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Dr Kavitha Ashok kumar
7/25/2014 2Dr. Kavitha Ashok Kumar
7/25/2014 3Dr. Kavitha Ashok Kumar
Diseases of external nose
Conditions affecting the nasal septum
Infections/inflammation of the nose
Tumours of the nose and nasopharynx
7/25/2014 4Dr. Kavitha Ashok Kumar
Congenital: Cleft lip/ palate, meningocoele, dermoid, hemangioma, etc.
Inflammatory Non-specific: Furuncle, cellulitis
Specific: Rhinoscleroma, TB, syphilis, leprosy, lupus, etc.
Trauma: Facial trauma, surgical trauma
Neoplastic Benign: Papilloma, rhinophyma
Malignant: Basal cell ca, squamous cell ca.
7/25/2014 5Dr. Kavitha Ashok Kumar
7/25/2014 6Dr. Kavitha Ashok Kumar
External nasal skeleton is made of various bones and cartilages
Differential growth rate of these components can give rise to deformed nose
Influenced by Fetal position in utero
Birth trauma
7/25/2014 7Dr. Kavitha Ashok Kumar
Bony/ cartilaginous/ both
Hump
Depressed dorsum- Saddle nose
Lateral deformities Crooked nose- C/ S/ V shaped
Deviated nose
Tip deformities
Alar deformities
‘Frog face’ deformity
7/25/2014 8Dr. Kavitha Ashok Kumar
7/25/2014 9Dr. Kavitha Ashok Kumar
7/25/2014 10Dr. Kavitha Ashok Kumar
7/25/2014 11Dr. Kavitha Ashok Kumar
7/25/2014 12Dr. Kavitha Ashok Kumar
7/25/2014 13Dr. Kavitha Ashok Kumar
Investigations
Radiological: rule out secondary sinusitis
Nasal endoscopy
Preoperative photography
Treatment
Treat associated or secondary rhinitis/ sinusitis
Treat the cause
Surgical treatment: Rhinoplasty/
septorhinoplasty
7/25/2014 14Dr. Kavitha Ashok Kumar
Acute staphylococcal infection of the hair
follicle commonly seen in the nasal vestibule
Etiology of recurrent furuncle:
Nose picking
Diabetes
Immuno-compromised states
7/25/2014 15Dr. Kavitha Ashok Kumar
Pain on touching the nose especially the tip/
ala
Pus pointing or swelling over the nose or in
the vestibule
Purulent discharge if it ruptures
Tenderness of the nasal tip/ ala
7/25/2014 16Dr. Kavitha Ashok Kumar
Not to squeeze the lesion
Dangerous area of the face—infection can spread along the angular and ophthalmic veins to cavernous sinus
Systemic antibiotics and analgesics
I&D if it becomes an abscess
Management of underlying diabetes, if present.
7/25/2014 17Dr. Kavitha Ashok Kumar
Facial cellulitis
Abscess of the upper lip
Septal abscess
Cavernous venous thrombophlebitis
Vestibular stenosis- in recurrent forms
7/25/2014 18Dr. Kavitha Ashok Kumar
Diffuse dermatitis of the nasal vestibule
caused by staphlococcus aureus
Etiology:frequent picking of the nose
Clinical features: red ,painful nose.crusts
and scales,fissures
Treatment:clean the crusts,ointment.
7/25/2014Dr. Kavitha Ashok Kumar 19
Thickening and heaped raised lesions of the
tip of the nose due to hypertrophy of the
sebaceous glands
Typically afflicts white males between 40 and
60 years of age (M:F::12:1)
End result of acne rosacea which is actually
more common in females
7/25/2014 20Dr. Kavitha Ashok Kumar
7/25/2014 21Dr. Kavitha Ashok Kumar
Medical treatment Treatment of secondary infection and
inflammation with antibiotics and steroids
Surgical: Full thickness excision followed by application
of split thickness skin grafts
Partial thickness "decortication" using cryosurgical techniques, chemical peels, dermabrasion, or Argon/CO2 lasers
7/25/2014 22Dr. Kavitha Ashok Kumar
Most common malignancy of the skin
commonly affecting the nose
long-term exposure to sunlight and
frequently occur on sun exposed skin, such as
the face, scalp, ears, etc.
