Rhinology Disorders of the nasal valve and septum

Question 1

What are the two general forms of nasal valve

obstruction?

Answer 1

● Static = does not change with respiration (i.e. caudal
septal deviation)
● Dynamic = changes with respiration, causes collapse of
the structures of the nasal valve (i.e. internal nasal valve
collapse)

Question 2

While examining a patient, you use lateral
distraction on the cheek while asking the patient
to breathe in and out and tell you whether this
maneuver increases airflow. What is the name of
this test, and what is it most useful for?

Answer 2

Cottle maneuver. Nonspecific. Almost all nasal obstruction
improves with this maneuver. It can point to internal nasal
valve collapse, which can also be demonstrated with
Breathe Right strips.

Question 3

How does the modified Cottle maneuver differ

from the Cottle maneuver?

Answer 3

The modified Cottle maneuver is performed by placing an
ear curette or end of a Q-tip inside the nose with gentle
support of the internal and/or the external nasal valve while
the patient breathes to determine whether his or her
breathing improves. The modified test is a better test than
the Cottle maneuver.

Question 4

What test can be used to determine whether the
inferior turbinates are a significant contributor of
nasal airway obstruction?

Answer 4

Spray the patient’s nasal cavities with phenylephrine spray
to decongest the patient’s inferior turbinates and determine
whether nasal obstruction improves.

Question 5

What is the point of highest resistance in the

adult airway?

Answer 5

Internal nasal valve

Question 6

What structure visualized on anterior rhinoscopy is responsible for two-thirds of upper airway resist-
ance at the internal nasal valve?

Answer 6

Inferior turbinate

Question 7

On anterior rhinoscopy you note a normal, but
enlarged, middle turbinate. On CT scan, there is an air-filled sinus within the head of the middle turbinate. What is the most likely cause?

Answer 7

Concha bullosa : Pneumatized middle turbinate

Question 8

What percentage of the population will have a

concha bullosa?

Answer 8

25%

Question 9

What is the approximate angle between the septum and upper lateral cartilage within the internal nasal valve?

Answer 9

10 to 15 degrees

Question 10

Identify treatment options for both internal and

external nasal valve collapse.

Answer 10

Septoplasty, batten grafts, spreader grafts, lateral crural strut grafts, lower lateral cartilage suture suspension

Question 11

List the possible causes of nasal septal perforation.

Answer 11

● Iatrogenic: Prior septal surgery, prior cauterization,
nasogastric tube placement, nasotracheal intubation, etc.
● Trauma: Nose picking (i.e., digital trauma), septal
hematoma
● Inhalants: Cocaine abuse, intranasal corticosteroids,
chronic vasoconstrictor use, glass dust, etc.

● Autoimmune: Wegener granulomatosis, sarcoidosis, sys-
temic lupus erythematosus, Crohn disease, etc.

● Infectious: Syphilis, leishmaniasis, tuberculosis, acquired
immunodeficiency syndrome (AIDS), etc.
● Neoplastic: T-cell lymphomas, etc.
● Miscellaneous: Lime dust, cryoglobulinemia, renal failure
● Idiopathic

Question 12

What common symptoms are associated with

septal perforation?

Answer 12

● Asymptomatic (vast majority)
● Nasal crusting
● Epistaxis
● Nasal obstruction
● Postnasal drip
● Whistling

Question 13

Where are septal perforations most commonly
found in the septum, and how large are they
usually?

Answer 13

Anterior septum. Most commonly 1 to 2 cm

Question 14

When should you take a biopsy of a septal

perforation?

Answer 14

When there is concern for malignancy, a biopsy should be
taken, although this is controversial and not recommended
routinely; yield is low when biopsy is done for vasculitic
disease, etc.

Question 15

What size septal perforation has a high risk of failed surgical closure?

Answer 15

Large perforation (> 2 cm)

Question 16

What perforations should you treat with
conservative management, and what does this
involve?

Answer 16

Asymptomatic perforations. The goal is to keep the
perforation moist (i.e., nasal saline sprays, Vaseline, saline
irrigations, etc.).

Question 17

For large septal perforations not amenable to surgical closure or smaller symptomatic
perforations, what nonsurgical option can be
offered that can decrease epistaxis, nasal crusting,
obstruction, and whistling?

