External nose
It is a pyramidal in shape upper boney pyramid and lower cartilaginous pyramid
Boney part consists of upper 1\3 and cartilaginous part consists of lower 2\3
Boney framework consists of
Pair of nasal bone
Frontal process of maxilla
Maxillary process of frontal bone
Cartilages of external nose
Pair of upper lateral cartilages
Pair of lower lateral cartilages(greater alar cartilage)
Part of septal cartilage
Vestibule is part of the nasal cavity just within the the external nose,the vestibular skin
contain hair follicles,hair and sebecious glands
Nasal cavity
Divided into two cavities by the nasal septum
It`s ant.openning called ant naris while it`s post. Opening called post.naris which open
into nasopharynx
Nasal septum
Formed by
Cartilaginous part anteriorly by quadrilateral cartilage
Boney part posteriorly which formed by
Perpendicular plate of ethmoid
Vomer
Nasal crest of maxilla
Nasal crest of palatine bone
Lateral nasal wall
Within the nasal cavity there are three turbinates (superior,middle and inferior) In the
inf.meatus
Opening of nasalcrimal duct
In the mid.meatus
There is bulge called bulla ethmoidalis below it there is Uncinate process between them
there is a fissure formed called hiatus similunaris
The following sinuses open in the middle meatus
Ant. Ethmoid air cell and frontal sinus in the anterior part of hiatus simlunaris
Maxillary sinus ostium and sometime accessory ostia open in the posterior part of hiatus
simlunaris
Superior and middle turbinate is part of ethmoid bone
Inferior turbinate is a separate bone
The air space beneath each turbinate is known as
the meatus of the corresponding turbinate.
i.e each meatus named after the turbinate above it
There are various ducts and sinuses open in the meati
Each turbinate is a cigar-shaed ridges or swellings are attached to the lateral nasal wall
,each is made of bone,superior and middle is part of ethmoid bone while inferior turbinate
is a separated bone,
All turbinates are coveres with vascular mucopreriostium and ciliated columnar
epithelium.
The space under each turbinate is called a meatus i.e inferior meatus lies under the
inferior turbinate etc…In the superior meatus
Posterior ethmoid sinus,sphenoid sinus drain in the sphenoethmoid recess which is a
small depression above and behind the superior turbinate
The vascular inferior turbinate contains the second errectile tissue in the body i.e it has
the ability to swell and shrink under autonomic nervous system control. Nasal resistance
The nose accounts up to half of the total airway resistance.
The resistance is made by two elements
A is essentially fixed made by bone,cartilage and attached muscle
B is variable made by mucosa
The nasal resistance is high in infants who initially are obligatory nasal breathers
Removal of nasal resistance by tracheostomy reduce the dead space but results in a
degree of alveolar collapse
Factors decrease nasal resistance
Exercise
Sympathmymetic
Rebreathing
Atrophic rhinitis
Erect position
Factors increase nasal resistance
Infective rhinitis
Allergic rhinitis
Vasomotor rhinitis
Aspirin
Ingestion of alcohol
Cold air
Supine position
Hyperventilation
Sympthatic antagonists
Factors that influence nasal resistance is nasal cycle
Nasal cycle
Demonstrated in over 80% of adults but it is more difficult to demonstrate in children.
The cycle consists of alternate nasal blockage between passages.
Cyclical changes occur between 4-12 hours;they are constant for each person
Various factors may modify the nasal cycle include
Allergy
Infection
Exercise
Hormones
Pregnancy
Fear
Emotiom
Autonomic nervous symptom vagal overactivity cause nasal obstruction
Drugs the anticholinergic effects of antihistamine can block the parasympthatic activity
and produce an increase of sympthatic tone ,hence improve airway
The function of the inferior turbinate is to control the passage of the air through the nose
via the nasal cycle,the inferior turbinate is one side enlarged,as and as aresult the air flow
through that nostril is restricted.
This reduse the drying effect of airflow and allows for rejuvenation of the nasal lining
and cilliary function.
After approximately 4 hours,the turbinate on the other side swells and on previously
rested side the turbinate shrinks.
This nasal cycle is a normal physiological mechanism that is present to some extent in all
of us but noticed only by some people.
Nasal epithelium is a pseudostratifi ed columnar ciliated mucous
membrane continuous throughout the sinuses. The epithelium contains
goblet cells, which produce mucus, and columnar cells with
mobile cilia projecting into the mucus, beating 12–15 times a second.
