Disease of external nose deviated nasal septum, fb in nose 02.05.16, dr.bini mohan

Disease of external nose deviated nasal septum, fb in nose 02.05.16, dr.bini mohan

1. DISEASES OF EXTERNAL EAR DEVIATED NASAL SEPTUM FOREIGN BODY NOSE

2. DISEASES OF EXTERNAL NOSE

3. Cellulitis : nasal skin may be invaded by streptococci or staphylococci leading to red, swollen and tender nose. It may be infection spreading from nasal vestibule. Rx: systemic antibacterial,hot fomentation and analgesics

4. cellulitis

5. NASAL DEFORMITY n SADDLE NOSE HUMP NOSE CROOKED NOSE OR DEVIATED NOSE

6. SADDLE NOSE : Depressed nasal dorsum may involve bony,cartilaginous or both component of the nasal septum. Aetiology : - Nasal trauma -Excessive removal of septum in SMR -Destruction of septal cartilage by haematoma , abcess -Leprosy, TB or syphilis

7. Treatement :Augmentation rhinoplasty by filling the dorsum with cartilage , bone,or synthetic implant .

8. Hump nose : may involve bone or cartilage or both. Corrected by reduction rhinoplasty (removal of hump and narrowing of the lateral wall)

9. HUMP NOSE

10. CROOKED NOSE OR DEVIATED NOSE:- In Crooked nose the midline of dorsum from fronto -nasal angle to the tip is curved in a C or S shaped manner. In Deviated nose, the midline is straight but deviated to one side. These deformities are usually traumatic in origin. TREATMENT :- Septorhinoplasty or Rhinoplasty

11. TUMOURS 1. Congenital 2. Benign 3. Malignant

12. Congenital Tumour 1)DERMOID CYST. 2)ENCEPHALOCELE or MENINGOENCEPHALOCELE. 3)GLIOMA

13. Congenital 1) Dermoid cyst : 2 types a) simple dermoid : it occur as a midline swelling under the skin but in front of the nasal bones -have no external opening

14. b) Dermoid with a sinus : - seen in infants and children - represented by a pit or a sinus in the midline of the dorsum of nose . - hair may be seen protruding through the sinus opening . - in these cases ,the sinus track may lead to a dermoid cyst lying under the nasal bone in front of upper part of nasal septum or may have an intracranial dural connection .

15. In those with intracranial extension sinus tract passes through the cribriform plate or foramen caecum and is attached to dura or has other intracranial connection. Treatment :splitting of the nasal bones to remove any extension in the upper part of the nasal septum. Combined neurosurgical otolaryngologic approach is required in case with intracranial extension

16. 2) Encephalocele or meningoencephalocele : herniation of brain tissue along with its meninges through a congenital bony defect. An extranasal meningoencephalocele presents as a subcutaneous pulsatile swelling in the midline at the root of nose( nasofrontal ),side of nose( nasoethmoid variety) or on the anteromedial aspect of the orbit( naso orbital variety )

17. Swelling show cough impulse and may be reducible . Treatement :neurosurgical removing the tumour stalk from the brain and repairingthe bony defect through which herniation has taken place.

18. 3) Glioma : It is a nipped off portion of encephalocele during embryonic development. Most of them (60%) are extranasal and present as firm subcutaneous swelling on the bridge, side of nose or near the inner canthus 30% purely intranasal ,while 10% are both intranasal and extranasal . Extranasal gliomas are encapsulated and can be easily removed by extranal nasal approach.

19. BABY WITH GLIOMA

20. BENIGN TUMOURS They arise from the nasal skin and include A) PAPILLOMA B) HAEMANGIOMA C) SEBORRHOEIC KERATOSIS D) NEUROFIBROMA E) TUMOUR OF SWEAT GLAND

21. Rhinophyma : or potato tumour is a slow growing benign tumour due to hypertrophy of the sebaceous glands of the tip of nose often seen in cases of long standing acne rosacea Presents as a pink, lobulated mass over the nose with superficial vascular dilation. Mostly affects men past middle age . Due to large size of the tumour it cause unsightly appearance, obstruction to breathing and vision .

22. Treatment consists of paring down the bulk of tumour with sharp knife or carbon dioxide laser and the area allowed to reepithelialize . Tumour is completely excised and the raw area skin grafted.

23. RHINOPHYMA

24. Malignant tumours :- Basal cell carcinoma (rodent ulcer). Squamous cell carcinoma ( epithelioma ). Melanoma.

25. a)Basal cell carcinoma: -most common malignant tumour involving skin of nose(87%). -equally affecting males and females in the age group of 40-60yrs. -common sites on the nose are the tip and the ala -present as a cyst or papulo pearly nodule or an ulcer with rolled edges.

26. Very slow growing and remains confined to the skin for a long time. Underlying cartilage or bone may get invaded. Nodal metastases are extremely rare. Treatment depends on the size ,location and depth of the tumour . early lesion can be cured by cryosurgery

27. Squamous cell carcinoma( epithelioma ): - second most common malignant tumour (11%). -equally affecting both sexes in 40-60age group -occurs as an infiltrating nodule or an ulcer with rolled out edges affecting side of nose or columella . - nodal metastases are seen in 20%of cases

28. Early lesion respond to radiotherapy More advanced lesions or those with exposure of bone or cartilage require wide surgical excision and plastic repair of the defect. Enlarged reginonal lymph nodes will require block dissection

29. c) melanoma: least common variety. -it is superficially spreading type or nodular invasive type. treatment: surgical excision

30. Deviated nasal septum

31. 2.DEVIATED NASAL SEPTUM Aetiology 1. Trauma 2. Developmental errors 3. Racial factors 4. Hereditary factors