Answer 17

Septal button placement. Prefabricated or custom buttons are available. Custom prostheses for large or irregular perforations can be optimally sized using a maxillofacial CT `scan.

Question 18

Identify complications associated with septal

button placement.

Answer 18

● Intranasal pain (particularly if displaced)
● Erosion of perforation edges (rare, usually protects)
● Intranasal crusting
● Bacterial colonization/biofilm
Note: All are relatively low risk but should be discussed.

Question 19

Describe the surgical approaches and techniques

available for nasal septal perforation repair.

Answer 19

Approaches: Endonasal versus open techniques:
● Primary closure
● Interposition grafts: Bone, cartilage, periosteum, tem-
poralis fascia, acellular dermis
● Flaps: Bipedicaled mucoperichondrial flap, rotational
mucoperichondrial flap
● Alternative flaps (large perforations > 2 cm): Inferior
turbinate pedicled flap, tunneled sublabial mucosal flap,
facial artery musculomucosal flap, radial forearm free
flap, pericranial/glabellar flap

Question 20

Describe the process and potential danger of

septal hematoma.

Answer 20

Blood collection causes elevation of the mucoperichon-
drium/mucoperiosteum off the septal cartilage causing
devascularization of underlying cartilage and potential for
avascular necrosis and reabsorption.

Question 21

Identify complications associated with septal

hematoma.

Answer 21

Septal perforation, subperichondrial fibrosis, septal abscess,
intracranial infection (spread to cavernous sinus through emissary veins, extremely rare)

Question 22

What factor places children at increased risk for developing nasal septal hematoma?

Answer 22

Loose adherence of the mucoperichondrium and muco-periosteum to the underlying bone and cartilage

Question 23

What is the treatment for septal hematoma?

Answer 23

Incision and drainage with application of nasal stent or
packing to keep the potential space reduced. The patient
should be receiving prophylactic antibiotics while packing is
in place.

Question 24

What is defined as a collection of purulent
material between the nasal septal mucoperiosteum/
mucoperichondrium and the bony and/or
cartilaginous septum?

Answer 24

Nasal septal abscess

Question 25

What are the risk factors for developing a nasal

septal abscess?

Answer 25

● Septal hematoma resulting from trauma or prior surgery
● Nasal vestibule furuncle
● Sinusitis
● Dental infection

Question 26

What is the recommended management for nasal

septal abscesses?

Answer 26

● Anti-staphylococal antibiotics

● Incision and drainage

Question 27

What complications are associated with nasal

septal abscesses?

Answer 27

Intracranial complications (abscess, cavernous sinus thrombosis), orbital cellulitis, septal perforation or weakening or loss of the nasal framework resulting in saddle-nose deformity

Question 28

A patient with pain and itching of the nasal
vestibule is examined, and you note small pustular
lesions with an erythematous base, pierced by a
single hair follicle. What is the diagnosis?

Answer 28

Nasal folliculitis

Question 29

Facial or nasal folliculitis can be superficial or deep

and is often associated with what pathogen?

Answer 29

S. aureus

Question 30

What pathologic condition generally follows
folliculitis, or hair follicle infection, and develops
as a small abscess with extension of purulent
material from the dermis to subcutaneous tissue?

Answer 30

Furuncle (boil)

Question 31

Why are incision and drainage of nasal furuncles,
if necessary, deferred for at least 24 hours after
initiating antistaphylococcal antibiotics?

Answer 31

Risk of cavernous sinus thrombosis

Question 32

Inflammatory nasal masses can form around a
foreign body, blood clot, or secretion and grow
as a result of accumulation of salts (calcium,
magnesium, phosphate, carbonate) over time,
potentially resulting in pressure injury to adjacent
structures and causing nasal obstruction, pain,
headache, infection, or recurrent epistaxis. This
process is referred to as what?

Answer 32

Rhinolith

Question 33

A previously healthy 3-year-old patient has had
2 days of unilateral rhinorrhea associated with a foul odor, intermittent ipsilateral epistaxis, and generalized irritability. Examination reveals a mass in the right nasal cavity. What is the most likely diagnosis?

Answer 33

Nasal foreign body

Question 34

What proportion of epistaxis arises from an

anterior source?

Answer 34

Approximately 90% to 95%

Question 35

What are the common local causes of epistaxis?

