Nose Flashcards
Infraorbital orbit carries which nerve?
Complications?
Infraorbit, carries sensation from cheek. If damaged will cause
Anastasia-
3 causes:
Maxillary sinus cancer
Maxillary fracture
Zygomatic fracture
1- Most commonly fractured facial bone?
2- 2nd most commonly fractured facial bone?
1- nasal bone
2- zygomatic bone( mallar prominence)
Has 3 points
1spine temporal bone
2 spine frontal bone
3 spine maxillary bone
Zygomatic bone fracture
Tripod fracture
Flattening of mallar eminence + infraorbital nerve injury (anasthesia of cheek)
Rx of tripod fracture
ORIF
Concha classification
Divided into three
Covered with mucosa are called turbinates space below turbinates called meatus, also 3.
Superior
Medial
(Part of ethmoid bone)
Inferior (Independent bone)
Space which lies above sup. Turbinate
Spheno-ethmoidal recess
Or supreme meatus
As it is present between the sphenoid bone and ethmoid bone
Longest meatus
Inferior meatus
Inferior meatus sinus drainage
Nasolacrimal duct-
Downwards, outwards and backwards
Through the Valve of Hasner
Middle meatus sinus drainage
1 frontal
2 maxillary
3 anterior ethmoidal air cells
Sinuses
Is the largest meatus.
Open into the ethmoidal infundibulum
Superior meatus sinus drainage
Posterior ethmoidal air cells
Supreme meatus sinus drainage
Sphenoid sinus
Most constant and the largest anterior ethmoidal air cell
Bulla ethmoidalis
Anterior most ethmoidal air cell
Agger nasi
Ectopic ethmoidal air cells
1 Most common- Concha bullosa- inside the middle turbinate
2 Holler cell- orbital floor
3 Onodi cell- along the optic nerve
Neonate, preterm, cyanotic at birth, then turns pink as soon as he starts crying
Dx?
Rx?
Dx- Bilateral choanal atresia/ persistence of BNS
At the posterior end of the nasal cavity an opening called Choana is formed usually before birth.
BuccoNasal septum (separates the nasal- oral cavity) is present, then obliterates to form the choana. If it persists there is no passage of air.
Rx-
1st line- McGoverns technique- insert a wide bore nipple to keep oral pathway open for breathing-
Can also use godels airway (orophagyngeal airway)
Definitive- SURGICAL resection of the BNS
Paranasal sinuses
Hollow cavities inside bone
Decrease weight of bone
Responsible for resonance
1- frontal- most irregular
2- sphenoid
3- ethmoidal- also called air cells.
4- maxillary- largest, vol is 15ml. Also called antrum of hymor
Nasal congestion, rhinorrhea, post nasal drip, headache.
Dx
Dx- sinusitis
(sinuses lined by mucosa, drain into the meatus, if blocked cause congestion…infection)
Retro orbital pain- sphenoid sinus
Office headache/ periodic- frontal sinus
Most common- strep pneumonia
Investigations-( diagnostic nasal endoscopy if present)
OR
X-ray paranasal sinuses
OR
CT paranasal sinus(best radiological investigation) check air fluid levels
X-RAYS
1- All sinuses- skull lateral view/ best for sphenoid sinus
2- Waters view X-ray/ occipitomental view
(Best for maxillary sinus)
open mouth wala also called Pierre’s view
closed mouth also present
Done to check the extra sphenoid sinus
3- Caldwells view- best for frontal and ethmoidal sinus. Laterally, pt looking 15-20• downward
Treatment of sinusitis
Medical-
Antibiotic for 3 weeks
NASAL decongestant- for one week w one week gap
Or steroid spray
Surgical-
FESS functional endoscopic sinus surgery. Sone if no relief after 3 weeks of antibiotics.
FESS surgery Complications
Synechiae formation due to fibroblast action after you scrape out the sinuses
To prevent: apply mitomycin C (anti fibroblastic action)
All sinuses are visible on which view of x-ray?
X-ray skull lateral view.
Best view of the X-ray for all sinuses?
