RHINITIS

Definition: Irritation & swelling of the mucous membrane in the nose.

Classification:
A. Type 1
1) Acute
I. Viral
 Common cold
 Influenza
 Rhinitis associated with exanthemus
II. Bacterial
 Non-specific
 Diptherial
III. Irritative

2) Chronic
I. Chronic simple
II. Hypertrophic
III. Atrophic
IV. Rhinitis sicca
V. Rhinitis caseosa

B. Type 2
1) Allergic – seasonal & perennial
2) Non-allergic – vasomotor

ACUTE RHINITIS:
A. Viral
a) Common cold
Etiology:
1) Infection through airborne droplets
2) Viruses- adenovirus, picornavirus, rhinovirus
3) Incubation period – 1-4 days
4) Illness lasta for 2-3 weeks

Clinical feature:
1) Burning sensation at back of nose
2) Nasal stuffiness
3) Rhinorrhea
4) Sneezing
5) Low-grade fever
6) Nasal discharge – watery & profuse – mucopurulent
 Treatment:
1) Bed rest & plenty of fluids
2) Anti-histamines & nasal decongestants
3) Analgesics
4) Antibiotics when secondary infection invades

Complication:
1) Sinusitis
2) Bronchitis
3) Tonsillitis
4) Pneumonia

b) Influenzal rhinitis
Causes – influenza viruses A, B, C
S/S – same as common cold

c) Rhinitis associated with exanthemus

Measles, rubella & chicken pox are associated with rhinitis which precedes exanthemus by
2-3 days.
Secondary infection & complications – severe

B. Bacterial
a) Non-specific infections
 It may be primary or secondary bacterial rhinitis seen in children.
Primary – in children, infection with pneumococcus, streptococcus, staphylococcus
Secondary – resulting from bacterial infection in acute viral rhinitis
 Greyish white tenacious membrane form in the nose.

b) Diptheric rhinitis
 Greyish white membrane covering the inferior turbinate & floor of nose
 Membrane is tenacious & removal causes bleeding
 Upper lip mass seen
 T/t – Isolation of the patient
Systemic penicillin
Diptheria antitoxin

C. Irritative
Causes:
1) Dust, smoke or irritating gases such as ammonia, formaline, acid etc
2) It may result from trauma inflicted on the nasal mucosa during intra-nasal manipulation
e.g. removal of foreign body

Clinical feature:
Immediate catarrhal reaction with,
1) Sneezing
2) Rhinorrhoea
3) Nasal congestion

Symptoms pass of with the removal of causing agent.

Recovery will depend upon the amount of epithelial damage & the infection that supervanes.

CHRONIC RHINITIS:
A. Chronic simple
Etiology:
1) Recurrent attacks of acute rhinitis
2) Persistence of nasal infection like sinusitis
3) Chronic irritataion from dust, smoke
4) Nasal obstruction due to DNS
5) Vasomotor rhinitis
6) Hypothyroidism

Pathology:
It is a early stage of hypertrophic rhinitis.
Hyperaemia & oedema of mucus membrane

Hypertrophy of sero-mucinous gland

Increased goblet cells

Blood sinusoids distended

Clinical feature:
1) Nasal obstruction
2) Nasal discharge – mucoid or mucopurulent
3) Headache
4) Swollen turbinates – pit on pressure
5) Nasal mucosa – red
6) Post nasal discharge – on posterior pharyngeal wall

Treatment:
1) Treat the cause first
2) Nasal irrigation with alkaline solution
3) Nasal decongestants – improve sinus ventilation
4) Short course of systemic steroids
5) Antibiotics
 B. Hypertrophoc rhinitis
It is characterised by,
Thickening of mucosa, submucosa, seromucinous glands, periosteum & bone.

Etiology:
1) Same as chronic simple
2) Industrial irritants
3) Prolonged use of nasal drops

Symptoms:
1) Nasal obstruction
2) Nasal discharge – thick & sticky
3) Headache
4) Heaviness of head
5) Anosmia

Signs:
1) Hypertrophy of turbinates
2) Turbinal mucosa – thick & doesn’t pit on pressure
3) Maximum changes seen on inferior turbinate
4) Mulberry appearance

Treatment:
1) Linear cauterization
2) Submucosal diathermy
3) Cryosurgery of turbinates
4) Partial or total turbinectomy
5) Lasers – to reduce size of turbinates

C. Atrophic rhinitis

Definition: It is a chronic inflammation of nose, characterised by atrophy of nasal mucosa.

