Rhinology Disorders of the nasal valve and septum Flashcards
What are the two general forms of nasal valve
obstruction?
● Static = does not change with respiration (i.e. caudal
septal deviation)
● Dynamic = changes with respiration, causes collapse of
the structures of the nasal valve (i.e. internal nasal valve
collapse)
While examining a patient, you use lateral
distraction on the cheek while asking the patient
to breathe in and out and tell you whether this
maneuver increases airflow. What is the name of
this test, and what is it most useful for?
Cottle maneuver. Nonspecific. Almost all nasal obstruction
improves with this maneuver. It can point to internal nasal
valve collapse, which can also be demonstrated with
Breathe Right strips.
How does the modified Cottle maneuver differ
from the Cottle maneuver?
The modified Cottle maneuver is performed by placing an
ear curette or end of a Q-tip inside the nose with gentle
support of the internal and/or the external nasal valve while
the patient breathes to determine whether his or her
breathing improves. The modified test is a better test than
the Cottle maneuver.
What test can be used to determine whether the
inferior turbinates are a significant contributor of
nasal airway obstruction?
Spray the patient’s nasal cavities with phenylephrine spray
to decongest the patient’s inferior turbinates and determine
whether nasal obstruction improves.
What is the point of highest resistance in the
adult airway?
Internal nasal valve
What structure visualized on anterior rhinoscopy is responsible for two-thirds of upper airway resist-
ance at the internal nasal valve?
Inferior turbinate
On anterior rhinoscopy you note a normal, but
enlarged, middle turbinate. On CT scan, there is an air-filled sinus within the head of the middle turbinate. What is the most likely cause?
Concha bullosa : Pneumatized middle turbinate
What percentage of the population will have a
concha bullosa?
25%
What is the approximate angle between the septum and upper lateral cartilage within the internal nasal valve?
10 to 15 degrees
Identify treatment options for both internal and
external nasal valve collapse.
Septoplasty, batten grafts, spreader grafts, lateral crural strut grafts, lower lateral cartilage suture suspension
List the possible causes of nasal septal perforation.
● Iatrogenic: Prior septal surgery, prior cauterization,
nasogastric tube placement, nasotracheal intubation, etc.
● Trauma: Nose picking (i.e., digital trauma), septal
hematoma
● Inhalants: Cocaine abuse, intranasal corticosteroids,
chronic vasoconstrictor use, glass dust, etc.
● Autoimmune: Wegener granulomatosis, sarcoidosis, sys-
temic lupus erythematosus, Crohn disease, etc.
● Infectious: Syphilis, leishmaniasis, tuberculosis, acquired
immunodeficiency syndrome (AIDS), etc.
● Neoplastic: T-cell lymphomas, etc.
● Miscellaneous: Lime dust, cryoglobulinemia, renal failure
● Idiopathic
What common symptoms are associated with
septal perforation?
● Asymptomatic (vast majority) ● Nasal crusting ● Epistaxis ● Nasal obstruction ● Postnasal drip ● Whistling
Where are septal perforations most commonly
found in the septum, and how large are they
usually?
Anterior septum. Most commonly 1 to 2 cm
When should you take a biopsy of a septal
perforation?
When there is concern for malignancy, a biopsy should be
taken, although this is controversial and not recommended
routinely; yield is low when biopsy is done for vasculitic
disease, etc.
What size septal perforation has a high risk of failed surgical closure?
Large perforation (> 2 cm)
What perforations should you treat with
conservative management, and what does this
involve?
Asymptomatic perforations. The goal is to keep the
perforation moist (i.e., nasal saline sprays, Vaseline, saline
irrigations, etc.).
For large septal perforations not amenable to surgical closure or smaller symptomatic
perforations, what nonsurgical option can be
offered that can decrease epistaxis, nasal crusting,
obstruction, and whistling?
Septal button placement. Prefabricated or custom buttons are available. Custom prostheses for large or irregular perforations can be optimally sized using a maxillofacial CT `scan.
Identify complications associated with septal
button placement.
● Intranasal pain (particularly if displaced)
● Erosion of perforation edges (rare, usually protects)
● Intranasal crusting
● Bacterial colonization/biofilm
Note: All are relatively low risk but should be discussed.
Describe the surgical approaches and techniques
available for nasal septal perforation repair.
Approaches: Endonasal versus open techniques:
● Primary closure
● Interposition grafts: Bone, cartilage, periosteum, tem-
poralis fascia, acellular dermis
● Flaps: Bipedicaled mucoperichondrial flap, rotational
mucoperichondrial flap
● Alternative flaps (large perforations > 2 cm): Inferior
turbinate pedicled flap, tunneled sublabial mucosal flap,
facial artery musculomucosal flap, radial forearm free
flap, pericranial/glabellar flap
Describe the process and potential danger of
septal hematoma.
Blood collection causes elevation of the mucoperichon-
drium/mucoperiosteum off the septal cartilage causing
devascularization of underlying cartilage and potential for
avascular necrosis and reabsorption.
Identify complications associated with septal
hematoma.
Septal perforation, subperichondrial fibrosis, septal abscess, intracranial infection (spread to cavernous sinus through emissary veins, extremely rare)
What factor places children at increased risk for developing nasal septal hematoma?
Loose adherence of the mucoperichondrium and muco-periosteum to the underlying bone and cartilage
What is the treatment for septal hematoma?
Incision and drainage with application of nasal stent or
packing to keep the potential space reduced. The patient
should be receiving prophylactic antibiotics while packing is
in place.
What is defined as a collection of purulent
material between the nasal septal mucoperiosteum/
mucoperichondrium and the bony and/or
cartilaginous septum?