Waters view
Post. Ethmoidal air cells not visible tho
Complications of sinusitis
- Pain redness, swelling- periorbital
Called orbital cellulitis
Commonly associated with ethmoidal sinusitis - Potts puffy tumour-
Subperiosteal abscess of frontal sinus
plus damage to the frontal bone (osteomyelitis)
Mucocele complication of a which sinusitis?
Frontal sinusitis
Aspergilloma complication of which sinusitis?
Maxillary sinusitis
Fungal.
Most common cause aspergillosis fumigatus
Fungal hyphae combine together they form a ball called aspergilloma.
1- Most common sinusitis in adult
2- most common sinusitis in children
1- Maxillary
2- Ethmoidal
Sequence of development of paranasal sinuses
M
E
S
F
PRESENT AT BIRTH- Maxillary and ethmoidal
Most developed sinus at birth- ethmoid sinus
Most common benign tumour paranasal sinus
Osteoma
Most commonly in frontal sinus
Most common sinus associated with malignancy
Malignancy = Maxillary
Maxillary sinus carcinoma
Investigation
Investigation - CT scan with no air fluid level, will be eroding born, no biopsy.
What is Ohngrens line + role
An imaginary line that divides the maxillary sinus into 2
extends from the medial canthus of the eye to the angle of mandible
Used for prognostic evaluation:
If cancer is in lower half better prognosis
If cancer is in upper half poor prognosis ( early orbital involvement)
Maxillary sinus carcinoma treatment
Total maxillectomy
Webber fergusson approach followed by radiotherapy
What is Inverted papilloma nose?
Rx
Also called ringertz tumour
Arises from the lateral wall of nose
Grows inside the wall, from mucosa towards submucosa
Unilateral
Locally, invasive,
benign, but aggressive
Rx
FESS
Pt taking nasal congestants for 3 month
Stop and develops rebound congestion
Dx
Rx
Rhinitis medicamentosa
Rx stop taking nasal decongestants
Start steroid nasal spray.
Sneezing,
increased watery discharge,
Nasal irritation ,
nasal obstruction,
mucosa is pale, swollen or bluish, inferior turbinate hypertrophy
Allergic rhinitis
Types of allergic rhinitis
Seasonal- pollen
Penennial- house dust mites
Less common after 50 years
Allergic rhinitis
Patho
Type 1 hypersensitivity
Increased Ig E levels and eosinophilia
Pale then later Bluish mucosa due to venous stasis.
Mucosa may become edematoud to form polyp esp in ethmoidal air cells
Generalised mucosal thinkening
Increased nasal discharge on cold exposure
Vasomotor rhinitis
Rx
Antihistamines
What are Nasal polyps?
Prolapsed pedunculated edematous mucosa
Nasal polyp types
Antrochoanal polyp / killians polyp
Ethmoidal / nasal polyp
Antrochoanal polyp / killians polyp
Grows from maxillary sinus towards The choana
Age- children
Most common cause- redcurrant/ chronic infections
Type- unilateral and single
Rx- FESS/ endoscopic polypectomy
Ethmoidal/ nasal polyp
Arises from the ethmoidal air cells
Age- adults
Most common cause- chronic allergy
Type- bilateral and multiple
Rx- steroid spray. If fails then FESS
Pt. Is known case of bronchial asthma, develops ethmoidal nasal polyp, he will be allergic to which drugs?
ASPIRIN
SAMTER’s TRIAD - BAN
B- bronchial asthma
A- allergy to nsaids (aspirin)
N- ethmoidal nasal polyp
Aspirin-exacerbated respiratory disease (AERD)
also known as Samter’s Triad, is a chronic medical condition that consists of three clinical features: asthma, sinus disease with recurrent nasal polyps, and sensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) that inhibit an enzyme called cyclooxygenase-1.
Mucormycosis/ ROC MM
Also called rhino orbital cerebral mucormycosis
MCC- rhizopus/ mucor (rhizomycetes species)
Since the fungus is ANGIO INVASIVE (damage to blood vessels)
it will penetrate and cause ischemia
Leading to necrosis and BLACKENING OF EVERYTHING.