Nasal cavity – roomy & full of foul-smelling crusts.

Types:
1) Primary
2) Secondary

a) Primary atrophic rhinitis

Etiology:
1) Exact cause in unknown
2) H – hereditary factors
3) E – endocrinal disturbance
 4) R – racial factors
5) N – nutritional deficiency
6) I – infective
7) A – autoimmune process

Pathology:
Ciliated columnar epithelium is lost

It is replaced by stratified squamous type

Atrophy of seromucinous glands, venous blood sinusoids & nerve element

Bone show obliterative endarteritis

Bone of turbinate undergoes resorption causing widening of nasal chambers

Symptoms:
1) Common in females & starts around puberty
2) Foul smell from nose
3) Anosmia
4) Nasal obstruction – due to large crusts filling in the nose
5) Epistaxis – when crusts are removed

Signs:
1) Nasal cavity – full of greenish or greyish black dry crusts
2) When crusts are removed – nasal cavity appears roomy with atrophy of turbinates

Treatment:
1) Medical
 Nasal irrigation with alkaline solution
 Removal of crusts – with forceps & suction
 Painting of nose with 25% glucose in glycerine
 Local antibiotics
 Oestradiol spray
 Systemic use of streptomycin – 1g/day for 10 days
2) Surgical
 Young’s operation
 Narrowing the nasal cavities
 Insertion of fat, cartilage, bone
 Section & medial displacement of lateral wall of nose

b) Secondary atrophic rhinitis

  Specific infections like syphilis, lupus, leprosy, rhinoscleroma may cause destruction of
the nasak structures leading to atrophic change.
 It can also result from long standing purulent sinusitis, radiotherapy to nose or excessive
surgical removal of turbinates.

D. Rhinitis sicca

It is a crust forming disease in patient who work in hot, dry & dusty surroundings.
Condition is confined to anterior third of the nose.

Pathology:
Ciliated columnar epithelium

Squamous metaplasia with atrophy of seromucinous glands

Clinical features:
1) Crust form on anterior part of septum
2) Crust removal causes ulceration & epistaxis, may lead to septal perforation

Treatment:
1) Correction of surroundings
2) Application of bland ointment or one with antibiotic & steroid
3) Nasal douche

E. Rhinitis caseosa

Usually unilateral & in males.

It arises from chronic sinusitis with collection of cheesy material.

Clinical features:
1) Nose filled with purulent discharge & cheesy material
2) Sinus mucosa – granulomatous

Treatment: removal of debris & granulation tissue & free drainage of affected sinus.

ALLERGIC RHINITIS:

Definition:
It is an IgE mediated immunological response of nasal mucosa to airborne allergens &
characterised by watery nasal discharge, nasal obstruction, sneezing & itching in the nose.

Etiology:
1) Inhalant allergens – pollens, debris etc.
 2) Genetic predisposition

Types:
1) Seasonal – Symptoms appear in particular season when the pollen of particular plant to
which the patient is sensitive.
2) Perennial – Symptoms are present throughout the year

Pathogenesis:
In a genetically predisposed individual

Inhaled allergens

IgE production

IgE binds to basophila & mast cells by its FC end

On subsequent exposure, antigen binds to FC fragment

Degranulation of mast cells

Release of chemical mediators

(responsible for symptomatology)

Allergic response:
1) Acute or early phase
 Within 5-30 mins
 Due to release of vasoactive amines like histamines
 Sneezing, rhinorrhea, nasal blockage & bronchospasm
2) Late or delayed phase
 2-8 hrs after exposure to allergen
 Due to infiltration of inflammatory cells at the site of antigen deposition
 Swelling, congestion & thick secretion

Symptoms:
1) Seasonal
 Paraoxysmal sneezing
 Nasal obstruction
 Watery nasal discharge
 Itching in the nose
2) Perennial
 Frequent colds
 Persistently stuffy nose
 Loss of sense of smell
  Post nasal drip
 Chronic cough
 Hearing impairment

