ANATOMY OF THE NOSE AND PARANASAL SINUSES

The nose is formed of 2 parts :

(A) External nose
(B) Nasal cavity which is divided into 2 nasal fossae by the nasal septum.

(A) External Nose :

- The upper 1/3 of the external nose is bony (2 nasal bones joined in the midline) and
the lower 2/3 is cartilaginous.
- The midline dorsum (the bridge) starts at the root and ends down at the tip. The
columella connects the nasal tip to the upper lip separating the 2 nostrils.
- Ala nasi forming the lateral sides of the nostrils.
(B) Nasal cavity :
- Formed of 2 nasal fossae on each sides of the nasal septum.
- Each nasal fossae is connected with the outside through the anterior nares (nostril)
and with the nasopharynx posteirorly through the choana.
Walls of the nasal cavities :
1- Roof :
- Formed of the cribriform plate of ethmoid bone.
- Separate the nasal fossa from the ant. cranial fossa.
- Olfactory nerve fibers passes through multiple small foramina.
2- Floor: Formed by the hard palate separate the nasal cavities from the oral cavity.
3- Medial wall : formed by the nasal septum.
4- Lateral wall : formed mainly by the medial wall of the maxilla and characterized by
the presence of :
 3 bony projections called conchae or turbinates (superior, middle and inferior).
 3 meatus, named after the turbinates and each meatus lies below the
corresponding turbinate.
 Spheno-ethmoidal recess lies above the superior turbinate and receives the
ostium of the sphenoid sinus.
 Superior meatus receives the ostia of posterior ethmoidal cells.
 Middle meatus receives the ostia of the frontal, anterior ethmoidal and maxillary
sinuses in an area called ostiomeatal complex.
 Inferior meatus receives the nasal opening of the nasolacrimal duct.
Blood supply of the nose:
(A) Arterial supply :
 The nose is supplied by branches from the internal carotid artery (above the
middle turbinate) and branches from the external carotid artery (below the middle
turbinate) :
- Ant. & post. ethmoidal arteries of the ophthalmic artery of internal carotid artery.
- Sphenopalatine and greater palatine arteries of maxillary artery of EC artery.
- Superior labial artery of the facial artery of EC artery.
  Littles area : an area in the anterior inferior part of the septum, about 1/4 inch
behind the columella. A plexus of blood vessels (kiesselbach's plexus) formed by
anterior ethmoidal a, septal branch of sphenopalatine a, greater palatine a, and
septal branch of superior labial artery. This area is the commonest site of
idiopathic epistaxis.
(B) Venous drainage :
1- Anterior and posterior ethmoidal veins → ophthalmic vein.
2- Sphenopalatine and greater palatine veins → ptyregoid venous plexus.
3- Angular vein → facial vein.
N.B : Ophthalmic vein and ptyrgoid plexus connected to the cavernous sinus, so nasal
infection may cause cavernous sinus thrombosis, so the triangle drained by these
veins extending from the root of the nose to the corners of the mouth called the
dangerous area of the face.
(C) Lymphatic drainage :
a-Anterior part → submental and submandibular lymph nodes.
b-Posterior part → retero-pharyngeal lymph nodes.
c- Submental, submandibular and retero-pharyngeal lymph nodes → upper deep
cervical lymph nodes.
Nerve supply :
1- Sensory : Trigeminal N. (ophthalmic and maxillary branches).
2- Olfaction : olfactory (1st cranial) nerve carries smell sensation to the higher centre.
3- Autonomic nerve supply :
a- Sup. Cervical ganglion → Deep petrosal nerve (sympathetic) vasoconstriction and
diminish secretion → increase nasal patency.
b- Facial nerve → Greater superficial petrosal nerve (Parasympathetic) vasodilation
and increase secretion → nasal obstruction.
c- Deep petrosal nerve + Greater superficial petrosal nerve → Vidian nerve →
Sphenopalatine ganglion → Nasal mucosa (blood vessels, mucous and serous
glands).
 ANATOMY OF THE PARANASAL SINUS
These are air spaces within the skull bones, 4 on each side continue with that of the
nose through their ostia. According to their relation to the middle turbinate, the
paranasal sinus are classified into :
A- Anterior group :
 Formed of the frontal sinus, anterior ethmoidal air cells and maxillary sinus.
 They drain below the middle turbinate.
B- Posterior group :
 Formed of the posterior ethmoidal air cells and sphenoidal sinuses.
 They drain above the middle turbinate.
 Functions of the nose
1-Respiratory function :
a-Air way.
b-Air conditioner by adjustment of temperature and humdification of inspired air
through vascular nasal mucosa.
2-Protective function :
a-Purifaction of air :
- Large particles are prevented from entering the nose by hairs (vibrissae) of the
vestibule.
- Fine parts adhere to the nasal mucosa (mucous blanket) which driven backwards
by the cilia into the nasopharynx to be swallowed.
b-Reflex sneezing for inhaled foreign body.
c- Lysozyme and immunoglobulins are present in nasal secretion.
d-Lymphoid tissue in the nasal mucosa.
3-Olfactory function.
4-Phonatory functions : Resonance of voice especially for letters (M) and (N).
5-Drainage of tears and paranasal sinus.
 Functions of the paranasal sinuses
No definite function could be known, but they may have a role in:
1-Air conditioning : Increase the surface area for warming and moistening of the
inspired air.
2-Reduction of the skull weight.
3-Resonance of the voice.
4-Brain protection during trauma of the face or atmospheric temperature changes.
 Diagnosis of sino-nasal disease
A- History :
Ask about symptoms of sino-nasal diseases :
1-Nasal obstruction.
2-Nasal discharge.
3-Bleeding (epistaxis).
4-Smell disorders.
5-Nasal tone of voice: change in the nasal resonance of voice (nasality) which either:
- Diminished (rhinolalia clausa) due to bilateral nasal obstruction (affect mainly
letters M and N).
- Increased (rhinolalia aperta) due to velo-pharyngeal incompetence (affect K, S).
6-Headache and facial pain.
7-Itching and sneezing.
8-External nasal deformity.
9-Eye symptoms e.g. proptosis.
B- Nasal examination:
(1) External examination:
- Inspection : swelling, deformity, scars, ulcers.
- Palpation : For tenderness, swelling or crepitus (fracture).
a-Digital palpation for :
- External nose.
- Paranasal sinuses.
(2) Examination of nasal cavity :
- Anterior rhinoscopy :
a-For children : Turn tip of the nose, by the examiner's thumb upwards and
backwards to see vestibule and ant. part of the nasal cavity.
b-For adult : By using a nasal speculum to see :
- Floor of the nasal cavity.
- Middle turbinate and meatus.
- Inferior turbinate and meatus.
- Nasal septum.
- Superior turbinate and meatus can not be ssen.
 - Posterior rhinoscopy : using tongue depressor and warmed post nasal mirror
behind the soft palate to see the posterior parts of the turbinates, the posterior
edge of the nasal septum and choana.
- Endoscopic examination : It allows visualization of inaccessible areas and detects
small lesions.
C- Investigations :
(1) Radiology :
- Plain x-rays : are of little value now.
- CT scan : To visualize the bony structures (essential before surgery).
- MRI : To visualize soft tissue structures (e.g. brain and orbit).
(2) Nasal functions :
- Nasal patency : Rhinometery which measures nasal resistance to air flow.
- Smell : Olfactometery.
(3) Biopsy.
(4) Culture and sensitivity for nasal discharge.
 CONGENITAL ANOMALIES OF THE NOSE
Congenital posterior choanal atresia.
Aetiology :
 Persistence of bucco-nasal membrane (between the nose and nasopharynx).
Types :
 Bony or membranous, - Unilateral or bilateral, - Partial or complete.
Clinical picture :
 Unilateral : may not be noticed until late in childhood when the patient notices
permanent unilateral nasal obstruction and discharge which does not move on
blowing the nose.
 Bilateral :
1- Early :
- Cyanosis which may be cyclical or during suckling.
- Asphyxia and death may occur because infant is obligatory nasal breather. It
takes about 2 weeks to learn breathing by mouth.
2- Late : If the infant passed asphyxia, there may be :
- Nasal discharge, - Mouth breathing, - Failure to develop taste and smell.
Diagnosis :
 Mirror test : No condensation of air on a cold mirror.
 Catheter can not pass into the nasopharynx.
 X-ray with lipidol (dye) : The dye cannot pass to the nasopharynx.
 C.T determines the thickness of the bony atresia and differentiate between bony
and membranous atresia.
 Endoscopic examination.
Treatment :
 Bilateral cases is a neonatal emergency : oral air way or endotracheal intubation.
 Transnasal (endoscopic) or transpalatal excision of the atretic plate.
 TRAUMATIC CONDITIONS
OF THE NOSE
(A) Foreign body in the nose :
Most commonly children.
Types :
 Vegetable foreign bodies : such as pea and bean. Their fatty acids are irritating →
inflammatory reaction.
 Non-vegetable foreign bodies : such as button and bead.
Clinical picture :
 Unilateral offensive purulent nasal discharge : may be blood-stained
(pathognomonic).
 Unilateral persistent nasal obstruction.
 The foreign body is seen by clinical or endoscopic examination.
Complications :
 Rhinitis and sinusitis.