The direction of ciliary beats is organized into well-defi ned pathways,
present at birth. These mucociliary pathways ensure drainage of the
sinuses through their physiological ostium into the nasal cavity
‫المحاضره الثانيه‬
The middle meatus is of special signifi cance as it contains the ostiomeatal
complex (OMC). This is an anatomical area in the bony
lateral nasal wall comprising narrow, mucosal lined channels and
recesses into which the major dependent sinuses drain. The OMC
acts physiologically as an antechamber for the frontal, maxillary
and anterior ethmoid sinuses. Irritants and antigens are deposited
there and may cause mucosal oedema. As the clefts in the OMC are
narrow, small degrees of oedema may cause outfl ow tract obstruction
with impaired ventilation of the major sinuses
The configuration of the structure of the middle meatus are complex and variable,in
disarticulated skull ,the maxillary bone has a large opening in its medial wall,the
maxillary hiatus.
In articulated skull this is filled by adjacent bones
1 inferior: maxillary process of inferior turbinate bone
2 posterior:perpendicular plate of palatine bone
3Anterosuperior:lacrimal bone
4superior:UP and Bulla ethmoidalis
So portion of maxillary hiatus is left open these osseous attachment which in life filled
wth mucous membrane of
1 Mucous membrane ofMM
2Mucous membrane of maxillary sinus
3 Intervening connective tissue and membranous portion of lateral wall
It is the site for the common pathway of the anterior group of sinuses(frontal,anterior
ethmoid,mawillary) structure contribute to this area:
Uncinate process
Thin bony structure runs anterosueriorly to psteroinferioly.it articulate with the ethmoidal
process of inferior turbinate,it artly cover the oening of maxillary sinuse
Hiatus similunaris
It is a semilunar groove which leads anteriorly to the ethmoidal infundibulum
Ethmoidal infundibulum
It is a short passage at the anterior end of the hiatus
Frontal sinus,maxillary and anterior ethmoid drain into it
Bulla ethmoidalis
It ia a round prominence formed buldging of ethmoid sinus
Frontal recess
Maxillary sinus
Middle Meats
Middle Meatus
Lies lateral to the MT
Structure important in the MM:
UP
HS
BE
Ethmoid infundibulum
Anterior and posterior fontanelle:
Are membranous areas between the interior turbinate and uncinated process,accessory
ostia are found mostly in the posterior fontanelle Arterial supply
external carotid arteryfacial arterysuperior labial artery
nasal branch
maxillary arterysphenopalatine
greater
palatine artery
internal carotid arteryanterior ethmoid artery
posterior ethmoid artery
Little`s area or Kiesselbach`s plexus
It is an area in the anterior part of the septum just behind the skin margin contain
aggregation of poorly supported blood vessels represents the most important and
commonest site of epistaxis
It formed by anastamasis of
*Septal br.of sphenopalatine artery
*Superior labial artery
Greater palatine artery*
*Ant.ethmoid artery
Nerve supply
Autonomic supply either1
Sympthatic
Parasympthatic
Special sence2
By olfactory nerve that supply olfactory mucosa which located in the sup.portion of the
nasal cavity
3 sensory supply mainly by branches of trigeminal nerve
Anterior ethmoid nerve from ophthalmic division which has medial branch supply
ant.end of the septum and lateral branch supply mid.&sup. Turbinate
Branches from sphenopalatine & greater palatine nerve which supply most of turbinate
4 motor nerves from facial neve for elevate and dilate nasal ala
‫المحاضره الثالثه‬
Rhinosinusitis
Rhinitis is defined as inflammation of the lining of the nose,characterized by one or more
of the following symptoms
Nasal congestion
Rhinorrhea
Sneezing and itching
The term sinusitis refers to a group of disorder charecterized by inflammation of the
mucosa of paranasal sinuses.
Because the inflammation always also involve the nose ,it is now generally accepted that
"Rhinosinusitis" is preferred term to desecribe the inflammation of the nose and paranasal
sinusesThe ciliated mucosa of the nose and paranasal sinuses are contiguous and it would
be rare for one to be affected without the other so the term rhinosinusitis always
usedDifferential diagnosis
Polyp
Mechanical factors
NSD
Hypertrophic turbinate
Obstruction OMC
F.B
Choanal atrasia
Tumours..Benign or malignant
Granuloma
CSF Rhinorrhea
Acute rhinosinusitis ARS is acute infection of sudden onset with duration of less than
four weeks, 7 days to four weeks as viral rhinosinusitis follow viral URTI and mimic it`s
symptoms so five to seven days was recommended perior to an acute bacterial
rhinosinusitis.
