diseases of nose by dr. kavitha ashok kumar msu malaysia

Dr Kavitha Ashok kumar

7/25/2014 2Dr. Kavitha Ashok Kumar

Diseases of external nose

Conditions affecting the nasal septum

Infections/inflammation of the nose

Tumours of the nose and nasopharynx

Congenital: Cleft lip/ palate, meningocoele, dermoid, hemangioma, etc.

Inflammatory Non-specific: Furuncle, cellulitis

Specific: Rhinoscleroma, TB, syphilis, leprosy, lupus, etc.

Trauma: Facial trauma, surgical trauma

Neoplastic Benign: Papilloma, rhinophyma

Malignant: Basal cell ca, squamous cell ca.

External nasal skeleton is made of various bones and cartilages

Differential growth rate of these components can give rise to deformed nose

Influenced by Fetal position in utero

Birth trauma

Bony/ cartilaginous/ both

Depressed dorsum- Saddle nose

Lateral deformities Crooked nose- C/ S/ V shaped

Deviated nose

Tip deformities

Alar deformities

‘Frog face’ deformity

Investigations

Radiological: rule out secondary sinusitis

Nasal endoscopy

Preoperative photography

Treatment

Treat associated or secondary rhinitis/ sinusitis

Treat the cause

Surgical treatment: Rhinoplasty/

septorhinoplasty

Acute staphylococcal infection of the hair

follicle commonly seen in the nasal vestibule

Etiology of recurrent furuncle:

Nose picking

Diabetes

Immuno-compromised states

Pain on touching the nose especially the tip/

Pus pointing or swelling over the nose or in

the vestibule

Purulent discharge if it ruptures

Tenderness of the nasal tip/ ala

Not to squeeze the lesion

Dangerous area of the face—infection can spread along the angular and ophthalmic veins to cavernous sinus

Systemic antibiotics and analgesics

I&D if it becomes an abscess

Management of underlying diabetes, if present.

Facial cellulitis

Abscess of the upper lip

Septal abscess

Cavernous venous thrombophlebitis

Vestibular stenosis- in recurrent forms

Diffuse dermatitis of the nasal vestibule

caused by staphlococcus aureus

Etiology:frequent picking of the nose

Clinical features: red ,painful nose.crusts

and scales,fissures

Treatment:clean the crusts,ointment.

7/25/2014Dr. Kavitha Ashok Kumar 19

Thickening and heaped raised lesions of the

tip of the nose due to hypertrophy of the

sebaceous glands

Typically afflicts white males between 40 and

60 years of age (M:F::12:1)

End result of acne rosacea which is actually

more common in females

Medical treatment Treatment of secondary infection and

inflammation with antibiotics and steroids

Surgical: Full thickness excision followed by application

of split thickness skin grafts

Partial thickness "decortication" using cryosurgical techniques, chemical peels, dermabrasion, or Argon/CO2 lasers

Most common malignancy of the skin

commonly affecting the nose

long-term exposure to sunlight and

frequently occur on sun exposed skin, such as

the face, scalp, ears, etc.

> White adult population

> Outdoor workers, sailors and the very fair

skinned.

>50 years and above

Locally slow growing and mutilating lesion

Lymphatic and distant metastasis-uncommon

Early diagnosis- prevents disfigurement of

Treatment: Excision and reconstruction

Prognosis- very good on complete removal

Deviated Nasal

Septum

C – SHAPED

S SHAPED

•Duplication

•SPUR

•DISLOCATION7/25/2014 29Dr. Kavitha Ashok Kumar

• TRAUMA

• DEVELOPMENT ERROR

• HEREDITARY

SIGNSExternal examination

Anterior rhinoscopy

Cottle’s Test

SYMPTOMSNasal obstruction

Headache

Sinusitis

Epistaxis

Anosmia

External deformity

Middle ear diseases

Anterior ethmoidalnerve syndrome.