 Formation of rhinolith i.e a nasal stone. Due to precipitation of calcium salts from
the nasal secretions on a foreign body, blood clot or inspissated mucus.
Treatment :
 Removal by a hook or forceps.
 General anesthesia with cuffed endotracheal intubation is necessary :
- If the patient is uncooperative or
- If the foreign body is impacted and it is necessary to push it back to the pharynx
to get it through the mouth.
- To avoid inhalation of the foreign body in the lower airway.
(B) Fracture nasal bones :
Due to direct trauma to the nose.
Symptoms :
1-History of trauma.
2-Pain, swelling and deformity of the external nose.
3-Epistaxis.
4-Nasal obstruction (septal deviation or haematoma).
Signs :
1-Deformity depressed bridge or lateral displacement.
2-External swelling : edema, surgical emphysema.
3-Tenderness and crepitus on palpation.
Investigations :
Plain x-ray of the nasal bones (may be of medico-legal importance).
Treatment :
a- Fracture without deformity : Medical treatment only for the swelling and edema for
one week.
- Analgesics for pain.
- Anti-inflammatory for edema.
- Cold compress for 24 hours follow by warm ones to reduce edema.
b- Fracture with deformity (either immediately after trauma or following medical
treatment) : Reduction of the fractured nasal bone using Walsham's forceps followed
by splinting.
c- If the patients presents late (more than 2 weeks) : Rhinoplasty
N.B :
 Septal fractures with deviation are corrected using Ash's forceps.
 Septal hematomas : evacuation with anterior nasal pack.
 Treatment of epistaxis.
(C) Oro-antral fistula :
A fistula between the oral cavity and the maxillary sinus.
Aetiology :
 Traumatic : is the commonest :
- Alveolar fistula as a complication of tooth extraction (2nd premolar or 1st molar).
- Sublabial fistula as a complication of Caldwell-Luc operation.
 Inflammatory : Osteomylitis of maxilla, syphilis and non healing granuloma.
 Malignant fistula as a complication of malignant tumour of the palate or the max.
antrum.
Clinical picture :
1-Unilateral nasal regurgitation of fluid.
2-Unilateral offensive nasal discharge.
3-On blowing the nose, air escape from the mouth.
4-The fistula can be seen through the oral cavity.
Investigations :
CT scan shows maxillary sinusitis and site of the fistula.
Treatment :
a-Small recent fistula : may heals spontaneously.
b-Large and old fistula : surgical closure by abuccal or palatal flap.
c- Treatment of maxillary sinusitis, inflammatory and neoplastic conditions.
(D) C.S.F. Rhinorrhea :
It is the leakage of cerebrospinal fluid through the nose. This may take place through :
a-The roof of the nose (cribriform plate).
b-The roof of frontal, ethmoid or sphenoid sinuses, or rarely
c- Middle ear via Eustachian tube. The main fear is the possibility of infection
causing meningitis.
Aetiology :
 Traumatic : is the most common. Trauma may be accidental (skull base fractures)
or surgical (during sinonasal surgery).
 Neoplastic : due to invasion of anterior skull base by malignant tumors.
 Inflammatory : e.g. gumma of syphilis.
 Spontaneous or idiopathic : no cause can be detected.
Clinical picture :
 Unilateral watery nasal discharge : which is clear, colourless, has salty taste,
dose not stiffen the handkerchief increased by coughing, straining and leaning
forwards.
 Headache : may be due to high CSF pressure (caused by Brain tumour) or low
CSF pressure (caused by CSF leakage).
Complications : Meningitis.
Investigations :
1-Biochemical analysis of discharge, CSF is characterized by :
- Clear, colourless and contain no mucus.
- Contain sugar more than 30 mg%.
- Contain B2 transferrin, which is diagnostic (B2 only in CSF).
2-CT with intrathecal metrizamide (Omnipaque) : can detect the site of leakage.
3-Intra-thecal dye (flourescine) : then detect it in the nasal cavity by nasal
endoscope.
Treatment :
A- Conservative : Most traumatic cases heal spontaneously :
- Bed rest in semi sitting position with the head-up.
- Avoid coughing and straining.
- Avoid blowing of nose.
- Avoid nasal medications (drops or packing).
- Prophylactic antibiotics to prevent meningitis.
B- Surgical : Covering the defect by graft (temporalis fascia) or flap
(mucoperi-osteal septal flap); if conservation failed. It can be done externally or
recently endoscopic.
 THE NASAL SEPTUM
(A) Deviated nasal septum :
Etiology :
a- Developmental : most common. b- Traumatic.
Types :
a-C-shaped : deviation to one side.
b-S-shaped : deviation to both sides.
c- Spur : sharp angulation at bony cartilaginous junction.
d-Dislocation of septal cartilage from the maxillary crest (traumatic).
Clinical picture :
a-Asymptomatic : most cases.
b-Persistent nasal obstruction which :
 Unilateral in C-shaped septum.
 Bilateral in S-shaped septum.
c- Hyposmia.
d-Epistaxis from :
 A prominent vessel over a bony spur.
 Kinking of a vessel on the convex side.
 Separation of a crust on the concave side.
e-Headache : due to contact between deviated septum and middle turbinate
(irritating anterior ethmoidal nerve).
f- Secondary effects : atrophic rhinitis and hypertrophy of inf. turbinate on the wide
side.
Treatment :
a-No treatment for minor symptomless deviation.
b-Septoplasty which preferred now over submucous resection (S.M.R) operation.
c- Septo-rhinoplasty : if there is associated ext. deformity.
(B) Septal hematoma :
Collection of blood between the septal cartilage and its perichondrium.
Etiology :
1-Traumatic : accidental or following septal surgery e.g. SMR or septoplasty.
2-Spontaneous: blood diseases.
Clinical picture :
1-Bilateral persistent nasal obstruction.
2-Smooth red soft swelling on both sides of the nasal septum.
3-Aspiration → blood.
Treatment :
1-Prophylactic antibiotics.
2-Incision and drainage of the haematoma with tight nasal packing to prevent
recollection of blood.
(C) Septal abscess :
Collection of pus between septal cartilage and its perichondrium.
Etiology :
Secondary infection to septal hematoma
Clinical picture :
 Fever, headache, anorexia and malaise.
 Severe throbbing nasal pain.
 Bilateral persistent nasal obstruction.
 Tender nasal dorsum.
 Bilateral smooth red tender soft swelling of the septum.
 Aspiration → pus.
Complications :
 Cartilage necrosis : supra-tip depression of the nasal dorsum.
 Cartilage and mucosal necrosis : septal perforation.
 Spread of infection : cavernous sinus thrombo-phlebitis.
Treatment : Similar to septal haematoma.
(D) Septal perforation :
Etiology :
1-Traumatic :
a- Septal operations e.g. S.M.R (common cause).
b- Repeated cauterization or cauterization of both sides at the same time.
c- Habitual nose picking.
2-Inflammatory :
a- Septal abscess.
b- Chronic specific inflammation e.g. lupus and syphilis.
3-Cocaine addiction (ischemia).
Clinical picture :
 It may be symptomless.
 Small perforation : may be cause whistling on inspiration.
 Large perforation : crusting and epistaxis after separation of the crusts.
 Site: bony part in syphilis and cartilaginous part in other causes.
Treatment :
 No treatment if a symptomatic.
 Alkaline nasal wash to diminish crusting.
 Surgical closure by mucosal flaps or grafts or an obturator (button-like).
 Epistaxis
Bleeding from the nose.
Causes :
(A) Local causes :
1- Idiopathic :
- Bleeding from little area.
- The commonest cause of epistaxis 90%.
- Occurs spontaneously, may be initiated by slight trauma or change of atmosphere.
- Occurs mainly in children and adolescents.
2- Congenital : hereditary haemorrhagic telengiectasia.
3- Traumatic :
- Accidental : nose picking, foreign body, fracture nasal bones and fracture skull base.
- Post nasal operations.
4- Inflammatory : acute rhinitis and sinusitis.
5- Neoplastic :
- Benign (haemangioma) and malignant (carcinoma).
- Nasopharyngeal fibroma (severe epistaxis).
- Nasopharyngeal carcinoma.
6- Septal deviation.
(B) General causes :
1-High arterial blood pressure (hypertension) :
- Mostly from the posterior part of the nose.
- The commonest cause of epistaxis in elderly patients.
2-High venous blood pressure due to heart failure and mediastinal tumours.
3-Fevers e.g. rheumatic fever and exanthemata due to toxic capillarities (vasculitis).
4-Haemorrhagic blood diseases e.g. purpura, haemophilia, leukaemia and vit. C or K
deficiency.
5-Drugs as anti-coagulants, non steroidal anti-inflammatory drugs and salicylate.
6-Hormonal : during menses (vicarious menstruation).
Site of bleeding :
1- Little's area : is the commonest site.
2- Above the middle turbinate (upper part of the nasal cavity). From the anterior and
posterior ethmoidal arteries.
3- Below the middle turbinate (posterior part of the nasal cavity) : from the
sphenopalatine artery (artery of epistaxis).
4- The middle meatus, the inferior turbinate and floor : are rare sites.
Clinical picture :
- Bleeding may be anterior (nasal) or posterior (post-nasal) or with both.
- Unilateral or bilateral.
- Mild or severe.
Investigations :
1-Blood pictures (anemia, leukemia).
2-Coagulation profile for bleeding tendency.
3-Liver function tests.
4-CT scan (nose and nasopharynx).
5-Biopsy : if tumour is seen.