Nasal septal abscess
What are the risk factors for developing a nasal
septal abscess?
● Septal hematoma resulting from trauma or prior surgery
● Nasal vestibule furuncle
● Sinusitis
● Dental infection
What is the recommended management for nasal
septal abscesses?
● Anti-staphylococal antibiotics
● Incision and drainage
What complications are associated with nasal
septal abscesses?
Intracranial complications (abscess, cavernous sinus thrombosis), orbital cellulitis, septal perforation or weakening or loss of the nasal framework resulting in saddle-nose deformity
A patient with pain and itching of the nasal
vestibule is examined, and you note small pustular
lesions with an erythematous base, pierced by a
single hair follicle. What is the diagnosis?
Nasal folliculitis
Facial or nasal folliculitis can be superficial or deep
and is often associated with what pathogen?
S. aureus
What pathologic condition generally follows
folliculitis, or hair follicle infection, and develops
as a small abscess with extension of purulent
material from the dermis to subcutaneous tissue?
Furuncle (boil)
Why are incision and drainage of nasal furuncles,
if necessary, deferred for at least 24 hours after
initiating antistaphylococcal antibiotics?
Risk of cavernous sinus thrombosis
Inflammatory nasal masses can form around a
foreign body, blood clot, or secretion and grow
as a result of accumulation of salts (calcium,
magnesium, phosphate, carbonate) over time,
potentially resulting in pressure injury to adjacent
structures and causing nasal obstruction, pain,
headache, infection, or recurrent epistaxis. This
process is referred to as what?
Rhinolith
A previously healthy 3-year-old patient has had
2 days of unilateral rhinorrhea associated with a foul odor, intermittent ipsilateral epistaxis, and generalized irritability. Examination reveals a mass in the right nasal cavity. What is the most likely diagnosis?
Nasal foreign body
What proportion of epistaxis arises from an
anterior source?
Approximately 90% to 95%
What are the common local causes of epistaxis?
● Trauma: Digital, fracture, nasotracheal intubation, feed-
ing tube placement, foreign body, recent surgery
● Drug related: Nasal steroid sprays, cocaine inhalation
● Desiccation: Nasal oxygen, continuous positive airway
pressure (CPAP)
● Inflammatory or infectious
● Neoplastic
What systemic processes can result in epistaxis?
Coagulopathy:
● Genetic: Hemophilia, hereditary hemorrhagic telangiec-
tasis (HHT), von Willebrand disease
● Drug related: Coumadin, heparin, aspirin
● Hypertension
● Neoplastic: Pancytopenia, thrombocytopenia, etc.
List nonsurgical methods of epistaxis
management.
ABCs (airway, breathing, and circulation): Epistaxis can be life threatening! ● Direct pressure ● Vasoconstrictive agents ● Cautery under direct visualization ● Nasal packing ● Absorbable packing ● Nonabsorbable packing ● Control hypertension and correct coagulopathy if possible ● Nasal hygiene ● Saline sprays, humidity, emollients (petroleum jelly, etc.)
What are the surgical methods available for
epistaxis control if bleeding continues despite maximum nonoperative intervention?
● Surgical ligation
● Sphenopalatine artery (transnasal endoscopic, identify
crista ethmoidalis, may use large maxillary antrostomy)
● Internal maxillary artery (transmaxillary endoscopic,
either via the Caldwell-Luc procedure, mega-antrostomy,
or partial medial maxillectomy)
● Anterior ethmoid artery (Lynch incision, identify fron-
toethmoid suture line)
● External carotid artery (transcervical)
● Endovascular embolization (most commonly internal
maxillary artery; risk of stroke)
External ligation of the anterior ethmoid artery is
obtained through what approach?
Accessed via Lynch incision, located approximately 24 mm posterior to the anterior lacrimal crest, along the frontoethmoid suture line
Describe the location of the sphenopalatine artery
for endoscopic ligation.
Posterior to the inferior attachment of the middle turbinate,
submucosal on the lateral nasal sidewall
Why are antibiotics prescribed while a patient has nasal packing in place?
To prevent toxic shock syndrome
What autosomal dominant disorder results in
punctate hemangiomas or vascular sinuses that are irregularly shaped, associated with thin epithelium, and have no muscular or elastic layers resulting in easy bleeding?
Osler-Weber-Rendu disease (HHT)
What are the organs most commonly associated
with HHT?
Nasal cavity, oral cavity, GI tract, lungs, liver
Which genetic mutations are most commonly
seen with HHT?
Endoglin gene (ENG, HHT1) and activin A receptor type II-
like 1 gene (ACVRL1, HHT2). Mutation detection rates are as high as 75% with sequence analysis of these two genes.
SMAD4 is less common (3%) and is associated with HHT and
juvenile intestinal polyposis.
What are the most common sign and symptom
associated with HHT?
Mucocutaneous telangiectasias and recurrent epistaxis
What are the nonsurgical treatment options
available for HHT patients with recurrent epistaxis?
● Anemia: Iron supplementation, blood transfusions
● Nasal hygiene: Oil of sesame with rose-geranium, nasal
saline spray; tolerated in some patients
● Intranasal bevacizumab
What are the surgical treatment options available
for HHT patients with recurrent epistaxis?
Surgical management: ● Potassium-titanyl-phosphate (KTP) laser ablation of le- sions ● Injection of bevacizumab ● Septodermoplasty ● Young’s procedure
Describe Saunder’s septodermoplasty.
Denuding of nasal mucosa affected by telangiectasias and
coverage of denuded area with a split-thickness skin grafts
In what surgical procedure are the nasal cavities
closed by creating two layered flaps (nasal mucosa
and skin), thus eliminating airflow through the
nasal cavities?
Young’s procedure