Subacute rhinosinusitis SRS the duration is last for 4- 12 weeks
Recurrent acute infection RARS are defined by four or more episodes per year
Chronic rhinosinusitis CRS occur when the duration of symptoms is greater than 12
weeks
Acute exacerbation of chronic rhinisinusitis AECRS is is sudden worsening of CRS with
return to baseline CRS
Signs and symptoms
Rhinosinusitis requires two major factors,or one major and two minor
Major symptoms
Facial pain\ pressure
Facial congestion/fullness
Nasal obstruction
Nasal discharge/purulent/posterior drainage
Hyposmia/Anosmia
Purulence on nasal examination
Fever (acute rhinosinusitis only
Minor symptoms
Headache
Fever (non acute)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
Microbiology of acute bacterial rhinosinusitis
Streptococcus pneumoniae 20-43%
Haemophilus influenzae 22-35%
Strep species
Anaerobes
Moraxella catarrhlis
Staphylococcus aureas
Predisposing factors
Either
Local or general
◙ mucosal obstruction ,deviation,polyp
◙ obstruction of the sinus ostea by allergic rhinitis
◙ neighbouring infection especially in children
General factors
◙immunedifficiancy
◙mucocilliary disorder
◙ allergy
Treatment
Medical
1 treatment of infection
Systemic penicilline always effective
If not do culture and sensitivity
2 treatment of pain
Asprin or codien
3 establishment of drainage of sinus
Either local like ephedrine and normal saline or systemic by pseudoephedrine and
antihistamine.
Always be aware of Rebound phenomenon on using common nasal decongestant
Surgical operations for chronic sinusitis
█ maxillary sinuses
►antral washout
►►intranasal antrostomy
●Middle meatus antrostomy (endoscopic)
●Inferior meatus antrostomy
►Caldwell-Luc operation
Frontoethmoidosphenoid
►Trephenation of frontal sinuses
►►Intranasal ethmoidectomy
►►►FESS Functional endoscopic sinus surgery
►►►►Transnasal ethmoidectomy
►►►►►external frontoethmoidosphenoidectomy
‫المحاضره الرابعه‬
Allergy and Allergic Rhinitis
Atopy is a tendency to develop an exaggerated IgE response while allergy is the clinical
resentation of atopic disease in the presence of allergen
Aetiology
A genetic and family history
Environmental factors like exposure to allergen ,air pollution and irritant, occupational
allergen like flour, wood dust, latex in surgical gloves,tobacco,detergents and
bleach.Food occasionally provoke IgE allergic rhinitis, it may be due to sensitivity to
preservatives, some type of food contain histamine like cheese and wine
Drugs like penicilline, asprin, antihypertensive, B-blocker, ACE inhibitor
The allergic responses can be divided into two phases. The first is an acute response that
occurs immediately after exposure to an allergen. This phase can either subside or
progress into a "late phase reaction" which can substantially prolong the symptoms of a
response, and result in tissue damage
Pathogenesis
IgE has a property of binding to high affinity receptor on the mast cell and basophil .the
interaction of allergen with IgE initiate secretion of active mediators that cause clinical
manifestation,thes mediators either preformed mediators (histamine, proteases,
chemokines, heparine); or newly formed mediators (prostaglandins, leukotrienes,
thromboxanes
Rhinitis if defined clinically by a combination of two or more nasal symptoms
Nasal obstruction…….blocking
Rhinorrhea…………...running
Itching and sneezing
Allergic rhinitis occur when these symptoms are the result of IgE mediated inflammation
following exposure to allergen
Classification
Seasonal
Perennial
New classification by ARIA guideline (allergic rhinitis and its impact on asthema)
Mild
Normal sleep
Normal daily activities
Normal work and school
No troublesome symptoms
Moderate or severe
Abnormal sleep
Impairment of daily activities
Problems caused at school and work
Troublesome symptoms
Intermittent symptoms
Less than 4 days/week
Or less than 4 weeks
Persistent symptoms
More than 4 days/week and more than 4 weeks
Co-morbidities
Other conditions associated with allergic rhinitis are asthema,sinusitis,otitis media,sleep
disorder,lower respiratory tract infection
Rhinitis and asthma are linked by epidemiological,pathophysiological characteristics and
by common therapeutic approach.
█Rhinitis is a risk factor for the development of subsequent asthma ,
█is a frequent cause of asthma exacerbations ,and
█effective rhinitis treatment reduce asthma
So patient with persistent allergic rhinitis should be evaluated for asthma and the
converse is true
Clinical presentation
Immediate type allergic symptoms of sneezing ,rhihinorrhea and itching are easily
recognized
Perennial allergic inflammation is mainly expressed as nasal obstruction,hyperreactivity
and poor sense of smell,the sinus lining is also usually involved so that the picture is of
one of a chronic inflammatory rhinosinusutus,in those patient immediate symptom not
present and may undergo unnecessary operations for septal deviation or turbinate befor
the true nature of the problem is diagnosed properly
Pharmacotherapy
Antihistamine
It relieve running,itching,and sneezing but have little or no effect on blockage
First generation like chlorpheneramine,diphenhydramines should be avoided because of
sedation,psychomotor retardation and learning impairment because it cross the BBB and
interact with histamine receptors
Second generation antihistamine act with an hour topical ones within 15 minutes
Terfenadine,astemazoleblock potassium channel and cause cardiac arrhythmia, QT
prolongation,so care taken not overdose and nor to combine with
erythromycin,ketokanazole,grapefruit juice,antiarrythmia .