COTTLE’S TEST

HEMATOLOGICAL

- OTHERS

RADIOLOGY

- X Ray - PNS

DIAGNOSTIC ENDOSCOPY

MEDICAL- EXERCISES

- DECONGESTANTS

SURGICAL- SEPTOPLASTY

-SUBMUCOSAL RESECTION OF SEPTUM(SMR)

Symptomatic DNS

Grafting material-cartilage/bone

Septal perforation closure.

Surgical access

INCISION

ELEVATION OF FLAPS

CORRECTION OF DEFORMITY

CLOSURE

ANTERIOR NASAL PACKING

COTTLE’S LINE

INCISION

FREER’S

KILLIAN’S

ELEVATION OF FLAPS

Inferior

Tunnel

BEFORE AFTER

KILLIAN’S INCISION

FLAP ELEVATED BOTH SIDES

CARTI+ BONY REMOVED

SUPRATIP DEFORMITY

COLLUMELLAR RETRACTION

DORSAL COLLAPSE

SEPTAL PERFORATION

FLAPPING SEPTUM

SEPTOPLASTY

FREER’S INCISION

FLAP ELAVATED ON ONE

ONLY CORRECTION OF DNS

COMPLICATIONS LESS

RESIDUAL DNS

EARLY ANAESTHETIC COMPLICATIONS

SEPTAL HEMATOMA / ABCESS

PERFORATION

LATESUPRATIP DEFORMITY

COLUMELLAR RETRACTION

SEPTAL PERFORATION

RESIDUAL DEVIATION

ATROPHIC RHINITIS

SEPTAL HEMATOMA

SEPTAL ABCESS

Trauma

Submucosal blood vessel

Chondrocytes die

Infected

abscess

Traumatic• Surgery / Cautery / Nose picking

Malignant • Tumours/ Granuloma

Chronic inflammation• Wegeners/syphilis/tuberculosis/candida/lupus

erythematosus/rheumatoid arthritis.

Poisons• Industrial/cocaine addicts/topical

corticosteroids/topical decongestants

Idiopathic

SEPTAL PERFORATION

Anterior Rhinoscopy

Small: upto 1 cm

Medium: 1-2 cm

Large: >2cm

REPAIR

SEPTAL BUTTONS

REPAIR

SURGERY

Aetiology: viral--influenza ,coxsackie , reovirus,ECHO virus and rhinovirus

Pathology: transient vasoconstriction followed by vasodilatation,oedema and increased secretions

Clinical features: Irritation—burning sensation---watery nasal

discharge 2-3days later—fever,nasal obstruction mucopurulant discharge

5-10 days-------recovery

Nonspecific:

Chronic hypertrophic rhinitis

Atrophic rhinitis

Rhinitis caseosa(nasal

cholesteatoma)

Rhinitis sicca

Allergic rhinitis

Vasomotor rhinitis

Specific:

Lupus vulgaris of the nose

Tuberculosis

Syphilitic rhinitis

Leprosy

Rhinosporidiosis

Rhinoscleroma

Clemens Von Pirquet,Viennesse Paediatrician

coined the term allergyin 1906

denoting an altered state of reactivity

to an organic substance

i.e ‘allergen’

Is a protein with a size of 2 to 50 micrometer in diameter & molecular weight of 1000 to

40,000 Daltons

Definition:

It is an IgE mediated

immunological response of the mucosa of

nose charecterized by bouts of sneezing

watery nasal discharge, itching and a sense

of nasal obstruction

Seasonal allergic rhinitis

March to May

(Hay fever)

July to September

Prevalence of

pollens of

grasses, flowers,

trees/shrubs

1. Pollens

Weed pollen

Grass Pollen

Timothy Grass(Phleumpratense)

Cocksfoot(Dactylis glomerata)

Birch, hazel, Plane tree ash

and pine

Tree pollens

NETTLE, DOCK & MUGWORT

FLOWER7/25/2014 56Dr. Kavitha Ashok Kumar

Perennial allergic rhinitis

Throughout the year

Exogenous allergens like

house dust, soaps, creams,

perfumes, egg, odours of fish

coffee

Commonest is house dust which contains faeces of mites- DermatophagoidesPteronyssinus

