Nasal Deformities

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Nasal Deformities
Septal Deviation
A congenital or traumatically acquired
bending or bowing of the nasal septum
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Symptoms

• Mild forms do not cause
• symptoms and have no pathologic significance

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Symptoms

• More pronounced degrees of septal curvature can
  obstruct nasal breathing and may also cause
  olfactory impairment due to inadequate
  ventilation of the olfactory groove.
• Deficient nasal airflow can also lead to
  paranasal sinus sequelae such as headaches and
  recurrent sinusitis.
• A large septal spur that comes into
• contact with the nasal turbinates can
  cause epistaxis

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Diagnosis

• Septal subluxation is a special form in which the
  anterior septal margin is displaced from the
  median plane. This condition is readily
  identified by external inspection of the nasal
  base.
• Further clinical examination consists of anterior
  rhinoscopy or endoscopy.
• The degree of nasal obstruction can be
  objectively evaluated by rhinomanometry.
• For medicolegal reasons, olfactory testing should
  always be done prior to surgical treatment

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Treatment

• The treatment of choice is surgical straightening
  of the deviated septum (septoplasty)

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Deformities of the External Nose
Causes and forms
Deformities may be congenital or traumatically
acquired The most common deformities are a
crooked nose, humped nose, saddle nose, and broad
nose, which may occur separately or in
combinations
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Diagnosis

• Inspection
• Anterior rhinoscopy
• Endoscopy

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Treatment

• The treatment of choice is functional
  septorhinoplasty, with correction of the nasal
  septum and external nose

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Nosebleed (Epistaxis)

• Nosebleed is a relatively common, usually
  harmless symptom that may reflect a number of
  diseases of variable severity

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Local causes

• Perforation
• traumatic
• iatrogenic
• Inflammatory
• spurs or ridges
• Foreign bodies
• rhinoliths
• trauma (including nose picking)

• allergy
• acute rhinitis
• Traumatic aneurysm of the internal carotid
• Benign neoplasms
• malignant neoplasms

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Systemic disease

• Atherosclerosis
• Infection
• Pregnancy
• Diabetes mellitus
• Congenital e.g., hemophilia A and B, Willebrand
  disease
• Acquired e.g., anticoagulant therapy,
• Hepatocellular insufficiency

• Platelet disorders
• Congenital
• Acquired uremia, dysproteinemia, adverse effects
  of dextrann and acetylsalicylic acid (ASA)
  therapy SchönleinHenoch purpura
• Osler disease

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Diagnosis

• Nosebleed requires a simultaneous, coordinated
  protocol of diagnostic and therapeutic actions

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Evaluation

• The diagnostic work-up begins with blood pressure
  measurement.
• Except in very minor cases, the Hb should also be
  determined, and a coagulation disorder should be
  excluded by determining the platelet count,
  bleeding time, thromboplastin time, partial
  thromboplastin time (PTT), and thrombin time

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Bleeding Site

• The nasal cavity is inspected by anterior
  rhinoscopy or endoscopy following decongestion
  and local anesthesia of the mucosa.
• In most cases the bleeding site is in
  Kiesselbachs area

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Treatment

• General measures
• The nostrils are compressed against the nasal
  septum
• the patient is told not to swallow blood running
  down the pharynx.
• The patient is kept in an upright posture
• An ice bag can be placed on the back of the neck
  to induce reflex vasoconstriction
• An intravenous line should be placed if bleeding
  is severe

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Silver nitrate cautery

• Mild epistaxis from Kiesselbachs area can often
  be controlled by selective local cauterization

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Nasal packing

• For severe epistaxis, the anterior nasal cavity
  can be packed with ointment-impregnated gauze
  strips

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Vascular ligation or embolization

• The most common source of bleeding from the
  posterolateral part of the nasal cavity is the
  sphenopalatine artery (branch of the maxillary
  artery), which can be coagulated or clipped under
  endoscopic control

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Surgical prevention of recurrent epistaxis

• The main indications for surgery are changes in
  the nasal septum such as septal spurs, ridges,
  and perforations.
• Treatment consists of straightening the nasal
  septum (septoplasty or closing the septal
  perforation (e.g., by implanting an auricular
  cartilage graft and using local mucosal flap
  advancement

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Fractures of the Nasal Pyramid and Lateral Midface
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Nasal Pyramid Fracture

• The nasal pyramid is predisposed to fractures
  because of its exposed location.

