A congenital or traumatically acquired bending or bowing of the nasal

septum
Mild forms do not cause
symptoms and have no
pathologic significance
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
 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
 The treatment of choice is surgical straightening
of the deviated septum (septoplasty)
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
 Inspection

 Anterior rhinoscopy

 Endoscopy
 The treatment of choice is “functional
septorhinoplasty,” with correction of the
nasal septum and external nose
 Nosebleed is a relatively common, usually
harmless symptom that may reflect a
number of diseases of variable severity
1. Perforation 1. allergy
2. traumatic 2. acute rhinitis
3. iatrogenic 3. Traumatic aneurysm
4. Inflammatory of the internal
5. spurs or ridges carotid
6. Foreign bodies 4. Benign neoplasms
7. rhinoliths 5. malignant
8. trauma (including neoplasms
nose picking)
1. Atherosclerosis 1. Platelet disorders
2. Infection  Congenital
3. Pregnancy  Acquired: uremia,
4. Diabetes mellitus dysproteinemia, adverse
5. Congenital: e.g., effects of dextrann and
hemophilia A and B, acetylsalicylic acid (ASA)
Willebrand disease therapy Schönlein–
6. Acquired: e.g., Henoch purpura
anticoagulant therapy,
7. Hepatocellular 1. Osler disease
insufficiency
 Nosebleed requires a simultaneous,
coordinated protocol of diagnostic and
therapeutic actions
 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
 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 Kiesselbach’s area
 General measures:
1. The nostrils are compressed against the nasal
septum
2. the patient is told not to swallow blood running
down the pharynx.
3. The patient is kept in an upright posture
4. An ice bag can be placed on the back of the neck
to induce reflex vasoconstriction
5. An intravenous line should be placed if bleeding is
severe
 Mild epistaxis from Kiesselbach’s area can often
be controlled by selective local cauterization
 For severe epistaxis, the anterior nasal
cavity can be packed with ointment-
impregnated gauze strips
 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
 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
 The nasal pyramid is predisposed to
fractures because of its exposed location.
Inspection
 Crepitus noted on palpation confirms the
suspicion of a fracture
 Further diagnostic measures
include radiographs of the
nose in the lateral projection

 Standard sinus projections to

exclude bony involvement of
the lateral midface
1. Subperichondria
l hemorrhage
with hematoma

2. Septal Abcess
 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
 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
 Facial asymmetry
 Limited mouth opening
 Diplopia
 Sensory disturbances
 Inspection

1. Swelling
2. subcutaneous hemorrhage
3. Asymmetry of the affected facial
4. Enophthalmos
 Palpation:

 Concomitant soft-tissue swelling can make it

difficult or impossible to palpate sites of bony
discontinuity or displacement
 Sensory testing

 Wisps of cotton can be used to test sensory

function on the healthy and affected sides
 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
 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
 CT Scans

 be helpful to obtain a more discriminating view of

the fracture and also to exclude an involvement of
the anterior skull base
 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
 Central midfacial fractures (Le Fort I-III)
 Frontobasal fractures (Escher classification)
 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)
 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
Glucose test

β2-transferrin
 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
 Testing of hearing and balance

 Olfactory testing
 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
 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
 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
 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
1. Define the paradoxical cyanosis.
2. Name four common nasal deformity.
3. Where is the common site of epistaxis in
old age?
4. What is the most definitive sign for nasal
fracture?
5. Name six common symptoms for
frontobasal fracture.
Inflammations of the External Nose, Nasal Cavity,
and Facial Soft Tissues
 Folliculitis: the disease is confined to the
hair follicles.

 Furuncle: the infection spreads to deeper

tissues and forms a central core of purulent
liquefaction.
 Nasal furuncles present as painful,
tender, erythematous swellings
about the nasal tip and nares
 Antibiotic that is active against staphylococci:

1. Dicloxacillin sodium , Cephalexin and so on

2. Combined with the local application of an
antibiotic-containing ointment
 Inadequate treatment or manipulations of the
nasal furuncle itself can result in:

Hematogenous spread to intracranial structures

 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)
 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
 The treatment of choice is the parenteral
administration of penicillin
 Acute rhinitis (common cold) is the most
prevalent infectious disease

 Rhinoviruses and coronaviruses comprise

almost half of the causative organisms of
acute viral rhinitis
 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.
 Viral damage to the epithelium promotes bacterial
colonization, which alters the consistency of the clear
nasal discharge, causing it to become mucopurulent.
 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
 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
 Patients present clinically with:

1. Obstructed nasal breathing

2. Mucous nasal discharge
3. Frequent throat clearing and occasional
hoarseness
 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)
 Tuberculosis  Fungal infections
 Sarcoidosis 1. Aspergillosis
 Rhinoscleroma 2. Mucormycosis
 Actinomycosis 3. Rhinosporidiosis
 Syphilis
 Wegner
Granulomatosis
 Triggered by an immediate, IgE-mediated
reaction of the immune system to any of a
number of foreign substances, particularly pollens
and animal allergens.
 Mainly by pollens

 Disappear at the end of the pollen season

 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)
 The clinical manifestations:

1. Obstructed nasal breathing

2. Sneezing attacks
3. Watery nasal discharge
4. Itching of the nose and eyes (conjunctivitis)
 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.
 The best treatment strategy is to avoid contact
with the allergen or eliminate allergenic irritants

 Pharmacologic treatment
1. Mast-cell stabilizers
2. Local and systemic H1 antihistamines
3. Local steroids

 Immunotherapy or hyposensitization therapy

 Surgical options
 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
 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.”
 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
 For intractable vasomotor rhinitis is
surgical reduction of the turbinates a
septoplasty should be performed.
 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.
 Primary atrophic rhinitis is unknown

 Secondary forms
1. Extensive prior tumor resection
2. Excessive use of nose drops drug abuse (cocaine)
3. Previous radiotherapy for nasal and sinus tumors
 Conservative:
 Symptomatic measures (saline “nasal douche,”
soothing mucosal ointments).

 Surgery :
 reduce the nasal cavity by the submucous
implantation of cartilage grafts.
 Occurs mainly during pregnancy and is
believed to be caused by estrogen-induced
swelling of the mucosa with nasal airway
obstruction.
 This disease occurs mainly as a side effect
from the long-term use of decongestant
nose drops
 Antihypertensive drugs
 Beta-blockers,
 Angiotensin-converting enzyme (ACE) inhibitors

 Oral contraceptive

 Clinical
symptoms consist of obstructed nasal breathing, dry
mucosa, and occasional olfactory disturbances.
 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
 Chronic sinusitis frequently affects the
maxillary sinus and ethmoid cells
 Pain (from feeling of pressure to persistent
or recurrent headaches)

 Nasopharyngeal drainage (postnasal drip)

 Obstructed nasal breathing

 Rhinoscopy
 Endoscopy
 Imaging studies
 Conservative treatment options

 Appropriate antiallergic therapy

 Sinus surgery
 The modern surgical treatment of chronic
sinusitis is performed intranasally under
endoscopic or microscopic control.
 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
 Nasal polyps are rarely observed in
children.

 Most occur in a setting of cystic fibrosis.

 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.
 Rhinoscopic or endoscopic evaluation
 Computed tomography
 Allergy tests
 Olfactory testing
 Conservative measures
 Use of corticoid containing nasal sprays
 Systemic antihistamines
 Systemic steroids

 Surgical treatment
 The prognosis is guarded even with modern
surgical techniques most meticulous
ablative sinus surgery cannot prevent a
recurrence
 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.
 Presents as an isolated, tense
swelling over the anterior wall
of the frontal sinus

 It may also cause inferolateral

displacement of the orbital
contents
 Swelling in the cheek area
with upward displacement of
the orbital contents
 Proptosis, limited ocular
movements, and diplopia may
also occur, depending on the
location of the mass.
 Computed tomography

 MRI
 The treatment of choice is surgical removal
of the mucocele
 They occur with highest frequency in children
under 6 years of age

1. Orbital edema
2. Periosteitis
3. Subperiosteal abscess
4. Orbital cellulitis
5. Orbital apex syndrome
6. Cavernous sinus thrombosis
 Osteomyelitis occurs mainly as a
complication of frontal sinusitis
 The patient presents clinically with
a tender, doughy, erythematous
swelling over the forehead
 Cranial CT scans
 The treatment of choice is surgical
eradication of the affected bone under
antibiotic coverage
 Epidural, subdural and
intracerebral abscesses
 Meningitis
 Sinus Thrombosis and
Thrombophlebitis
1. What is so serious regarding nasal
foliculitis?
2. Name the common symptoms of sinusitis.
3. When orbit shift to the inferolateral the
mucocel perhaps is located in …. sinus.
4. Name the causes of sinonasal polyposis.
5. Subdural abscess is more common when
the ….. Sinus is involved.