> White adult population
> Outdoor workers, sailors and the very fair
skinned.
>50 years and above
7/25/2014 23Dr. Kavitha Ashok Kumar
Locally slow growing and mutilating lesion
Lymphatic and distant metastasis-uncommon
Early diagnosis- prevents disfigurement of
face
Treatment: Excision and reconstruction
Prognosis- very good on complete removal
7/25/2014 24Dr. Kavitha Ashok Kumar
7/25/2014 25Dr. Kavitha Ashok Kumar
Deviated Nasal
Septum
7/25/2014 26Dr. Kavitha Ashok Kumar
7/25/2014 27Dr. Kavitha Ashok Kumar
C – SHAPED
S SHAPED
7/25/2014 28Dr. Kavitha Ashok Kumar
•Duplication
•SPUR
•DISLOCATION7/25/2014 29Dr. Kavitha Ashok Kumar
• TRAUMA
• DEVELOPMENT ERROR
• HEREDITARY
7/25/2014 30Dr. Kavitha Ashok Kumar
SIGNSExternal examination
Anterior rhinoscopy
Cottle’s Test
SYMPTOMSNasal obstruction
Headache
Sinusitis
Epistaxis
Anosmia
External deformity
Middle ear diseases
Anterior ethmoidalnerve syndrome.
7/25/2014 31Dr. Kavitha Ashok Kumar
COTTLE’S TEST
7/25/2014 32Dr. Kavitha Ashok Kumar
HEMATOLOGICAL
- Hb
- WBC
- OTHERS
RADIOLOGY
- X Ray - PNS
DIAGNOSTIC ENDOSCOPY
7/25/2014 33Dr. Kavitha Ashok Kumar
MEDICAL- EXERCISES
- DECONGESTANTS
SURGICAL- SEPTOPLASTY
-SUBMUCOSAL RESECTION OF SEPTUM(SMR)
7/25/2014 34Dr. Kavitha Ashok Kumar
Symptomatic DNS
Grafting material-cartilage/bone
Septal perforation closure.
Surgical access
7/25/2014 35Dr. Kavitha Ashok Kumar
Steps
INCISION
ELEVATION OF FLAPS
CORRECTION OF DEFORMITY
CLOSURE
ANTERIOR NASAL PACKING
7/25/2014 36Dr. Kavitha Ashok Kumar
COTTLE’S LINE
7/25/2014 37Dr. Kavitha Ashok Kumar
INCISION
FREER’S
KILLIAN’S
7/25/2014 38Dr. Kavitha Ashok Kumar
ELEVATION OF FLAPS
Anterior
Tunnel
Inferior
Tunnel
7/25/2014 39Dr. Kavitha Ashok Kumar
BEFORE AFTER
7/25/2014 40Dr. Kavitha Ashok Kumar
SMR
KILLIAN’S INCISION
FLAP ELEVATED BOTH SIDES
CARTI+ BONY REMOVED
SUPRATIP DEFORMITY
COLLUMELLAR RETRACTION
DORSAL COLLAPSE
SEPTAL PERFORATION
FLAPPING SEPTUM
SEPTOPLASTY
FREER’S INCISION
FLAP ELAVATED ON ONE
SIDE
ONLY CORRECTION OF DNS
COMPLICATIONS LESS
RESIDUAL DNS
7/25/2014 41Dr. Kavitha Ashok Kumar
EARLY ANAESTHETIC COMPLICATIONS
SEPTAL HEMATOMA / ABCESS
PERFORATION
LATESUPRATIP DEFORMITY
COLUMELLAR RETRACTION
SEPTAL PERFORATION
RESIDUAL DEVIATION
ATROPHIC RHINITIS
7/25/2014 42Dr. Kavitha Ashok Kumar
SEPTAL HEMATOMA
SEPTAL ABCESS
7/25/2014 43Dr. Kavitha Ashok Kumar
Trauma
Submucosal blood vessel
Chondrocytes die
Infected
abscess
7/25/2014 44Dr. Kavitha Ashok Kumar
Traumatic• Surgery / Cautery / Nose picking
Malignant • Tumours/ Granuloma
Chronic inflammation• Wegeners/syphilis/tuberculosis/candida/lupus
erythematosus/rheumatoid arthritis.
