Nose

Question 1

NASAL ANATOMY Outline the key structures & functions of the nose, nasopharynx & sinuses

Answer 1

Nose

• Function: Olfactory, warms/humidifies inspired air, removes particles/pathogens, drains paranasal sinuses
• Vestibule (opening), respiratory (inferior 3/4 ciliated epithelium & goblet cells), olfactory (superior 1/4 olfactory receptors)
• Conchae/turbinates (superior, middle, inferior)
• Bony- superiorly: nasal bones, maxilla & frontal bone
• Cartillaginous- inferiorly: 2x lateral cartillages, 2x alar cartillages, 1x septal cartillage
• Supplied facial artery & facial vein, external: sensory= trigeminal, motor = facial
• Paranasal sinuses, eustachian tube & nasolacrimal duct all drain into

Paranasal sinuses

• Function to decrease weight of head, immune defense, humidifying inspired air, increase vocal resonance
• Formed by nasal cavity eroding into bone- all drain back to nose - 2x frontal (drain via frontonasal duct), 2x sphenoid (drain via spheno-ethmoidal recess), 3x ethmoid sinuses, 2x maxillary sinuses (drain from hiatus semilunaris)

Question 2

NASAL MALFORMATIONS- Choanal atresia
Outline the features, presentation, diagnosis & associated syndromes/anomalies, treatment

Answer 2

Choanal atresia

• Most common congenital anomaly of nose 1/7,000 births, 2:1 F>M, unilateral more common, bony 90%/membranous 10% - 70% associated with congenital abnormaity
• Associated
• CHARGE (10-20% of patients have atresia- CHD7 mutation)
• Treacher-Collins
• Kallman Syndrome
• VATER
• Pfeiffer syndrome
• Presentation
• Bilateral: ENT emergency, increased WOB, cyanosis, desaturations- relieved by crying (mouth breathing)
• Unilateral: asymptomatic, unilateral discharge
• Diagnosis: inability to pass NGT, atretic plate on rhinoscopy/FNE, high res CT to confirm
• Treatment: if complete obstruction (bilateral)- oropharyngeal airway, intubation/tracheostomy
• Trans-nasal repair, stents to keep patent
• Surgical Rx as neonate if nil other co-morbidities, otherwise may consider tracheostomy
• Mitomycin C can prevent granulation

Question 3

NASAL MALFORMATIONS
Congenital septal defects (perforation, deviation) - Congenital midline masses - Pyriform aperture stenosis
Outline the features, presentation, diagnosis & associated syndromes/anomalies, treatment

Answer 3

• *Septal perforation**
• Trauma, infection- syphillis/TB, CPAP
• Can be corrected immediately with blunt realingnment, surgical correction deferred until midface developed
• *Septal deviation**
• Common, usually asymptomatic or cause of nasal obstructive symptoms
• Uncommon unless other abnormalities present (i.e cleft palate)
• *Pyriform aperture stenosis**
• Bony deformity of nasal aperture
• Present at birth, severe nasal obstruction (worsening respiratory distress, improved by crying)
• Can occur alone, or with other malformations (holoprosencephaly, hypopituitarism, cardiac/urogenital malformations)
• Dx CT
• Treat: conservative- oropharyngeal airway, decongestants, humidifiers, reflux Rx, surgical (if feeding/breathing difficulty)

Congenital midline nasal masses
- Occur intra or extranasally, dermoids/gliomas >60%, can communicate with subarachnoid space or intracranially
1. Dermoids: dimple or pit +/- hair on dorsum of nose (can predispose to infections), can fistulate
2. Gliomas: firm
3. Encephalocoeles: enlarge with valsalva/crying
Other haemangiomas, polyps, rhabdomyosarcoma
Diagnosis- clinical, CT if suspect intracranial extension
Treatment: surgical

Question 4

ALLERGIC RHINITIS