5

الدكتور سعد يونس سليمان

بسم الله الرحمن الرحيم

Lecture objectives
Epistaxis (nosebleed) Nasal Fractures Foreign bodies in the Nose Rhinolith Disorders of nasal septum CSF Rhinorrhoea Oroantral fistula Choanal Atrasea

Epistaxis (nosebleed)

Usually harmless but may be life-threatening disease . All ages without sex predilection. Anterior epistaxis is more common in child or young adult, while posterior nasal bleeding is more often seen in the older adult with hypertension or arteriosclerosis. The incidence is higher during the winter months .

Sources of bleeding;

Causes of epistaxis;
A. Local causes; 1) Idiopathic. 2) Trauma . 3) Inflammatory reactions . 4) Anatomical and structural abnormalities. 5) Intranasal tumours, benign or malignant.

B. Systemic causes

1) Cardiovascular (arteriosclerosis +HT) 2) Drugs 3) Blood disorders e.g. ITP 4) Toxic agents 5) Hereditary haemorrhagic telangiectasia (Osler-Weber-Rendu disease)


MANAGEMENT
A. First aid management; 1. Arrest of haemorrhage 2. Assessment of blood loss 3. Determination of cause 4. Determination of site B. Control of bleeding 1. Stop spontaneously 2. Cauterization 3. Packing 4. Examination under general anaesthesia &surgical ligation of the arterial supply of the nose .

Management;

A. First aid management; Arrest of haemorrhage Calming the patient Pinching the nostrils The patient should sit upright and lean forward

Assessment of blood loss Recording the pulse and blood pressure Look for signs of shock; pallor, raising pulse and sweating. In severe blood loss; IV line should be inserted. Blood taken for cross match. Administration of suitable plasma expander

Determination of cause History Hb, full blood count and clotting screenDetermination of site A search is made in the clean dry nose …removal of clots … cotton-wool pledglet soaked in vasoconstrictor (e.g. 1:1000 adrenaline)

B. Control of bleeding

Stop spontaneously Cauterization electrical chemical Packing anterior packing postnasal pack

If bleeding continues despite the mentioned measures?

1. Examination under general anaesthesia. Septal deviation Nasal endoscopy Thorough packing 2. Surgical ligation of the arterial supply of the nose Anterior ethmoidal artery Maxillary artery External carotid artery

Nasal Fractures;

Skeletal injuries in the head and neck region are not unusual and may arise from accidental injuries or from assault. Road traffic injuries (RTA) account for most major injuries to the nose and facial skeleton. This can occur in isolation or in combination with fractures of the maxilla or zygomatic arch; therefore, we should not forget that the patient may also have received a head injury.


The fractures of the nasal bones are common due to its prominent location

Clinical feature

1. Deformity, black eye and swelling. 2. Pain and headache. 3. Epistaxis. 4. Nasal obstruction due to septal haematoma or septal dislocation. Remember to inquire regarding preexisting deformity.


Radiographs are clinically unhelpful and serve only to provide medicolegal documentation of fracture.

Open fracture or septal haematoma requires immediate treatment.

Foreign bodies in the Nose
common in children..organic or inorganic inflammatory reactionX – ray if the foreign body is radiopaque.Treatment; Removal of the FB by a probe, hook or forceps, sometimes G.A. is required. Unilateral foul smelling nasal discharge.
. Epistaxis
Pain

Rhinolith

Hard masses in the nasal cavity consist of deposits of phosphate, and carbonate of calcium and magnesium around a central nucleus called the nidus. The nidus may be FB Dried blood and pus. Clinical Picture 1. Unilateral offensive nasal discharge. 2. Unilateral nasal obstruction. 3. If it is long standing, it leads to atrophy of the nasal mucosa.

Examination Probe --- hard mass can be felt. Investigations X - ray Treatment Removal under G.A.


Disorders of nasal septum
Septal haematoma Collection of blood beneath the mucoperichondrium or mucoperiosteum of the nasal septum. Therefore H. separate the cartilage from its blood supply may cause cartilaginous atrophy and necrosis Cause; 1. Trauma surgical or non surgical. 2. Blood dyscrasia.