Treatment : The aim is to stop the bleeding and treat the cause.

A- Control bleeding :
(1) Mild and moderate attack :
i- First aid :
The patient sites with the head leant forwards (to prevent swallowing of blood), the
nostrils are compressed by the fingers (to compress little's area), apply cold
compresses over forehead and nasal bridge (to induce reflex vasoconstriction),
packing nasal fossae using piece of cotton soaked with vasoconstrictor solution.
ii- Cautery : Under local anesthesia
- Chemical using chronic acid or silver nitrate crystals.
- Electrical (diathermy).
iii- Anterior nasal pack :
When above lines fails using Vaseline gauze, inflatable tampons or merocel sponges for
24-48 hours under antibiotic cover.
(2) Sever attack :
If the patient is shocked, treatment of shock should start immediately.
i- Treatment of shock :
- Patient head down (elevation of foot of bed) to increase blood flow to the brain.
- I.V fluids and blood transfusion according to Hb %.
- Sedative as diazepam, avoide morphia (to avoid respiratory center depression).
- I.V corticosteroids.
- Monitoring vital signs e.g. pulse, blood pressure, temperature and urinary output.
ii- Anterior nasal pack.
iii- Posterior nasal pack :
- Used if anterior pack fail or if the bleeding is posterior – using Vaseline pack
(under general anesthesia), inflatable balloon or fooly's catheter.
iv- Surgical control :
When nasal packing fails to control bleeding.
- Ligation of anterior ethmoidal artery via the orbit if bleeding is coming from above
the middle turbinate.
- Ligation of internal maxillary artery in pterygopalatine fossa through radical
antrostomy if bleeding comes from below the middle turbinate.
- Endoscopic ligation of sphenopalatine artery.
N.B. Ligation of external carotid artery in the neck is less effective due to cross anastmosis.
v- Emoblization : Angiography to detect the bleeding vessel then injection of embolus
(e.g. Gelatin sponge) to occlude it.
B- Treatment of the cause e.g. tumours, hypertension.
 ALLERGIC RHINITIS
Abnormal reaction of nasal mucosa due to exposure to antigenic substances.
Pathogenesis : (Type I hypersensitivity reaction) :
1-When the patient exposed to the antigen, the body produces IgE.
2-IgE + mast cells (in nasal mucosa) → mast cell bound IgE.
3-Antigen + mast cell bound IgE → rupture of mast cell with release of chemical
mediators as histamine, serotonin, prostaglandins and leukotrienes. These
mediators will act on :
 Nerve ending causing itching and sneezing.
 Smooth muscles causing bronchospasm.
 Seromucinous glands causing increased secretions (rhinorrhea).
 Blood vessels causing vasodilatation (congestion) and increased capillary
permeability (oedema).
 Eosinophilic infiltrate.
Types :
 Seasonal occurs in seasons e.g. hay fever which occurs in spring.
 Perennial persistent all over the year.
Etiology :
 Predisposing factors :
- Positive family history.
- Psychogenic.
- Physical factors e.g. changes in temperature and humidity.
- Infection which decrease tissue resistance.
 Precipitating factors : Exposure to allergens which may be
- Inhalant : the commonest. It may be :
a-Seasonal as pollens, grasses and moulds.
b-Perennial as house dust, dust mite, animal dander and feather.
- Ingestant as egg, milk and wheat.
- Injectant as penicillin.
- Contactant : as face powders.
- Infectants : parasites end fungi.
Clinical picture :
 Paroxysmal attacks of sneezing, profuse watery rhinorrhea and nasal obstruction.
 Anosmia or hyposmia
 Palatal itching.
 Allergic conjunctivitis and bronchial asthma may be associated.
Anterior rhinoscopy :
 Swollen and pale bluish nasal mucosa.
 Hypertrophy of turbinate especially inferior turbinate.
 Nasal polyp may be present.
Investigations :
A- To confirm the diagnosis :
 Microscopic examination of a nasal smear → excess eosinophils.
 Blood examination : eosinophilia and increased total plasma IgE level.
B- To define the offending allergen :
 Nasal provocation tests.
 Skin sensitivity tests.
 Radio-allergo-sorbent test (RAST) to detect plasma IgE to a specific allergen.
C- To detect complications :
 CT scan for paranasal sinus to detect sinusitis or polypi.
Treatment :
A- Prophylaxis :
 Avoid antigens exposure when the antigen is known.
 Zaditen or sodium cromglycate (stabilize mast cells prevents degranulation).
 B- Medical :
 Antihistamine : local or systemic.
 Steroids : local or systemic.
 Immunotherapy (desensitization) by using small repeated doses of the antigen. It
is useful in seasonal allergy (grass pollen) but anaphylaxis may occur.
C- Surgical : (to relieve nasal obstruction)
 Polypectomy.
 Partial turbinectomy or submucous diathermy.
 Septoplasty.
N.B : Medical treatment should be continued after surgery to avoid recurrence.

