Osteomeatal complex

→ an area where Ostia of

1. Frontal
2. Ethmoidal (bulla ethmoidalis, agger nasi cells )
3. Maxillary sinuses
Drain into the middle meatus
→ common drainage pathway of art.grp. Of sinuses

Osteomeatal complex includes:

① Structures:
→ middle turbinate
→ uncinate process -
Rhinophyoma:

→ benign tumour of external nose M/c cause

→ hypertrophy of the sebaceous glands on the tip of nose

Cause: long-standing case of acne rosacea

Clinical features:

→ Mass
1. Pink
2. Lobulated
3. Over the nose
4. With superficial vascular dilatation

→ C/o
① unsightly appearance of tumour
② obstruction to breathing or vision - due to large size of tumour

Treatment:
→ Surgical: excision with
① knife → allowed to re-epithelize
② CO2 laser → skin grafting
Cottle’s test:

→ subjective test of nasal obstruction due to abnormality in nasal valve

Sites of nasal obstruction:

1. Vestibular( caudal septal deviation, synechiae, stenosis)
2. at the nasal valve ( synechiae post rhinoplasty)
3. Attic ( high septal deviation)
4. Turbinal ( hypertrophic turbinates or concha bullosa)
5. Choanal ( choanal atresia, choanal polyp)

Significance of cottle‘s test:

→ helps diagnose the site of nasal obstruction ( if at the nasal valve, if not- rules it out)
→ self-performable diagnostic procedure
→ non- invasive

Procedure:
① cheek of one side is withdrawn laterally with a fingers
② patient is asked to breathe
③ assess if there is improvement in the nasal air way on the test side
Result:
+ve - obstruction at nasal valve
-ve - obstruction in other above mentioned sites
Septal hematoma:
→ The collection of blood under periosteum of the nasal septum

Aetiology:
① Nasal trauma Or presents with
Nasal trauma following surgery
② Septal surgery
→ occurs spontaneously in bleeding disorders

Clinical features:
1. Bilateral nasal obstruction
2. Associated frontal headache
3. Sense of pressure over nasal bridge
On examination,
→ smooth rounded swelling of the septum in both nasal fossae
→ on palapation - soft, fluctuant mass

Treatment:
→ Aspiration- with wide bore sterile needle. Small hematomas
→ Incision and drainage Large hematomas
1. Anteroposterior septal incision, parallel to nasal floor
2. Excision of mucosa at the edge of incision - better drainage
3. Drainage
4. Nasal packing- b/l - prevent reaccumulation
→ systemic antibiotics - prevent septal abscess

Complications:
D/t delay in draining of hematoma
1. Septal abscess- d/t secondary infections
2. Saddling of nose - necrosis of septum as it is in hypoxic state because it has been
separated from periosteum Chas its arterial supply)
Mucociliary clearance mechanism:

Structure of nasal mucosa

1. Cellular layer- ciliated columnar epithelium
2. Serous layer
3. Mucous layer Mucous blanket
# floats above

Mechanism of clearance:
→ ‘Conveyer belt’ mechanism
→ Movement of mucous blanket is unidirectional, d/t
1. Rapid "Effective stroke" - extends and reaches the
mucous layer, and pushes the blanket towards
nasopharynx
2. Slow "Recovery stroke" - bends down and travel
slowly in reverse direction through the sermons Disturbances in this mechanism:
layer Ciliary dyskinesia (defective or no
→ Cilia beats 10-20 times per second (@ room temp.) function )
→ The mucous blanket moves at a speed of 5-10 mm/min D/t
→ A complete sheet is cleared in 10-20 min 1. Congenital
2. Drying
→ 600 - 100mL of nasal secretions produced in 24hrs 3. Drugs
→ Turbinates doubles the surface area to perform this 4. Excessive heat or cold
function 5. Smoking
6. Infections
Significance: Effect: stagnation of mucus in nose and
1. Physical barrier against infections: inspired sinuses and bronchi
microorganisms and dust are entrapped in the mucous →chronic rhino sinusitis and
blanket and carried to nasopharynx and swallowed.
bronchiectasis
2. Humidification of inspired air
 Nasal septum perforation:

Aetiology

Traumatic perforations Idiopathic Drugs and Pathological

→ m/c cause chemicals perforations

Repeated cauterisation Prolonged use of Cocaine Septal Nasal myasis

Injury during SMR
of septum with chemicals steroid sprays addicts abscess
for epistaxis
Habitual Occupational
nose Rhinolith
Deliberate 1. Chromium plating
picking perforation 2. Dichromate
for putting 3. Soda ash
ornaments Chronic granulomatous
conditions
1. Cartilaginous part -
Clinical features: lupus, TB, leprosy
1. Whistling sound - during inspiration or expiration, small ant perforations 2. Bony part - syphilis
2. Crust - in large perforations, obstructs the nose; epistaxis when removed

Treatment:
1. Biopsy- i) from granulations ii) of edge of perforations; try to find the cause
2. Surgical - small perforations closed by plastic flaps; large perforations are difficult to close
3. Medical - alkaline nasal douches and application of a bland ointment → to keep nose crust free;
for larger perforations
4. Symptomatic relief - thin silastic button
Rhinoscleroma
→ chronic granulomatous disease

Causative agent: Klebsiella rhinoscleromatis or Frisch bacillus

Pathology:
① Mode of infection is unknown
② From nose → nasopharynx → oropharynx → larynx → trachea → bronchi

Clinical features:

① Atrophic stage:
→ resembles atrophic rhinitis
→ characteristics: Foul smelling purulent nasal discharge and crusting
② Granulomatous stage:
→ granulomatous nodules in nasal mucosa; painless and non-ulcerative
→ “woody feel" in lower part of external nose and upper lip - d/t subdernal infiltration
③ Cicatricial stage:
→ stenosis of nares
→ distortion of upper lip
→ adhesions in nose, nasopherynx, oropharynx
Diagnosis:
→ Biopsy findings
1. Infiltration of submucosa - with plasma cells, lymphocytes, casinophils, Mikulicz cells, Russel bodies
2. Mikulicz cells - large foamy cell with a central nucleus and raculated cytoplasm containing
causative bacilli.
3. Russell bodies - homogenous eosinophilia inclusion bodies found in plasma cells; occur d/t
accumulation of Ig secreted by plasma cells.

→ Culture: causative organism can be cultured from the biopsy material

Treatment:
Streptomycin (1g/day) + Tetracycline (2g/day) , X (4-6 weeks)
- repeated if necessary, after I month
- treatment is stopped only when 2 consecutive cultures from biopsy is -ve
Steroids - reduce fibrosis

Surgical treatment - establish air way and correct nasal deformity

Rhinolith

Aetiology:
→ Stone formation in the nasal cavity
→ the irregular mass cause pressure necrosis of
septum and/or lateral wall of nose

Clinical features:
1. Unilateral nasal obstruction
2. Foul-smelling nasal discharge- often bloodstained
3. Frank epistaxis and neuralgic pain - ulceration of surrounding mucosa

On examination,
→ grey brown or greenish-black mass
→ irregular surface Large
Irregular
→ stony hard
Fills the cavity
→ seen in nasal cavity b/w the septum and turbinate
→ brittle, breaks while manipulating
→ surrounded by granulations, sometimes

Treatment:
→ surgically removed
→ General anesthesia
→ mostly removed through art. nares
→ large ones are broken and removed
→ hard and irregular ones - lateral rhinotomy
Nasal myiasis
→ infestation of maggot on nose, nasopharynx, paranasal sinuses and causing excessive destruction

Aetiology: Treatment:
1. All maggots are picked up- with
Chrysoma forceps
Atrophic rhinitis 2. Chloroform water and oil instillation -
Syphilis kills them
Leprosy Foul smell 3. Nasal douche with warm saline - to
Lay eggs remove crusts, slough and dead
Infected wounds maggots.
Precaution:
→ Maggots more into darker cavities on
exposure to light
→ Pt. Must be isolated to prevent the
perpetuation of this cycle through flies
Clinical features: → Pt. Should receive instructions for nasal
→ First 3-4 days hygiene before leaving the hospital
1. Present as simple epistaxis - pt. Not aware of the presence of maggots
2. Symptoms - irritation, sneezing, lacrimation, headache ,thin blood-
stained discharge, puffy eye lids and lips
→ on 3rd /4th day
1. Foul smell
2. Maggots crawl out