== BLACK ESCHAR on nose eyes or pallate
In mostly immunocompromised pt. And on steroids
Life threatening
Investigations- MRI head (rule of cerebral involvement)
Nasal swab for mucor
DRUG OF CHOICE- LAMP (liposomal amphoterecin B)
Rx of choice- debridement +- exenteration (enucleation plus bones also)
Pt w c/o infertility and history of anosmia
Dx-
Kallman’s syndrome
(Hypogonadotropic hypogonadism) low fsh and lh
Esthesioneuroblastoma
Malignancy of olfactory nerve
Complete loss of sense of smell
Investigation- MRI
Rx- surgical excision
1st and smallest cranial nerve- olfactory nerve
Framework of external nose
Upper 1/3rd bony.
1 pair of bone
Lower 2/3rd is cartilaginous.
3 paired cartilages
Cartilages of nose
3 paired cartilages, total, six.
Biggest -
1. upper lateral Cartlidge
Below
2. Lower lateral Cartlidge also called alar cartilage.
At the junction between upper and lower ,
3. Sesamoid Cartlidge also called lesser alar.
Narrowest portion of nasal cavity
The junction between the upper and lower lateral cartilage called nasal valve.
Most common side of blockage
Test to check nasal patency
Cottles manoeuvre
Rhinophyma (potato nose)
Hyper trophy of sebaceous glands of skin of external nose
Turn on the
Rx. Laser excision with skin grafting.
Subtype of acne rosacea
Saddle nose
Depression over external loss, mostly caused due to trauma because of damage of bone or cartilage
or granulomatous conditions like leprosy syphilis or SLE
Rx. Augmentation rhinoplasty. Iliac crest used as a draft
Basal cell carcinoma/ rodent ulcer
- Ulceration/ necrosis at the base and rolled out edges
- Seen on medial canthus or lateral wall of the nose
- Most common cancer of skin of face
- Will never metastasise ( brain tumour also never mets)
Rx. Wide local excision. WLE
OR EXCISIONAL BIOPSY
Rhinolith
Nasal stones.
Complains of nasal blockage, foul smell and discharge. Decrease sense of smell. Epistaxes also common if sharp edges.
Rx. Endoscopic removal
Stones usually formed by calcium carbonate, crystals, magnesium carbonate, magnesium phosphate
Nasal myiasis
Maggot infestation in the nose by larvae of Cryosomia specie (housefly)
Homeless person with poor hygiene.
Foul-smelling, hyposmia, anosmia, nasal blockage
Rx. Maggot oil(chloroform)
OR Turpentine oil
Most common fractured facial bone
Nasal bone
Nasal bone fracture
Rx. Immediate closed reduction.
With ✨walsham forceps.✨
Before edema sets in.
It’s patient comes late with edema wait for 7 to 10 days for edema to subside, then go for a closed reduction.
Nasal septum fracture types
- Force from front causes horizontal fracture- jarjjaway fracture
- Force from below causes, vertical fracture - chevallet fracture
Rx. Closed reduction with ✨ash septum forceps, ✨ which are angulated.
A for Ash
A for Angulated
What are 3 main parts of Medial wall of nose (nasal septum)
1 septal/ quadrangular cartilage
2 Vomer
3 Perpendicular plate of ethmoid bone
Minor contributions in the nasal septum
1 Crest of maxillary and Palatine bone
2 rostrum of sphenoid bone,
3 nasal spine of the maxilla,
4 nasal spinal frontal bone
Deviated nasal septum
diagnosis
treatment
Clinical features:
-external is a deformity
-Crusts in wider side
-Epistaxes due to sharp spur
-Sludders neuralgia: headache, due to -irritation of nerves by the spur
-nasal congestion on the narrow side
Hyper trophy of inferior turbinate in the wider/patent side- strawberry/ mulberry nasal mucosa
Rx- septoplasty
(Synechie may form so give mitomycin C)
Most patients are asymptomatic
strawberry/ mulberry nasal mucosa
Hyper trophy of inferior turbinate in the wider/patent side in DEVIATED NASAL SEPTUM
Hx of fist fight
Complaint of nasal blockage
With BL Nasal swellings
Dx
Rx
Septal hematoma
Rx-
1 aspiration/excision and drainage followed by packing
Septal perforation
Caused by trauma.