Signs:
1) Nasal
 Transverse nasal crease – black
 Pale & oedematous nasal mucosa
 Swollen turbinates
 Thin, watery & mucoid discharge
2) Ocular
 Oedema of lids
 Congestion
 Cobble stone appearance of conjunctiva
3) Otologic – E-tube blockage – retracted TM & serous otitis media
4) Pharyngeal – hyperplasia of submucosal lymphoid tissue – granular pharyngitis
5) Laryngeal – hoarseness of voice

Examination: Detailed history & physical examination

Investigation:
1) Total & differential count – peripheral eosinophilia
2) Nasal smear – large number of eosinophils
3) Skin test – prick, scratch & intradermal test
4) RAST – radioallergosorbent test
Measures specific IgE antibody concentration in patient’s serum

Complication:
1) Obstruction of nasal ostia
2) Nasal polyp
3) Blockage of E tube
4) Bronchial asthama

Treatment:
1) Avoidance of allergens
2) Treatment with drugs
 Antihistamines
 Α-adrenergic drugs – oral or topical
 Nasal decongestants
 Corticosteroids – oral very effective
3) Immunotherapy – suppress formation of IgE
 Allergen is given in gradually increasing dose
 Increased IgG antibody, upto 3 years
VASOMOTOR RHINITIS:
 It is non-allergic rhinitis.
 These persists throughout the year
 All nasal allergy test –ve
 Clinically resembles allergic rhinitis

SINUSITIS

Definition: inflammatory condition of the mucous membrane lining of the sinuses.

It may progress to pus formation.

Types:
1) Acute
 Maxillary
 Frontal
 Ethmoid
 sphenoid
2) Chronic (external fungal sinusitis)

Depending on whether the inflammatory products of sinus cavity can drain freely into NC
through natural ostia or not.
1) Open
2) Closed

ACUTE SINUSITIS:

Definition: acute inflammation.

Causes:
1) Exciting causes
 Nasal infection – viral followed by bacterial
 Swimminh & diving – Infected water
 Trauma – compound fractures & penetrating injuries
 Dental infections
2) Predisposing causes
Local,
 Obstruction to sinus ventilation & drainage
 Stasis of secretions in NC
 Previous attack of sinusitis
General,
 Environment – cold & wet climate
 Poor general health – nutritional deficiencies, systemic disorders
 3) Bacteriology
 Starts as viral infection, then bacterial
 Bacteria – streptococcus pneumonia, H. influenza. Streptococcus pyogens,
staphylococcal aureus

Pathology:
 Acute inflammatory changes – hyperaemia, oedema
Acute inflammator infiltrate

Increased activity of serous & mucous glands

Initially, serous exudates & later mucopurulent or purulent

 Severe infection cause destruction of mucosal lining

A. Acute maxillary sinusitis

Etiology:
1) Same as explained above
2) Viral rhinitis

Clinical features:
1) Constitutional symptoms – fever, general malaise & bodyache
2) Headache
3) Pain – over upper jaw & referred to gums or teeth
4) Tenderness
5) Redness & oedema of cheek
6) Nasal discharge – pus & mucous in middle meatus
7) Post nasal discharge – pus seen on upper soft palate

Diagnosis:
1) X-ray – Water’s view – opacity or fluid level
2) CT scan
3) Transillumination test – affected sinus – opaque

Treatment:
1) Medical
 Antimicrobial drugs – ampicillin, erythromycin
 Nasal decongestant drops – 1% ephedrine or 0.1% xylometazoline
 Steam inhalation
 Analgesics – paracetamol
 Hot fomentation – local heat
2) Surgical
 Antral lavage – when medical t/t is failed
 Cannula is inserted into opening of maxillary sinus via inferior meatus to allow
drainage of the sinus.

Complication:
1) Chronic sinusitis
2) Frontal sinusitis
3) Osteomyelitis of maxilla

B. Acute frontal sinusitis

Etiology:
1) Viral infection of URT
2) Diving or swimming
3) Trauma

Clinical feature:
1) Frontal headache/ office headache – comes up on walking, gradually increased & reaches
its peak by mid day & then start subsiding
2) Tenderness
3) Oedema of upper eyelid
4) Nasal discharge – mucopus in anterior part of middle meatus

Diagnosis:
1) CT scan
2) X ray

Treatment:
1) Medical – same as maxillary
Nasal decongestant with antihistamine
2) Surgical
 Trephination of frontal sinus – small opening is made in the floor of the frontal sinus
facilitating drainage above inner canthus
 Antral lavage