Poisons• Industrial/cocaine addicts/topical
corticosteroids/topical decongestants
Idiopathic
7/25/2014 45Dr. Kavitha Ashok Kumar
SEPTAL PERFORATION
Anterior Rhinoscopy
Size:
Small: upto 1 cm
Medium: 1-2 cm
Large: >2cm
7/25/2014 46Dr. Kavitha Ashok Kumar
REPAIR
SEPTAL BUTTONS
7/25/2014 47Dr. Kavitha Ashok Kumar
REPAIR
SURGERY
7/25/2014 48Dr. Kavitha Ashok Kumar
Aetiology: viral--influenza ,coxsackie , reovirus,ECHO virus and rhinovirus
Pathology: transient vasoconstriction followed by vasodilatation,oedema and increased secretions
Clinical features: Irritation—burning sensation---watery nasal
discharge 2-3days later—fever,nasal obstruction mucopurulant discharge
5-10 days-------recovery
7/25/2014 49Dr. Kavitha Ashok Kumar
Nonspecific:
Chronic hypertrophic rhinitis
Atrophic rhinitis
Rhinitis caseosa(nasal
cholesteatoma)
Rhinitis sicca
Allergic rhinitis
Vasomotor rhinitis
7/25/2014 50Dr. Kavitha Ashok Kumar
Specific:
Lupus vulgaris of the nose
Tuberculosis
Syphilitic rhinitis
Leprosy
Rhinosporidiosis
Rhinoscleroma
7/25/2014 51Dr. Kavitha Ashok Kumar
Clemens Von Pirquet,Viennesse Paediatrician
coined the term allergyin 1906
denoting an altered state of reactivity
to an organic substance
i.e ‘allergen’
7/25/2014 52Dr. Kavitha Ashok Kumar
Is a protein with a size of 2 to 50 micrometer in diameter & molecular weight of 1000 to
40,000 Daltons
7/25/2014 53Dr. Kavitha Ashok Kumar
Definition:
It is an IgE mediated
immunological response of the mucosa of
nose charecterized by bouts of sneezing
watery nasal discharge, itching and a sense
of nasal obstruction
7/25/2014 54Dr. Kavitha Ashok Kumar
Seasonal allergic rhinitis
March to May
(Hay fever)
or
July to September
Prevalence of
pollens of
grasses, flowers,
trees/shrubs
7/25/2014 55Dr. Kavitha Ashok Kumar
1. Pollens
Weed pollen
Grass Pollen
Timothy Grass(Phleumpratense)
Cocksfoot(Dactylis glomerata)
Birch, hazel, Plane tree ash
and pine
Tree pollens
NETTLE, DOCK & MUGWORT
FLOWER7/25/2014 56Dr. Kavitha Ashok Kumar
Perennial allergic rhinitis
Throughout the year
Exogenous allergens like
house dust, soaps, creams,
perfumes, egg, odours of fish
coffee
Commonest is house dust which contains faeces of mites- DermatophagoidesPteronyssinus
7/25/2014 57Dr. Kavitha Ashok Kumar
7/25/2014 58Dr. Kavitha Ashok Kumar
Seasonal
Paroxysmal sneezing
Watery Nasal
discharge
Nasal obstruction
Itching
Perennial
Frequent colds
persistently stuffy
nose
Loss of smell
Postnasal drip
Chronic cough
Hearing impairment
7/25/2014 59Dr. Kavitha Ashok Kumar
Nosetransverse crease on nose
pale, oedematous nasal mucosa
turbinates are swollen
thin, watery/ mucoid discharge
Earsretracted T M
Serous otitis media
7/25/2014 60Dr. Kavitha Ashok Kumar
Investigations
1. Blood - TC, DC, AEC2. Nasal smear for eosinophils3. Nasal provocation tests4. Skin test (Prick/ Scratch/ Intradermal tests)5. Radioallergosorbent test
Antigen (radioactive) + Pt’s serum (Contains IgE)
Radioactive IgE complex (Measured)
7/25/2014 61Dr. Kavitha Ashok Kumar
a. Avoid possibly known allergen
b. Drugs
1. Antihistamines2. Sympathomimetic drugs3. Corticosteroids
Oral/Local/Injection4. Mast cell stabilizer (2% Sodium
chromoglycate nasal spray)
c. Immunotherapy
7/25/2014 62Dr. Kavitha Ashok Kumar