Citrizine,fexofenadine,and desloratidine not block potassium channels even at
supranormal dose
Desloratidine is exception that affect on nasal blockage
Topical corticosteroid
Are the most effective treatment of rhinitis especially if started prior to allergen exposure
it reduce the relative risk of asthma exacerbation by 50%
Side effects are minor include epistaxis and nasal irritation
Sodium cromoglicate
It is weakly effective against all rhinitis but safe means it is useful for small children less
than four years for whom a topical corticosteroid is not available
Decongestants
Used topically reduce nasal obstruction but increase rhinorrhea,regular use for more than
few days result in rhinitis medicamentosa
Systemic decongestant are relatively ineffective with side effects like
hyperactivity,insomnia in children and hypertension in adult
Ipratropium bromide
Response in patients who do not response to topical corticosteroid alone
Systemic corticosteroid
Used to unlock the nose at start of treatment or for sever symptoms,used for few days
Depot injection not recommended because they are not if side effects occur
Antileukotriens LRA
Recently been licensed in rhinitis it can also be helpful in polyposis
Nasal douching
Immunotherapy
‫المحاضره الخامسه‬
Epistexis
Epistaxis is the commonest otolaryngologic emergency, affecting up to
60% of the population in their lifetimes, with 6% of cases requiring
medical attention.
The nasal cavity is extremely vascular.
Terminal branches of the
external
and internal carotid arteries supply the mucosa of the nasal cavity
with frequent anastomoses between these systems
The anterior nasal septum is the site of a plexus of vessels called Little’s or
Kiesselbach’s area, which is supplied by both systemsThe maxillary sinus ostium
serves as the dividing line between
“anterior” and “posterior” epistaxis. Anterior bleeding is usually easier
to access and is therefore less dangerous. Posterior epistaxis is more
difficult to treat because visualization is more difficult and blood is often swallowed,
making it more difficult to gauge the amount of
blood loss
The
term “posterior bleeding” is all too often used incorrectly to
label bleeding that cannot be visualized with a head lamp. It transpires
in many cases that endoscopic examination shows the bleeding to be
located high on the septum Primary No proven causal factor
Secondary Proven causal factor
Childhood <16 years
Adult >16 years
Anterior Bleeding point anterior to piriform aperture
Posterior Bleeding point posterior to piriform aperture
Aetiology:
A idiopathic---------from little`s area
B Trauma
Nose picking
F.B
Maxillofacial trauma
Itrogenic
C infection acute or chronic.viral or
bacterial
D Inflammatory
Rhinosinusitis
Nasal polyp
E Neoplasm
Benign angiofibroma, papilloma
Malignant
sq.cellcarcinoma,adenocarcinoma,
lymphoma
F Drug induced
Cocaine abuse
Rhinitis medicamentosa
medicamentosa,asprin,anticoagulant.chloramphinicol,immunosuppressant,alcohol
G inhalant
Tobacco
H endocrine
2 General
A atherosclerosis
B bleeding disorder
A coagulopathy
1inhereted coagulation factors deffeciancy like
factor vii,factor ix
2acquired :anticoagulant,liver disease,vitamin
k defficiancy
B platelate disorders
●thrombocytopenia
●●platelate disfunction
►congenital like vonwillbrand disease
►► acquired like leukemia,uremia,drugs as
NSAID
C blood vessel disorders
●congenetal----osteogenesis imperfecta
●●acquired-----amyloid,vasculitis,vit.K
D hyperfibrinolysis
●congenital------αantitrypsin deficiency
●● acquired------malignant DIC
asprin &
defeciancy
Management
Initial Assessment
The amount of blood loss should be estimated (the physician should
ask about whether the patient has lost enough to soak a handkerchief,
a facecloth, or a towel; the last would indicate a significant loss), and
over what period (a regular minor bleed can cause anemia). A clinical
assessment of the patient’s cardiac status and circulating blood volume
should include looking to see if the patient is pale, sweating, or cool,
or has tachycardia; any of these findings would indicate significant
hypovolemia. A reduction in blood pressure is often a late sign, particularly
in young people, who can maintain blood pressure until the
circulatory volume is critical.
Obtaining intravenous access, checking for and correcting any
clotting abnormalities, and taking blood for “group and save” and/or
crossmatching may be required. In our unit patients admitted via the
emergency department can be “fast-tracked” to the otorhinolaryngo- logic
emergency unit if stable This practice helps avoid
unnecessary and counterproductive nasal packing in the emergency
department as well as transfer of patients before they are fit enough to
travel.