VASOMOTOR RHINITIS
Abnormal reaction of the nasal mucosa to non allergic factors.
Mechanism :
Unknown : may be due to over-activity of the nasal parasympathetic system :
 Vasodilatation of the blood vessels (congestion).
 Increased capillary permeability (oedema).
 Increased secretion of the sero-mucinous glands (rhinorrhoea).
Etiology :
 Environmental factors : irritants (as dust and tobacco) and changes in humidity or
temperature.
 Endocrinal factors : pregnancy, menopause, puberty, old age and contraceptive
pills.
 Drugs : anti-hypertensive and abuse of vasoconstrictive nasal drops (called rhinitis
medicamantosa).
 Psychogenic.
Clinical picture : Similar to allergic rhinitis but :
- No itching. - Tests of allergy are negative.
Treatment :
 Prophylaxis : avoidance of predisposing factors.
 Psychological treatment (very important in many cases).
 Medical : antihistamines and steroids.
 Surgical :
- For nasal obstruction : Polypectomy, partial turbinectomy and septoplasty.
- For rhinorrhea : Vidian neurectomy : cutting of the nerve leads to vasoconstriction of
the nasal mucosa.
 NASAL POLYPI
Edematous pedunculated mucosa of the nose or paranasal sinuses.
Etiology (Causes – Types):
- Allergic rhinitis.
- Vasomotor rhinitis.
- Inflammatory e.g. antro-choanal polyp.
- Malignant : polyp may accompany malignant neoplasm of the nose due to
lymphatic obstruction.
N.B. : Bleeding polyps :
a- Bleeding polyps of the septum (angioma).
b- Fungal (Rhinosporidosis).
(A) Ethmoidal polyp :
The commonest type (allergic)
Symptoms :
- Bilateral persistent nasal obstruction and hypo- or anosmia.
Signs :
- Bilateral, multiple, glistening, pale grayish, mobile and insensitive.
- Arises from the ethmoid sinuses due to loose submucosa (may arise from middle
turbinate and middle meatus).
 - In long standing cases : broadening of the nose and polyps may protrude through
anterior nares.
Investigations : CT to show origin and extent of the polyp.
Treatment :
- Surgical treatment : Endoscopic removal (treatment of choice).
- Medical treatment :
 Systemic steroids for small polypi (called medical polypectomy) and local steroid
sprays postoperatively to avoid recurrence.
 Anti-histaminics.
(B) Antro-choanal polyp :
 Unilateral single polyp which arises within the maxillary sinus (antrum) then passes
through its ostium to enter the nasal cavity → then passes backwards through the
choana to enter the nasopharynx.
 Much less common than ethmoidal polypi and occurs in teenagers (13-20 years).
Etiology : Unknown. May be inflammatory or a retention cyst.
Symptoms :
 Unilateral persistent nasal obstruction. - Unilateral mucoid nasal discharge.
Sign :
 Unilateral single pale grayish glistening smooth soft pedunculated mass which
arises from the middle meatus → passes backwards to the choana, it may be seen
in the oropharynx during oropharyngeal examination (if large).
Investigation : C.T scan : Diagnostic.
Treatment :
 Endoscopic polypectomy with widening of the natural ostium of the maxillary sinus
(treatment of choice).
 Radical antrum (Caldwell-Luc) operation may be done in recurrent cases.
 INFLAMMATION OF THE NASAL CAVITY
(A) Acute inflammation :
1- Vestibulitis :
a- Localized (Frunclosis) : Staphylococcus infection of a hair follicle in the nasal
vestibule.
Predisposing factor :
 Trauma (nose picking), diabetes or lowered immunity.
Clinical picture :
 Pain and tenderness.
 Swelling and redness (usually at nasal tip).
 Pus pointing (usually at nasal vestibule).
 It may be recurrent in diabetes.
Complications :
 Do not squeeze the furuncle (danger. area) to avoid cavernous sinus thrombosis.
 Septal abscess.
Treatment :
 Systemic antibiotics e.g. flucloxacillin or cephalexin and local antibiotic cream.
 Analgesics.
 Incision if there is pus.
b- Diffuse :
Predisposing factor : Rhinorrhoea lead to skin maceration and skin laceration due to
repeated rubbing with handkerchieves.
Clinical picture : Nasal pain and diffuse redness, oedema and tenderness of the skin
lining of the vestibule.
Treatment :
 Treatment of the cause.
 Systemic treatment : Antibiotics and analgesics.
 Local treatment : Antibiotics and steroid cream.
2- Rhinitis :
a- Non specific e.g. common cold, and influenza.
b- Specific e.g. diphtheria.
COMMON COLD (Coryza)
Caused by rhinovirus followed by secondary bacterial infection, transmitted by droplet
infection. Incubation period 1-3 days.
Predisposing factors :
1- General factors :
a-Over-crowding and poor personal hygiene.
b-Fatigue and low immunity.
c- Exposure to temperature changes i.e a cold air after a hot bath.
2- Local factors : Allergic and vasomotor rhinitis.
Clinical picture : 4 stages :
1-Ischaemic stage : dryness, burning sensation and sneezing.
2-Hyperemic stage : nasal obstruction, watery discharge and mild fever (nasal
mucosa congested and swollen).
3-Secondary infection stage : thick mucopurulent discharge with more obstruction,
more fever and toxemia.
4-Stage of resolution : recovery by gradual improvement within 5 days.
Complications :
1- Vestibulitis due to rhinorrhea and repeated rubbing of the nose.
2- Spread of infection e.g. sinusitis, otitis media, bronchitis.
3- Anosmia due to viral neuritis of the olfactory nerve.
Treatment :
 Avoid predisposing factors.
 Rest, fluid and analgesics.
 Antihistamines.
 Nasal vasoconstrictors.
 Antibiotics for secondary infection.
 No vaccine is available against common cold virus because large number of the
causative viruses and their continuous mutation.
INFLUENZA :
Etiology : Similar to cold but the causative organism is influenza virus: types A,B & C.
Clinical picture: Similar to cold but the constitutional symptoms are more severe.

Complications :
Similar to cold but are more common and may also cause anosmia, labyrinthitis,
vestibular neuritis, meningitis, encephalitis, pericarditis, pneumonia and gastroenteritis.
Treatment and prophylaxis :
 Similar to common cold but vaccines prepared from the prevalent strain of the
virus are available. They are used :
- during epidemics and
- for individuals with high risk of complications as elderly, children, medical staff
and immunocompromised patients.

ACUTE SPECIFIC RHINITIS

NASAL DIPHTHERIA :
Usually secondary to faucial diphtheria (rare primary).
Clinical picture :
- Unilateral nasal obstruction and purulent discharge.
- Low grade fever with toxemia.
Ant. Rhinoscopy :
- Unilateral grayish white pseudomembrane.
Complications and treatment : As faucial diphtheria.
Chronic non-specific rhinitis :
(A) Atrophic rhinitis :
Chronic non specific inflammation characterized by atrophy of nasal mucosa and
underlying bone.
Etiology : 2 types
1- Primary : cause unknown may be :
 Hormonal theory : it is common in females at puberty due to oestrogen
deficiency.
 Infection theory : infection by klebsiella ozaena and other gram –ve organisms.
 Autoimmune theory.
 Vitamin A and iron deficiency.
 Autonomic imbalance with sympathetic overactivity.
2- Secondary :
 Deviated nasal septum on the wider side or large septal perforation on both
sides.
 Postoperative : Excessive inf. turbinate removal in partial turbinectomy.
 Inflammatory : Lupus, syphilis and scleroma.
 Post-irradiation for malignant disease.
Pathology :
Endarteritis or peri-artenitis → ischaemia (if prolonged) → dryness (if prolonged) will
cause atrophy of :
a- Glands leading to diminished secretion.
b- Mucosa leading to destruction of cilia and stasis of secretions.
c- Turbinal bones leading to wide (roomy) nose.
d- Secondary infection by klebsiella ozaena → offensive smell (ozaena).
Clinical picture :
 Nasal discharge : greenish, crusty and has foul odour.
 Nasal obstruction (inspite of the roomy nose) due to accumulation of crusts or
dullness of the sensation of air as a result of atrophy of the sensory nerves.
 Anosmia: atrophy of olfactory mucosa, patient does not smell his own bad odour.
 Epistaxis due to separation of the crusts.
Ant. Rhinoscopy :
 The nasal cavity is roomy and lined with greenish offensive crusts.
 The nasal mucosa and the turbinates are atrophic.
Treatment :
A- Medical treatment :
 Treatment of the cause in case of secondary atrophic rhinitis.
 Alkaline nasal lotion to separate the crusts.
 Oily nasal drops as paraffin (lubricant) to prevent adherence of the new crusts.
 Menthol nasal drops to mask the foul odour.
 Glucose 25% in glycerine nasal pack to diminish foetor. How ? It inhibit growth of
the proteolytic saprophytic organisms which are responsible for the foul odour.
 Local oestrogen and oral potassium iodide to stimulate the nasal glands.
B- Surgical treatment :
Narrowing the roomy nasal cavities till the nasal mucosa regenerates. If medical
treatment fail to control the patient's symptoms by :
 Submucosal insertion of a graft as fat, bone, cartilage or Teflon.
 Closure of the nostril(s) for 6-24 months by skin flaps from the vestibule.
Chronic specific inflammation
(Granuloma of the nose)
(A) Rhinoscleroma :
Chronic specific inflammation of the upper respiratory tract especially the nose by
klebsiella rhinoscleroma (Gram negative Frisch bacillus).
It may affects :
- The nose : Rhinoscleroma.
- The pharynx : Pharyngoscleroma.
- The larynx : Laryngoscleroma.
- The trachea : Tracheoscleroma.
- The lacrimal apparatus : Dacryoscleroma.
Pathology :
1-Stage of invasion : similar to acute non-specific rhinitis.
2- Active stage : Either atrophic or nodular form :
a-Atrophic : similar to atrophic rhinitis.
b- Nodular: The submucosa is infiltrated by granulomatous tissue characterized by:
i- Mikulicz cells : large foamy cell with a central nucleus and vacuolated

cytoplasm. The vacuoles contain the Frisch bacilli (gram negative intracellular
diplo-bacilli). These cells are diagnostic.
ii- Russell bodies : bright red oval or rounded bodies devoid of nuclei. They
represent plasma cells undergoing hyaline degeneration.
iii- Plasma cells and lymphocytes.
Clinical picture :
1-Stage of invasion : similar to prolonged attacks of acute non specific rhinitis that
does not respond to treatment.
2-Atrophic stage : similar to atrophic rhinitis.
3-Active granulomatous stage :
- Nasal obstruction and mucoid discharge.
- Bilateral discrete reddish non ulceration of firm nodules at the muco-cutanous
junction between the nasal cavity and the vestibule, the nodules coalesce to fill
the nasal cavity.
- It may extend into surrounding structures : upper lip, larynx and a trachea (air way
obstruction) and lacrimal passages (epiphora).
4-Fibrotic stage : narrowing of the nasal cavity and external nasal deformity. It may
extend to the pharynx (shortening of the soft palate), subglottic stenosis and
tracheal stenosis.
Investigations :
1-Culture and sensitivity : shows gram –ve diplobacilli (Klebsiella rhinoscleromatous).
2-Biopsy :
- Shows (Mickulicz cells, Russel bodies, plasma cells, …etc).
- Diagnostic only in granulomatous stage.
Treatment :
 Medical treatment :
- Antibiotics : rifampicin, quinolones, 3rd generation of cephalo-sporins or better
according to the results of sensitivity tests.
- In the atrophic stage : similar to atrophic rhinitis.
 Surgical treatment :
- Removal of the granulomatous masses or fibrous tissue better by laser surgery.
- Rhinoplasty operation to correct nasal deformities.
- Reconstructive procedures for laryngeal and tracheal stenosis.
 Radiation therapy : was used in active stage to induce fibrosis – now it is not
used, it may induce malignancy in other area e.g. cancer thyroid.

