Nasal Blockage & Sinus

Disease
Group C
 Case 1
Patient’s details: HOPI:

- Name: Mrs.B - Incidental discovery in March 2023 during a prior

- Age: 37 y/o admission for ACS preceding a URTI
- Gender: Female - A nasal endoscope was done to confirm the diagnosis
- She often has SOB, unilateral nasal congestion, and post
nasal drip preceding a common cold.
Chief complaint: - During the last ENT visit in September last year,
attempted removal was unsuccessful and associated
- Elective admission to remove with bleeding
right-sided nasal foreign - Could not perform her surgery last year due her
body. pregnancy
- No pain or tenderness
- No hyposmia or anosmia
- No fever
- No facial puffiness
- No epistaxis
PMH:
- Migraine as a teenager
- Cardiac syncope in 2021. ECHO on 11/8/22 EF 70%
- Admission in March 2023 for ACS
- Allergic to seafood
Social history:
- She is a housewife with 3 children
- Husband works in the military

Family History:
- Eldest child has allergic rhinitis exacerbated by cold weather
- No history of asthma, allergic rhinitis
Medications:
- Nil
Physical Examination Alert, Patient look comfortable

Attached to an IV line
Vitals:
CVS Examination
RR: 18 - S1 and S2 sound are heard and insync with
carotid pulsations
PR: 91 - No heaves or thrills felt during palpitations
- No murmur heard on auscultation
Temp: 37

BP: 110/70 Respiratory Examination

- Lung sounds are clear
SpO2: 98% - Equal air entry heard on both sides
- No added lung sounds
- Vesicular breath sound heard on auscultation
 Differential Diagnoses
Differential diagnoses Features

Antrochoanal polyps
● Nasal congestion and obstruction
(can be associated with atopy and non- atopic (unilateral)
patients) ● Clear rhinorrhea
● Post nasal drip
● Facial pain or pressure
● Hyposmia or anosmia
● Snoring and sleep disturbances
● Epistaxis

Rhinolith ● Nasal obstruction and congestion of the

● Develops usually from the introduction of a
foreign object into the nose that leads to
minerals, salts and fluid to accumulate
around the foreign body
● Can occur after trauma or recent surgery
and introduction of nasal medication
● There can be a marked lag between the
initial foreign body insertion and symptoms
affected nostril
● Nasal discharge (foul - smelling)
● Occasional epistaxis
● Post nasal drip
● Pain and discomfort around the affected
area
● Hyposmia or anosmia
Differential diagnoses Features

Allergic rhinitis associated with nasal polyp

● Nasal congestion (unilateral)
● Clear rhinorrhea
● Post nasal drip
● Nasal pruritus
● Family history of allergic rhinitis
● Personal history of atopy
● Reported triggers (tobacco smoke,
change in weather, animal fur, URTI)

Neoplasm (benign or malignant) ● Unilateral nasal obstruction/ congestion

● Rhinorrhea and post- nasal drip
● Hyposmia or anosmia
● Facial pain or pressure
● Epistaxis
● Cranial nerve palsies
● Lymph node enlargement
Investigations
Date : 8/5/24 Results Normal range

Hb 12.6 12.0-16.0 g/dL

TWC 10 4-11 x 10^9 /L

Plt 388 150-400 x 10^9/L

Urea 3.5 2.5-6.4 mmol/L

Na 140 141-152

K 3.5 3.8-5.0

Creatinine 79 71-110 umol/L

PT 10.6 11.6-14.1 secs

ECG: Normal

INR 0.97 0.9-1.1

aPTT 329
 Operative procedure
Procedure ● Patient put under GA with
reversed trendelenburg
Findings position
● Patient cleaned and draped
● Rhinolith measuring 2x2 cm at right ● Nose packed with cocaine
nasal cavity, adherent to inferior soaked ribbon gauze
turbinate, septum and floor ● Examination with nasal
● Removal as whole septum and findings as above
● Foreign body removed
● Raw area over floor, septum and
● Haemostasis secured
posterior stump of inferior turbinate ● Washed with copious amount
● Inferior turbinate atrophy, sparring of warm saline
head of inferior turbinate and tail of ● Right nasal cavity packed
inferior turbinate with shincort
ocainesoakedribbongauie smpofgauzesawrandwcoiainesolution.co
caineisapowerful
procedure
● Marocele sized 8 inserted
paying over right nasal cavity
anesthetic vasoconstrictor tnatneipsnumbtheareas.to duringsurgical
b leeding

