly without a cold) then adenoidectomy and
tonsillectomy may be helpful.
Choanal atresia
• Incidence of 1 in 5000 to 1 in 10,000 births and is more often
unilateral than bilateral.
• The atresia is bony in 90% of cases and membranous in only
10%.
• The choana develop between the 3rd and 7th embryonic
weeks.
• Symptoms:
• Bilateral choanal atresia is an acutely life threatening emergency!
The resulting hypoxia is manifested by cyanosis that is present at
rest and improves with exertion is called paradoxical cyanosis.
• Unilateral choanal atresia may be manifested by a purulent nasal
discharge on the affected side.
• Diagnosis:
• Both choanae in newborns should be routinely catheterized in
the immediate postnatal period (e.g., with the suction catheter)
to exclude choanal atresia.
• Rigid or flexible endoscope.
• Treatment:
• Bilateral: intubation followed by perforation of the atresia plate.
• Recurrent: stenosis is prevented by inserting a stent and securing
it with a suture (to prevent aspiration).
• The definitive surgical repair of bilateral choanal atresia is
performed during the first weeks or months of life.
• Unilateral: Surgery can be postponed until school age.
Coanal Atresia
Nasal Polyps
• Defined as benign swelling of most commonly ethmoid sinus
mucosa of unknown cause.
• Histology: waterlogged stroma infiltrated with inflammatory
cells and eosinophils.
• They rise from each ethmoid air cells and hang down inside
the nasal cavity.
• Polyps can arise from other sinuses as a single large polyp
arising from the maxillary sinus called antrochoanal polyp, this
prolapse done the nasopharynx.
• Associated with: Asthma, Aspirin Sensitivity and Cystic
fibrosis.
• Samter’s Triad: Nasal Polyposis, Aspirin Allergy and Asthma.
• Hx:
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Nasal obstruction,
watery rhinorrhea,
sinus infection,
anosmia.
• Ex:
• Pale, Semitransparent gray mass.
• Mobile.
• Insensitive when palpated. ( differentiate it for hypertrophied
turbinate)
• May prolapse out of the nose if left untreated.
• !! Role out Malignancy in Adults with unilateral polyp.
• !! Role out Meningocoele or encephalocoele By CT
• TTT:
• Topical Steroids spray
• Surgery
Nasal polyps
ALL POLYPS SHOULD BE SENT
TO HISTOPATHOLOGY!
Cephalpcele
• Cephaloceles are herniations of intracranial contents through
a bony defect in the skull.
• Types:
• Meningocele.
• Meningoencephalocele.
• Meningoencephalocystocele (meningocele + portions of the
ventricular system)
• Etiology:
• Most cephaloceles are congenital.
• Rare cases are post-traumatic (e.g., after a frontobasal fracture)
• Presentation:
Closely resemble Nasal Polyp. But have to be role out in Unilateral
nasal polyp in children.
• Diagnosis:
• CT or MRI can supply information on the location and extent of
the mass and the associated bony defect.
• Treatment:
Always surgical and consists of removing the cephalocele and
repairing the dural defect
Tumors Of the Nasal Cavity
• Unilateral nasal blockage, discharge and bleeding are often
the presenting symptoms of nasal or sinus tumors.
• Osteomas are often asymptomatic.
• Transitional cell papilloma is the most common benign tumor (
may undergo malignant changes)
• Squamous cell carcinoma is the most common malignant
tumor.
• 50% of Sinonasal cancer arise from lateral nasal wall,
33% in Maxillary antrum.
Juvenile angiofibroma (JNA)
• A benign tumor that arise adjacent to the sphenopalatine
foramen, tends to bleed and occurs in the nasopharynx of
prepubertal and adolescent males.
• Epidemiology:
• 0.05% of all head and neck tumors.
• Occurs in MALES.
• Affects age 7-19 years.
• Presentation:
• Nasal obstruction (80-90%)
• Epistaxis(45-60%) unilateral sever bleeding.
• Headache (25%)
• Diagnoosis:
• Vascular unilateral nasal mass.
• CT and MRI showing the extent of the tumor growth.
• Angiography shows branches of external carotid that feeds the
tumor.
• Treatment:
• Hormonal: Testosterone receptor blocker
• Surgical Resection and Radiotherapy.
Foreign Bodies of the Nose
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Mostly are self inserted by children.
Organic materials present early by Purulent Discharge
Inorganic materials may remain for ages.
Presentation:
• unilateral, foul smelling nasal Discharge ± blood
• Management:
• Forceps: Pieces of paper or cotton swabs.
• blunt hook: for Rounded objects, pass it deeper than the object then
try to bring it out by dragging it over the floor of the nose.
• Removal under General Anastasia might be required, make sure to
protect the airway!
• Complications:
• Nasal infection and sinusitis.
• Rhinolith formation.
• Inhalation into the tracheobronchial tree.
Nasal Foreign body removal
Foreign body removal by balloon catheter
Be aware !
• In children with a blocked nose on one side and a one sided
nasal discharge, a foreign body may be in the nose.
• Nasal polyps are rare in children and further tests should be
done.
• Nasal obstruction of one side of the nose in adults, with or
without bleeding, needs to be REFERED to be examined
carefully by an otolaryngologist.
• Instruct the patient to Avoid the long-term use of nasal
medication purchased over the counter unless specifically
prescribed.
• References:
• Clinical Otolaryngology online (COOL)
http://www.entnet.org/EducationAndResearch/cool.cfm
Under the American Academy of otolaryngology, Head and Neck Surgery
• The British Association of Otolaryngology Head and Neck Surgery
http://www.entuk.org/patient_info/nose/obstructions_html
• Otolaryngology head and neck surgery by Raza Pasha,MD
• Primary care otolaryngology
• www.emedicine.medscape.com
• Bailey and Love Short practice in surgery 25th edition.
• Oxford Handbook of clinical specialties.
T h a n k
y o u
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