INFLAMMATION OF THE PARANASAL SINUS

a- Acute sinusitis
b- Chronic sinusitis
c- Fungal sinusitis
(A) Acute sinusitis : Acute inflammation of the muco-periosteal lining of one or more
of the paranasal sinuses.
Causative organisms :
 Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
 Anaerobic organisms in maxillary sinusitis of dental origin.
Routes and sources of infection :
 Nasal route : infection reaches the sinus via its ostium :
- Acute rhinitis (commonest).
- Swimming and diving in polluted water.
- Nasal packing.
- Nasal foreign body.
 Dental route : Causes maxillary sinusitis :
- Infection of the 2nd premolar or 1st molar teeth.
- Oro-antral fistula.
 Trauma :
- Compound fracture of the sinus.
- Penetrating foreign bodies as gunshots.
 - Sinus barotrauma due to rapid changes in an pressure during flight leading to
edema and obstruction of sinus ostium.
Predisposing factors :
1-General :
- Bad hygienic conditions and overcrowding.
- Low general resistance as in diabetes and immuno-compromized patients.
2-Local : Any conditions that leads to obstruction of sinus ostia will predispose to
infection e.g. septal deviation, allergic rhinitis and nasal polypi.
Pathology :
The inflammatory changes of the mucosa of the affected sinus include :
 Hyperaemia and oedema leading to obstruction of the sinus ostium and stasis of
secretions.
 Exudation, first mucous (catarrhal) then purulent (suppurative) inflammation.
Symptoms :
 General symptoms : Fever, headache, anorexia and malaise.
 Local symptoms :
1-Nasal obstruction usually bilateral and may alternates from side to side.
2-Nasal discharge :
 - Muco-purulent or purulent.
- Scanty or profuse.
- Post-nasal or nasal in sinusitis of the anterior group of sinuses and post-nasal
in sinusitis of the posterior group of sinuses.
- Offensive in maxillary sinusitis of dental origin (anaerobic organisms).
3-Hyposmia or anosmia due to nasal obstruction. Dental maxillary sinusitis causes
cacosmia.
4-Facial pain : severe and increases by straining and leaning forwards. It is due to
accumulation of discharge in the sinus under tension (tension pain).
- Ethmoidal sinusitis between the eyes.
- Maxillary sinusitis over the cheek.
- Frontal sinusitis over the forehead. It is characteristically, periodic i.e starts in
the morning, decreases at noon and subsides in the afternoon.
- Sphenoidal sinusitis behind the eye.
5-Facial swelling : edema over the affected sinus may occurs specially in infants
and children.
Signs :
1-External examination : Tenderness over the affected sinus :
- Ethmoidal sinusitis (over the medial canthus).
 - Maxillary sinusitis (over the cheek).
- Frontal sinusitis over the floor of the sinus (at the roof of the orbit).
2-Anterior rhinoscopy :
- Congestion and edema of the nasal mucosa.
- Muco-purulent or purulent discharge :
o In the middle meatus (infection of anterior group of paranasal sinus).
o Above the middle turbinate in (in posterior and ethmoidal sinusitis).
Investigations :
 Radiological examination : CT scan used only :
a-In case of failure of medical treatment : for proper assessment of the disease.
b-In case of suspected complications.
 Culture and sensitivity tests : of the discharge.
Treatment :
1- Medical : main treatment
- Antibiotics for 10 days.
- Nasal decongestants (local and systemic) to open the sinus ostia.
- Analgesic, antibiotics and bed rest.
- Anti-inflammatory drugs.
- Mucolytics : to liquefy viscid discharge to facilitate drainage.
2- Surgical :
- Indicated in case of failed medical treatment as in impending complications.
Surgery in the form of endoscopic widening of the natural ostium of the affected
sinus.
(B) Chronic sinusitis :
Chronic inflammation of the mucoperiosteal lining of the penanasal sinus.
Causative organism :
Gram –ve (H. influenza, pneumocci, proteus, pseudomonas) and Gram +ve bacteria.
Etiology : (Causes of Chronicity)
1-Persistent obstruction of the sinus ostium e.g. deviated septum, allergic rhinitis and
polypi.
2-Incomplete resolution of recurrent acute sinusitis due to inefficient treatment,
virulent organism and low resistance of the patient.
3-Persistence of the predisposing factors e.g. dental.
Pathology :
1-Early : congestion, edema and cellular infiltration (reversible).
2-Late : hypertrophic or atrophic mucosa (irreversible).
Clinical picture :
1-Similar to acute sinusitis.
2-Headache : dull ache, may be tension, vaccum or toxic types, periodic (more in the
morning) may occur with chronic frontal sinusitis.
3-Symptoms of septic focus : fatigue, malaise, mental dullness.
4-Symptoms of descending infection : pharyngitis, laryngitis.
Investigations :
 CT scan : should be done because it shows :
a-Opacity or thickening of the mucosal lining of the affected sinus for proper
assessment of extent of the disease.
b-Cause of ostium obstruction.
c- Exclude complications.
d-Avoid false +ve results of plain x-ray.
 Culture and sensitivity tests : of the discharge.
Treatment :
(A) Medical : Antibiotics, anti-inflammatory drugs and mucolytics.
(B)Surgical : aims at
1- Correcting a predisposing factors e.g. deviated septum, polypi.
2- Clearance of the sinus disease by :
a-Functional endoscopic sinus surgery (FESS)
 Using sinoscope of different angles.
 Restore ventilation and drainage of blocked sinuses by removal of popylpi,
granulation from osteomeatal complex.
b-Conventional surgery : uncommonly practiced now :
 For maxillary sinusitis :
- Repeated puncture and lavage (by creation of small temporary opening
in the medial wall of the maxillary sinus) for temporary drainage and lavage.
- Intranasal antrostomy (creating an artificial opening for the sinus in the
inferior meatus).
- Radical antrostomy i.e. Caldwell-Luc or through sublabial incision (a hole
in the anterior sinus wall is made) through which the diseased sinus
mucosa is removed.
 External fronto-ethmoidectomy : for ethmoid sinuses, frontal and
sphenoid can be approached by the same procedures.
 Obliterative operations : when radical operations fail, the sinus cavity is
closed completely by implantation of fat e.g. osteoplastic flap for the frontal
sinus.
(C) Fungal sinusitis :
 Recently there are increasing incidence of fungal sinusitis (7-10%).
 Aspergillus is the commonest but mucor species (mucormycosis) causing
fulminating fungal sinusitis.
 It is either invasive or non invasive.
(1) Invasive : Occurs in :
a- Immunocompromised patient e.g. elderly diabetics, AIDS patients and those
receiving immunosuppressive therapy (acute fulminating type).
b- Immunocompetent patients (chronic indolent type) :
Caused by mucor (Acute fulminating) or Aspergillus (Chronic indolent).
Clinical picture :
- As in bacterial sinusitis followed rapidly (or slowly in chronic type) by extension of
infection to the orbit or intracranially.
Investigations :
- CT scan : Unilateral opacity involving most of the sinuses and extending beyond
the sinuses.
- Smears from nasal discharge or by fungal cultures.
Treatment :
- Amphotercin-B (Nephro and hepatotoxic).
- Surgical debridment of necrotic tissue and bone sequestra.
(2) Non-invasive :
a- It is either mycetoma (Fungal ball)
- Patient's immunity : Immunocompetent.
- Causative organisms : Aspergillus species.
- Pathology : Accumulation of fungal hyphae within the paranasal sinuses
(maxillary or sphenoid), with minimal mucosal reaction.
- Clinical picture : Unilateral nasal discharge.
- CT scan : Unilateral sinus opacity.
- Treatment : Endoscopic removal of the fungal ball.
b- Allergic: It is allergic reaction of the sinonasal mucosa due to contact with specific
fungus (type I and II allergic reactions).
Clinical picture :
- Common in atopic patients.
- Unilateral nasal polypi
- CT scan: unilateral sinus opacity with characteristic focal hyperdense spots.
- Skin tests +ve for fungal extracts.
Treatment :
- Endoscopic sinus surgery followed by systemic and local steroids for a long time to
avoid recurrence.
 COMPLICATIONS OF SINUSITIS
Spread of infection beyond the muco-periosteal lining of the paranasal sinuses.
Incidence :
Uncommon : the commonest are orbital infections.
Etiology :
- Acute exacerbation on top of chronic sinusitis (commonest).
- Acute sinusitis, especially in children.
- Invasive fungal sinusitis.
Routes of spread of infection :
1-Through bone :
a-Bone erosion by osteitis in compact bone of the ethmoid and sphenoid sinuses or
by osteomyelitis in cancellous bone of the frontal and maxillary sinuses.
b-Preformed pathway as congenital dehiscence, fracture line or opening in bone by
previous surgery.
2-Through veins: By retrograde thrombo-phlebitis of the draining veins.
Types :
1- Descending infections : Otitis media, pharyngitis, laryngitis, bronchitis and gastro-
intestinal disturbances.
2- Septic focus : arthritis, nephritis.
3- Local complications (sinus walls or cavity) :
A- Osteomyelitis of the frontal bone or maxilla :
Frontal bones much more commonly than the maxillary bone.
Clinical picture :
1- General :
- Fever, headache, anorexia and malaise.
2- Local :
 Stage of osteomyelitis :
- Frontal osteomyelitis → forehead oedema and tenderness.
- Maxillary osteomyelitis → maxillary oedema and tenderness.
 Stage of sub-periosteal abscess :
- Frontal osteomyelitis → forehead fluctuant swelling called Pott's puffy tumour.
- Maxillary osteomyelitis → maxillary fluctuant swelling.
 Stage of sinus fistula :
 - Frontal osteomyelitis → forehead fistula.
- Maxillary osteomyelitis → oro-antral fistula.
Investigation :
 CT : Diagnostic.
Treatment :
 Massive antibiotic therapy.
 Surgical drainage of the paranasal sinuses and bone infections.
B- Mucocele and pyocele :