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Diagnostic procedure

• Inspection

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Palpation

• Crepitus noted on palpation confirms the
  suspicion of a fracture

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Imaging

• Further diagnostic measures include radiographs
  of the nose in the lateral projection
• Standard sinus projections to exclude bony
  involvement of the lateral midface

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Complications

• Subperichondrial hemorrhage with hematoma
• Septal Abcess

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Lateral Midfacial Fractures

• Lateral midfacial fractures are usually caused by
  blunt trauma to the side of the face.
• Affected structures of the bony facial skeleton
  are the maxillary sinus, orbit, and the zygoma or
  zygomatic arch

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• An isolated fracture of the orbital floor with a
  partial herniation of the orbital contents into
  the maxillary sinus is a special type of lateral
  midfacial fracture called a blow-out fracture

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Symptoms

• Facial asymmetry
• Limited mouth opening
• Diplopia
• Sensory disturbances

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Diagnosis

• Inspection
• Swelling
• subcutaneous hemorrhage
• Asymmetry of the affected facial
• Enophthalmos

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• Palpation
• Concomitant soft-tissue swelling can make it
  difficult or impossible to palpate sites of bony
  discontinuity or displacement

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• Sensory testing
• Wisps of cotton can be used to test sensory
  function on the healthy and affected sides

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• Radiographs
• Whenever a lateral midfacial fracture is
  suspected, standard sinus radiographs should be
  obtained (occipitomental and occipitofrontal
  projections to define the extent of the bony
  discontinuity or displacement

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• The zygomatic arches may be poorly visualized in
  standard projections, and so a bucket handle
  view should be added when a concomitant zygomatic
  arch fracture is suspected

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• CT Scans
• be helpful to obtain a more discriminating view
  of the fracture and also to exclude an
  involvement of the anterior skull base

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Inspection
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Imaging
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Imaging
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Treatment

• Surgical treatment
• is unnecessary for undisplaced, asymptomatic
  fractures
• is indicated for displaced fractures or fractures
  that are causing symptoms such as sensory
  deficits in the distribution of the infraorbital
  nerve, diplopia on upward gaze, enophthalmos,
  restricted jaw opening, or facial asymmetry.
• Treatment consists of reduction and fixation of
  the bone fragments using miniplates, interosseous
  wiring, or both

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Fractures of the Central Midfaceand Anterior
Skull Base
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Classification

• Central midfacial fractures (Le Fort I-III)
• Frontobasal fractures (Escher classification)

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Le Fort classification
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Escher classification
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Notice

• Frontobasal fractures occupy a special place
  among skull fractures because they are usually an
  indirectly open injury that creates a
  communication between the cranial cavity and the
  environment lead to life-threatening intracranial
  complications (e.g., meningitis, brain abscess)

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Symptoms

• Unilateral or bilateral periorbital hematoma
• Dish face the midface has been separated from
  the skull base and displaced inward
• Cerebrospinal fluid (CSF) rhinorrhea
• Vision loss
• Diplopia
• Cerebral prolapse
• Anosmia

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Examination
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CSF Leakage
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Detection of CSF

• Glucose test
• ß2-transferrin

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Diagnosis

• Computed tomography
• Axial scans are for evaluating the anterior and
  posterior walls of the frontal sinuses and
  sphenoid sinus
• Coronal scans more clearly define the ethmoid
  roof and cribriform plate

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Complementary tests

• Testing of hearing and balance
• Olfactory testing

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Treatment

• Every confirmed fracture of the anterior skull
  base should be treated surgically in operable
  patients, regardless of whether or not a CSF leak
  has been detected

