Diseases of Nose & PNS.pptx

nose and pns

1. Diseases of the Nose & PNS Zemkiel H. (MD )

2. Contents Anatomy of Nose and PNS Diseases of external Nose Diseases of Nasal vestibule Diseases of Septum Diseases of Nasal cavity Epistasis Diseases of PNS

3. Nose Pyramidal in shape Osteocartilaginous framework covered by muscle & SKIN Upper 1/3 –bony Lower 2/3 -cartilage

4. NOSE anatomy.. Made of nasal bones, connective tissue and hyaline cartilage External Nares = Nostrils: openings into nasal cavity Internal Nares = Choanae : - openings between nasal cavity and nasopharynx

5. Nose… Boundaries Roof = ethmoid bone ( cribiform plate) Floor = hard palate & soft palate Lateral walls = nasal bones, superior+ middle nasal conchae ( ethmoid bone), inferior nasal conchae , maxilla, palatine bone Nasal Septum = divides cavity into 2

6. Nasal cavity consist of 3 general regions 1.Vestibule a small dilated space ,Lined by skin( squamus epi .) numerous thick stiff hairs / vibrissae/ - filtering larger particles Sebaceous glands -greasy secretion collect dirt, lubricate, kill bacteria & Sweat glands -acidic, slows growth of bacteria 2.Respiratory region-lower 2/3 of nasal cavity Has a rich neurovascular supply goblet cells & Seromucinous glands found in sub mucus Ciliated psudostratified columnar epithelium 3.Olfactory region-upper 1/3 of nasal cavity Lined by nonciliated pseudostrstified columnar epi

7. Nasal turbinates ( concha ) bony projections from each lateral wall of nasal cavity They are 3 Corresponding meatus below each concha Inferior - opening of nasolacrimal duct Middle - opening of ant. ethmoid , frontal & maxillary sinuses Superior - opening of post. ethmoid , sphenoid sinus Covered with Mucosa Functions Create turbulance Reclaim heat from exhaled air and warm the inspired air

8. Functions of the nose Exchange air Transporting mucus Protection of the lower air way Cools & remove water from the expired air Warming ,humidifying & cleans inspired air Olfaction Serving as a resonation of sound

9. Ds of external nose Congenital – arrhinia ,nasal clefts Inflamatory - Cellulitis Trauma –saddle nose ,hump nose , crooked Tumours Congenital- dermoid cysts , encephalocele , meningoencephalocele , glioma Benign tumours – papilloma (skin wart), haemangioma … Malignant tumours -basal cell ca , squamous cell carcinoma ,melanoma

10. Arrhinia

11. Hemangioma

12. Saddle nose

13. Ds of nasal vestibule Stenosis or atresia of the nares- c ongenital or traumatic Inflamatory - Vestibulitis , Furuncle Cause: Staph.auerus is the commonest Treatment: Po Cloxacillin for 7 days trauma Tumours –benign & malignant Nasoalveolar cyst Papilloma or wart Squamus cell carcinoma

14. vestibulitis

15. Ds of the nasal septum Deviated nasal septum Septal hematoma Septal abscess Perforation of the nasal septum

16. Septal deviation

17. Septal Hematoma

18. Ds of the nasal cavity Inflammatory -Rhinitis ,nasal polyp Trauma - epistaxis ,nasal bone fracture ,foreign body Granulomatous ds –syphilis ,leprosy ,TB , actinomycosis Tumours Benign malignant

19. Rhinitis Allergic Infectious- viral ,bacterial ,fungal Occupational Hormonal Drug induced Atrophic vasomotor

20. Allergic rhinitis Allergy is a state of exaggerated susceptibility to various physical agents 10-20 % of the population Can be classified as Seasonal Perennial Perennial with seasonal exacerbations. Predisposing factors Genetic predisposition….50 % are atopic patients. Changes in temperature and humidity

21. Allergic rhinitis … Allergens Inhalants Tree and grass pollen House dust mites and domestic pets Micro organisms Foods and drugs………….. Pathogenesis …Type I hypersensitivity reaction- IgE -mediated hypersensitivity to foreign allergy

22. Allergic rhinitis… Clinical pictures Symptoms It starts by rapid onset on exposure Sense of itching, repeated sneezing Bilateral profuse watery nasal discharge Other manifestations of associated allergies. Signs Edematous nasal mucosa which is pale blue Swollen edematous turbinate Excessive mucoid thin secretion Nasal polyps may be present in the middle meatus.