4- Near by complications :
A- Orbital complications :
The commonest complications of sinusitis especially in children.
Etiology :
 Commonly complicates ethmoidal sinusitis. Because the ethmoidal sinus are
separated from the orbit by a very thin bone (lamina papyracea).
Clinical picture :
 Stage of orbital cellulitis :
- Pathology : Inflammation of the orbital contents without pus formation.
 - Symptoms : Fever, headache, anorexia, malaise and pain in the eye.
- Signs : Conjunctival chemosis, limitation of eye movements, ophthalmoplegia and
diminution of vision. These manifestations are reversible with treatment.
 Stage of sub-periosteal abscess :
- Pathology : Collection of pus between the orbital periosteum and lamina
papyracea.
- Symptoms : Throbbing pain in the eye.
- Signs : Proptosis and lateral displacement of the globe. These manifestations are
reversible with treatment.
 Stage of orbital abscess :
- Pathology : Collection of pus within the orbit.
- Impaired vision, severe throbbing pain in the eye, irreversible ophthalmoplegia
and irreversible impairment of vision.
Investigation :
 CT scan : diagnostic.
 Fundus examination.
Complications :
  Cavernous sinus thrombo-phlebitis.
Treatment :
 Massive antibiotic therapy.
 Surgical drainage of the paranasal sinuses and orbital infections (External fronto-
ethmoidectomy + FESS).
N.B. Posterior group of sinuses (posterior ethmoid and sphenoid) :
- Infections of these sinuses which are closely related to the orbital apex (optic
foramen, superior and inferior orbital fissure) causing orbital apex syndrome : ptosis,
ophthalmoplegia, impaired vision and trigeminal pain (ophthalmic). If vision is normal
these symptoms are called superior orbital fissure syndrome.
- Treatment is drainage of posterior group by FESS.
B- Intracranial complications :
Every sinus shows a tendency to be associated with a particular intracranial lesion.
1-Frontal sinusitis : can cause frontal lobe abscess, via an osteitis of the posterior
sinus wall.
2-Ethmoidal sinusitis : can cause meningitis, via a perforation near the cribriform plate.
3-Sphenoidal sinusitis : can cause cavernous sinus thrombosis via thrombophlebitis of
the diploic venules in the sinus wall.
4-Maxillary sinusitis : rarely causes any intracranial lesion.
Frontal lobe abscess :
 Signs of increased ICT.
 Its focal symptoms and signs are difficult to be recognized by clinical means
because this is a silent area of the brain. There may be personality changes and
memory defects.
 Treatment : Surgical drainage of the paranasal sinus and brain abscess.

CAVERNOUS SINUS THROMBOSIS

Sources of infection :
1-Skin of the dangerous area of the face e.g. nasal frunclosis (via the facial veins to
the ophthalmic veins).
2-Sinus infection e.g. frontal via supraorbital and ophthalmic veins, and sphenoid sinus
via direct spread that may lead to bilateral cavernous sinus thrombosis.
3-Orbital infections (via ophthalmic veins).
4-Pharyngeal suppuration e.g. quinsy (via the ptergoid plexus of veins).
5-Chronic supp. otitis media (via the superior or inferior petrosal sinus).
Clinical picture :
1-General : High fever, rigors and severe headache.
2-Ipsilateral eye :
- Edema and chemosis of the upper lid with ptosis.
- Conjunctival chemises.
- Proptosis (forward) that may be pulsating.
- Complete ophthalmoplegia (3,4,6 palsy).
- Diminution of vision that may be followed by blindness.
- Fundus exam shows venous engorgement and papilledema.
- Other eye may be affected in late stage.
Investigations :
- MRI and MRA (MR angiography) is diagnostic.
Treatment :
- Massive antibiotic : I.V and can cross the blood brain barrier e.g. 3rd generation
cephalosporins.
- Anticoagulants e.g. Heparin I.V.
- Surgical drainage of the sinus infection when the general condition of the patient
permits.
 TUMOURS OF THE NOSE
AND PARANASAL SINUSES
(A) Benign tumours:
Epithelial:
1- Papilloma :
 The usual site is the nasal vestibule.
 It simulate a simple wart.
 Treatment : Excision and cautery of the base to prevent recurrence.
2- Inverted papilloma :
 The usual sites are lateral wall of the nose and may be from maxillary and
ethmoid sinuses.
 Usually occurs in men over 50.
 Always unilateral rapidly growing firm red or grey mass with high tendency to
recur after removal.
 Histopathological examination : Gross thickening and infolding of the epithelium
due to epithelial inversion into underlying stroma (instead of growing outwards
as in other papillomas).
  Malignant change may occur in 5-10% of cases.
 Clinical picture :
- Unilateral nasal obstruction, offensive nasal discharge and epistaxis.
- Unilateral fleshy reddish polypoidal mass arising from the lateral nasal wall.
 Investigation :
- C.T to show size, site and extension.
- Biopsy (see above).
 Treatment : Complete removal with excision of the lateral wall (medial
maxillectomy) via lateral rhinotomy or endoscopic.
Connective tissue:
1- Osteoma:
 The most common benign tumour of the nose and paranasal sinuses.
 May be compact (in frontal sinus) or cancellous (in maxilla and ethmoid sinus).
 If it is small, it may be symptomless.
 If it is big, it causes symptoms by:
 Expansion leading to proptosis.
 Obstruction leading to mucocele of the sinus.
 Pressure: leading to atrophy of sinus wall with Ch. rhinorrhea.
  Treatment: Excision, only if symptoms develop.
2- Angioma:
a- Capillary:
 Common site is the nasal septum causing recurrent epistaxis (bleeding polypus of
the septum).
 Treatment: excision and cautery of the base to prevent recurrence.
b- Cavernous:
 It effects lateral wall of the nose and may involve the who tip of the nose (cirsoid
aneurysm).
 Treatment: Exsicion by laser.
c- Multiple telangiectasia (osler's disease).
 Familial condition affecting nasal mucosa (septum), or mucosa (tounge) and face.
 Treatment: diathermy, laser or surgical excision.
3- fibrous dysplasia:
 Slowly progressive tumor in which normal bone is replaced by fibrous tissue that
calcifies in an abnormal pattern.
 It may be localized involving the maxillary or ethmoid sinuses, or diffuse involving
several facial and cranial bones.
  The tumor is hard with smooth lobulated surface and ill-defined edge causing
deformity which is usually the main symptopm.
 Treatment: partial remove after puberty for cosmetic reasons.
(B) Malignant tumours of the nose and paranasal sinus :
Epithelial :
1-Squamous cells carcinoma : The commonest malignant tumour in the nose and
paranasal sinuses.
2-Adenocarcinoma : Usually arises from the glands of the maxillary sinus.
Connective tissue :
1-Sarcoma : Rare, fibrosarcoma, osteosarcoma and lympho-sarcoma may occur.
2-Malignant lymphoma : It has a strong relation to Epstein-Burr virus, affecting
children, especially the maxilla.
Etiology :
 Sites :
- 80% of malignant tumours of the nose and sinuses are squamous cell carcinoma
60% in the maxillary sinus.
30% in the nose.
10% in the ethmoid sinus.
 - Tumours of the frontal and sphenoidal sinuses are rare.
 Commonly in males over 60 years
 Predisposing factors : Prolonged exposure to nickel (squamous carcinoma) and
wood dust (adenocarcinoma).
 Spread :
1-Local spread :
To the surrounding structures.
2-Lymphatic spread : Late and uncommon.
a-Anterior group of the paranasal sinuses and anterior part of the nasal cavity →
the submandibular → upper deep cervical lymph nodes.
b-Posterior group of the paranasal sinuses and posterior part of the nasal cavity
→ the retro-pharyngeal lymph nodes (cannot be palpated clinically) → upper
deep cervical lymph nodes.
3-Blood spread : Rare and late
To the lungs, liver, bone and brain.
Clinical picture :
 As the maxillary and ethmoid sinuses are silent areas, early cases are a
symptomatic
 Depends on the primary site, direction of spread :
a-Maxillary sinus :
- Medially (To the nose) : Progressive nasal obstruction, offensive blood stained
discharge and epiphora due to invasion of nasolarcimal duct.
- Downwards (floor) : Ulceration and swelling of the palate, loosening of the teeth
and oroantral fistula.
- Upwards (orbit) : Proptosis upwards and diplopia.
- Anterior spread : swelling and numbness of the check (infra-orbital nerve).
- Pterygopalatine fossa : Trisums (infiltration of pterygoid muscles) and facial
paraesthesia (maxillary nerve).
b- Nasal cavity tumours :
- Unilateral nasal obstruction, epistaxis and offensive blood stained discharge.
- Anterior rhinoscopy : unilateral, friable mass, bleeds easily on touch.
c-Ethmoid tumours : Nasal symptoms and orbital symptoms (Proptosis, epiphora
and diplopia is late).
 d- Frontal tumours : Orbital symptoms and intracranial manifestation
(headache, CSF rhinorrhea).
e-Sphenoid tumours : Neurological symptoms.
 Neck examination (to exclude lymph node metastasis).
 General examination (to exclude distant metastasis).
Investigations :
 CT scans reveals bone obstruction. MRI may be used to detect invasion of
surrounding soft tissue structures.
 Biopsy : to confirm diagnosis
 X-ray chest, bone scans and abdominal ultrasonography to detect metastasis.
Treatment :
A- Surgical treatment :
1- Cancer maxillary sinus :
 Medial maxillectomy : when the tumour is limited to the medial wall, through
lateral rhinotomy.
 Palatal resection through sublabial incision in localized tumour involving
inferior wall.
  Total maxillectomy : When the tumour involves the whole maxillary sinus.
Through Weber Ferguson's incision.