Seasonal

Paroxysmal sneezing

Watery Nasal

discharge

Nasal obstruction

Itching

Perennial

Frequent colds

persistently stuffy

Loss of smell

Postnasal drip

Chronic cough

Hearing impairment

Nosetransverse crease on nose

pale, oedematous nasal mucosa

turbinates are swollen

thin, watery/ mucoid discharge

Earsretracted T M

Serous otitis media

Investigations

1. Blood - TC, DC, AEC2. Nasal smear for eosinophils3. Nasal provocation tests4. Skin test (Prick/ Scratch/ Intradermal tests)5. Radioallergosorbent test

Antigen (radioactive) + Pt’s serum (Contains IgE)

Radioactive IgE complex (Measured)

a. Avoid possibly known allergen

b. Drugs

1. Antihistamines2. Sympathomimetic drugs3. Corticosteroids

Oral/Local/Injection4. Mast cell stabilizer (2% Sodium

chromoglycate nasal spray)

c. Immunotherapy

Vasomotor rhinitisRhinitis medicamentosaEndocrinal rhinitis

a. Thyroid dysfunctionb. pregnancyc. Honeymoon Rhinitis

Drug induced rhinitisa.Contraceptive pillsb. Antihypertensivesc. Neostigmine

Definition

It is a clinical condition due to imbalance of

autonomic nervous system

Epidemiology

Common in emotionally unstable

persons( Women of 20 to 40 years)

Nasal Obstruction, Rhinorrhoea

Postnasal drip, Head ache, fatigue

Enlargement of turbinates

Mucosa is dusky red in color (Mulberry

like appearance)

Physical exerciseTranquillizersDecongestantsSurgical treatment

Cauterization of turbinatessubmucosal diathermyCryosurgerySurgical resection of turbinatesVidian Neurectomy ( Malcomson 1959) in intractable rhinorrhoea

Atrophy of nasal mucosa & turbinate bones.

• Excessive drying, crusting and infection

Klebsiella colonization

Types:

Primary:Cause is not known Theories proposed : Hereditary,Endocrinal,Racial,Nutritional

def,Infective, Autoimmune.

Secondary: in Syphilis,Tuberculosis Leprosy,Lupus.

Metaplasia from ciliated columnar to

squamous

Type 1;Endarteritis & periarteritis due to

chronic inflammation

Type 2;Vasodilatation of capillaries

Nasal block, epistaxis

(Merciful) anosmia

Choking when detached crusts slips from the nasopharynx to oropharynx

Atrophic pharyngitis & laryngitis

Greenish/grayish black crusts,

Roomy nasal cavity

Shrivelled turbinates.

Nasal douche

3-4 times per day for 2-3 months,then 1-2 times per day indefinitely

280ml of water + 28.4gm(1tsp)Sodium bicarbonate +1tsp sodium diborate + 56.7gm(2tsp) sodium chloride

Drops of 25% glucose in glycerin locally

Local antibiotics

Oestradiol spray

Placental extract

Rifampicin 600mg daily / Streptomycin

Oral KI

Narrowing:

Young’s operation; Modified young’s

Lautenslager’s operation, Submucous inj

of Teflon,Cancellous bone graft.

Transplant: Witmack’s procedure,

Nerve destructive: Ganglion nerve blocks,

Crust formation seen in patients who

work in hot dry surroundings

Confined to anterior1/ 3rd Nose

Treatment

Correction of occupational

surroundings,

Local application of ointment,

Nasal douche.

Mostly affects males

Nose filled with offensive,cheesy

material

Secondary to chronic sinus infection

Treatment-Removal of debris,

drainage of sinus.

Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.