The clinician must remember that epistaxis is frequently idiopathic
but can be a manifestation of a possible underlying pathology
). Your patient should undergo further investigation
First aid measures include asking the patient to apply constant firm
pressure over the lower (non-bony) part of the nose for 20 minutes and
to lean forward with the mouth open over a bowl so that further blood
loss can be estimated. Otherwise, blood dripping postnasally will be
swallowed, and the next warning sign of a serious loss could be several
hundred milliliters of blood being vomited up.
It is important to establish both the site and the cause
The philosophy of this approach can
be summarized as follows:
1. Establish the site of bleeding.
2. Stop the bleeding.
3. Treat the cause.
Headlamp Examination Using Local Anesthesia—
Initial Overview
The key to controlling most epistaxis is to find the site of the bleeding,
and although chemical cautery with silver nitrate can be used, bipolar
diathermy is more effective for stopping the bleeding. Protection from
blood contamination is important. A plastic apron for both parties is
helpful in order to avoid staining of clothes, and eye protection is advisable
if there is active bleeding because some patients have a reflex to
blow away any fluid dripping down the upper lip, which can create a
bloody aerosol. Once the clots have been sucked out, the nasal airway
should be inspected, initially with a headlamp and then, if the bleeding
point cannot be located, with an endoscope
Epistaxis in Children
Young children usually bleed from a vessel just inside the nose at the
mucocutaneous junction on the septum, and the bleeding invariably
stops spontaneously. In children with epistaxis in whom no prominenvessel can be
seen, the regular local application of a cream can help,
but petroleum jelly (Vaseline) alone does not.
As many as 5% to 10% of children with recurrent nosebleeds
may have undiagnosed von Willebrand’s disease.
Children
who have leukemia or are undergoing chemotherapy often have
epistaxis associated with thrombocytopenia. Older children, adolescents,
and adults often bleed from Little’s area or a maxillary spurt
Epistaxis in Adults
The caudal end of the septum, where several branches of the external
and internal carotid anastomose in Little’s area or Kiesselbach’s plexus,
is the most common site of bleeding in adultsLess commonly bleeding,
comes from further back on the septum, and a septal deviation
may make it difficult to visualize Some patients with
seasonal allergic rhinitis complain of more nosebleeds in the hay fever
season, and topical nasal steroids aggravate the bleeding in approximately
4% of users. Many people believe that a nosebleed signifies a
release of pressure and may herald a stroke, and it is important for the
clinician to address these anxieties for the patient. Although many
patients are found to be hypertensive during nosebleeds, few remain so on followup. The association between hypertension and epistaxis is
disputed.
Many clinicians report that hypertension is not related to
Nosebleed
However, nosebleeds in patients with hypertension
are more likely to lead to admission and to be associated with
comorbidity.
In over-anticoagulated
patients, fresh frozen plasma, clotting factor extracts, and vitamin K
help. Vitamin K takes more than 6 hours to work, however, and it can
delay anticoagulation for 7 days after warfarin is started.
. Tranexamic cyclocapron
acid, an antifibrinolytic agent, has not been shown to help.
But other litriture advice to give it Scott brown) Tranexamic
acid has been shown to reduce the severity and risk of rebleeding in epistaxis at a
dose of 1.5 g
three times a day. These drugs do not increase fibrin deposition and so do not
increase the risk of
thrombosis. Preexisting thromboembolic disease is a contraindication.
Other drugs associated with bleeding are aspirin, which interferes with
platelet function for up to 7 days, clopidogrel, and nonsteroidal antiinflammatory
drugs.27,28 In patients who do not have a history of a
bleeding disorder or undergoing anticoagulant therapy, routine clotting
studies do not add to the management.22,24 There is a higher incidence
of epistaxis in patients with a high alcohol intake, even when there is
no laboratory evidence of a coagulation abnormality.29,30
Topical Treatment
Topical Treatment
A randomized controlled trial of silver nitrate cautery with topical
antiseptic nasal carrier cream versus topical alone showed both to be
effective
Use of cold pack is advisable although hot water irrigation 50c has been proposed as
an alternative to packing
Cautery
Most anterior epistaxis can be controlled with identification of the
bleeding point and cautery using a headlamp. The vast majority of
posterior bleeding sites can be identified by endoscopy without the use
of general anesthesia
After cautery the patient should be advised against blowing the
nose for about 10 days to allow the area to heal. A greasy antiseptic barrier cream
should be applied several times daily for 2 weeks to
prevent the eschar from drying and coming off with a resulting rebleed.
The ointment should not be placed directly on the area treated but is
best placed inside the rim of the nostril with the tip of the finger, and
“milked up” by massaging the nostril rims, and then sniffed up. This
advice can also be given to patients with a crusted septal area from
picking or excessive drying.
Nasal Packing
If a bleeding point cannot be found, ideally the nose is packed with an
absorbable hemostatic agent that produces minimal mucosal trauma.