2- Cancer nasal cavity and ethmoidal sinuses :

 External ethmoidectomy : Through lateral rhinotomy.
 Cranio-facial resection : When the tumour invades the roof of the nose
(Cribriform plate).
3- Orbital excenteration : When the tumour invades the orbit.
4- Radical neck dissection : In presence of palpable cervical lymph nodes.
B- Radiotherapy : Post-operative.
 MISCELLANEOUS CONDITIONS
OF THE NOSE
(A) HEADACHE AND FACIAL PAIN
 Headache means pain felt in the head (supraorbital to occiput).
 Facial pain is the pain felt in the face.
I- Primary facial pain :
No organic cause can be detected.
a- Facial pain of vascular origin (Migraine) :
Incidence :
 Common (about 10% of cases of headache) usually adult females. Positive family
history is common.
Etiology : Unknown may be vasospasm → aura, then vasodilatation → headache.

Clinical picture :
 Classic migraine :
- Recurrent attacks of unilateral severe temporal or frontal pulsating pain. It lasts
for few to several hours. It is associated with photophobia, nausea and vomiting.
 - It may be preceded by an aura as flashes of light or numbness in face and hand.
It lasts for minutes. It is due to vasoconstriction of the intracranial blood vessels.
 Common migraine : Similar to classic migraine but has no aura and may be
bilateral.
Treatment :
 During the attack : Ergotamine.
 In between the attacks (i.e prophylaxis) : beta blockers and calcium channel
blockers.
b- Facial pain of neural origin (Neuralgia).
Unilateral sudden severe sharp pain that occurs in short lived attacks along the
distribution of the involved sensory nerve.
a- Trigeminal neuralgia (Tic Douloureux) :
 Usually elderly females.
 Recurrent attacks of unilateral sudden severe brief (seconds)
sharp pain in the sensory distribution of maxillary and/or
mandibular divisions of the trigeminal nerve.
 It is induced by stimulation of a trigger zone as during shaving
or teeth brushing.
Treatment :
 Medical : Carbamazepine (Tegretol).
 Surgical : Decompression or section of the sensory root of the trigeminal nerve in
resistant cases.
b- Glosso-pharyngeal neuralagia :
 Recurrent attacks of unilateral sudden severe brief (seconds) sharp pain in the
tonsil and may be referred to the ipsilateral ear.
 It is induced by swallowing or talking.
 The cause is unknown but long styloid process compressing the nerve.
Treatment :
 Medical : Carbamazepine (Tegretol).
 Surgical : Section of the glosso-pharyngeal nerve in resistant cases or fracture of
long styloid process.
II-Secondary facial pain :
1-Intracranial causes : Pain may originate from the dura and blood vessels (middle
meningeal arteries) e.g.
- Inflammations as meningitis, encephalitis and extradural abscess.
- Increased intracranial tension as tumours.
 - Decreased intracranial tension as after lumbar puncture or CSF rhinorrhea.
- Head trauma.
2-Cranial causes :
- Trauma e.g. head and facial trauma or postoperative pain.
- Inflammations e.g. petrositis.
- Tumours of skull base e.g. nasopharyngeal carcinoma.
- Ear diseases e.g. otitis externa, complications of otitis media.
- Sino-nasal diseases :
 In sinusitis its site depends on the affected sinus, it is more severe in
the morning and increased by coughing, straining and leaning forwards.
 Vacuum headache caused by obstruction the frontal recess which is
the opening of the frontal sinus as in frontal sinusitis and deviated septum
causing obstruction of the recess. It is characterized by periodic attacks (starts
in the morning, increases in the mid-day, and subsides by the end of the day)
this is due to absorption of air in the sinus.
 Contacted headache caused by contact of medial wall (septum) and
lateral wall (middle turbinate) in deviated septum.
3-Extracranial causes :
 - Dental causes : caries.
- Tempanomandibular joint disorders e.g. arthritis.
- Ocular : glaucoma, errors of refraction.
- Cervical : spondylosis, myositis.
- Temporal arteritis : affect old patients due to acute inflammation of the branches
of superficial temporal arteries, may be autoimmune. The sup. Temporal arteries
become tender and cord like. The condition treated by corticosteroids.
4-General causes :
- Tension headache : due to fatigue, most common, starting from the back of the
neck and occiput.
- Hypertension and hypotension.
- Renal and hepatic disorders.
- G.I.T disturbance e.g. constipation.
- Withdrawal of chemical substance e.g. Nicotine and caffeine.
Clinical evaluation of headache :
A- History :
 Time of onset, duration and intensity.
 What precipitate ? Trigger zones in neuralgia, fatigue, noise, eye strain, sinusitis,
drugs.
  Relieved by : Medications, sleep, rest.
 Localization and radiation of pain.
 Associated symptoms e.g. nasal, ocular, dental, gastrointestinal.
B- Examinations :
 General exam : B.P, anaemia, gastrointestinal, diabetes, cervical spine, T.M.J.
 E.N.T exam :
- Ant. rhinoscopy : Discharge, septal deviation, frunclosis.
- Oropharyngeal exam : Dental infection, swellings, ulcers.
- Ear exam : Mastoiditis, otitic intracranial complications.
 Ophthalmological exam : Iritis, error of refraction, glaucoma.
 Neurologic or psychiatric evaluation.
C- Investigations :
 Laboratory : Haematological, liver and kidney function …etc.
 Radiological : Paranasal sinuses, spines …. etc.

(B) NASAL OBSTRUCTION

A- Bilateral :
1- Congenital : Congenital choanal atresia.
2- Developmental : Deviated septum (S-shape).
3- Traumatic :
- Fracture nasal bone and septum.
- Septal haematoma.
4- Inflammations : Acute and chronic rhinitis, septal abscess.
5- Allergic rhinitis and allergic polypi.
6- Malignant tumours of the nose and sinuses.
7- Causes in the nasopharynx :
- Adenoids.
- Benigns tumours (angiofibroma).
- Malignant tumours (carcinoma).
B- Unilateral :
1- Congenital : Unilateral congenital choanal atresia.
2- Developmental : Deviated septum (C-shape).
3- Traumatic :
- Fracture nasal bone and septum.
- Foreign body.
4- Inflammatory :
- Nasal diphtheria.
 - Unilateral sinusitis (of dental origin).
- Antro-choanal polyp.
5- Neoplastic :
- Benign e.g. papilloma.
- Malignant (early).
- Nasoph. Tumours (small).