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Indications for surgery
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Vital indications (operate immediately)

• Life-threatening rise of intracranial pressure
  due to intracranial hemorrhage
• Bleeding from the nose or sinuses that is
  refractory to conservative treatment
• Bleeding from an open skull injury that is
  refractory to conservative treatment

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Absolute indications (operate as soon as
possible)

• Open brain injury
• Dural tear from an indirectly open head injury
• Penetrating foreign bodies and impalement
  injuries
• Early complications (e.g., meningitis,
  encephalitis, brain abscess)
• Late complications (e.g., meningitis, brain
  abscess, osteomyelitis)
• Orbital complications

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Relative indications (operate in 12 weeks)

• Displaced bone fragments
• Fractures involving the drainage tracts of the
  paranasal sinuses (ostiomeatal unit)
• Acute or chronic sinusitis at the time of the
  injury
• Post-traumatic sinus inflammation, mucopyocele
  formation
• Supraorbital nerve injury due to an adjacent
  fracture

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Questions

• Define the paradoxical cyanosis.
• Name four common nasal deformity.
• Where is the common site of epistaxis in old age?
• What is the most definitive sign for nasal
  fracture?
• Name six common symptoms for frontobasal
  fracture.

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Session 4

• Inflammations of the External Nose, Nasal Cavity,
• and Facial Soft Tissues

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Inflammations of the Hair Follicles

• Folliculitis the disease is confined to the hair
  follicles.
• Furuncle the infection spreads to deeper
  tissues and forms a central core of purulent
  liquefaction.

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Symptoms

• Nasal furuncles present as painful, tender,
  erythematous swellings about the nasal tip and
  nares

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Treatment

• Antibiotic that is active against staphylococci
• Dicloxacillin sodium , Cephalexin and so on
• Combined with the local application of an
  antibiotic-containing ointment

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Complications

• Inadequate treatment or manipulations of the
  nasal furuncle itself can result in
• Hematogenous spread to intracranial
  structures

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Erysipelas

• Causative organisms are beta-hemolytic group A
  streptococci
• Less common pathogens are streptococci of other
  groups, Staphylococcus aureus, and gram-negative
  rods (e.g., Klebsiella pneumoniae)

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Symptoms

• High fever
• Feeling of tension in the soft tissues
• Rapidly by broad areas of erythema and swelling,
  which are sharply demarcated from unaffected skin
• The tissue is warm to the touch, and small
  blisters occasionally form

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Treatment

• The treatment of choice is the parenteral
  administration of penicillin

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Inflammations of the Nasal Cavity
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Acute Rhinitis

• Acute rhinitis (common cold) is the most
  prevalent infectious disease
• Rhinoviruses and coronaviruses comprise almost
  half of the causative organisms of acute viral
  rhinitis

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Symptoms

• Dry stage
• Malaise (lethargy, headache, fever) and local
  discomfort in the nose and nasopharynx (burning,
  soreness).
• Catarrhal stage
• Watery, initially serous nasal discharge and
  nasal obstruction due to mucosal swelling, which
  mainly involves the turbinates.

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Bacterial Superinfection

• Viral damage to the epithelium promotes bacterial
  colonization, which alters the consistency of the
  clear nasal discharge, causing it to become
  mucopurulent.

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Treatment

• Treatment consists of supportive measures to
  relieve nasal obstruction and prevent sinusitis
  and other sequelae by the use of decongestant
  nose drops
• Antibiotics may also be prescribed in patients
  with bacterial superinfection or paranasal sinus
  involvement

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Nonspecific Chronic Rhinitis

• Nonspecific chronic rhinitis can develop due to
  anatomic changes (e.g., marked septal deviation,
  septal spur) or other lesions of the nasal cavity
  (polyps, tumors) and nasopharynx (adenoids)
• Environmental factors such as sustained extreme
  temperatures or air pollutants can also bring on
  this condition

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Symptoms

• Patients present clinically with
• Obstructed nasal breathing
• Mucous nasal discharge
• Frequent throat clearing and occasional
  hoarseness

