Nose disorders

Question 1

Important Consideration - Unilateral Disease

Question 2

Red Flags for serious complications! 8

Answer 2

High Fever
Double or reduced vision
Proptosis
Dramatic periorbital edema
Ophthalmoplegia
Severe headache
Meningeal signs
Severe/ Recurrent epistaxis

Question 3

Nasal Vestibulitis

general

Answer 3

Infection/ irritation of nasal vestibule usually because of ingrown hair as a result of trimming/ plucking
Infection usually caused by staph aureus

Question 4

Nasal Vestibulitis

Tx

Answer 4

Treatment
Topical abx (mupirocin 2% nasal ointment 2-3 times daily)
Systemic antibiotics
Dicloxacillin 250mg 4 times daily x 7-10 days for initial infection
Rifampin 10mg/kg twice daily for last 4 days in addition to diclox for recurrent infxns
Incision and drainage of furuncle if large enough

Follow up carefully! If infxn spreads to veins, it has high likelihood of entering brain.

Question 5

S. Aureus and the Nose

general

Answer 5

Most common nosocomial bacteria is staph aureus
Happy home for the bacteria; warm and humid with agar-like mucus
Big concern with MRSA
“nosocomial infections”
Many patients are swabbed preoperatively to check for this before elective procedures (especially ortho cases with implants)
Typically have no symptoms

Question 6

S. Aureus and the Nose

Tx

Answer 6

Treatment: mupirocin 2% topical plus chlorhexidine face wash twice daily for 5 days

Question 7

Nasal polyps

general

Answer 7

Usually sign of severe underlying sinus inflammation
Self-perpetuating
Almost always require surgical excision
Underlying sinus disease must be addressed

Question 8

Nasal polyps

general

Answer 8

Nasal Polyps (Antrochoanal)
Occasionally an antral polyp arising from the mucosa of the maxillary sinus may protrude through one of the natural or accessory ostiums and become present in the nasal chamber stretching posteriorly into the nasopharynx as a hanging mass.

Question 9

Question 10

tumors

Answer 10

The slide on the left side shows a small inverted papilloma located in the posterior portion of the middle turbinate. The picture on the right side shows an inverted papilloma arising from the ethmoid region through the middle meatus. In both tumors the characteristic, irregular “bumpy” mucosa of the papilloma is seen.

Question 11

Inverted Papilloma

Answer 11

If you see any tissue in the nose that isn’t inferior turbinate, middle turbinate, or septum, refer to ENT.

Inverted Papilloma
The picture on the left side demonstrates an inverted papilloma from the ethmoid region inducing an almost complete obstruction of the nasal chamber. A specimen is exposed on the right side.

Question 12

Epistaxis

RF

Answer 12

Risk factors
Anticoagulation
Age
Hypertension
Dryness
Winter months
Oxygen via nasal cannula

Question 13

Epistaxis

Dx and Tx

Epistaxis – Ulceration
The slide on the left side shows the nasal septum with an area of ulceration/abrasion of the K-L area. On the right side a small area of granulation tissue can be seen.

Answer 13

Diagnosis does not require much experience.
Epistaxis treatment ladder

Treatment of epistaxis varies according to the severity of the condition, age of the patient, general physical status and location of the hemorrhage. Bleeding of the nasal chambers usually is treated by electrocautery; however, anterior and/or posterior nasal packing, arterial embolization, or surgery may be necessary.

Question 14

Epistaxis

Before & after cautery

Answer 14

The slide on the left side shows a small, active, arterial bleeding. On the right side, the bleeding has been controlled by the use of cautery. The use of a topical anesthetic agent (lidocaine 4%) and a local submucosal injection (lidocaine 1% with epinephrine 1:100,000) allows the surgeon to cauterize the area with minimal discomfort.

Question 15

Juvinile nasopharyngeal angiofibroma

CAT scan

Answer 15

Most of the time, when you hear hoof beats, think horses, not zebras. But occasionally, you may see some zebras. If ever persistent epistaxis in a teenage boy, refer to rule out JNA. It’s exclusively an adolescent male disease.

CAT scan and angiography are standard tests in the evaluation and management of JNA. Erosion or deformities of the bony structures adjacent to the nasopharynx are a common occurrence, and include the medial wall of the maxillary sinus, pterygoid plates, septum, etc.
The tumor has characteristic angiographic patterns. In the arterial phase there are increased numbers of dilated tortuous vessels; the capillary phase demonstrates a dense stain. The predominant blood supply comes from the ipsilateral internal maxillary artery, but as the tumor grows bilateral vascular irrigation occurs.

