NOSE - Chapter 2 and 3 Flashcards
Congenital posterior choanal atresia.
It is the commonest congenital anomaly of the nose.
Aetiology :
* Persistence of bucco-nasal membrane (between the nose and nasopharynx).
Types :
* Bony or membranous.
* Unilateral or bilateral.
* Partial or complete.
The commonest type is unilateral complete bony atresia.
Clinical picture :
* Unilateral : may not be noticed until late in childhood when the patient notices permanent unilateral nasal obstruction and discharge which does not move on blowing the nose.
* Bilateral :
1- Early :
- at or soon after birth.
- Cyanosis which may be cyclical or during suckling.
- Asphyxia and death may occur because infant is obligatory nasal breather. It takes about 2 weeks to learn breathing by mouth.
2- Late : If the infant passed asphyxia, there may be :
- Nasal discharge.
- Mouth breathing.
- Failure to develop taste and smell.
Diagnosis :
* Mirror test: No condensation of air on a cold mirror.
* Catheter can not pass into the nasopharynx.
* X-ray with lipidol (dye): The dye cannot pass to the nasopharynx.
* C.T determines the thickness of the bony atresia and differentiate between bony and membranous atresia.
* Endoscopic examination.
Treatment :
* Bilateral cases is a neonatal emergency : oral air way or endotracheal intubation.
* Transnasal endoscopic (preferred) or transpalatal excision of the atretic plate (obsolete).
Foreign body in the nose
Most commonly children.
Types :
* Vegetable foreign bodies: such as pea and bean. Their fatty acids are irritating → inflammatory reaction.
* Non-vegetable foreign bodies: such as button and bead.
Clinical picture :
* Unilateral offensive purulent nasal discharge: may be blood-stained (pathognomonic).
* Unilateral persistent nasal obstruction.
* The foreign body is seen by clinical or endoscopic examination.
Complications :
* Rhinitis and sinusitis.
* Formation of rhinolith i.e a nasal stone. Due to precipitation of calcium salts from the nasal secretions on a foreign body, blood clot or inspissated mucus.
Treatment:
* Removal by a hook or forceps.
* General anesthesia with cuffed endotracheal intubation is necessary:
- If the patient is uncooperative.
- If the foreign body is impacted and it is necessary to push it back to the pharynx to get it through the mouth.
- To avoid inhalation of the foreign body in the lower airway.
Fracture nasal bones
Due to direct trauma to the nose.
Symptoms :
1- History of trauma.
2- Pain, swelling and deformity of the external nose.
3- Epistaxis.
4- Nasal obstruction (septal deviation or haematoma).
Signs :
1- Deformity depressed bridge or lateral displacement.
2- External swelling : edema, surgical emphysema.
3- Tenderness and crepitus on palpation.
Investigations :
Plain x-ray of the nasal bones (may be of medico-legal importance).
Treatment :
a- Fracture without deformity : Medical treatment only for the swelling and edema for one week.
1- Analgesics for pain.
2- Anti-inflammatory for edema.
3- Cold compress for 24 hours follow by warm ones to reduce edema.
b- Fracture with deformity (either immediately after trauma or following medical treatment) : Reduction of the fractured nasal bone using Walsham’s forceps followed by splinting.
c- If the patients presents late (more than 2 weeks) : Rhinoplasty
N.B :
* Septal fractures with deviation are corrected using Ash’s forceps.
* Septal hematomas : evacuation with anterior nasal pack.
* Treatment of epistaxis
Oro-antral fistula
A fistula between the oral cavity and the maxillary sinus.
Aetiology :
* Traumatic : is the commonest :
- Alveolar fistula as a complication of tooth extraction (2nd premolar or 1st molar).
- Sublabial fistula as a complication of Caldwell-Luc operation.
* Inflammatory : Osteomylitis of maxilla, syphilis and non healing granuloma.
* Malignant fistula as a complication of malignant tumour of the palate or the max. antrum.
Clinical picture :
1- Unilateral nasal regurgitation of fluid.
2- Unilateral offensive nasal discharge.
3- On blowing the nose, air escape from the mouth.
4- The fistula can be seen through the oral cavity.
Investigations :
CT scan shows maxillary sinusitis and site of the fistula.
Treatment :
a- Small recent fistula : may heals spontaneously.
b- Large and old fistula : surgical closure by a buccal or palatal flap.
c- Treatment of maxillary sinusitis, inflammatory and neoplastic conditions.
C.S.F. Rhinorrhea
It is the leakage of cerebrospinal fluid through the nose. This may take place through :
a- The roof of the nose (cribriform plate).
b- The roof of frontal, ethmoid or sphenoid sinuses, or rarely
c- Middle ear via Eustachian tube. The main fear is the possibility of infection causing meningitis.
Aetiology :
* Traumatic : is the most common. Trauma may be accidental (skull base fractures) or surgical (during sinonasal surgery).
* Neoplastic : due to invasion of anterior skull base by malignant tumors.
* Inflammatory : e.g. gumma of syphilis.
* Spontaneous or idiopathic : no cause can be detected.
Clinical picture :
* Unilateral watery nasal discharge : which is clear, colourless, has salty taste, dose not stiffen the handkerchief increased by coughing, straining and leaning forwards.
* Headache : may be due to high CSF pressure (caused by Brain tumor or idiopathic) or low CSF pressure (caused by CSF leakage).
Complications : Meningitis.
Investigations :
1- Biochemical analysis of discharge, CSF is characterized by :
- Clear, colourless and contain no mucus.
- Contain sugar more than 30 mg%.
- Reduce Fehling’s solution.
- Contain B2 transferrin, which is diagnostic (B2 only in CSF).
2- CT with intrathecal metrizamide: can detect the site of leakage.
3- MRI
Treatment :
A- Conservative : Most traumatic cases heal spontaneously :
- Bed rest in semi sitting position with the head-up.
- Avoid coughing and straining.
- Avoid blowing of nose.
- Avoid nasal medications (drops or packing).
- Prophylactic antibiotics to prevent meningitis.
B- Surgical: Covering the defect by a graft (fat or fascia) or flap (mucoperiosteal flap); if conservation failed. It can be done endoscopically and rarely through external approach.