Anatomical considerations:

Osteo-meatal complex

Depending on the site Unilateral/ bilateral Pansinusitis Multisinusitis Maxillary/ frontal/ ethmoidal/ sphenoidal

Depending on whether the sinus is draining or not Open type Closed type

Depending on the pathology Suppurative Non-suppurative

Rhinogenic- Commonest (85%) Usually after viral rhinitis (Flu)

Any form of rhinitis

Dental (Maxillary)

Root abscess, dental procedure, etc.

Trauma RTA, Swimming and diving, FB, barotrauma,

Iatrogenic- nasal packing, septal surgery

Hematogenous- Rare

Mucosal odema of MM Any form of rhinitis: Viral, bacterial, Irritant, allergic,

VMR, atrophic, etc. (environmental factors play role)

Mechanical (anatomical) obstruction of nose/ MM DNS, spur, polyp, hypertrophic turbinate, any mass, FB,

nasal packing, etc.

Pathological mucous Thick mucous (mucoviscidosis, cystic fibrosis)

Primary mucociliary dysfunction

Others: Poor general health, immunodeficiency states, DM, nutritional def., etc,

Str.Pneumoniae

B-hemolytic streptococcus

H.influenzae

Stap. Aureus

Klebsiella pneumoniae

Others

Obstruction to sinus ostium/ meatus

Stasis of secretions (serous-mucinous): Non-suppurative

Secondary bacterial invasion: Suppurative

Severity and resolution depends on Open/ closed. May drain creating accessory

opening.

Organism virulence

Host resistance

Treatment received

Acute inflammatory changes: Hyperemia,

odema, acute infl. infliterate.

Increased activity of the mucous glands

Severe suppuration

Mucosal destruction

Empyema

Bony destruction

Complications

Constitutional symptoms: Fever, malaise, lethargy

Headache/ facial pain: Dull ache, postural/diurnal. Max: Facial, forehead

Frontal: Forehead, “Office headache”

Ethmoid: Between the eyes, may > with eye movement

Sphenoid: Vertex, occipital

Nasal discharge mucous/ mucopurulent/ purulent/ blood stained

Anterior/ postnasal

Nasal obstruction

Cheek/ lid congestion, swelling

Tenderness

Cheek swelling

Lid edema: in ethmoid and frontal

Inflamed nasal mucosa especially the meatus

Discharge in MM/ SM as on anterior/posterior rhinoscopy

Signs of complications

Endoscopic appearance of acute infective sinusitis, with pus

exuding from under the right middle turbinate and down into the

middle meatus.

Clinical diagnosis

Diagnostic nasal endoscopy (DNE)

Radiological X-ray PNS

Water’s view (Occipetomental)

Caldwel view (Occipetofrontal)

Lateral view

Base skull view (Submento-vertical)

CT scan: indicated in impending complications

C/S: rarely done

Postural test

Transillumination

X-Rays PNS

CT Scan

Pus swab

CT – Coronal views centered on OMC

Investigations (cont…)

Coronal CT shows the

inflammatory changes in

the right frontal recess

and anterior middle

meatus (star).

•Acute Sinusitis

Antibiotics

Nasal decongestants (Topical/systemic)

Anti-inflammatory analgesics

Medicated steam inhalation

Mucolytics

Hot fomentation

If not responding to medical treatment

Impending or manifest complications

Depends on the sinus involved

Acute maxillary: Antral washout/ endoscopic MMA

Acute frontal: Frontal trephination/ endoscopic frontal recess clearance

Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy

Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy

Chronic sinusitis

Acute sinusitis or acute exacerbations of chronic sinusitis may give rise to following complications:

Orbital

Intracranial

Osteomyelitis

Septic focus for other infections

Spiking feverLid odema, facial/orbital swellingProptosis, reduced vision, reduced extraoccular movt.Severe headache and hyperirritableProjectile vomitingMeningeal signsHypothermiaAltered sensorium

Common in acute ethmoiditis or frontal sinusitis

Direct spread/ ostitis/ thrombophlebitic Odema of the lidsSubperiosteal abscessOrbitial cellulitisOrbital abscessSuperior orbital fissure syndrome: Deep

orbital pain, frontal headache, progressive paralysis of extraoccular movements

Blindness

A patient with acute ethmoiditis threatening vision.