Complications:
1) Orbital cellulitis
2) Osteomyelitis of frontal bone
3) Meningitis
4) Extradural abscess

C. Acute ethmoid sinusitis

Etiology:
1) Associated with infection of other sinuses
2) Common in infants & young children
Clinical feature:
1) Pain – over bridge of the nose, medial & deep to the eye
2) Oedema of lids
3) Nasal discharge – pus in middle ear or superior meatus
4) Swelling of middle turbinate

Treatment:
1) Medical same as maxillary
2) Surgical – drainage into nose through external ethmoidectomy incision

Complications:
1) Visual deterioration & blindness
2) Cavernous sinus thrombosis
3) Other as frontal

D. Acute sphenoid sinusitis

Etiology:
1) Isolated involvement of sphenoid sinus – rare
2) Often part of parasinusitis or associated with infection of posterior ethmoid sinuses

Clinical feature:
1) Headache – occiput or vertex
2) Postnasal discharge

D/D: mucocele of sphenoid sinus

Treatment: same as other sinuses

CHRONIC SINUSITIS:

Definition: Sinus infection lasting for months or years.

Cause: failure of acute infection to resolve
Bacteriology: mixed – aerobic + anaerobic

Pathology:
 Destruction and healing of sinus mucosa
 Hypertrophic sinusitis
 Atrophic sinusitis
 Submucosa infiltrated with lymphocytes & plasma cells

Clinical features:
1) Similar to acute but of lesser intensity
2) Purulent nasal discharge
 3) Foul smelling discharge
4) Nasal stuffness
5) Anosmia

Diagnosis:
1) X-ray – mucosal thickening
2) X-ray with contrast
3) CT scan – in ethmoid & sphenoid sinus infection
4) Aspiration – finding of pus
5) Culture & sensitivity – selection of antibiotic

Treatment:
A. Conservative – Antibiotics, decongestants, antihistamines & sinus irrigations
B. Surgical
1) Chronic maxillary sinusitis
 Antral puncture & irrigated
 Intranasal antrostomy – window created in inferior meatus
2) Chronic frontal sinusitis
 Intranasal drainage operations
 Trephination of frontal sinus
 External frontoethmoidectomy – through floor
3) Chronic ethmoid sinusitis
 Intranasal ethmoidectomy
 External ethmoidectomy
4) Chronic sphenoid sinusitis - sphenoidotomy
5) Fungal sinusitis
 Fungus – aspergillus, rhizopus etc
 4 varieties
I. Fungal ball – implantation of fungus into healthy sinus
 T/t – removal of fungal ball & drainage
II. Allergic fungal sinusitis – allergic reaction to causative fungus
 CT scan shows mucosal thickening
 T/t – endoscopic surgery with drainage
III. Chronic invasive sinusitis
 Fungus invades into sinus mucosa
 Bone erosion by fungus
 Chronic rhinosinusitis
 T/t – surgical removal of involved mucosa, bone & soft tissues
Antifungal therapy with IV – amphotericin B. upto 2-3 g.
IV. Fulminant fungal sinusitis
 Acute presentation in immune-compromised or diabetic patients
 T/t – surgical removal of necrotic tissues & IV amphotericin B, antifungal
therapy
 EPISTAXIS

Definition: Bleeding from inside the nose.

It is a sign not a disease.

Causes:
1) Local – DN FIT
 In nose or nasopharynx
 Trauma
 Infection
Acute – viral rhinitis
Chronic – all crust-forming disease
 Foreign bodies
 Neoplasms of nose & paranasal sinuses
 Atmospheric changes – high altitude
 DNS
 Adenoiditis
 Juvenile angiofibroma
 Malignant tumours

2) General
 Cardiovascular system – HTN
 Disorders of blood & blood vessels – a plastic anaemia
 Liver disease – cirrhosis
 Drugs – increased salicytes, anticoagulant
 Kidney disease – chronic nephritis
 Infection – influenza, measles, pneumonia
 Vicarious menstruation

3) Idiopathic

Sites of epistaxis:
1) Little’s area
2) Above the level of middle turbinate
3) Below the level of middle turbinate
4) Posterior part of nasal cavity
5) Diffuse – both from septum & nasal wall
6) Nasopharynx