Vasomotor rhinitisRhinitis medicamentosaEndocrinal rhinitis
a. Thyroid dysfunctionb. pregnancyc. Honeymoon Rhinitis
Drug induced rhinitisa.Contraceptive pillsb. Antihypertensivesc. Neostigmine
7/25/2014 63Dr. Kavitha Ashok Kumar
Definition
It is a clinical condition due to imbalance of
autonomic nervous system
Epidemiology
Common in emotionally unstable
persons( Women of 20 to 40 years)
7/25/2014 64Dr. Kavitha Ashok Kumar
Nasal Obstruction, Rhinorrhoea
Postnasal drip, Head ache, fatigue
Signs
Enlargement of turbinates
Mucosa is dusky red in color (Mulberry
like appearance)
7/25/2014 65Dr. Kavitha Ashok Kumar
Physical exerciseTranquillizersDecongestantsSurgical treatment
Cauterization of turbinatessubmucosal diathermyCryosurgerySurgical resection of turbinatesVidian Neurectomy ( Malcomson 1959) in intractable rhinorrhoea
7/25/2014 66Dr. Kavitha Ashok Kumar
Atrophy of nasal mucosa & turbinate bones.
• Excessive drying, crusting and infection
Klebsiella colonization
Types:
Primary:Cause is not known Theories proposed : Hereditary,Endocrinal,Racial,Nutritional
def,Infective, Autoimmune.
Secondary: in Syphilis,Tuberculosis Leprosy,Lupus.
7/25/2014 67Dr. Kavitha Ashok Kumar
Metaplasia from ciliated columnar to
squamous
Type 1;Endarteritis & periarteritis due to
chronic inflammation
Type 2;Vasodilatation of capillaries
7/25/2014 68Dr. Kavitha Ashok Kumar
Nasal block, epistaxis
(Merciful) anosmia
Choking when detached crusts slips from the nasopharynx to oropharynx
Atrophic pharyngitis & laryngitis
O/E
Greenish/grayish black crusts,
Roomy nasal cavity
Shrivelled turbinates.
7/25/2014 69Dr. Kavitha Ashok Kumar
Nasal douche
3-4 times per day for 2-3 months,then 1-2 times per day indefinitely
280ml of water + 28.4gm(1tsp)Sodium bicarbonate +1tsp sodium diborate + 56.7gm(2tsp) sodium chloride
Drops of 25% glucose in glycerin locally
Local antibiotics
Oestradiol spray
Placental extract
Rifampicin 600mg daily / Streptomycin
Oral KI
7/25/2014 70Dr. Kavitha Ashok Kumar
Narrowing:
Young’s operation; Modified young’s
Lautenslager’s operation, Submucous inj
of Teflon,Cancellous bone graft.
Transplant: Witmack’s procedure,
Nerve destructive: Ganglion nerve blocks,
7/25/2014 71Dr. Kavitha Ashok Kumar
Crust formation seen in patients who
work in hot dry surroundings
Confined to anterior1/ 3rd Nose
Treatment
Correction of occupational
surroundings,
Local application of ointment,
Nasal douche.
7/25/2014 72Dr. Kavitha Ashok Kumar
Mostly affects males
Nose filled with offensive,cheesy
material
Secondary to chronic sinus infection
Treatment-Removal of debris,
drainage of sinus.
7/25/2014 73Dr. Kavitha Ashok Kumar
7/25/2014 74Dr. Kavitha Ashok Kumar
Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.
Anatomical considerations:
Osteo-meatal complex
Depending on the site Unilateral/ bilateral Pansinusitis Multisinusitis Maxillary/ frontal/ ethmoidal/ sphenoidal
Depending on whether the sinus is draining or not Open type Closed type
Depending on the pathology Suppurative Non-suppurative
Rhinogenic- Commonest (85%) Usually after viral rhinitis (Flu)
Any form of rhinitis
Dental (Maxillary)
Root abscess, dental procedure, etc.
Trauma RTA, Swimming and diving, FB, barotrauma,
etc.