anman
Plan Post op order
Pre -op 1. Monitor vitals ½ hourly for 4 hours - then 2
● Plan for elective removal removal of hourly for 4 hours- then 4 hourly once stable
foreign body in the nose, 2. Allow orally when fully conscious
turbinoplasty (right) on 13/5/2024 3. Continue IV Augmentin
(2nd case) 4. T.PCM 1g QID
● To bring IV augmentin STAT to 5. Keep merocele for 48 hours to remove at
available OT 15/5/24
6. Start oxynase nasal spray 2 puffs BD x 5/7
● Anaesthesia
7. Start back budesonide nasal spray after
● KNBM at 2 am with IVD
completing oxynase nasal spray
● GSH taken on 12/5/2024
8. Start nasal douching after off nasal packing
● General Anaesthesia form, FA
9. Continue T. Loratadine 10mg OD
consent 10. If discharge, TCA ENT on 24/5/24 at 9 am
● Branula intact at right hand 11. Bolster charting
 Anatomy of the nose
External nose
● Composed of:
○ Nasal bones
○ Frontal
processes of
maxilla
○ Nasal part of
frontal bone
 Nasal Cavity - Floor, Roof, Medial wall and Lateral

Ethmoid Septal
bone cartilage
Sup. meatus

middle
meatus

inf. meatus

Horizontal
plate of
palatine
bone

Palatine process
of maxilla
Blood supply to External nose and Nasal Cavity

Physiology of nose
● Respiration- inspiration/expiration
● Air conditioning of inspired air- heat exchange, filtration and humidification
● Protection of lower airway by trapping particles in mucus that is moved by cilia
● Vocal resonance
● Nasal reflex function- sneezing reflex, tears or nasal secretions
● Olfaction
Paranasal Sinuses
● Paranasal sinuses are filled with air and
communicate with nasal cavity through small
openings called meatus
● Maxillary and frontal sinus opens into the
middle meatus
● Ethmoid sinus
○ Ant. and middle -> drains into middle
meatus
○ Post. -> drains into superior nasal
meatus
○ Ethmoid sinuses are separated from
orbit by a thin plate so infection can
easily spread from sinuses into orbit

● Physiology of Paranasal sinus

○ Resonators of voice
○ Help reduce skull’s weight
○ Help warm and moisten inhaled air
○ Act as shock absorbers in trauma
Pathophysiology of nasal polyposis
● Benign lesions of the nasal mucosa or paranasal sinuses due to chronic mucosal inflammation

Causes/Risk Factors
● Seasonal allergies , Asthma , Chronic sinusitis
● Genetic: Cystic fibrosis, primary ciliary dysplasia

Pathophysiology
● Nasal polyps develop when the epithelial cells that line the respiratory region and paranasal sinuses overgrow
(hyperplasia)
↓
● Often obstructs airflow and mucous drainage
↓
● Pathogens accumulate in the sinuses and cause infection
↓
● Recurrent infection causes mucosal swelling due to an inflammatory response
↓
● The swelling makes airway obstruction and mucus drainage even worse
Pathophysiology of Deviated Nasal Septum
Causes:

● Congenital.
● Acquired: Trauma.

Pathophysiology:

● Deviated septum occurs when nasal septum is significantly displaced to one side.
↓
● Making one nasal passage smaller than the other.
↓
● Nasal blockage or congestion.
Causes & Common Conditions of Nasal Blockage & Sinusitis
Condition & causes Clinical Features Investigations Complications

Nasal Polyposis - Postnasal drip - Nasal cytology - Mucocele

● Chronic - Bilateral nasal - Nasal endoscopy lesionoccurringin
like
cyst
rhinosinusitis obstruction - CT
● Cystic fibrosis - Impaired
nasalcavity
caused
by
traumatosalivary glands
● Aspirin olfactory
exacerbated function
causing of
blockage salivary
gland
disease

Foreign Body - Unilateral - Anterior - Nasal septal

nasal rhinoscopy perforation
obstruction - Flexible fiberoptic - Foreign body
- Unilateral nasolaryngoscopy aspiration
purulent - Infections:
discharge or rhinitis,
epistaxis sinusitis
- Pain in the
nose
Nasal polyp
Causes & Common Conditions of Nasal Blockage & Sinusitis
Condition & Suggestive Investigation Complications
causes findings

VIRAL URTI - Watery to - FBC - LRTI

Cause: rhinovirus, mucoid - ESR & CRP - Otitis media
adenovirus, discharge - Secondary
coronavirus, - Sore throat bacterial
influenza virus - Malaise infection
- Erythematous
nasal mucosa