23. Allergic rhinitis… Treatment Avoid the allergen- mainstay Medical treatment Anti histamine- loratidine Topical decongestant eg . xylomethazoline …. For a short period Steroids usually local if not responding to the above management. Surgery Turbinectomy Polypectomy . R hinitis medicamentosa : it is reactive vasodilation due to prolonged use (>5 days) of nasal decongestant drops .

24. Atrophic rhinitis Atrophic mucosa on septum, turbinates & lateral nasal walls Can occur with & without ozena ozena ( thick adherent, green/yellow nasal crusts usually accompanied by noticeable odour) Transformation of epith to keratinizing squamous epith

25. Atrophic rhinitis… Aetiology I. primary( Ozaena )-unknown H ereditary E ndocrine imbalance R ace N utritional ( Vit and mineral deficiency) I nfectious. Klebsiella ozena A utoimmmune II. Secondary Destructuion of the nasal mucosa with squamous metaplasia Chronic specific rhinitis-granulomatous inflammation like TB Excessive removal of nasal mucosa- Multiple cautery ,Total turbinectomy Post irradation

26. Atrophic rhinitis… Clinical features Bilateral ,female and puberty Symptoms Thick crusty and greenish nasal discharge Foul smelling discharge and breathing Nasal obstruction Anosmia……………. merciful anosmia Mild epistaxis Sore throat and chocking Signs Atrophied nasal mucosa and turbinates Roomy nasal passages with crusts

27. Atrophic rhinitis… Treatment Treat the primary cause Medical Saline nasal wash with slightly warm water ( 1 litre of water + 1 tea spoon of salt) Antibiotic for associated chronic sinusitis Nutritional supplementation - multivitamin C. Surgical I. narrow the wide nasal cavity II. Temporal occlusion of the nostrils

28. Nasal Polyps edematous pedunculated & prolapsed mucosa of the PNS 2 types – nasal polyposis & antrochoanal polyp Nasal polyposis Usually bilateral & multiple Aetiology –not well understood a) Allergy is the most accepted cause b) Inflammatory c) Asthma Clinical features Bilateral continuous nasal obstruction, sneezing and watery discharge Mechanical effects- hyposmia ,headache , epiphora Signs Wide nasal bridge Soft, smooth ,mobile, glistening, pale or greyish white and pedunculated mass which is insensitive to touch.

29. Nasal polyposis

30. Nasal polyps... Frequency Adults 1-4% Children 0.1% All races and social classes M/F 2-4:1 in adults Increasing incidence with age diagnosis Clinical examination CT scan Flexible/rigid nasal endoscopy

31. Nasal polyps... Treatment I. Medical Systemic or Topical steroids Antibiotic for secondary infection II. Surgical Simple polypectomy Endoscopic sinus surgery High rate of recurrence after surgery

32. Antrochoanal polyp (Killian polyp ) A single unilateral polyp arise from the maxillary sinus and reaches the naso pharynx Clinical features Unilateral nasal obstruction which becomes bilateral as it progresses. Snoring Hyponasal speech

33. Antrochoanal polyp… Sign Accumulated mucoid secretion When the polyp is large it may be visible behind the Uvula. Investigations PNS x-ray CT scan Treatment Manual removal of the polyp through the nose or mouth Caldwell Luc’s operation

34. Antrochoanal polyp

35. Choanal atresia Due to persistence of embroyonic bucconasal membrane . 90% bony ,10% membraneous a. Unilateral Choanal atresia - May not be symptomatic , persistent unilateral nasal obstruction MX- reconstruction b. Bilateral choanal atresia It is an emergency situation at birth ,Newborns are obligate nasal breathers

36. Choanal atresia … Symptoms -Bilateral nasal obstruction, nasal discharge, difficult suckling Becomes cyanotic unless they cry. Signs - Failure to pass rubber catheter through the nose in to the pharynx Investigation -X-ray with lipidol dye -CT-scan of the nose and nasopharynx Treatment - Emergency management…… Insertion of plastic oral airway Emergency trans nasal endoscopic perforation When the infant is stable the atresia has to be excised

37. Choanal atresia (unilateral)

38. Epistaxis Bleeding from the nose Common condition in 7-14% of general population Higher in males ,Bimodal 2-15 yrs & 45-65yrs More frequent in winter than summer Is a sign not a disease so attempt should be made to find the cause

39. Why bleeding from the nose Vasculature runs just under the mucosa Arterial and venous anastomosis ICA & ECA blood flow