If hematoma not treated it will become infected and necrotise the septum making an opening/ hope
Septal perforation caused by which local anaesthetic
Cocaine
How does cocaine cause nasal perforation?
It is a potent vasoconstrictor, if taken in high doses and chronically it can cause constriction and stop the blood supply that will cause necrosis and perforation
Bony septal perforation caused by what
Syphilis
Septal perforation in cartilage caused by what
Leprosy and tuberculosis
Septal perforation of both, bone and cartilage caused by what
Wegeners granulomatosis/ granulomatosis with polyangitis
Septal perforation
treatment
diagnosis
Characteristic whistling sound
Treatment: septal buttons or obturators
Female patient with nasal stuffiness, + merciful anosmia (foul smell)
Crusts and nasal cavity
Atrophic rhinitis
More common in females around puberty
Atrophic rhinitis caused by?
Autoimmune
Vitamin D deficiency
Oestrogen deficiency
Klebsiella ozeane
Also known as ozeana
Why is there an excessive crust formation in atrophic rhinitis?
As there is atrophy of the mucosa, submucosa and bony part of the turbinates, the nasal cavity will become rider, some more at pass through causing excessive drying of mucus.
Mucus will also get infected causing foul smell.
What is merciful anosmia?
When the person has lost sense of smell, and there is foul smell coming from the crust formation, but the patient himself cannot smell it
Why is there merciful anosmia in atrophic rhinitis?
As there is a trophy of the turbinates, there is also a trophy of the olfactory nerves present at the apex of the nasal cavity that causes complete anosmia
Atrophic rhinitis treatment
Treatment of choice: alkaline nasal douching
Solution of NaCl and NaCo3 pushed into the nasal cavity with the help of a syringe, so all the crusts come out getting rid of the foul smell
Surgery is done after this fails
Sergio choice is — modified Young’s operation
Modified Young’s operation
Permanent partial closure of both the nasal cavities
Non-modified was you close one cavity for six months and then open it and then close the other cavity for another six months
Male from Rajasthan
History similar to atrophic rhinitis
Obstruction, Crust, foul smell, merciful anosmia
+
Nodules over external nose, and Woody hard nose
Rhinoscleroma/ woody nose
Rhinoscleroma
Cause
Bacterial infection caused by klebsiella rhinoscleromatis
Also known as, fresh bacillus
Stage 1 exactly similar to Atrophic rhinitis (catarrhal)
Stage 2 woody nose (granulomatous)
Stage 3 complete fibrosis of nose (sclerotic)
Rhinoscleroma biopsy histo pathology
The Mikulicz cell is a large macrophage with clear cytoplasm that contains the bacilli
Russell’s bodies
Rhinoscleroma treatment
Streptomycin, plus tetracycline
Strawberry/Mulberry nasal Mass scene in which condition
Rhinosporidiosis
Rhinosporidiosis
Cause
Rx
Caused by rhinosporidium seeberi
Which is an aquatic protozoa
Pt will come w strawberry mass and epistaxis
Rx. Excision of mass and cauterisation of the base
DOC- to prevent recurrence = dapsone
CSF Rhinorrhea
Cause
diagnosis
Cause- trauma or iatrogenic (during surgery) infection or erosion of the CRIBRIFORM PLATE
diagnosis-
1- ask patient to sniff, sniffing back will not be possible with CSF
2- handkerchief test- spread some fluid on the handkerchief, will remain
Watery with CSF
3- if there’s bloody discharge, take sample on a filter paper, the blood and CSF will separate out in concentric rings target sign
Blood will form a halo around CSF halo sign
CSF rhinorrhoea investigation
Best investigation gold standard - send sample for culture and look for (estimation) protein called beta 2 transferrin
If Present, it is CSF.
