Nasal obstruction

causes of unilateral and bilateral nasal obstructions
(for undergraduates)

1. Dr. Ramesh Parajuli,MS Chitwan medical college teaching hospital, bharatpur-10,chitwan Nepal Differential Dx of n asal obstruction & Neoplasms of Nose and PNS

2. Differential diagnosis of nasal obstruction 1.Structural: DNS, inf.turbinate hypertrophy,concha bullosa 2.Infection: Unilateral sinusitis 3.Polyp: Antrochoanal polyp 4.FB 5.Neoplasms 6.Congenital:choanal atresia 7.Trauma 8.Granulomatous Dx:Rhinoscleroma 1.Infection: -Acute rhinitis -CRS, Atrophic rhinitis 2.Allergy:Allergic rhinitis 3.Non allergic,non infective: Vasomotor rhinitis 4.Adenoid hypertrophy 5.Structural: DNS 6.Trauma:Septal hematoma 7. Ethmoidal polyposis 8.Neoplasms 9.Rhinitis medicamentosa Causes of unilateral nasal obstruction Causes of Bilateral Nasal obstruction

3. Neoplasms of Nose and PNS Benign Papilloma Ossifying Fibroma Osteoma Haemangioma Neurofibroma Intermediate Inverted papilloma Malignant Squamous cell carcinoma Adenocarcinoma Anaplastic carcinoma Transitional cell carcinoma Malignant melanoma Salivary gland tumours Rhabdomyosarcoma Classification

4. Frontal sinus osteoma

5. Normal medullary bone is replaced by abnormal proliferation of fibrous tissue, resulting in distortion & expansion of bone C.T. scan: ground - glass appearance Treatment: complete surgical excision Fibrous dysplasia

6. Locally aggressive sino -nasal tumour Synonyms: Ringertz or Schneiderian papilloma Common in males between 50-70 years It arises from the lateral wall of nose Presents as unilateral, friable, pink mass Diagnosis made by punch biopsy Inverted papilloma

7. Treatment: Medial maxillectomy (& ethmoidectomy )by lateral rhinotomy approach Tendency to recur after surgical removal Squamous cell ca is present in 10­15% cases Radiotherapy is avoided

8. Lateral rhinotomy

9. Epidemiology Maxillary sinus> ethmoid >frontal>sphenoid >80% are squamous cell carcinoma Male : female = 2:1 Commonly seen in 45-60 years Sinonasal malignancy

10. Hardwood dust ( adenocarcinoma ) Softwood dust ( squamous carcinoma) Nickel refining; chromium workers Boot, shoe and textile workers Mustard gas exposure Human papilloma virus Risk factors

11. Carcinoma Maxillary Sinus(Maxilla) Early symptoms Mimic maxillary sinusitis Nasal blockage Blood-stained nasal discharge Facial paraesthesia or pain Epiphora

12. Spread

13. Medial spread: Unilateral nasal obstruction Unilateral purulent nasal discharge Epistaxis Unilateral, friable, nasal mass Anterior spread: Cheek swelling Invasion of facial skin Late Clinical features Inferior spread: Expansion of alveolus with dental pain Loosening of teeth, poor fitting of dentures Swelling in hard palate or alveolus Superior spread: Proptosis Diplopia Ocular pain

14. Posterior spread: Pterygoid muscle involvement  trismus Intracranial spread via: Ethmoids , cribriform plate or foramen lacerum Lymphatic spread: Neck node metastases in late stages Systemic spread: Lungs, bone

15. Initial presentation 7 months 11 months

16. Diagnostic nasal endoscopy C.T. Scan Nose & Paranasal sinus: expansion & destruction of bony wall Biopsy Diagnosis

17. C.T. Scan

18. Ohngren’s Classification

19. Lederman’s Classification

20. TNM Staging T1 = T umor confined to antral mucosa T2 = Bone destruction of hard palate / middle meatus T3 = I nvolvement of skin of cheek, floor or medial wall of orbit, ethmoid sinus, posterior antral wall, pterygoid plates, infratemporal fossa T4 = I nvolvement of orbital contents, cribriform plate, frontal or sphenoid sinus, skull base, nasopharynx

21. Treatment T1 & T2 = Surgery or Radiotherapy T3 = Surgery + Radiotherapy T4 = Surgery + Radiotherapy + Chemotherapy Surgery  post-operative Radiotherapy after 4-6 weeks

22. Surgical Options 1.Total maxillectomy : Weber Fergusson incision M alignancy limited to maxilla 2.Radical maxillectomy (with orbital exenteration ): I nvolvement of orbital fat 3. Anterior Cranio - Facial Resection: I nvolvement of cribriform plate, frontal sinus

23. Weber Fergusson incision

24. Osteotomy cuts

25. Total maxillectomy done & incision closed

26. Palatal defect & prosthesis

27. Orbital exenteration indications Involvement of orbital apex Involvement of extra-ocular muscles Involvement of bulbar conjunctiva or sclera Lid involvement beyond a reasonable hope for reconstruction Non-resectable full thickness invasion through periorbita into retrobulbar fat

28. Orbital exenteration

29. Post-operative defect & prosthesis

30. Cranio-facial resection