Anterior cranial fossa and cavernous sinus

closely related

Meningitis

Extradural abscess

Subdural abscess

Frontal lobe abscess

Cavernous sinus thrombophlebitis, etc

•BRAIN, ABSCESS,SINUSITIS

“Acute sinusitis especially in a child should be

treated adequately to prevent consequent

chronic sinusitis or other more severe

complications which may be even fatal”.

DR KAVITHA ASHOKKUMAR

HISTOLOGICALLY BENIGN, LOCALLY

AGGRESSIVE NONENCAPSULATED

VASOFORMATIVE NEOPLASM SEEN

EXCLUSIVELY IN MALE ADOLESCENTS.

MACROSCOPY

WELL CIRCUMSCRIBED .LOBULATED

PURPLE RED MASS

COVERED WITH INTACT MUCOSA

APPEAR DECEPTIVELY AVASCULAR

TWO MAIN CELLULAR COMPONENTS

FIBROUS STROMA

BLOOD VESSEL CHANNELS -- RICH

DISTINCT LACK --SMOOTH MUSCLES

ELASTIC FIBRES

JUVENILE --OCCURS 10 TO 25 YR

NASAL BLOCK --UNILATERAL

EPISTAXIS --80 PERCENT

FACIAL SWELLING

PROPTOSIS

OCULAR SYMPTOMS

WELL DEFINED ROUTES

PLAIN X-RAY --ANT.BOWING OF THE

POSTERIOR WALL OF MAXILLARY

SINUS(HOLMAN-MILLER’S SIGN)

CT-SCAN --BONY INVOLVEMENT

MRI --SOFT TISSUE—INTRA

CRANIAL SPREAD

ANGIOGRAPHY --FEEDING VESSEL

1.ENDOSCOPIC INTRANASAL

2.OPEN ACCESS

# TRANSPALATAL

# MIDFACIAL DEGLOVING

# LATERAL RHINOTOMY

INTRACRANIAL APPR. --SURGERY

--RADIATION

EMBOLISATION

RECURRANCE-30-40%

Most common in southern states of China

Taiwan and Indonesia

Etiology

Genetic

Abnormality in chromosome 1 to 6,

9,11,13,14,16,17,22, and X

Viral -Epstein Barr virus

Environmental – smoking, airpollution

Dietary – Nitrosamines from dry salted

Pathology

Squamous cell carcinoma ( 85%)

Graded in to well, moderately, poorly

differentiated

Lymphoma (10%)

Rhabdomyosarcoma, Malignant salivary

tumour, malignant chordoma (5%)

Clinical features

Age – 4th to 5th decades of life

Male : female - 3:1

Symptoms

Neck mass, hearing loss, Nasal obstruction,

epistaxis, cranial nerve palsies, weight loss

Signs –

proliferative/ulcerative/ infiltrative

Unilateral serous otitis media

Rhinolaliaclausa

Squint and diplopia (CN - VI)

Opthalmoplegia (CN –III, IV, VI)

Facial pain and reduced cornial reflex (CN – V)

Blindness (CN – II)

Jugular Foramen Syndrome (CN - IX, X, XI)

Collet – Sicard syndrome (CN – IX, X, XI, XII)

Horner’s syndrome (cervical sympathetic chain)

Trotter’s triad

Cervical Neck Nodes

Distant metastasis

Investigations

Endoscopy and biopsy

MRI Scan

CT Scan

Serology for Epstein Barr virus

Positron emission tomography (for residual or

recurrent disease after treatment)

Treatment

Irradiation

Systemic chemotherapy

Radical neck dissection

Overall survival is 50 to 80%7/25/2014 118Dr. Kavitha Ashok Kumar

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