→ Extensive tissue destruction of nose, sinuses, soft tissue of face, palate

and eyeball
→ Fistula in palate or around the nose
→ Death - d/t meningitis
Choanal atresia

→ persistence of bucconasal membrane

Clinical features:
→ U/l or B/l
1. Unilateral atresia is more common; undiagnosed
until adult life
2. Bilateral atresia presents with severe
respiratory obstruction at birth itself.
Newborn is an obligate nasal breather, hence
has difficulty in breathing
→ Complete/Incomplete
→ Bony (90%) / Membranous (10%)

Diagnosis:
→ in newborn, Treatment:
1. Breastfeeding - cyanotic → Emergency treatment:
2. Crying. - pink 1. Tracheostomy
→ in adults, 2. McGovern's technique- a feeding nipple
1. Absence of air bubbles in nasal discharge with a large hole, provides good air way
2. Failure to pass catheter from nose to pharynx → Definitive treatment:
3. Putting a few drops of methylene blue into the 1. Correction of atresia by transnasal of
nose and seeing its passage into the pharynx transpalatal approach
4. Flexible nasal endoscopy 2. Nasal endoscopes and drill
5. CT scan in axial plane 3. Removal of a part of posterior nasal
septum trans nasally
Vasomotor rhinitis
→ Non-allergic rhinitis with symptoms of nasal obstruction , rhinorrhoe and sneezing
→ Persists throughout the year
→ All tests of nasal allergy is -ve

Pathogenesis:
Stimuli
1. Emotions Nasal mucosa
2. Change in temperature
3. Humidity
4. Blasts of air Parasympathetic system stimulation
5. Dust or smoke (small) Overactivity

Vasodilation and engorgement

Excessive secretion

Symptoms:
1. Paroxysmal sneezing - bouts of sneezing just after getting out of bed
2. Excessive rhinorroea - profuse, watery, wets several hand kerchiefs, drips when leaning for ward
3. Nasal obstruction - marked at night
4. Postrasal drip
Signs:
→ Nasal mucosa over turbinates- congested and hypertrophic or normal
Complications:
→ long standing cases develop nasal polyps, hypertrophic rhinitis, sinusitis
Treatment:
→ Medical:
1. Avoid the physical factors
2. Anti-histaminies and nasal decongestants
3. Topical steroid sprays
4. Systemic steroids- inseverecases
5. Ipratropium bromide-for excessive rhinorrhoea
6. Psychological factors should be removed
→ Surgical
1. Hypertrophic rhinitis, DNS, polyps - corrected surgically
2. Vidian neurectomy- sectioning the parasympathetic
secretomotos fibres to nose in cases with excessive whinershoee
that couldn't be corrected medically
Oroantral fistula
→ communication b/w the maxillary antrum and the oral cavity
→ the opening may be situated on the alveolus or gingivolabial sulcus

Aetiology: - M/c
> cause

1. Dental extraction - extraction of roots of 2nd premolar and upper molars that are closely related to
the antrum
2. Failure of sublabial incision to heal - after Caldwell - Luc operation
3. Erosion of antrum - carcinoma
4. Osteitis of maxilla- syphils or malignant granuloma

Clinical features:
1. Regurgitation of food: from oral cavity → Antrum → nose
2. Discharge: foul smelling, filling the nose, exuding from the fistulas opening into the mouth
3. Inability to build +ve or -ve pressure in the mouth: difficulty to blow the wind instruments or drink
through straw

Diagnosis:
Probing- passed from the fistulous opening in the oral cavity → Antrum

Treatment:
→ recent fistula: discovered immediately after tooth extraction; with no infection or retained tooth in
the antrum. Conservative treatment,
1. Suturing of gum margins
2. Antibiotics course
→ chronic/large fistula
1. Irrigation and antibiotics- maxillary sinusitis
2. Surgical repair by palatal or buccal flap