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Treatment

• The most important step is to eliminate the cause
  by removing chronic irritants from the
  environment or by surgically correcting any
  intranasal pathology (e.g., septoplasty)

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Specific Chronic Rhinitis

• Tuberculosis
• Sarcoidosis
• Rhinoscleroma
• Actinomycosis
• Syphilis
• Wegner Granulomatosis

• Fungal infections
• Aspergillosis
• Mucormycosis
• Rhinosporidiosis

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Allergic Rhinitis

• Triggered by an immediate, IgE-mediated reaction
  of the immune system to any of a number of
  foreign substances, particularly pollens and
  animal allergens.

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Seasonal allergic rhinitis

• Mainly by pollens
• Disappear at the end of the pollen season

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Perennial allergic rhinitis

• Is caused by year-round allergen exposure
• The predominant causative allergens are house
  dust, pet dander, and molds
• The disease may also be caused by certain foods
  (e.g., strawberries, nuts, eggs, fish) as well as
  occupational exposure to allergens (e.g., bakers
  and hairdressers)

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Symptoms

• The clinical manifestations
• Obstructed nasal breathing
• Sneezing attacks
• Watery nasal discharge
• Itching of the nose and eyes (conjunctivitis)

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Diagnosis

• Detailed allergy history (do the symptoms present
  year-round or only during contact with certain
  animals or plants).
• Seasonal allergic rhinitis, a bluish-purple
  discoloration of the mucosa.
• Perennial rhinitis, the mucosa is bright red and
  shows inflammatory changes.
• Careful allergy testing is necessary to identify
  the antigens involved.

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Treatment

• The best treatment strategy is to avoid contact
  with the allergen or eliminate allergenic
  irritants
• Pharmacologic treatment
• Mast-cell stabilizers
• Local and systemic H1 antihistamines
• Local steroids
• Immunotherapy or hyposensitization therapy
• Surgical options

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Vasomotor Rhinitis

• Resembles allergic rhinitis in its clinical
  features, but there is no evidence that the
  patient has been previously sensitized.
• Neurovascular autonomic disturbances in
  regulating the tonus of the nasal mucosal vessels

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Symptoms

• Obstructed nasal breathing
• Watery nasal discharge
• Sneezing
• The history shows that the symptoms are related
  to a temperature change, the consumption of hot
  liquid or alcohol, or less specifically to
  emotional stress.

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Treatment

• Medical therapy includes
• Antihistamines
• corticosteroid-containing nasal sprays
• In the Kneipp system of therapy, ice-cold water
  is sniffed up the nose as a way of training the
  neuroautonomic regulation of the blood supply to
  the nasal mucosa

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Traetment

• For intractable vasomotor rhinitis is surgical
  reduction of the turbinates a septoplasty should
  be performed.

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Atrophic Rhinitis

• Characterized by pronounced dryness of the nasal
  mucosa.
• Severe cases, especially with secondary bacterial
  colonization, are marked by a fetid nasal odor
  that is not perceived by the patient due to
  degeneration of the olfactory epithelium.

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Etiology

• Primary atrophic rhinitis is unknown
• Secondary forms
• Extensive prior tumor resection
• Excessive use of nose drops drug abuse (cocaine)
• Previous radiotherapy for nasal and sinus tumors

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Treatment

• Conservative
• Symptomatic measures (saline nasal douche,
  soothing mucosal ointments).
• Surgery
• reduce the nasal cavity by the submucous
  implantation of cartilage grafts.

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Hormonal Rhinitis

• Occurs mainly during pregnancy and is believed to
  be caused by estrogen-induced swelling of the
  mucosa with nasal airway obstruction.

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Rhinitis Medicamentosa

• This disease occurs mainly as a side effect from
  the long-term use of decongestant nose drops

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Drug induced Rhinitis

• Antihypertensive drugs
• Beta-blockers,
• Angiotensin-converting enzyme (ACE) inhibitors
• Oral contraceptive
• Clinical
• symptoms consist of obstructed nasal
  breathing, dry mucosa, and occasional olfactory
  disturbances.