40. Arterial supply of the nose

41. Venous drainage

42. Classification of nasal bleeding Anterior epistaxis Posterior epistaxis More common(80-85%) Mostly from little’s area or anterior part of lateral wall Mostly in children & young adults Mostly trauma-nasal pricking Usually mild & easily controlled Less common(15-20%) Infrequently linked with SPA/woodruff’s plexus From posterosuperior part of nasal cavity & may be difficult to localize After 40 yrs of age Spontaneous often due to HTN or arteriosclerosis Severe & requires hospitalization

43. Causes of nasal bleeding can be idiopathic ,local or systemic systemic

44. Local causes con’t

45. DIAGNOSIS OF NASAL BLEEDING Assessment of hemodynamic stability & potential air way compromization - v/s Complete history including- severity ,duration ,recurrence ,side of bleeding ,Spontaneous or traumatic Physical examination Thorough H&N examination if pt condition permits R hinoscopy before & after administration of topical medications- Detect sites of bleeding E ndoscopy

46. Diagnosis con’t Laboratory studies CBC with differential Platelet count Bleeding time PT& PTT Imaging CT(with or without contrast) MRI angiography

47. MANAGEMENT Most episodes are minor & stop spontaneously Identification and treatment of the cause is necessary Efficient Mx requires knowledge of anatomy of nose

48. Mx protocol for acute epistaxis

49. Medical management Follow ABC Prepare basic equipments For mild ,recurrent & with out active bleeding Intended to minimize or eliminate initiating or exacerbating factors Limiting trauma Nasal moistening with vaseline humidification-antiseptic creams If minimal bleeding- pinch nostril & bending forward for 15min . - Local cold application If severe bleeding - Iv fluid & blood transfusion

50. Nasal cautery T o control acute epistaxis & to provide prophylaxis against recurrent epistaxis Anterior or posterior Chemical (silver nitrate) or thermal (electrical) Endoscopic nasal cautery –for posterior refractory. Post cauteriazation instruction. avoid nasal manupilation humidification ,lubrication ,elevation of head. Nasal packing if bleeding doesn’t stop.

51. Anterior nasal packing Vaseline gauze , balloons Left it there for 24- 48 hrs. give Analgesics & prophylactic Abxs if the pack is not removed within 24 hours.

52. Posterior nasal packing For posterior bleeding & location is predicted on failure of ant. Packing Ballone or Foley catheter, Vaseline gauze Associated with significant potential risks Almost always placed in conjunction with ant. Pack Prophylaxis antibiotic & analgesics are needed

53. surgical Mx Reserved for refractory bleeding(30%) Performed under GA Anterior & posterior ethmoidal artery ligation Sphenopalatine artery ligation through transantral ECA ligation Success rates 90% & complication rate of 30%

54. Nasal bone fracture

55. Diagnostic assessment History Significant trauma Epistaxis Altered appearance Pain Airway obstruction Physical examination Edema Echymosis Tenderness Emphysema Mobility Septal hematoma Other – X- ray Only 50% accuracy causes Fights auto accidents  most serious. sports activities Farm/work accident

56. Management of nasal bone fracture Control the epistaxis If the patient is seen shortly after trauma a) If no edema Reduction can be done manually or with walsham’s forceps under general anesthesia Nasal pack is placed for 24-48 hrs for support External fixation is done by nasal splint. b) If there is marked edema wait till the edema subsides. Usually 5- 10 days. After 3 weeks, callus will form  better to do rhinoplasty latter. after 6 months Prophylactic antibiotic is given in all case

57. Management of nasal bone fracture Closed reduction Simple depressed # of nasal bones Mild # dislocation of septum Open reduction # dislocation of the caudal septum Pyramid # with deviation > ½ width of nasal bridge. Open septal #s Communited # ,dislocation of the septum Persistent deformity after closed reduction.

58. Foreign body in the nose Seen in children and mentally retarded adults Clinical picture- Initially pain and sense of discomfort Unilateral offensive mucopurulent nasal discharge. The commonest place is the nasal valve Sometimes endoscopy may be necessary. Investigations Anterior rhinoscopy plain x-ray….if radiopaque . Complications- Infections ,Pulmonary complications , Rhinolith Treatment It can be removed by a hook, forceps or by suction. General anesthesia if its deep or uncooperative patient.