Classification:
1) Anterior epistaxis
 When blood flows out from the front of nose with the patient in sitting position
 2) Posterior epistaxis
 Mainly, blood flows back into the throat
 Patient may swallow it & later have a “coffee-coloured” vomitus

Difference between anterior & posterior epistaxis:

Anterior Posterior
Incidence More common Less common
Site Mostly from Little’s area or Mostly from postero-superior part of
anterior part of lateral wall nasal cavity
Age Children or young adults After 40 years of age
Cause Mostly trauma Spontaneous, HTN or arteriosclerosis
Bleeding Mild Severe
Management Local pressure or arterial pack Hospitalisation, post nasal pack

Management:
1) First aid
 Pinching the nose with thumb & index finger for about 5 minutes
 Compress the vessels of Little’a area
 Cold compresses

2) Cauterisation
 In anterior epistaxis
 With a bead of silver nitrate or eelctrocautery

3) Anterior nasal packing

 In anterior epistaxis
 Ribbon gauze soaked with liquid paraffin
 Inserted along floor & whole nsal cavity layering the gauze from floor to root or from
floor to the roof
 Removed after 24 hrs

4) Posterior nasal packing

 In posterior epistaxis
 Iit is prepared by tying 3 silk ties to a piece of gauze rolled into shape of cone
 Nasal balloons are also available

5) Endoscopic surgery – in posterior epistaxis

6) Ligation of vessels
 External carotid
 Maxillary
 Ethmoidal arteries
General measures:
1) Make the patient sit up with a back rest and record any blood loss through spitting or
vomiting
2) Mild sedation & counselling
3) Check pulse, BP & respiration
4) Maintain haemodynamics
5) Antibiotic to prevent sinusitis
6) Intermittent oxygen in patients with bilateral packs

NASAL POLYP

Definition: Non-neoplastic masses od oedematous nasal or sinus mucosa.

Types:
1) Bilateral ethmoidal polyp
2) Antrochoanal polyp

A. Bilateral ethmoidal polyp

Etiology:
1) Chronic rhinosinusitis – inflammatory condition of nasal mucosa
2) Asthma
3) Aspirin intolerance
4) Cystic fibrosis – disorder of ciliary motility or abnormal composition of nasal mucus
5) Allergic fungal sinusitis
6) Young’s syndrome – sinopulmonary disease + azospermia
7) Nasal mastocytosis

Pathogenesis:
Nasal mucosa

Becomes oedematous due to collection of ECF

Polypoidal change

Polyp – sessile(flat) – pedenculated (muschroom like) (due to gravity & excessive sneezing)

Pathology:
Early stage – nasal polyp (surface covered by ciliated columnar epithelium)

Metaplastic change in exposure to atmospheric condition

Transitional & squamous epithelium

Submucosa – large ICS filled with serous fluid + infiltration with eosinophils and round cells

Site of origin:
1) Multiple nasal polyp – from lateral wall of nose, middle meaus
2) Common sites –
Uncinate process,
Bulla ethmoidalis,
Ostia of sinuses

Symptoms:
1) Mostly seen in adults
2) Nasal stiffness – leading to nasal obstruction
3) Partial or total loss of smell
4) Headache
5) Sneezing and watery nasal discharge
6) Protruding mass

Signs:
1) On anterior rhinoscopy, polyps –
 Smooth, glistening, grape like masses
 Pale in colour
 Sessile or pedenculated
 Insensitive to probing
 Don’t bleed on touch
 Multiple & bilateral
2) Broadening of nose – in long standing case
3) May protrude from nostril & appear pink
4) Purulent discharge

Diagnosis:
1) Clinical examination
2) CT scan of paranasal sinuses – exclude neoplasia
3) Histological examination

Treatment:
1) Conservative
 Antihistamines & control of allergy – may revert early polypoidal changes
 Short course steroids – who cant tolerate antihistamines or with asthma

2) Surgical
 Polypectomy
 Intranasal ethmoidectomy
 Extranasal ethmoidectomy – when reoccur after intranasal
  Transantral ethmoidectomy – through antrum
 Endoscopic sinus surgery (FESS) – functional

B. Antrochoanal polyp
Etiology:
1) Exact cause – unknown
2) Nasal allergy with sinus infection
3) Seen in children & young adults
4) Single & unilateral

Site of origin:
1) Arise from mucosa of maxillary antrum near its accessory ostium, comes out of it and
grows in choana & nasal cavity
2) It has 3 parts,
Antral – thin stalk
Choanal – round & globular
Nasal – flat from side to side