Clinical Picture 1. Nasal obstruction 2. Septal swelling. Complications 1. Infection of the haematoma septal abscess ,cartilage necrosis and perforation. 2. External deformity (Saddle-nose)

Treatment;

2. Septal Abscess:
Collection of pus beneath the mucoperichondrium or the mucoperiostium. Complication of haematoma, furunculosis, measles or scarlet fever. Nasal obstruction, fever, pain and tenderness over the nasal bridge with symmetrical swelling of the nasal septum. Complications 1. Cartilage necrosis ---perforation --- external deformity. 2. Cavernous sinus thrombophlebitis. Treatment 1. Drainage+packing+antibiotics. 2. Plastic surgery for external nasal deformities.

3. Septal deviation;

Generally a few adults have a complete straight septum. Only gross deflections causing symptoms require treatment. Aetiology 1) Trauma 2)Developmental errors Symptoms Examination 1) Nasal obstruction 1) Ext. nasal deformity. 2) Recurrent sinus infection 2) S or C shaped deviation. 3) Headache 3) Signs of sinus infection. 4) Epistaxis

Treatment

3. Ulceration and perforation of the septum
Aetiology; Trauma; surgical, repeated cautery, digital trauma (nose picking) Malignant disease. Chronic inflammation; TB, syphilis Poisons; industrial, cocaine addicts, topical corticosteroid, topical decongestants. Idiopathic.


If small the perforation may produce an irritating whistling noise with respiration If larger it produces a considerable crusting with subsequent bleeding.


Treatment; 
Treatment of underlying medical condition. Medical treatment of crusting (alkaline nasal douche + 25%glucose in glycerol drops). Surgical closure (e.g. with split skin-graft or the use of septal mucopericondrial flaps).

Cerebrospinal fluid (CSF) Rhinorrhoea

Nasal trauma+Clear rhinorrhoea =CSF leak. Aetiology 1) Trauma: fracture of the base of the skull e.g. the cribriform plate and the posterior wall of the frontal sinus 2) Spontaneous: Destructive lesion involving the floor of the anterior cranial fossa

Diagnosis;

Clinical Picture 1) Watery fluid drips from the nose which increase in bending forward. 2) Meningitis. Examination 1) Handkerchief test: The fluid associated with rhinitis contains mucous which stiffens a handkerchief while CSF does not. 2) Nasal endoscope to see the site of the lesion. Investigations 1) Identification of glucose in the secretion. 2) Injection of radioactive material into CSF via lumber puncture. 3) CT. scan of the base of the skull.

Treatment;

Medical (Conservative); Bed rest in the head up position. Avoidance of coughing ,sneezing, nose blowing and straining. Reduction of CSF production rate by drugs ( acetazolamide , frusemide ) or by repeated lumber puncture. Prophylactic antibiotics to prevent development of meningitis. Surgical treatment; If no response after 10-14 days--- craniotomy with repair of dura with fascia lata.

Oroantral fistula

Definition; a fistula that communicates the oral cavity with the maxillary sinus. Aetiology 1) Dental extraction , particularly of the 1st upper molar teeth. 2) Malignant tumours of the antrum. 3) Penetrating wound. 4) Fistula following Caldwell-Luc operation.

Management of OAF

At time of tooth extraction and in the absence of retained piece
Immediate suture
If there is retained piece, food particles & infection


Pus culture Radical antrostomy for removal of FB Trimming of the bony edges of the fistula Repair of fistula using a mucoperiosteal or palatal flap

Choanal Atresia

Congenital atresia of the posterior nares due to persistence of the bucconasal membrane. usually unilateral but bilateral cases can occur and observed at birth because the neonate is obligate nasal breather. The obstruction either composed of bone (most commonly) or membrane. The condition occurs in 1 out of every 7,000 to 8,000 live births.

Clinical Picture

Females are more commonly affected than males.Bilateral  Neonatal emergency leads to asphyxia because the infant is obligate nasal breather and commonly associated with other congenital anomalies Unilateral (60%) with a right-sided predominance  nasal obstruction and excessive nasal discharge in the affected side which may be not noticed for some years.

Examination

1. Total absence of nasal air flow by mirror test and cotton test.2. Plastic catheter or probe can’t be passed through the affected side to the nasopharynx.3. Fibroptic endoscopy

Investigations

Contrast radiography by instillation of radioopaque substance in the affected side. CT scan to see the thickness of a bony atresia.

Treatment

Bilateral  oral airway  surgical intervention.Unilataral  elective perforation of the occlusion usually prior starting of school.

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