VASOMOTOR - Sneezing - Serum specific - Nasal polyps

RHINITIS - Nasal IgE antibodies - Sinusitis
Cause: irritant congestion
odors, temp change, - Hypertrophic
drugs & emotional turbinates
stimuli
Causes & Common Conditions of Nasal Blockage & Sinusitis
Condition & causes Clinical features Investigation Complication

Allergic rhinitis - Sneezing - Skin prick test - Sinusitis

- Inhalant (dust, - Watery rhinorrhea - Nasal cytology - Otitis media
animal fur) - Nasal obstruction
- Food allergy - Allergic shiners
- Allergic salute
- Pale, boggy nasal
mucosa with
hypertrophic
turbinates
Causes & Common Conditions of Nasal Blockage & Sinusitis
Condition & causes Clinical features Investigation Complication

Sinusitis - Facial - Diagnostic nasal - Orbital cellulitis

- Mucociliary pain/pressure, endoscopy - Cavernous sinus
clearance erythema and - CT scan thrombosis
abnormality swelling over the - Meningitis
- Focal infection affected area - Osteomyelitis
- Allergy - Headache
- Nasal obstruction
How do nasal ethmoidal polyposis and antrochoanal polyps differ
from one another when they are presented
 Nasal ethmoidal polyposis
Definition A a chronic inflammatory disease of the nasal
and paranasal sinus mucosa
Location Primarily arises from the ethmoid sinuses,
which are located between the eyes and
behind the nose
Presentation - Nasal congestion
- Rhinorrhea
- Reduced sense of smell
- Facial pressure or pain
- Occasionally, headaches
These polyps can obstruct the nasal
passages, leading to difficulty breathing
through the nose and increased susceptibility
to sinus infections
Appearance - Multiple and grape-like appearance
- Pale, gelatinous masses within the
nasal cavity
- Originating from the ethmoid sinuses
Antrochoanal polyps
Benign lesions that arise from the mucosa of the maxillary
sinus, grow into the maxillary sinus and reach the choana,
and nasal obstruction being their main symptom.
Originate from the maxillary sinus, located beneath the eyes
and behind the cheeks
- Unilateral nasal obstruction
- Postnasal drip
- Mouth breathing
- Sensation of a lump in the throat
- Difficulty swallowing
- Snoring
- single, elongated mass extending from the maxillary
sinus into the nasal cavity and occasionally into the
throat
- more fleshy appearance compared to ethmoidal
polyps.
How to suspect the case of sinonasal tumours from the
presentation of the patient and clinical examination of
sinonasal tumours (Inverted papilloma, JAN, NPC)
 Brief intro of sinonasal tumors
- Sinus and Nasal cavity.
- Presents similar as chronic sinusitis.
- Usually diagnosed in advanced stage.

Early symptoms Later symptoms: Invasion

Unilateral Invasion:
- facial pain ● Orbit →Proptosis
- nasal discharge ● Lateral pterygoid muscle →
Trismus
Epistaxis
Altered sensation of V2 division

Affected visual activity

Epiphora
Inverted Papilloma
- Benign epithelial tumour that grows inward and into the
underlying bone

Sites of origin:
- Lateral wall of nose in the middle meatus / paranasal
sinuses

Clinical Features :
- Unilateral obstruction, discharge, anosmia,
epistaxis
- Symptoms of chronic rhinosinusitis (e.g. postnasal drip,
headache)
- Proptosis, lacrimation and diplopia due to orbital
involvement
Gross appearance on physical examination:
● Dull pink/gray opaque (polypoidal) mass with
irregular surface which completely fills the nasal cavity
→ pushes the septum to the contralateral side
● Friable (tends to bleed on touch)
Investigation:
● CT scan with contrast
○ Nonspecific unilateral mass displacing or
distorting the nasal septum/paranasal sinus
(PNS)
● MRI: Convoluted cerebriform pattern
● Nasal endoscopy: to confirm the site of origin
and obtain a sample for histopathological
examination
● Biopsy: nonkeratinizing transitional epithelium
with fibrovascular stroma
Juvenile Nasopharyngeal Angiofibroma (JNA)
● Rare, benign, but locally aggressive
tumor (0.05% of ENT tumors)
● Almost exclusively in adolescent
males (10-20 years old)
● Vascular and fibrous tissue
● Arises from posterior choanal tissues
Clinical Presentation
Severity dependent on extent of tumor
● Progressive unilateral nasal obstruction →
contralateral septum deviation
● Recurrent epistaxis (torrential)
● Nasal Sx: Rhinorrhea, nasal intonation,
impaired nasal breathing, anosmia
● Unilateral conductive hearing loss
● Recurrent headaches → Chronic sinusitis
Clinical Examination Diagnostics