59. Anatomy of the PNS 4 ,Paired air filled cavities except ethimoid (8-18 air cells) Communicate with the nasal cavity directly or indirectly Mucosa – ciliated Pseudostratified columnar epi

60. Functions of PNS make the head lighter Humidification & warming Regulating intranasal pressure ↑ surface area of Olfactory epithelium. Add resonance to voice Absorb applied shock to the head Contribute to facial growth

61. Diseases of the PNS Inflammatory - sinusitis Viral ,bacterial ,fungal ,syphilis ,TB ,leprosy Trauma Neoplasm Benign malignant

62. Sinusitis I nflammation of the mucosal lining of the sinuses  Classification acute: <4 weeks subacute : 4 weeks to 3 months chronic: >3 months    Pathogenesis anything that blocks mucus from exiting the sinuses predisposes them to inflammation 

63. Acute Sinusitis clinical diagnosis --at least 2 major symptoms or 1 major and 2 minor symptoms Major Symptoms: Facial pain/pressure Facial fullness/congestion Nasal obstruction Purulent/discoloured nasal discharge Hyposmia / anosmia Fever Post nasal dischrge Minor Symptoms: Headache Halitosis/bad smelling breath Fatigue Dental pain Cough Ear pressure/fullness

64. Acute Sinusitis... Etiology maxillary sinus most commonly affected Organisms - Viral (most common): Rhinovirus, influenza, parainfluenza viruses Bacterial: S. pneumoniae (35%), H. influenzae (35%), M. catarrhalis , anaerobes (dental) children are more prone to a bacterial etiology than adults, but viral is still more common

65. Acute Sinusitis... Routes of infection Nasal route- acute rihinitis -Polluted water ,Nasal packing , Nasal FB. Pharyngeal infections –tonsillitis ,adenoiditis Dental route -Infection of the second premolar or first mollar , Oroantral fistula. External route - Compound fracture of the sinus , Penetrating injury

66. Medical management 1 . Antibiotics-Amoxicillin , A mox / clav - Ampicillin,Erythromycin or doxycycline or cotrimoxazole are equally effective 2. Nasal decongestant drops . 0.1 % xylomethazoline or oxymethazoline – used to decongest sinus ostium and encourage drainage. 3. Steam inhalation - provides symptomatic relief and encourages sinus drainage. - 15 to 20 minutes after nasal decongestant for better penetration. 4. Analgesics. like Paracetamol for relief of pain and headache .

67. Functional Endoscopic Sinus surgery

68. Chronic Sinusitis I nflammation of the paranasal sinuses lasting >3 months Aetiology inadequate treatment of acute sinusitis untreated nasal allergy allergy fungal rhinosinusitis anatomic abnormality e.g. deviated septum underlying dental disease ciliary disorder e.g. cystic fibrosis chronic inflammatory disorder e.g. Wegener’s granulomatosis

69. Chronic Sinusitis... organisms bacterial: S. pneumoniae , H. influenzae , M. catarrhalis , S. pyogenes , S. aureus , anaerobes mixed aerobic and anaerobic organisms fungal: Aspergillus Clinical Features (similar to acute, but less severe) chronic nasal obstruction purulent nasal discharge pain over sinus or headache halitosis yellow-brown post-nasal discharge chronic cough maxillary dental pain

70. Chronic Sinusitis... Investigations Nasal endoscopy X-ray……opacity and thickening of the mucosal lining. CT scan if it is complicated Culture&Sensitivity Treatment Medical treatment Antibiotics like Amoxicillin, Augmentin for at least for 3 to 6 weeks for infectious etiology Decongestant nasal drops Saline nasal wash. Moist heat and steam inhalation. Surgical treatment –open & FESS when medical treatment fails .

71. Chronic sinusitis

72. Complications of sinusitis Local Mucocele / mucopyocele subperiosteal frontal bone abscess Osteomyelitis ,fistula( oroantral , sublabial ) Orbital a. periorbital cellulitis b. orbital cellulitis c. subperiosteal abscess d. orbital abscess e. cavernous sinus thrombosis 3. Intracranial a. meningitis b. Abscess C . cavernous sinus thrombosis 4. Neurologic-CN damage

73. Mucocele

74. Orbital cellulitis

75. Orbital abscess

76. Tumours of the sinonasal tract benign Papilloma Adenoma Fibroma Chondroma Osteoma Neurofibroma hemangioma malignant Squamous cell carcinoma Adenocarcinoma Adenocystic carcinoma Melanoma Soft tissue sarcoma (RMS ,FS ,AS ,CS) Lymphoma Plasmacytoma Metastatic cas

77. Tumors of the sinonasl tract Both benign & malignant tumors are uncommon Benign –smooth ,localized ,grows slowly ,covered with mucous membrane Malignant –friable ,have a granular surface & tend to bleed easily Common in 5 th -6 th decade of life >80% -squamous cell carcinoma C/F -depends on involved PNS ,metastasis Dx –x-ray ,CT-scan ,biopsy Mx - surgery + radiotherapy