Question 16

Epistaxis

Tx

Answer 16

Treatment
Moisturization: Vaseline, Humidifier, Nasal Saline
Afrin for acute bleed
Spray
Soaked onto cotton ball, inserted just inside nose
Refer if persistent

Question 17

Nasal foreign bodies

Sx

Answer 17

Classic symptom—rhinorrhea that is:
Unilateral
Purulent
Foul-smelling
History sometimes very helpful
Exam can be difficult

Question 18

Nasal foreign bodies

Question 19

Nasal foreign bodies

Kissing technique

Answer 19

Positive pressure technique, aka “kissing” technique

Question 20

Nasal fracture

general

Answer 20

History of direct nasal trauma
Almost always with epistaxis
Criteria to reduce:
Cosmetic deformity
Acute onset nasal obstruction

Question 21

Nasal fracture

3 times to reduce

Answer 21

3 times to reduce:
Immediately
7-14 days later (closed nasal reduction)
3-6 months later (formal septorhinoplasty)

Question 22

Septal Ulcer / Septal Hematoma

Answer 22

The slide on the left side shows a mucosal ulcer induced by repetitive factitial trauma. In the form of “nasal neurosis” the patient has the persistent need to clean the nose through the introduction of a hard instrument or even a long fingernail. Ultimately, the mucosa ulcerates and frequently a through and through septal perforation will develop if the persistent trauma does not stop.

The slide on the right side shows a septal hematoma after nasal trauma. The accumulation of blood in either or both sides of the septum produces obstruction. Septal hematomas need to be drained and stented in order to try to save the integrity of the nasal septum. If left unattended, infection with formation of an intraseptal abscess will form and the cartilage may be destroyed.

Question 23

Septal Hematoma

General

Answer 23

Usually post-traumatic
Complete nasal obstruction
Soft to palpation with Q-tip
Natural history
Septal abscess, then
Saddle nose deformity
Refer emergently

Question 24

Septal perforation

General

Answer 24

Usually at skin/mucosa junction
Risk factors
Trauma
Afrin
Cocaine
Malignancy
Epistaxis most common symptom

Question 25

# septal perf Tx

Answer 25

Treatment: moisture Refer if symptoms persist

Question 26

# Nasal papilloma

Answer 26

Usually at skin/mucosa junction Refer any nasal mass Papillomas of the nasal chambers are unusual lesions located mainly in the nasal septum; however, they may be found anywhere in the nasal chambers. The slide shows on the left side a papilloma of the nasal septum, and on the right side a papilloma situated in the posterior aspect of the soft palate visible only through nasal endoscopy. Human papilloma viruses (HPVs) are widely spread throughout the population. They are known to induce a variety of epithelial tumors of the skin and the mucous membranes. Over 60 HPVs have been classified according to the degree of nucleic acid homology. Classification by serologic techniques is not possible since type-specific antigens are not available. Each HPV has been associated with a distinct histopathologic process. Common warts (associated with HPVs # 2, 1, 4, 41; in order of frequency) are the most frequent clinical manifestation. Less frequently, plantar warts (HPV # 1, 2, 4) are found usually among adolescents. Condyloma acuminatum (HPV # 6, 11, 10, 40-44, 45, 51) is a common sexually transmitted disease of increasing incidence in the United States. The lesions may be seen anywhere in the oral cavity, and possibly by seeding, in the nasal chambers. They consist of vascular fleshy exophytic lesions of pediculated or sessile attachment. The lesions may be single or multiple. As mentioned before, condyloma acuminatum has not been associated with malignant potential. Usual treatment is destruction by surgical excision or electric cauterization of the lesions. A large amount of information has been collected suggesting that epithelial lesions of the genital tract containing HPVs of the types # 5, 8, 16, 18, 30, 31, 33 have a high malignant potential. This has not been found in the nasal or oral cavity lesions, which involve a different type of virus (from “Diseases of the Oral Cavity and Oropharynx” Vol II – AAO&HNS Slide Lecture Series).

Question 27

# Nasal Squamous Cell Carcinoma general

Answer 27

If the septum has any lesion that does not resolve with moisture, it warrants biopsy. Squamous Cell Carcinoma – Septum  The slide shows two pictures of squamous cell carcinoma of the nasal vestibule. Squamous cell carcinoma of the vestibule is the most common squamous cell carcinoma found in the nasal chambers and is usually seen in cigarette users. Untreated, this carcinoma will invade the adjacent structures including the dome of the nose and the upper lip.

Question 28

# Squamous Cell Carcinoma - Rhinophyma general

Answer 28

Squamous Cell Carcinoma - Rhinophyma The slide on the right side shows a rhinophyma. A rhinophyma is a hypertrophy of the sebaceous glands usually due to longstanding rosacea. The lesion can induce severe deformity of the nasal pyramid. Treatment when early may be focused as a treatment for the rosacea. Surgery may be necessary when the disfigurement is severe. The slide on the left side shows an extensive squamous cell carcinoma of the skin with destruction of the nasal pyramid.