Iatrogenic- nasal packing, septal surgery
Hematogenous- Rare
Mucosal odema of MM Any form of rhinitis: Viral, bacterial, Irritant, allergic,
VMR, atrophic, etc. (environmental factors play role)
Mechanical (anatomical) obstruction of nose/ MM DNS, spur, polyp, hypertrophic turbinate, any mass, FB,
nasal packing, etc.
Pathological mucous Thick mucous (mucoviscidosis, cystic fibrosis)
Primary mucociliary dysfunction
Others: Poor general health, immunodeficiency states, DM, nutritional def., etc,
Str.Pneumoniae
B-hemolytic streptococcus
H.influenzae
Stap. Aureus
Klebsiella pneumoniae
Others
Obstruction to sinus ostium/ meatus
Stasis of secretions (serous-mucinous): Non-suppurative
Secondary bacterial invasion: Suppurative
Severity and resolution depends on Open/ closed. May drain creating accessory
opening.
Organism virulence
Host resistance
Treatment received
Acute inflammatory changes: Hyperemia,
odema, acute infl. infliterate.
Increased activity of the mucous glands
Severe suppuration
Mucosal destruction
Empyema
Bony destruction
Complications
Constitutional symptoms: Fever, malaise, lethargy
Headache/ facial pain: Dull ache, postural/diurnal. Max: Facial, forehead
Frontal: Forehead, “Office headache”
Ethmoid: Between the eyes, may > with eye movement
Sphenoid: Vertex, occipital
Nasal discharge mucous/ mucopurulent/ purulent/ blood stained
Anterior/ postnasal
Nasal obstruction
Cheek/ lid congestion, swelling
Fever
Tenderness
Cheek swelling
Lid edema: in ethmoid and frontal
Inflamed nasal mucosa especially the meatus
Discharge in MM/ SM as on anterior/posterior rhinoscopy
Signs of complications
Endoscopic appearance of acute infective sinusitis, with pus
exuding from under the right middle turbinate and down into the
middle meatus.
Clinical diagnosis
Diagnostic nasal endoscopy (DNE)
Radiological X-ray PNS
Water’s view (Occipetomental)
Caldwel view (Occipetofrontal)
Lateral view
Base skull view (Submento-vertical)
CT scan: indicated in impending complications
C/S: rarely done
Postural test
Transillumination
test
X-Rays PNS
CT Scan
Pus swab
7/25/2014 89Dr. Kavitha Ashok Kumar
CT – Coronal views centered on OMC
Investigations (cont…)
7/25/2014 90Dr. Kavitha Ashok Kumar
7/25/2014 91Dr. Kavitha Ashok Kumar
CT
Coronal CT shows the
inflammatory changes in
the right frontal recess
and anterior middle
meatus (star).
7/25/2014 92Dr. Kavitha Ashok Kumar
7/25/2014 93Dr. Kavitha Ashok Kumar
•Acute Sinusitis
Antibiotics
Nasal decongestants (Topical/systemic)
Anti-inflammatory analgesics
Medicated steam inhalation
Mucolytics
Hot fomentation
If not responding to medical treatment
Impending or manifest complications
Depends on the sinus involved
Acute maxillary: Antral washout/ endoscopic MMA
Acute frontal: Frontal trephination/ endoscopic frontal recess clearance
Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy
Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy
Chronic sinusitis
Acute sinusitis or acute exacerbations of chronic sinusitis may give rise to following complications:
Orbital
Intracranial
Osteomyelitis
Septic focus for other infections
Spiking feverLid odema, facial/orbital swellingProptosis, reduced vision, reduced extraoccular movt.Severe headache and hyperirritableProjectile vomitingMeningeal signsHypothermiaAltered sensorium
Common in acute ethmoiditis or frontal sinusitis
Direct spread/ ostitis/ thrombophlebitic Odema of the lidsSubperiosteal abscessOrbitial cellulitisOrbital abscessSuperior orbital fissure syndrome: Deep
orbital pain, frontal headache, progressive paralysis of extraoccular movements
Blindness
A patient with acute ethmoiditis threatening vision.