(C) NASAL DISCHARGE

A- Bilateral :
1- Mucopurulent and purulent : The same causes as nasal obstruction.
2- Bloody : Causes of epistaxis.
3- Watery :
- Allergic rhinitis.
- Early acute rhinitis.
- Excessive lacrimation.
4- Water and fluid (nasal regurgitation) :
- Cleft palate and short palate.
- Syphilitic perforation of hard palate.
 - Palatal paralysis e.g. post diphtheritic, bulbar palsy, myasthenia gravis.
- Immobile palate due to malignant invasion.
5- Crusty : Atrophic rhinitis, granuloma, septal perforation.
B- Unilateral :
1- Mucopurulent and purulent : The same causes of unilateral nasal obstruction.
2- Bloody : Local causes of epistaxis.
3- Watery : CSF rhinorrhea.
4- Unilateral nasal regurge : Oro-antral fistula
5- Unilateral yellow and serous : Rupture cyst in the maxillary sinus.
6- Crusty : Atrophic rhinitis (if unilateral as after turbinectomy).
=

(D) SMELL
Smell is the process by which an odorous substance stimulates the olfactory mucosa.

Smell pathway :
1-The olfactory nerve transmits the odorous impulses from the olfactory mucosa to the
olfactory bulb.
2-The olfactory bulb transmits the impulses to the smell center in the brain (uncus and
hypocampic gyrus).
Smell disorders :
Most patients of olfactory disturbance will fall into one of 4 groups.
1-After head trauma.
2-After viral infection.
3-Poor odorant access to the olfactory mucosa.
4-As manifestation of other diseases.
Types :
1-Anosmia : means loss of the sense of smell. Smell is perceived when the air-borne
odoriferous particles dissolve first in the mucus to reach the olfactory endings,
impulses hence travel by the olfactory nerves to the brain.
The causes of anosmia may be classified as :
A- Nasal :
a- Obstruction : the smell particles do not reach the olfactory mucosa,e.g. acute
rhinitis, deviated septum and nasal polypi.
b- Maldirection of the air current, e.g. after removal of the inferior turbinate.
c- Causes in the mucus : in allergic rhinitis there is excess secretion which washes the
smell particles. In atrophic rhinitis the mucus is too thick to dissolve the smell particles.
d- Interference with nerve endings :
- Degeneration : in atrophic rhinitis.
- Irritant vapours : e.g. sulphuric acid, benzene, formaldehyde, and many industrial
dusts ..etc.
- Post-influenza neuritis, has been observed more often in the last few years, some
cases recover, but if persists more than 3 months it is unlikely to recover.
B- Intracranial :
a- Fracture base involving the cribriform plate and olfactory nerves.
b- Senile atrophy.
c- Tumours of the anterior cranial fossa, e.g. meningioma, neuroblastoma.
N.B : Patients with anosmia are at a risk from dangerous fumes and gases and also from fires
as they cannot detect the smoke odour.

2-Cacosmia : Perception of a bad smell.

Causes :
a- Foreign bodies in the nose.
b- Maxillary sinusitis of dental origin.
c- Presence of foetid discharge in ch. suppurative otitis media.
3-Parosmia : Perception of a non-existent smell.
Causes :
a- Hysteria.
b- Epileptic aura.
c- Uncinate fits (lesion of the temporal lobe).
4-Hyperosmia : Increase sensitivity of smell which may occur with hysteria.
N.B :
- Smell is the sensation arising from the olfactory receptors due to stimulation by an odorous
substance.
- Taste is the sensation arising from taste receptors.
- Flavor is the combined sensation of both taste and smell so it may be affected in smell
disorders.
 OPERATIONS OF
THE NOSE AND SINUSES
(A) Correction of septum deviation :
Indications :
 Deviated septum giving rise to symptoms e.g. nasal obstruction.
 To gain access to the posterior part of the nose to deal with polypi, masses or
epistaxis.
Contraindication :
 Submucous resection operation is contraindicated before the age of 18 years.
Because it may disturb growth of the face. Only septoplasty can be done in
children.
Anaesthesia : General or local.
Technique :
I- Submucous resection operation :
 Incision : incise the muco-perichondrium vertically on one side, few mm's behind
the anterior border of the septal cartilage.
  Mucosal flap elevation : Elevate a muco-perichondrial/muco-periostial flap on this
side, incise the septal cartilage, elevate a muco-perichondrial/muco-periostial flap
on the opposite side.
 Correction of deviation : Remove the deviated parts of the septal cartilage and
bones.
 Closure :
- Reposition the mucosal flaps in the midline.
- Suture the muco-perichondrial incision.
- Put anterior nasal packs for 24 hours to maintain apposition of the flaps.
II- Septoplasty operation :
 Incision : Similar to submucous resection operation.
 Mucosal flap elevation : Elevate a muco-perichondria/muco-periostial flap on this
side.
 Correction of deviation : Removal the deviated parts of the septal cartilage.
 Closure : Similar to submucous resection operation.
Complications :
 Epistaxis.
 Adhesions between the septum and lateral wall.
  Septal haematoma more common (after submucous resection operation).
 Septal perforation more common (after submucous resection operation).
 Deformity of the external nose (due to excess removal of septal cartilage) only
after submucous resection operation.
 Incomplete removal leading to recurrence of symptoms.
(B) Puncture and lavage of the maxillary sinus :
This operation is rarely done nowadays. It is replaced by the CT and FESS.
Indications :
 To confirm the presence of pus in the sinus and to take specimen for culture and
sensitivity.
 Repeated puncture for the treatment of chronic sinusitis.
Technique :
 Under local surface anaesthesia, a trocar and canula is introduced into the sinus
beneath the inferior turbinate, one inch behind its anterior end.
 The tip of the trocar is directed towards the outer canthus.
 The sinus is washed with sterile warm saline by a syringe connected to the canula.
(C) Intra-nasal antrostomy :
This operation is rarely done nowadays. It is replaced by FESS.
Technique :
 Under general anaesthesia, an opening is made in the medial wall of the antrum
under the inferior turbinate to improve drainage.
(D) Radical antrostomy :
Via a sublabial incision, an opening is made in the anterior surface of the maxilla.
Indications : The opening facilitates :
 Removal of the mucosal lining of the sinus if the mucosal damage is irreversible.
 Removal of F.B in the sinus e.g. tooth root.
 Removal of an antrochoanal polyp, if recurrent.
 Biopsy of a tumour.
 Closure of an oroantral fistula.
Technique :
 The sublabial incision is placed immediately superior to the line of gingivolabial
reflection.
 Elevate the soft tissues from the anterior wall of the maxilla.
 Open the anterior surface of the maxilla by a gouge and hammer (now by a drill).
  Remove all the diseased mucosa and polypi.
 Intranasal antrostomy is then done.
 The wound is closed by catgut.
Complications :
 Hemorrhage or ecchymosis.
 Facial paraesthesias or numbness due to damage of the infra-orbital nerve
(temporary or permanent).
 Recurrent disease.
 Oroantral fistula.
 Devitalized teeth.
(E) Functional endoscopic sinus surgery (FESS) :
Principle :
As inadequate ventilation and drainage of the sinuses is the main cause of chronic
sinusitis, the aim of functional endoscopic sinus surgery is to restore normal ventilation
and drainage of the affected sinuses through their natural ostia allows the sinus
mucosa to return to its normal functioning state.
Technique :
  The operation is carried out with rigid nasal endoscope (0º, 30º, 70º) which
provides excellent illumination and visulalization.
 Removal of the cause of ostium obstruction e.g. Polypi.
 Endoscopic widening of the natural ostium of the affected sinus.
Indications :
 Chronic sinusitis (bacterial and fungal).
 Nasal polypi.
 Mucoceles of the sinuses.
 Choanal atresia.
 Repair of CSF leak.
 Hypohysectomy.
 Septal surgery.
Complications :
 Orbital haematoma and optic nerve injury.
 Skull base trauma causing CSF rhinorrhaea.
 Intranasal adhesion.
 Failure due to residual disease.
(F) Rhinoplasty :
Definition :
Rhinoplasty is an operation ot modify the aesthetic appearance and functional
properties of the nose with operative manipulation of the skin, underlying cartilage,
bone and lining.
Approaches :
The incision type that the surgeon uses classifies the rhinoplasty as open or closed.
 Open approach rhinoplasty, the surgeon makes a small incision in the columella
between the nostrils and then makes additional incisions inside the nose.
 Closed approach rhinoplasty involves incision only inside the nose.
Indications :
 Nasal tip modifications.
 Internal nasal valve collapse.
 Post-traumatic nasal deformity.
 Nasal hump removal.
 Cleft lip and palate deformity.
 Repair of septal perforation.
Operation :
Rhinoplasty could be done under local or general anaesthesia. Each operation is
tailored to achieve the preoperative goals however there are common steps in
rhinoplasty. It includes :
 Incisions either external or inside the nose.
 Skeletonisation of the nose where a skin envelope is elevated.
 Cartilaginous and bony framework of the nose.
 Nasal hump removal with osteotomes.
 Nasal tip modification.
 Nasal dorsum or tip grafting when required.
 Osteotomies.
 Closure of the incisions.
 Placement of nasal dorsal stent.