Various nonabsorbable packs have been used, but their insertion is
uncomfortable, as is their presence once in position. The insertion of
a pack can cause local mucosal trauma and complicate localization of
the bleeding point The insertion of a nasal pack has
conventionally meant that the patient has to be admitted, although one
study discharged 46 of 62 patients whose nasal airways had been
packed, with outpatient follow-up arranged for 48 hours later If anterior packing
fails, a posterior balloon may have to
be placed and inflated in the postnasal space. An anterior pack is then
placed, and gentle traction used to pull the balloon forward against the
anterior pack this arrangement is held by placement of a clip over the
catheter anteriorly as it emerges through the anterior pack The morbidity and
physical discomfort
associated with nasal packing includes pain, hypoxia, alar necrosis, and
toxemia, and is well described in the literature; Packing not only traumatizes the
nasal lining but also can
cause cardiorespiratory complications and local infection.
The role of prophylactic systemic antibiotics in patients who have
nasal packs is not well established. If the patient does not experience rebleeding
within 12 to 24
hours, the packs should be removed
removal.” Endoscopic sphenopalatine
artery ligation (ESPAL; see later) has replaced the need for
posterior nasal packs, oLigation od sphenopalatine arteryLigation of ant ethmoid
artery
Ligation of posterior ethmoid artery
Ligation of external carotid artery
Angiography and embolization
Septal surgery
When epistaxis originates behind a prominent septal deviation or vomeropalatine
spur, septoplasty
or submucosal resection (SMR) may be required to access the bleeding point. Some
authors have
advocated septal surgery as a primary treatment for failed packing. The rationale is
that by
elevating the mucoperichondrial flap for septoplasty or SMR, the blood supply to
the septum is
interrupted and haemostasis secured. Cumberworth et al. showed a strategy
involving SMR and
repacking to be more effective and economic than ligation in patients who had failed
with packing.
Embolization
Embolization under angiographic guidance has been shown to control severe
epistaxis in between
‫المحاضره السادسه‬
Nasal obstruction
Nasal Breathing Function
During normal nasal breathing, air passes through the anterior nares
over the nasal mucosa to the nasopharynx, with resulting humidification,
cleansing, filtering, and warming of the air but without the sensation
of obstruction. These functions are influenced by changes in the
natural environment, normal physiologic reflexes, normal anatomic
variations, and pathologic conditions
Nasal Septal Deviation
Nasal septal deviation is an asymmetric bowing of the nasal septum
that may compress the middle turbinate laterally, narrowing the middle
meatus Bony spurs are often associated with septal deviation,
which may further compromise the ostiomeatal unit. Nasal septal
deviation is usually congenital but may be a posttraumatic finding in
some patientslife
in
utero onwards there are many risks of nasal trauma in which the septum
is involved. Therefore, in adulthood a straight septum is more the exception than the
rule
A straight septum is the exception rather than
the rule.
Cleft lip and palate
are two of the most common congenital conditions in which the septum is
involved, not only because the basal support of the septum is missing, but also
because surgical
closure at a very young age causes scar formation that inhibits further development
of the
surrounding structures
Septal trauma is very common. It may occur at any stage of life. Often a septal
deformity is the
only sign of trauma, which previously went unnoticed or was forgotten
so the causes of septal deviation
Trauma
Minimal with caecerian section
Moderate with normal vertex presentation
Severe with persistant occipitoposterior position
Genetic
Can be divided to
Spur……sharp angulation occur at junction of vomer with septal cartilage usually
result of vertical compression force
Deviation…….c or s shape involve cartilage and bone
Dislocation….lower border of septal cartilage displaced from its medial position into
one of the nostril
The symptoms and signs accompanying septal deviation may be nasal blockage,
dryness,
crusting, bleeding, itching, rhinorrhoea, anosmia, headache and cosmetic
complaints
examination
First, the mucosa is inspected for swelling, vulnerable
blood vessels, secretions, pus, crusts, atrophy and dysplasia. Congestion of the
mucosa can mask
or accentuate pathology related to the skeleton, such as septal deviations, spurs and
crests. In
order to observe these properly, decongestion by adrenaline or similar is strongly
recommended
In
rhinomanometry, two graphs are produced, one representing the relationship
between the
pressure and flow in the right half of the nose and the other in the left half of the
nose
Acoustic rhinometry is a means of measuring the cross-sectional area of the nose
INDICATIONS FOR SEPTOPLASTY
Nasal obstruction, crusting, rhinorrhoea, post-nasal discharge, recurrent sinus
pressure or pain,
epistaxis, headache, snoring and sleep apnoea
In septoplasty four general principles
1 Incision
2 Exposure
3Mobilization and straightening
3 fixation
Nasal polyp
It is around ,smooth,translucent,soft,yellow or pale structure results from prolapsed
lining of ethmoid sinus
Aetiology
1 bernouilli phenomenon
If there is constriction the pressure will drop result in prolapse of mucosa
2 polysaccride changes in ground substance
3vasamotor imbalance when patient is not atopic
4 infection
5 allergy 90% or more of polyps have eosinophil and threr is association with
asthema,and the nasal finding mimic allergy(rhinorrhea,sneezing &nasal
obstruction
Incidence
It is a disease of adult, male predominance.