Anterior cranial fossa and cavernous sinus
closely related
Meningitis
Extradural abscess
Subdural abscess
Frontal lobe abscess
Cavernous sinus thrombophlebitis, etc
•BRAIN, ABSCESS,SINUSITIS
“Acute sinusitis especially in a child should be
treated adequately to prevent consequent
chronic sinusitis or other more severe
complications which may be even fatal”.
DR KAVITHA ASHOKKUMAR
HISTOLOGICALLY BENIGN, LOCALLY
AGGRESSIVE NONENCAPSULATED
VASOFORMATIVE NEOPLASM SEEN
EXCLUSIVELY IN MALE ADOLESCENTS.
7/25/2014 108Dr. Kavitha Ashok Kumar
MACROSCOPY
WELL CIRCUMSCRIBED .LOBULATED
PURPLE RED MASS
COVERED WITH INTACT MUCOSA
APPEAR DECEPTIVELY AVASCULAR
7/25/2014 109Dr. Kavitha Ashok Kumar
TWO MAIN CELLULAR COMPONENTS
FIBROUS STROMA
BLOOD VESSEL CHANNELS -- RICH
DISTINCT LACK --SMOOTH MUSCLES
ELASTIC FIBRES
7/25/2014 110Dr. Kavitha Ashok Kumar
JUVENILE --OCCURS 10 TO 25 YR
NASAL BLOCK --UNILATERAL
EPISTAXIS --80 PERCENT
FACIAL SWELLING
PROPTOSIS
OCULAR SYMPTOMS
7/25/2014 111Dr. Kavitha Ashok Kumar
WELL DEFINED ROUTES
PLAIN X-RAY --ANT.BOWING OF THE
POSTERIOR WALL OF MAXILLARY
SINUS(HOLMAN-MILLER’S SIGN)
CT-SCAN --BONY INVOLVEMENT
MRI --SOFT TISSUE—INTRA
CRANIAL SPREAD
ANGIOGRAPHY --FEEDING VESSEL
7/25/2014 113Dr. Kavitha Ashok Kumar
1.ENDOSCOPIC INTRANASAL
2.OPEN ACCESS
# TRANSPALATAL
# MIDFACIAL DEGLOVING
# LATERAL RHINOTOMY
INTRACRANIAL APPR. --SURGERY
--RADIATION
EMBOLISATION
RECURRANCE-30-40%
7/25/2014 114Dr. Kavitha Ashok Kumar
Most common in southern states of China
Taiwan and Indonesia
Etiology
Genetic
Abnormality in chromosome 1 to 6,
9,11,13,14,16,17,22, and X
Viral -Epstein Barr virus
Environmental – smoking, airpollution
Dietary – Nitrosamines from dry salted
fish
7/25/2014 115Dr. Kavitha Ashok Kumar
Pathology
Squamous cell carcinoma ( 85%)
Graded in to well, moderately, poorly
differentiated
Lymphoma (10%)
Rhabdomyosarcoma, Malignant salivary
tumour, malignant chordoma (5%)
Clinical features
Age – 4th to 5th decades of life
Male : female - 3:1
Symptoms
Neck mass, hearing loss, Nasal obstruction,
epistaxis, cranial nerve palsies, weight loss
7/25/2014 116Dr. Kavitha Ashok Kumar
Signs –
proliferative/ulcerative/ infiltrative
Unilateral serous otitis media
Rhinolaliaclausa
Squint and diplopia (CN - VI)
Opthalmoplegia (CN –III, IV, VI)
Facial pain and reduced cornial reflex (CN – V)
Blindness (CN – II)
Jugular Foramen Syndrome (CN - IX, X, XI)
Collet – Sicard syndrome (CN – IX, X, XI, XII)
Horner’s syndrome (cervical sympathetic chain)
Trotter’s triad
Cervical Neck Nodes
Distant metastasis
7/25/2014 117Dr. Kavitha Ashok Kumar
Investigations
Endoscopy and biopsy
FNAC
MRI Scan
CT Scan
Serology for Epstein Barr virus
Positron emission tomography (for residual or
recurrent disease after treatment)
Treatment
Irradiation
Systemic chemotherapy
Radical neck dissection
Overall survival is 50 to 80%7/25/2014 118Dr. Kavitha Ashok Kumar
7/25/2014 119Dr. Kavitha Ashok Kumar