Symptoms:
1) Unilateral nasal obstruction
2) Bilateral nasal obstruction – when polyp grows ontonasopharynx
3) Voice – thick & dull due to hyponasality (not enough air)
4) Nasal discharge – mucoid

Signs:
1) Anterior rhinoscopy
 Large, smooth, greyish mass covered with nasal discharge
 Soft, can be moved up & down with probe
 Large polyp – protrude from nostril & show pink congested look
2) Posterior rhinoscopy
 Globular mass filling the choana or nasopharynx
 Large polyp – hang down behind soft palate and present in oropharynx

Differential diagnosis:
1) A blob of mucus (thick liquid) – diappear on blowing nose
2) Hypertrophied middle turbinate – hard feel of bone on probe testing
3) Angiofibroma – firm, easily bleed on touch
4) Neoplasms – tendency to bleed

Investigations:
1) Nasal endoscopy
2) X-ray of paranasal sinuses
3) Lateral view x-ray – column of air behind polyp
Treatment:
1) Avulsion – removed by nasal or oral route
2) In case of recurrence, complete removal of polyp from site of origin
3) Endoscopic sinus surgery (FESS) – functional

Polypectomy:
 One or two polyps which are pedenculated can be removed with snare
 Multiple & sessile polyp require special forceps

FESS:
 Ethmoidal polyp are removed by endoscopic sinus surgery
 It is done with various endoscopes 0, 30 & 70 degree angulations
 Polyp can be removed more accurately when ethmoid cells are removed & drainage &
ventilation provided to other involved sinuses such as maxillary, sphenoid & frontal

DNS (DEVIATED NASAL SEPTUM)

Important cause of nasal obstruction.

Etiology:
1) Trauma
 Lateral blow on nose cause septal displacement of septal cartilage
 Crushing blow cause twisting, fractures
 Birth injuries
2) Developmental error
 Nasal septum is formed by tectoseptal process which decends to meet 2 halves of
developing palate
 Unequal growth between palate & base of skull cause buckling of nasal septum
 The palate is often highly arched & the septum is deviated
3) Racial factors – Caucasian – increased
4) Hereditary factors

Types:
Deviation may involve only cartilage, bone or both.
1) Anterior dislocation
 Dislocated into one of the nasal chambers
 Better by looking at base of nose when patient’s head tilted backwards

2) C-shaped deformity
 Septum is deviated in a simple curve to one side
 Nasal chamber on concave side – wider & may show hypetrophy of turbinates
 3) S-shaped deformity
 S-shaped curve either in vertical or anteroposterior plane
 May cause bilateral nasal obstruction

4) Spurs
 Shelf-like projection often found at junction of bone & cartilage
 A spur may press on lateral wall & gives rise to headache

5) Thickening
 Due to unorganised haematoma or over-riding of dislocated septal fragments

Clinical features:
1) Increased in male
2) Nasal obstruction – unilateral or bilateral
3) Headache – especially spur
4) Sinusitis – may obstruct sinus ostia
5) Epistaxis – mucosa exposed to drying effects of air currents leads to formation of crusts
which when removed, cause bleeding
6) Anosmia
7) External deformity
8) Middle ear infection

Treatment:
1) Minor degrees of septal deviation with no symptoms are commonly seen in patients and
require no t/t.
2) When deviated septum produces mechanical nasal obstruction or the symptoms given
above that an operation is indicated.

Submucus resection (SMR) operation:

 Done under the L/A
 It consists of elevating the mucoperichondrial & 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 the bony & cartilagenous septum
 Then repositioning the flaps

Septoplasty:
 Conservative approach to septal surgery
 In this operation, much of the septal framework is retained
 Only the most deviated parts are removed
 Rest of the septal framework is corrected repositioned by plastic means
 Mucoperichondiral/ periosteal flap is generally raised only on one side of the septum,
retaining the attachment & blood supply on the other
 Septoplasty has now almost replaced SMR operation
 FOREIGN BODY IN NOSE
Etiology:
1) Commonly seen in children
2) They maybe organic or inorganic
3) Pieces of paper, chalk, button, pebbles & seeds are the common objects
4) Cotton wool or swabs maybe accidently left in the nose
5) Similarly maggots are seen in some patients