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Chronic Sinusitis

• Intranasal anatomic changes such as
• Septal deviation
• Septal spurs
• Chronic inflammation
• Allergy
• Trauma
• Neoplasms
• The common pathogenic mechanism is impaired
  ventilation of the ostiomeatal unit

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• Chronic sinusitis frequently affects the
  maxillary sinus and ethmoid cells

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Symptoms

• Pain (from feeling of pressure to persistent or
  recurrent headaches)
• Nasopharyngeal drainage (postnasal drip)
• Obstructed nasal breathing

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Diagnosis

• Rhinoscopy
• Endoscopy
• Imaging studies

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Treatment

• Conservative treatment options
• Appropriate antiallergic therapy
• Sinus surgery

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Endoscopic sinus surgery

• The modern surgical treatment of chronic
  sinusitis is performed intranasally under
  endoscopic or microscopic control.

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Nasal Polyposis

• Genetic causes
• Chronic irritation of the mucosa, like that
  occurring in chronic rhinitis or sinusitis
• In response to allergic rhinitis and
  acetylsalicylic acid (ASA) intolerance

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Notice

• Nasal polyps are rarely observed in children.
• Most occur in a setting of cystic fibrosis.

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Symptoms

• Obstructed nasal breathing
• Hyposmia or anosmia
• Headache
• Snoring
• Rhinophonia clausa
• Frequent throat clearing
• Spread to the lower airways can lead to
  laryngitis with hoarseness and bronchitic
  symptoms.

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Diagnosis

• Rhinoscopic or endoscopic evaluation
• Computed tomography
• Allergy tests
• Olfactory testing

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Treatment

• Conservative measures
• Use of corticoid containing nasal sprays
• Systemic antihistamines
• Systemic steroids
• Surgical treatment

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Prognosis

• The prognosis is guarded even with modern
  surgical techniques most meticulous ablative
  sinus surgery cannot prevent a recurrence

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Mucoceles and Pyoceles

• Adhesions due to
• Postinflammatory
• Post-traumatic
• Postoperative
• The most common site of occurrence is the frontal
  sinus, followed by the ethmoid cells, maxillary
  sinus, and sphenoid sinus.

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Frontal Sinus

• Presents as an isolated, tense swelling over the
  anterior wall of the frontal sinus
• It may also cause inferolateral displacement of
  the orbital contents

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Maxilla

• Swelling in the cheek area with upward
  displacement of the orbital contents

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Ethmoid

• Proptosis, limited ocular movements, and diplopia
  may also occur, depending on the location of the
  mass.

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Diagnosis

• Computed tomography
• MRI

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Treatment

• The treatment of choice is surgical removal of
  the mucocele

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Rhinosinogenic Complications
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Orbital Complications

• They occur with highest frequency in children
  under 6 years of age
• Orbital edema
• Periosteitis
• Subperiosteal abscess
• Orbital cellulitis
• Orbital apex syndrome
• Cavernous sinus thrombosis

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Orbital Cellulitis
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Bone and Soft-Tissue Inflammations
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Osteitis and Osteomyelitis

• Osteomyelitis occurs mainly as a complication of
  frontal sinusitis

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Symptoms

• The patient presents clinically with a tender,
  doughy, erythematous swelling over the forehead

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Diagnosis

• Cranial CT scans

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Treatment

• The treatment of choice is surgical eradication
  of the affected bone under antibiotic coverage

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Intracranial Complications

• Epidural, subdural and intracerebral abscesses
• Meningitis
• Sinus Thrombosis and Thrombophlebitis

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Question

• What is so serious regarding nasal foliculitis?
• Name the common symptoms of sinusitis.
• When orbit shift to the inferolateral the mucocel
  perhaps is located in . sinus.
• Name the causes of sinonasal polyposis.
• Subdural abscess is more common when the ..
  Sinus is involved.