Best radiological investigation-
HRCT skull base
CSF rhinorrhea Rx
Conservative management-
ask patient for bedrest
Give mannitol
to decrease intracranial pressure
Give antibiotics to avoid meningitis
Continue for 7 to 14 days after that do surgical repair
Blood supply of nose
Above the middle turbinate= (20%)
internal carotid artery branches
- Anterior ethmoidal artery
- posterior ethmoidal artery
Below the middle turbinate= (80%)
External carotid artery branches:
- Superior labial artery branch of facial artery
- Sphenopalatine artery and greater palatine artery = branches of maxillary artery
Which artery is known as the artery of epistaxes?
Sphenopalatine artery
Most common site for epistaxes
Littles area
At the anteroinferior part of the nose were the 5 arteries form a plexus known as kiesselbach’s plexus.
The Kiesselbach plexus arteries
anterior ethmoid,
greater palatine,
sphenopalatine,
and superior labial artery
Which artery is not part of Keisselbachs plexus
Posterior ethmoidal artery
Most common type of epistaxes in children
Anterior epistaxis
mostly caused by Nail picking and trauma
Causes of epistaxis
Bleeding disorders:
Von Willebrand disease and
Haemophilia
Deficiency of clotting factors: cirrhosis, nephrotic syndrome
thrombocytopenia: ITP and Dengue
Person suffering from epistaxis, on pinching nostrils the bleeding did not stop, on examination, bleeding side was not identified
next line of management?
1- Pinch nostrils for 5 to 7 minutes. Ask patient to set bending forward.
2- If fails go for electrical or a chemical cauterisation after identifying bleeding side.
Use silver nitrate, or phenol solution for chemical cauterisation
3- packing ( either posterior or anterior using foleys catheter or nasal pacing catheter)
If fails
4- ESPAL - endoscopic sphenopalatine artery ligation
If ESPAL - endoscopic sphenopalatine artery ligation fails (flowchart)
1-Sphenopalatine arteryligation
2-Maxillary artery ligation
3-External carotid artery ligation
DO NOT LIGATE AFTER THAT (ICA)
LIGATE the ant. And post. Ethmoidal arteries
Cause of epistaxes in the elderly
Uncontrolled hypertension.
More likely, there is posterior epistaxes from the Woodruff’s plexus which is a venous plexus
Maxillary sinus carcinoma types
1- nickel exposure- squamous cell carcinoma
2- hardwood dust/ furniture dust- adeno carcinoma
Pt. presents with:
weight loss,
cheek Anastasia,
cheek mass,
nasal blockage
Dx?
Maxillary sinus carcinoma
BLACK ESCHAR on nose eyes or pallate
Rx
Mucormycosis
Allergic rhinitis investigations
- Total and differential count: Eosinophil count may rise in the peripheral blood. This is not a very sensitive test and may be normal.
- Nasal smear: made during active phase. may show large number of eosinophils.
- Serum IgE level: A high serum IgE level is present in patients having allergy.
- RAST test: Radio-Allergo-Sorbent test (RAST) measures the specific IgE antibodies concentration in the patient’s serum.
- Nasal provocation test: In this test, different allergens are applied on the patient’s nasal mucosa and its response is noted. It is similar to skin test with specific allergens.
- Skin tests: Specific allergens are given intradermally and its response is noted.
- Imaging studies:
Plain X-ray PNS (water’s view) or CT scan nose and PNS without contrast.
Allergic rhinitis Rx
- Avoidance
- Antihistamines
- Decongestants (pseudoephedrine) 10days
- Mast cell stabilisers (sodium chromoglycate 2%)
- Leukotriene inhibitors (montelukast zafirlukast)
- Corticosteroids (oral and topical)
- immunotherapy
- Anticholinergics (topical ipratropium bromide)
- Anti- IgE antibody (omalizumab)
- Surgical: only for inferior turbinate hypertrophy or polyps
ARIA classification for allergic rhinitis
- Mild:
- Sleep: Normal
- Daily activities (includes sports):
Normal
- Work or school activities: Normal
- Severe symptoms: No - Intermittent
Symptoms present for:
- < 4 days/week
- or < 4 weeks - Persistent
Symptoms present for.