If present below 2 year think of meningocele
If present below 10 year think of cystic fibrosis
Any child with nasal polyps should be regarded as having cystic fibrosis until
proved otherwise
Unilateral nasal polyp need histopathological study
Sign and symptoms
☻Polyp seen by anterior rhinoscopy occasionally
seen normal externally
☻ Mouth breathing due to nasal obstruction which
is constantly present but of
varying degree
depending on the size of polyp
☻ Watery rhinorrhea
☻ Post nasal drip
☻ Anosmia
☻ Hyponasal voice
☻ Hypertelorism may develop if patient develop
polyp befor fusion of facial
bone
Management
Anteroir rhinoscopy is enough to diagnose nasal polyp
Plain x-ray
CT scan
Nasal polyp treated either medically by short course of systemic steroid or
intranasal steroid(betamethasone) or steroid nasal drops for one month this
depend on the extent of the polyposis
Surgical treatment
1 simple polypectimy
2 intranasal ethmoidectomy which done
endoscopically
3 external ethmoidectomy
Antrochoanal polyp
Antrchoanal polyps are a separate entity,this polyp has two components,a solid
nasal one and a cystic maxillary one
It is less common arise from maxillary antrum and prolapsed through the ostium of
the sinus to the nasal cavity and nasopharynx
It is common in adolescence
Ther is no place of medical treatment in antrochoanal polyp
Septal haematoma
It is due to collection of blood beneath the mucoprechondrium of the nasal septum
this collection interfere with the vitality of the cartilage ,the cartilage remain
viable for 3 days more than 3 days the chondrocyte die lead to absorption of
the cartilage
Clinical pictures
Nasal obstruction---complete bilateral
nasal obstruction
Discomfort
Septal swelling soft red in colour
Complication
Septal abcess
Cartilage necrosis
Nasal saddle deformity
Treatment
Simple aspiration ---if haematoma is small
Incision and drainage
Packing to obliterate dead space with or without quilting suture
Systemic AB
Septal abcess
*Mostly due to trauma 75%
*Infective –measle,scarlet fever,furenculosis,AIDS.
*Complicate ethmoid and sphenoid sinus infection
Complication
Spread infection to orbit,meningies,brain,cavernous sinus
Clinical pictures
Sever pain
Septal swelling
Nasal obstruction
Pyrexia
Treatment
Immediate drainage
Systemic AB
Reconstruction of the defect in the acute phase will reduce growth impaction
Fracture nasal bone
Treatment of nasal fractures was first recorded 5000 years ago during the early
Pharonic period in
Ancient Egypt
Delays in management can result in significant cosmetic
and functional deformity that is often a cause for subsequent medicolegal action
The prominence and delicate structure of the nose make it vulnerable
to a broad spectrum of injurywhich accounts for why it is the most
frequently fractured facial bone.
Sports, falls, and assaults are the
usual mechanisms responsible for the majority of nasal fractures, with
alcohol consumption being an important contributing factor in many
cases. Males are affected approximately twice as often as females
in both the adult and pediatric populations, with a peak incidence
occurring during the second and third decades of life
Deformity, swelling, epistaxis, and periorbital ecchymosis are signs that
are suggestive of nasal fracture, whereas bony crepitus and nasal segment
mobility are diagnostic
Pathophysiology
Understanding the process by which nasal fractures occur and how
injuries to key areas of support can alter appearance and function are
essential to appropriate treatment. Variables such as force, impact direction,
nature of the striking object, patient’s age, and other host factors
will influence the pattern of injury to both the bony and cartilaginous
components of the nose.
The cartilaginous portions of the external nose are able to absorb
a greater amount of force without fracture as compared with the bony
components,
Pattern of fracture
Nasal fractures can be subdivided into three broad categories that characterize the
patterns
of damage sustained with increasing force. This classification has some practical
utility as each
category of fracture requires a different method of treatment
CLASS 1 FRACTURES
Class 1 fractures are the result of low–moderate degrees of force and hence the
extent of
deformity is usually not marked. The simplest form of a class 1 fracture is the
depressed nasal
bone. The fractured segment usually remains in position due to its inferior
attachment to the upper
lateral cartilage which provides an element of recoil. The nasal septum is generally
not involved. In the more severe variant, both nasal bones and the septum are
fracturedClass 1 fractures tend not to cause gross lateral displacement of the nasal
bones and may not
even be perceptible. Deformity generally results from a persistently depressed
fragment, which is
often due to impaction of the flail segment beneath the residual nasal bone. In
children, these
fractures may be of the ‘greenstick’ variety and significant nasal deformity may
only develop at
puberty when nasal growth becomes accentuated
Class 2
fractures are
the result of greater force and are often associated with significant cosmetic
deformity. In addition to fracturing the nasal bones, the frontal process of the
maxilla and septal
structures are also involved. The ethmoid labyrinth and adjacent orbital structures
remain intact.