Clinical feature:
1) History – the patient may or may not give proper history about the time duration & type
of foreign body
2) Pain, bleeding, sneezing, blocking etc may present
3) In unilateral foul smelling & blood stained discharge, an old impacted foreign body
should be suspected which might have over looked
4) Rhinolith – stone present in nasal cavity
5) Nasal diphtheria
6) Nasal myiasis – oedematous, ulcerated mucous membrane with crawling maggots
7) Sinusitis

Diagnosis:
1) Anterior rhinoscopy
2) X-ray (for radio-opaque foreign body)

D/D:
1) Unilateral blood stained discharge
Rhinolith, nasal diphtheria, myiasis (maggots in nose) & acute or chronic unilateral
sinusitis
2) Rhinolith & sequestra are seen as hard irregular mass

Treatment:
1) Nasal endoscope is very useful to locate the foreign body & carefully remove it
2) Blowing the nose or inducing the sneezing may expel the foreign bodies situated
anteriorly
3) Cotton swab, piece of paper can be removed with forcep
4) Buttons, seeds can be removed by a blunt hook
5) Foreign bodies situated for behind in the nose are pushed back into the nasophrynx & the
removed
6) In children & in non-co-operative patients, G/A should be used with cuffed endotracheal
tube is used
7) Rhinolith – removed under general anaesthesia
 Large are broken into small pieces
 In hard-lateral rhinotomy
 8) Maggots
 Visible maggots picked up with forceps
 Other like FB in ear
 Nasal douche with warm saline

Complications:
1) Nasal infection
2) Sinusitis
3) Rhinolith may form over an old impacted foreign body
4) Inhalation into the tracheobronchial tree

NASAL TRAUMA

Definition: It is an injury to nose or the areas that surround & support nose.
Internal and external injuries can cause nasal trauma.

Types:
1) Nose bleeds
2) Fractures
3) Chemical irritation or injuries to the inside of nose
4) Obstruction by a foreign object

Causes:
1) Causes of external trauma
 Falls
 Sports injury
 Motor vehicle accidents
 Physical abuse
2) Causes of internal trauma
 It can occur when cartilage or blood vessels inside nose gets damaged
 Infection from nasal piercing
 Irritation caused by inhaling certain substance
 Sniffing cocaine or other illegal drugs
 Foreign object lodged in nose

Clinical features:
1) Pain in & around nose
2) Bleeding from nose
3) Clear fluid from nose
4) Swelling of face, particularly around nasal area
5) Loss of sense of smell
6) Trouble breathing
Diagnosis:
1) Gently touch the bridge of nose to feel for irregular alignment or movement
2) Examine the inside of nose to look for obstruction or chemical damage
3) X-ray
4) CT scan

Treatment:
1) First aid & home care
 To treat minor nose bleeds
 Sit upright & lean foreword to reduce blood pressure in nose
 Pinch both of nostrils shut at the soft portion of nose for 5-15 mins
 While completing these steps, breath through mouth & keep head higher than
heart
 Refrain from pricking or blowing nose for several hrs afterward
 To treat blunt force trauma
 Apply ice for 1-20 mins
 Wrap the ice in a thin cloth or towel to protect skin from frostbite
 Anti-inflammatory pain reliever – Ibuprofen

2) Medication
 Painkillers
 Antibiotics
 Nasal sprays

3) Cauterization or packing
 Use cauterization to stop nose bleeds
 Apply either a topical medication to the broken blood vessels or use a heating device
to seal them closed
 In packing – place gauze or an inflatable balloon inside one or both nostrils to exert
pressure on the broken blood vessels in case of bleeding

4) Surgery
 Reconstructive surgery – for repair of nasal fracture
 Nasal fracture with clear fluid
 Clear fluid in CSF
 May insert a drain in lower back to help in change the coarse of the spinal fluid

TUMOURS OF NOSE
External nose tumours

They maybe congenital, benign or malignant.

 Congenital tumours:
1) Dermoid cyst
Types:
i. Simple
 Occurs as a midline swelling under the skin but in front of nasal bones
 No external opening
ii. Demoid with a sinus
 Seen in infants & children
 Represented by a pit or sinus in the midline of the dorsum of the nose
 Sinus track may lead to dermoid cyst under nasal bone infront of upper part of the
nasal septum
 Meningitis occur if infection travels

Treatment:
 Splitting of nasal bones to remove any extension in upper part of nasal septum
 Neurosurgical – otolaryngologic approach required
In case of dermoid with an intracranial connection to dura.