32. TRAUMA A lateral blow on the nose may cause displacement of septal cartilage from the vomerine groove and maxillary crest A crushing blow from the front may cause buckling , twisting ,fractures and crushing of nasal septum Trauma during delivery

33. 2 . DEVELOPMENTAL ERRORS Nasal septum is formed by the tectoseptal process which descends to meet the two halves of developing palate in the midline During primary and secondary dentition further developments takes place in palate Unequal growth between palate and base of skull may cause buckling of nasal septum In mouth breathers-high arched palate and DNS In cleft palate,cleft lip,dental abnormalities

34. Types of DNS

35. ANTERIOR DISLOCATION

36. SEPTAL SPUR

37. Effects of DNS Compensatory hypertrophy of turbinates of opposite side External deformity Impairment of drainage to sinus Secondary atrophic rhinits

38. Clinical features 1 . NASAL OBSTRUCTION Sites 1. Vestibular 2. At the nasal valve 3. Attic 4. Turbinal 5. Choanal Bilateral/unilateral obstruction

39. COTTLE TEST Used in nasal obstruction due to abnormality of nasal valve In this test ,cheek is drawn laterally while patient breathes quietly.If the nasal airway improves on test side,the test is positive and indicates abnormality of vestibular component of nasal valve

40. 2. HEADACHE 3. SINUSITIS 4. EPISTAXIS 5. ANOSMIA 6. EXTERNAL DEFORMITY 7. MIDDLE EAR INFECTION

41. TREATMENT Minor degrees of septal deviation require no treatment If produces mechanical nasal obstruction or other symptoms, an operation is indicated

42. 1. SUBMUCOUS RESECTION OPERATION Generally done in adults under local anaesthesia Elevating the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework by a single incision made on one side of the septum Removing the deflected parts of bony and cartilaginous septum R epositioning the flaps

43. 2.SEPTOPLASTY Conservative surgery Only most deviated parts are removed Rest of the septal framework is corrected and repositioned by plastic means. Mucoperichondrial or mucoperiosteal flap is generally raised only in one side of the septum retaining the attachment and blood supply of the other

44. Foreign body nose

45. What is foreign body? An object is considered a "foreign body" if the object is in a location in the body where it does not belong

46. Commonly encountered in emergency department In children (2-4years) Seen in adults who are mentally retarder or psychiatric illness Foreign body nose harbors potential for mortality if the object is dislodged into airway

47. Frequently encountered foreign bodies: Pebbles Slate pencils Beads marbles peas Beans nuts button batteries paper wads

48. Types of foreign body ANIMATE: Maggot Worms INANIMATE: Vegetable FB : paes ,beans Mineral FB : metal , plastic toys Post surgical : swabs , packs Sequestra : syphilis , neoplasms

49. Button batteries: result in severe destruction of the nasal septum.  These are composed of various types of heavy metals: mercury, zinc, silver, nickel, cadmium, and lithium. Liberation of these substances causes various types of lesions depending on the localisation, it causes intense local tissue reaction and liquefaction necrosis. As a result they can cause septal perforations, synechiae , constriction, and stenosis of the nasal cavity.

50. Consequences: Inert Foreign body Infection and inflammation of mucous membrane Granulation tissue formation and ulceration of mucosa Necrosis of bone or cartilage Vegetable foreign body Absorb water and swell evoke brisk inflammatory response

51. Symptoms: Unilateral foul smeling discharge: mucopurulent or blood stained u/l nasal obstruction Pain Nasal bleed Excoriation of nasal vestibular skin

52. local examination: Main diagnostic tool Object mostly found beneath inferior turbinate or anterior to middle turbinate Erythema , edema Bleeding ,fetid nasal discharge

53. Rhinoliths F oreign body buried in granulations or firmly impacted. Receives a coating of calcium, magnesium phosphate , carbonate . Usually at the floor Radiopaque O/E : Brown , greyish nasal mass near the floor. Stony hard / gritty Xray

54. Removal of rhinolith : Done under general anaesthesia If very large –it is removed by lateral rhinotomy

55. NASAL MYIASIS (maggots in nose) Larval forms of flies ( chrysomyia ) Attracted by foul smelling discharge ( atropic rhinitis , syphilis , leprosy , infected wound) Patient presents with intense irritation , sneezing , lacrimation , headache , epistaxis , foul smell Maggots can cause extensive damage to nose , sinuses ,soft tissue of face ,palate and eyeball Death can occur from meningitis

56. Investigations Nasal endoscopy X-ray may reveal radiopaque FB CT nose and PNS

57. MANAGEMENT: ANIMATE FOREIGN BODY (Maggots) Isolation and broad spectrum antibiotics and analgesics Good nourishment Tablet vitamins and iron Inj . Tetanus Manual removal of maggots after placing cotton pledgets soaked in 25% chloroform and terpentine oil(4:1) Alkaline douchings Primary causative factor is taken care of

58. Inanimate FB removal: Child is restrained in upright position Add few drops of nasal decongestant Proper suctioning to visualise FB Curved hook is passed beyond FB and gradually drawn forward and removed completely

59. Indications for general anaesthesia Uncooperative and very apprehensive patients If troublesome bleeding is anticipated If the FB is posteriorly placed with a risk of pushing it back in to nasopharynx If a foreign body is strongly suspected but cannot be seen in anterior rhinoscopy and radiolucent

60. Removal of FB under general anaesthesia: Patient is anaesthetised with cuffed ET tube Pharyngeal pack placed If FB is placed posteriorly , patient positioned in rose position and mouth gag applied. Palate is generally retracted with a catheter which is placed through unaffected nasal cavity FB is pushed from anterior nares in to the nasopharynx and pick up with foreps

61. Thank you