- > 4 days/week
- or > 4 weeks - Moderate to Severe
One or more of the following present.
- Sleep: Disturbed
Daily activities: Restricted
- Work or school activities: Disrupted
- Severe symptoms: Yes
Viral rhinosinusitis
Common cold or coryza
Air borne
Adenovirus, rhinovirus, coxsakie virus
1-7 days resolution
Irritation and burning in the nose.
Sneezing.
Rhinorrhea: watery.
Nasal obstruction.
Fever.
Headache.
Malaise and bodyache.
Dx.
Viral rhinosinusitis
Rx viral rhinosinusitis
• Mainly symptomatic.
• Bed rest.
• Antihistamine: for rhinorrhea and irritation.
• Nasal decongestant: for nasal obstruction.
• Analgesic and antipyretic.
• Steam inhalation.
• Antibiotic: if Secondary bacterial infection
Post op after care for septal surgery
NPO: 4 to 6 hours in cases of G/A.
• Position: supine with the head end up.
• Soft diet.
• Antibiotic and analgesic.
• Removal of pack: after 24 to 48 hours.
• Cleaning of the nose: nasal douching.
• Application of topical lubricant in the nose.
• Removal of splints: if placed after 10 to 14 days.
Types of DNS
‘C’ shaped septum
‘S’ shaped septum
septal spur
thickened nasal septum.
4 Types of cartilage settings after fracture
- edge to edge angulation
- angulation with overlap
- bowing of edges
- duplication of edges.
Nasal foreign body
Pt may come w unilateral foul smelling discharge, nasal congestion
Istg. X-ray lateral view
Rx.
Under general anaesthesia
Flat things- Removal thru crocodile forceps
Round- hook or probe
V large pushed to the nasopharynx and removed thru mouth
Nasopharyngeal angiofibroma
Patho
-benign but locally aggressive tumor
- most common benign tumor of the nasopharynx.
- mostly in adolescent males so is also called a juvenile angi-ofibroma.
-age of onset: second decade.
- arises from the posterior part of lateral wall of the nose close to sphenopalatine foramen.
Nasopharyngeal angiofibroma features
Profuse and recurrent epistaxis- first and most prominent presenting symptom.
progressive nasal obstruction
hyponasal voice
obstruction of the eustachian tube, conductive hearing loss
middle ear effusion
facial swelling, proposis, diplopia, broadening of nasal bridge,
palatal bulge and cranial nerve palsies
Frog face deformity
On examination in the nose and nasopharynx, a pink or purplish lobulated soft mass is seen
The mass may bleed on touch.
Nasopharyngeal angiofibroma investigation
1st- CECT
Will show characteristic anterior bowing of the maxillary sinus knowns as the hollman miller sign or antral sign
X-ray lateral and waters view
LAngiography
Biopsy is ❌
Nasopharyngeal angiofibroma Rx
Surgical excision of a tumor is the treatment of choice.
- Trans-antral.
- Transpalatal.
- Trans-mandibular.
- Lateral rhinotomy.
- Lateral pharyngeal.
- Mid facial degloving.
- Endoscopic (FESS).
Profuse bleeding during surgery is the main problem in removal of nasopharyngeal angiofibroma.
super selective embolization is done prior to surgery. Usually maxillary artery
Common causes of unilateral nasal obstruction
Vestibule
• Furuncle
• Vestibulitis
• Stenosis of nares
• Atresia
• Nasoalveolar cyst
• Papilloma
• Squamous cell carcinoma
Nasal cavity
• Foreign body
• Deviated nasal septum (DNS)
• Hypertrophic turbinates
• Concha bullosa
• Antrochoanal polyp
• Synechia
• Rhinolith
• Bleeding polypus of septum
• Benign and malignant tumours of nose and paranasal sinuses
• Sinusitis, unilateral
Nasopharynx
• Unilateral choanal atresia