● Lobular, pink mass: Hard, rubbery, bleeds easily
on touch
● Facial swelling
○ Widened nasal bridge
○ Exophthalmos + Frog face deformity
○ Cheek or infratemporal fossa swelling
● CT scan (contrast): Assess extent, bone
involvement
● MRI: Evaluate intracranial extension
● Xray PNS: Opacified sinuses, Displaced nasal
septum
● Carotid angiogram: Feeding vessels (if planning
pre-op embolization)
● Biopsy: Only if diagnosis is uncertain
 Nasopharyngeal carcinoma (NPC)
● Squamous cell carcninoma
● Arises from the epithelium of
Clinical presentation
nasopharynx
1. Nasal Sx
● Common cancer of the nasopharynx
● purulent bloody rhinorrhea
Epidemiology ● frank epistaxis
● Hyponasal speech
➔ common in the South China Sea region 2. Otological Sx
(especially southern Chinese and ● Middle ear effusion
Southeast Asian ancestry)
● Hearing loss
Etiology/Risk factors (Environmental & Genetic 3. Neurological Sx
Susceptibility) ● Cranial nerve palsies - CN III, IV, , VI
4. Nodal involvement
➔ EBV Infection ● enlarged cervical lymph node.
➔ Dietary exposure to nitrites salted fish
Diagnosis :
● Nasopharyngeal endoscopy and biopsy

● Imaging tests for staging

○ CT scan -> modality of choice for bone invasion
○ MRI -> intracranial extension, cranial nerve involvement, and defining paranasal sinus involvement
○ PET scan -> assessing remission and investigating recurrence or identify distant metastasis
Management of nasal block

1. Bilateral nasal blockage

Nasal polyposis -
Initial medical therapy for all patients :
● Topical intranasal corticosteroids (INCS)
● If unsuccessful :
Topical steroid drops
Oral steroids (prednisolone) 25mgs/day
Broad spectrum antibiotics (only if purulent nasal discharge)
Refer to ENT for Endoscopic sinus surgery (FESS)
2. Unilateral nasal blockage

Deviated nasal septum -

● No symptoms - no treatment
● Submucous resection (SMR) Operation
● Septoplasty -tissue sparing procedure

Complications of surgery:
Nasal septum perforation
Management of rhinosinusitis Chronic rhinosinusitis

Acute rhinosinusitis 1. Corticosteroid

1. Symptomatic relief - Intranasal (16-52 weeks)

- Analgesics, nasal irrigation, nasal - Short-term oral corticosteroids
decongestant (oxymetazoline) (25mg/day for 2 weeks)

2. Saline nasal irrigation

2. Antibiotics (>5-7 days)
- amoxicillin 500 mg 8-hourly (5-7 days)
or amoxicillin/clavulanate 625 mg
8-hourly (5-7 days)

3. Intranasal corticosteroids
- Mometasone furoate ( 14-21 days)
- Allergic rhinitis, polyps
3. Functional endoscopic sinus surgery
(FESS)
Allergic rhinitis management
 Management Sinonasal Tumor ( Nasopharyngeal Carcinoma)
Stage I ( T1NOMO)
Definitive RT (nasopharynx) &
Elective RT (neck)
● 1 ° site : 6-7 weeks &
Prophylactic neck : 6
weeks.
● 1.8 - 2.0 Gy/fraction
● IMRT: recom. To min dose
to critical structure.
In recurrent
NPC
Stage II, III, IVA , IVB Stage IVC (distant metastasis)
- Concurrent - Palliative Txt
Chemoradiotherapy
- Cisplatin + RT ● Clinical trial
- Conventional Fractionation: ● Palliative Chemotherapy (
● 1 ° site (6-7 weeks) & Neck (6-7 patients w ECOG
weeks) performance status (0-2)
● 1.8 - 2.0 Gy/fraction ● RT to palliative symptoms
● Referral to Palliative
IMRT care/home care
Local :
● Nasopharyngectomy, Reirradiation
Regional
● Neck dissection, reirradiation. Chemotherapy
Distant
● = Stage IVC
Juvenile Nasopharyngeal Angiofibroma (JNA) Inverted Papilloma
● Surgical resection of the tumor ● Medial maxillectomy
- depends on size & extent of tumor
( lateral rhinotomy, transpalatal, transmaxillary, or (medial aspect of maxilla and the ethmoids, is done
sphenoethmoidal ( small tumors) // Infratemporal with lateral rhinotomy. Small lesions (endoscopically -
fossa (large lateral extension) laser)
- Preoperative embolisation

● Stereotactic radiotherapy (ie, Gamma Knife)

● Hormonal therapy : androgen receptor blockers

(flutamide)