Answer 35

● Trauma: Digital, fracture, nasotracheal intubation, feed-
ing tube placement, foreign body, recent surgery
● Drug related: Nasal steroid sprays, cocaine inhalation
● Desiccation: Nasal oxygen, continuous positive airway
pressure (CPAP)
● Inflammatory or infectious
● Neoplastic

Question 36

What systemic processes can result in epistaxis?

Answer 36

Coagulopathy:
● Genetic: Hemophilia, hereditary hemorrhagic telangiec-
tasis (HHT), von Willebrand disease
● Drug related: Coumadin, heparin, aspirin
● Hypertension
● Neoplastic: Pancytopenia, thrombocytopenia, etc.

Question 37

List nonsurgical methods of epistaxis

management.

Answer 37

ABCs (airway, breathing, and circulation): Epistaxis can be
life threatening!
● Direct pressure
● Vasoconstrictive agents
● Cautery under direct visualization
● Nasal packing
● Absorbable packing
● Nonabsorbable packing
● Control hypertension and correct coagulopathy if
possible
● Nasal hygiene
● Saline sprays, humidity, emollients (petroleum jelly, etc.)

Question 38

What are the surgical methods available for

epistaxis control if bleeding continues despite maximum nonoperative intervention?

Answer 38

● Surgical ligation
● Sphenopalatine artery (transnasal endoscopic, identify
crista ethmoidalis, may use large maxillary antrostomy)
● Internal maxillary artery (transmaxillary endoscopic,
either via the Caldwell-Luc procedure, mega-antrostomy,
or partial medial maxillectomy)

● Anterior ethmoid artery (Lynch incision, identify fron-
toethmoid suture line)

● External carotid artery (transcervical)
● Endovascular embolization (most commonly internal
maxillary artery; risk of stroke)

Question 39

External ligation of the anterior ethmoid artery is

obtained through what approach?

Answer 39

Accessed via Lynch incision, located approximately 24 mm posterior to the anterior lacrimal crest, along the frontoethmoid suture line

Question 40

Describe the location of the sphenopalatine artery

for endoscopic ligation.

Answer 40

Posterior to the inferior attachment of the middle turbinate,
submucosal on the lateral nasal sidewall

Question 41

Why are antibiotics prescribed while a patient has nasal packing in place?

Answer 41

To prevent toxic shock syndrome

Question 42

What autosomal dominant disorder results in
punctate hemangiomas or vascular sinuses that are irregularly shaped, associated with thin epithelium, and have no muscular or elastic layers resulting in easy bleeding?

Answer 42

Osler-Weber-Rendu disease (HHT)

Question 43

What are the organs most commonly associated

with HHT?

Answer 43

Nasal cavity, oral cavity, GI tract, lungs, liver

Question 44

Which genetic mutations are most commonly

seen with HHT?

Answer 44

Endoglin gene (ENG, HHT1) and activin A receptor type II-
like 1 gene (ACVRL1, HHT2). Mutation detection rates are as high as 75% with sequence analysis of these two genes.
SMAD4 is less common (3%) and is associated with HHT and
juvenile intestinal polyposis.

Question 45

What are the most common sign and symptom

associated with HHT?

Answer 45

Mucocutaneous telangiectasias and recurrent epistaxis

Question 46

What are the nonsurgical treatment options

available for HHT patients with recurrent epistaxis?

Answer 46

● Anemia: Iron supplementation, blood transfusions
● Nasal hygiene: Oil of sesame with rose-geranium, nasal
saline spray; tolerated in some patients
● Intranasal bevacizumab

Question 47

What are the surgical treatment options available

for HHT patients with recurrent epistaxis?

Answer 47

Surgical management:
● Potassium-titanyl-phosphate (KTP) laser ablation of le-
sions
● Injection of bevacizumab
● Septodermoplasty
● Young’s procedure

Question 48

Describe Saunder’s septodermoplasty.

Answer 48

Denuding of nasal mucosa affected by telangiectasias and

coverage of denuded area with a split-thickness skin grafts

Question 49

In what surgical procedure are the nasal cavities
closed by creating two layered flaps (nasal mucosa
and skin), thus eliminating airflow through the
nasal cavities?

Answer 49

Young’s procedure