Class 3
fractures
are the most severe nasal injuries encountered and usually result from high
velocity trauma. They are also termed naso-orbito-ethmoid fractures and often have
associated
fractures of the maxillae. The external butresses of the nose give way and the
ethmoid labyrinth
collapses on itself. This causes the perpendicular plate of the ethmoid to rotate and
the
quadrilateral cartilage to fall backwards. These movements cause a classic, ‘piglike’ appearance
to the patient, with a foreshortened saddled nose and the nostrils facing more
anteriorly, like the
snout of a pig. There is also telecanthus, which may be exaggerated further by
disruption of the
medial canthal ligament from the crest of the lacrimal bone
Management
Look after • details of how the injury was sustained;
• nasal obstruction;
• change in appearance;
• epistaxis;
• hyposmia;
• watery rhinorrhoea;
• visual disturbance;
• diplopia;
• epiphora;
• altered bite;
• loose teeth;
• trismus
Examination
deviation, depression, step deformities;
• mobility, crepitus, specific areas of point tenderness;
• generalized swelling;
• skin lacerations;
• septal fracture/haematoma/abscess/perforation;
• mucosal lacerations
Investigation
The need for nasal x-rays is controversial and in many places it is actively
discouraged. Unlike
other fractures, nasal x-rays are not required in order to make the diagnosis or aid
subsequent
reduction.
Treatment
A very significant number of patients do not
require any active treatment.
Many do not have a nasal fracture and, in those that do, the fracture
may not be displaced.
Soft tissue swelling can produce the misleading appearance of a deformity
which disappears as the swelling subsides. Reassurance is all that these patients
require and
some may heed suggestions to avoid further trauma. Topical vasoconstrictor drops
are helpful to
alleviate congestion and obstructive symptoms. A reexamination about five days
later is prudent
where there is uncertainty about the need for reduction.
A large number of patients will have a preexisting nasal deformity caused by a
previous incident
Manipulation of the nose will, at best, only return it to its most recent appearance.
Patients that fall
into this category are probably better advised to consider a formal rhinoplasty when
everything has
settled down some months later.
The indications for surgical intervention in the acute phase are significant cosmetic
deformity and
nasal obstruction caused by a septal haematoma
As a general rule, primary care physicians should refer all patients to ENT
departments for
evaluation if there is any deformity or significant nasal obstruction. Patients with a
suspected
septal haematoma should be seen urgently at the first possible opportunity
Reduction of a fractured nose can be performed under local or general anaesthesia.
Local
anaesthesia has the advantages of reduced cost and convenience
Local anaesthetic can be used as a combination of external infiltration with internal
application of
topical preparations. Lignocaine is injected along the nasomaxillary groove,
infraorbital nerve in its
foramen and around the infratrochlear nerve.
Within the nose, sprays, injections, pastes or packs
coated with local anaesthetic are all acceptable, using combinations of cocaine,
lignocaine,
adrenaline and phenylephrine.
The general principle of fracture reduction is to mobilize the fragments first by
increasing and then
decreasing the degree of deformity
Ashe and Walsham forceps
Splints or packs may be necessary, depending on the stability of the reduction and
the surgeon's
preference. A splint or plaster applied to the nasal bridge maintains, to some extent,
the position of
the nasal bones and prevents accidental displacement. Splints are usually kept in
place for about
seven days. It is advisable to refrain from contact sports for at least six weeks
All class 1 and most class 2 fractures can be reduced
with these techniques.
indications for open reduction:17
• bilateral fractures with dislocation of the nasal dorsum and significant (preexistent
or recent) septal
deformity;
• infraction of the nasal dorsum;
• fractures of the cartilaginous pyramid, with or without dislocation of the upper
laterals
For depressed tip or flail lateral fractures that are unstable despite closed reduction
techniques, Kirschner
(K) wires can be used
The external wire can be covered by dressings or plaster to protect the
wires from disruption and the patient from injury. The wires are removed after two
weeks
Management of the nasal septum
Septal fracture is often missed and is a major reason for poor functional and
cosmetic results
Septal reduction can sometimes be performed with Ashe's forceps, but often
requires a Killian or
hemitransfixion incision, elevation of mucosal flaps to expose the cartilage and bone
fragments,
and replacement and/or removal of cartilaginous and bony fragments, as in a
standard
septoplasty