2) Encephalocele or meningoencephalocele
Definition: It is a herniation of brain tissue with meninges through a congenital bony defect.

Clinical feature:
 Pulsatile swelling in midline at roof, side of nose & anteromedial aspect of orbit
 Swelling shows cough impulse & may be reducible

Treatment:
 Neurosurgical – severing (cutting) the tumour stalk from the brain repairing the bony
defect through which herniation taken place

3) Glioma
 It is a nipped off portion (remove by squeezing) pf encephalocele during embryonic
development
 Mostly extranasal
 Firm subcutaneous swellings on the bridge, side of nose or near the inner canthus

Treatment:
 Extranasal glioma are encapsulated & can be easily removed by external nasal approach

Benign tumours:
They arise from nasal skin & include papilloma, haemangioma, seborrhoeic keratosis,
neurofibroma.
 Rhinophyma/ Potato nose:
 It is a slow growing benign tumour.
 Due to hypertrophy of the sebaceous glands of the tip of nose
 It is pink, lobulated mass over the nose with superficial vascular dilatation
 Mostly affects men past middle age

Symptom: Obstruction to breathing & vision

Treatment:
 Puring down the bulk of tumour with sharp knife or CO2 laser & the area allowed to
epithelialize
 Sometimes, excised & the raw area skin grafted

Malignant tumours:
1) Basal cell carcinoma (rodent ulcer)
 Most common tumour involving skin of nose
 Common site – tip & ala
 It may present as a cyst or papulo-pearly nodule or an ulcer with rolled edges
 Slow growing & underlying cartilage or bone may get involved

Treatment:
 Depends on size, location & depth of tumour
 Early lesion – cryosurgery, irradication or surgical excision with 3-5 mm of skin around
palpable borders of tumour
 Recurrent, extensive lesion – excised & surgical defect closed by local or distant flaps

2) Squamous cell carcinoma (epithelioma)

 2nd most common malignant tumour
 Equally affects both sexes
 It occurs as an infiltrating nodule or an ulcer with rolled out edges affecting side of nose
or columnella

Treatment:
 Early lesion – radiotherapy
 Advance lesion with bone & cartilage – surgical excision & plastic repair of defect
 Enlarged lymphnodes – block, dissection

3) Melanoma
 last common variety
 superficially spreading type or nodule invasive type
 t/t – surgical excision
 Internal nose tumours
1) Nasoalveolar cyst
 Smooth bulge in lateral wall & floor of nasal vestibule
 t/t – excised by sublabial approach

2) Papilloma or wart
 Single or multiple
 Pedunculated or sessile
 t/t – surgical excision under L/A

3) Squamous cell carcinoma

 Arise from lateral wall of the vestibule & extend into nasal floor, columella & upper tip
 Metastasis to parotid & submandibular nodes
 t/t – surgical excision or irradication

TUMOURS OF PARANASAL SINUS

Paranasal sinuses maybe affected by both benign & malignant neoplasms.

Benign neoplasms
1) Osteomas
 Most commonly seen frontal sinus
 Asymptomatic
 T/t is indicated when it become symptomatic
 Causing obstruction to sinus ostium, formation of mucocele

2) Fibrous dysplasia
 Mostly involve maxillary sinus
 In this condition, bone is replaced by fibrous tissue

3) Ossifying fibroma
 Seen in young adults
 Tumour can be shelled out easily

4) Adamantinoma (Ameloblastoma)
 Locally aggressive tumour
 Arises from odontogenic tissue & invades maxillary sinus

Malignant neoplasms
Incidence:
 Cancer of nose & paranasal sinuses constitutes 0.44% of all body cancers
 Most frequently involved are maxillary sinuses
Etiology:
 Largely unknown
 Working in hardwood furniture industry, nickel refining, leather work & manufacture of
mustard gas

Histology:
 More than 80% of the malignant tumours are squamous cell variety
 Rest are adenocarcinoma, adenoid cystic carcinoma, melanoma & various type of
sarcomas

Name of tumours:
1) CA of maxillary sinus
2) Ethmoid sinus malignancy
3) Frontal sinus malignancy
4) Sphenoid sinus malignancy