Nose

Nose and paranasal sinus
Anatomy OF Nose and paranasal sinus

Nerve cells: These cells communicate with your brain to provide a sense
of smell.
Nostrils (nares): These are the openings to the nasal cavities that are on
the face.
Septum: The septum is made of bone and firm cartilage. It runs down the
center of your nose and separates the two nasal cavities.
Sinuses: You have four pairs of sinuses. These air-filled pockets are
connected to your nasal cavities. They produce the mucus that keeps your
nose moist.
Turbinates (conchae): There are three pairs of turbinates located along
the sides of both nasal cavities. These folds inside your nose help warm
and moisten air after you breathe it in and help with nasal drainage.
Congenital anomalies of the Nose
Midline masses
Nasal dermoid cysts
• -usually a slow growing nasal mass or midline pit
• -don,t compress it
• -contain dermal and skin element
• -may have intracranial connection(20%-45%)
• -could be masses or sinus tracts
• -complications- abscess, periorbital cellulitis, cavernous sinus
thrombosis, nasal deformities
• Rx -surgery
Neonatal bony nasal obstructions
Choanal atresia(congenital narrowing of the back of the nasal cavity

that causes difficulty of breathing)
• bilateral cases present at birth with respiratory distress
• unilateral cases present with unilateral rhinorrhea/nasal obstruction
• CT scan confirms the diagnosis
• F:M=2:1
• unilateral(2x)
• cyclical cyanosis which improves with crying and worsens with
feeding.
• 90% bony and 10% membraneous
• Rx; surgery
Trauma nose
• nasal fracture-involves the ostecartilage portion of nose
• may form comminution, dislocation,twisting,deviation,etc
• depends on the magnitude of force and direction.
Deviation of nasal septum(DNS)
• may involve bone, cartilage or both.
• different forms eg;-s-shaped,c-shaped,anterior,etc
clinical features
• nasal obstruction
• headache
• sinusitis
• epistaxis
• anosmia
• external deformity
Septal hematoma
• blood collection in the perichondrium of the septal cartilage.
• bilateral septal swelling which is fluctuant
• Rx-aspiration or incision –drainage
Septal abscess- bilateral nasal obstruction with pain and
tenderness
Mgt -incision and drainage with antibiotics use
SINUS INFECTIONS
 Sinusitis:
• Inflammation of paranasal sinuses.
• The maxillary sinus is most commonly involved.
• The next most common sites are the ethmoid, frontal, and
sphenoid sinuses.
• Sinuses become infected when sinus ostia are obstructed or
when ciliary clearance is impaired.
Fig. 1. There are four paired paranasal sinuses.
© 2009 UpToDate 17.1

SINUS INFECTIONS…
 Classification of sinusitis is based on symptom duration:

• Acute sinusitis - symptoms < 4 weeks.
• Subacute sinusitis - symptoms for 4 to 12 weeks.
• Chronic sinusitis - persists > 12 weeks.
• Recurrent acute sinusitis - four or more episodes of acute
sinusitis per year, with interim symptom resolution.
Acute Sinusitis
• defined as sinusitis of <4 weeks' duration.
 Etiology:
 Bacterial sinusitis is caused by:
• Streptococcus pneumoniae, Haemophilus influenzae.
• Moraxella catarrhalis (in children).
 Other causative organisms are:
• S. aureus, S. pyogenes, Gram-negative bacilli.
• Respiratory viruses, fungi.
Acute Sinusitis: Clinical Features
• Thick purulent nasal discharge, congestion.

• Facial pain or pressure, headache and tooth pain.
• Pain localizes to the involved sinus.
 Life-threatening complications include:
 Meningitis, epidural abscess, and cerebral abscess.
Acute Sinusitis: Diagnosis
• It is difficult to distinguish viral from bacterial sinusitis clinically.

• Disease of < 7 days’ duration is considered viral.
• Of pts with symptoms of >7 days’ duration, 40–50% have
bacterial sinusitis.
• CT or sinus radiography is not recommended for routine cases
early in the course of illness (i.e., at <7 days).
Acute Sinusitis: Treatment
• Most pts improve without antibiotic therapy.
• Treatment to facilitate drainage (e.g., oral and topical
decongestants, nasal saline lavage ) should be used.
• Pts who do not improve after 7 days or with severe disease at
presentation should be given antibiotics.
 Amoxicillin, 500 mg PO TID or TMP-SMX 960 mg PO BID for 10–
14 d.
• Exposure to antibiotics within 30 days
 Amoxicillin/clavulanate 2000 mg PO BID for 10 days.
Chronic Sinusitis
• Sinusitis of >12 weeks’ duration.
• Most commonly associated with either bacteria or fungi.
• Repeated infections due to impaired mucociliary clearance.
• Pts have constant nasal congestion and sinus pressure with periods of increased
severity.
• Sinus CT scans can define the extent of disease and response to treatment.
Chronic Sinusitis: Treatment
• Repeated courses of antibiotics are required for 3 – 4 weeks at a

time.
• Adjunctive treatments include intranasal administration of
glucocorticoids, sinus irrigation, and surgical evaluation.
• Recurrence is common.
Allergic Rhinitis
• Seasonal or perennial occurrence of watery nasal discharge,
sneezing, nasal congestion and nasal itching.
• Often accompanied by allergic conjunctivitis, characterized by itchy,
red, irritated eyes.
• Common allergens causing allergic rhinitis include:
 Pollens, dust and household mites , cockroaches.
• On physical examination, the mucosa of the turbinates is usually pale
because of venous engorgement.
Allergic Rhinitis: Treatment
• Allergen avoidance.
• Antihistamines:
 Chlorpheniramine 4 mg PO TID
 Diphenhydramine 25 mg PO TID.
 Cetirizine 10 mg PO/d, Loratadine 10 mg PO/d.
• Intranasal corticosteroid sprays: mainstay of treatment.
 Mometasone furoate 200 µg once daily per nostril.
 Beclomethasone 42 µg/spray twice daily each nostril.
• Short-course systemic steroids for severe cases.
Epistaxis = Nasal Bleeding
ANATOMY
Fig.2. Blood supply to

the nasal septum,
demonstrating
Kiesselbach's plexus.
Epistaxis…
 Anterior nosebleeds:
• The most common type of epistaxis encountered
• Up to 80% occur within the vascular watershed area of the
nasal septum (Kiesselbach's plexus)
 Posterior nosebleeds:
• Arises most commonly from the posterolateral branches of the
sphenopalatine supply.
• Posterior nosebleeds can result in significant hemorrhage.
Epistaxis: Etiology
• Nasal trauma: nose picking, foreign bodies

• Coagulation or platelet disorders
• Rhinitis
• Nasal tumors
Epistaxis: Treatment
 Anterior nosebleeds:
• Evaluate hemodynamic stability.
• Squeeze the nasal alae while patient sitting up, bent forward at the
waist, and expectorating blood.
• Anterior nasal packing.
 Posterior nosebleeds:
• Patients who continue to bleed after anterior packing most likely have
a posterior bleed.
• Posterior packing with a Foley catheter.

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Nose and paranasal sinus

Anatomy OF Nose and paranasal sinus

Choanal atresia(congenital narrowing of the back of the nasal cavity

© 2009 UpToDate 17.1

 Classification of sinusitis is based on symptom duration:

• Thick purulent nasal discharge, congestion.

• It is difficult to distinguish viral from bacterial sinusitis clinically.

• Repeated courses of antibiotics are required for 3 – 4 weeks at a

Fig.2. Blood supply to

• Nasal trauma: nose picking, foreign bodies

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