KAU Rabigh School of Medicine Department of Otolaryngology, Head
and Neck Surgery Slide 2 NASAL OBSTRUCTION By Razan A. Basonbul,
MBBS Tutorial 6 Slide 3 Objectives Definition Differential
diagnosis History Examination Investigation Common issues: Mucosal
Swelling Septal deviation Collapse of nasal valves Nasopharyngeal
obstruction: Adenoids Choanal atresia Nasal polyps Cephalocele
Tumors, JNA Slide 4 Definition Nasal obstruction is the sensation
of reduced air flow either through one nostril (unilateral) or both
nostrils (bilateral). There are four main subdivisions: Mucosal
swelling Septal deviation Collapse of the nasal valves
Nasopharyngeal obstruction Slide 5 Differential Diagnosis KITTENS
Method (K) congenitalInfectious & IdiopathicToxins &
TrumaTumor ( Neoplasia) Neurogenic tumors. Conginital
Nasopharyngeal cysts. Teratoma Choanal atresia. Nasoseptal
deformaties Infectious Rhinitis Rhinoscleroma Chronic Sinusitis
Adenoid Hyperplasia Nasal & septal Fractures Medicatios side
effects ( Rhinitis medimentosa) Synechia Environmental irritants
Septal Hematoma Foreign bodies Papillomas Nasal Polyps Hemangiomas
Pyogenic granulomas Juvenile nasopharyngeal angiofibromas
Malignancy EndocrineNeurologicsystemic Diabetes Hypothroidism
Pregnancy Vasomotor rhinitis Granulomatous diseases Vasculitis
Allergy Cystic fibrosis Slide 6 History Common Drugs that cause
Nasal Congestion Antihypertensive, Asprin OCP Chronic Nasal
Decongestants Cocaine, Marijuan Tobacco Antithyroid Medication
Slide 7 Associated Symptoms and signs: Allergic component: Sneezing
Itching Watery eyes Clear Rhinorrhea Sinus Involvement: Facial Pain
Headaches Acute Infection: Fever Malaise Purulent or odorous nasal
discharge Pain H&N: Sore throat. Postnasal drip Cough Ear
complaints Halitosis Ocular pain hoarseness Slide 8 Examination
External Nasal Exam: External deformities: ( firmness, tenderness
on palpation) Nasal flaring Nasal airflow Anterior Rhinoscopy/
Nasal endoscopy: Examine twice ( with and without topical
decongestion) Quality of turbinates ( hypertrophic, pale, blue)
Quality of nasal mucosa, Septum. Osteometal complex obstruction
Foreign body, Nasal Masses, Choanal opening Quality of Nasal
Secretions: Purulent and thick ( infectious) Watery and clear (
Vasomotor rhinitis, Allergy) Salty and clear ( CSF leak) Slide 9 H
& N exam: Facial Tenderness Tonsil and adenoid hypertrophy
Cobblestoned posterior pharynx Cervical lymphadenopathy Otologic
exam Slide 10 Investigations Allergy Evaluation CT/MRI of Paranasal
Sinus: CT is Indicated if Obstruction secondary to; Nasal Masses
Nasal Polyps Work up for Chronic rhinosinusitis MRI is preferred
if; Suspected Tumors Intracranial involvement Complicated
rhinosinusitis Biopsy: For any mass suspecious of malignancy, avoid
biopsy of vascular neoplasms or encephaloceles. Ciliary Biopsy and
mucociliary Clearance Tests: Electron microscopy and ciliary
motility studies for ciliary defects. Nasal secretion protien,
Glucose or B2-transferrin: For CSF leak. Slide 11 Culture and
Sensitivity: Direct Nasal Swabs or Surgically obtained cultures may
be indicated of r complicated acute rhinosinusitis and resistant
chronic rhinosinusitis. Pulmonary Function test: Considered if
suspected coexisting reactive airway disease process. Slide 12
Nasal obstruction Children *Large Adenoids *Choanal Atresia
*Rhinitis *Postnasal space tumors (angiofibroma) *Foreign body
Refer to ORL in the same day if: Unilateral obstruction foul or
bloody discharge. Adults *Deviated Nasal Septum *Rhinitis,
Sinusitis *Polyps *Granuloma ( wegners) *Topical vasoconstrictors
Refer to ORL urgently: Numbness, tooth pain, bleeding, unilateral
obstruction, tumor suspected Slide 13 Mucosal swelling Autonomic
rhinitis Clear mucus production is the primary problem with less
nasal obstruction. This is due to over activity of the glands in
the nose. It is not common and usually occurs in the over 60s.
Rhinitis medicamentosa Overuse of some decongestant nasal sprays
(Otrivine, Sinex). These can help decongest the nose for a few
hours if you have a cold but should not be taken for more than a 5
days as they damage the lining of the nose. Chronic infection It is
associated with a mucky discolored production of green mucus
through the day. Idiopathic rhinitis Where neither allergy nor
infection can be found yet the lining of the nose is swollen. Slide
14 Turbinate Hypertrophy Slide 15 With lower two showing management
with coblation Slide 16 Septal deviation Septum is bent or deviated
over to one side and this blocks the air passage of the nose.
Septal deviation may be associated with a visibly deformed nose and
a history of nasal trauma although it is not necessary as the
cartilage may bend and deform as the nose grows. Nasal obstruction
is the predominant symptom, usually on one side. However, if other
symptoms are present other disease processes must be excluded.
Management depends on the severity of nasal obstruction. Surgery to
correct the deformity can be undertaken if the nose is blocked or
unsightly. Slide 17 Deviated nasal septum Slide 18 Septal Hematoma
Occurs following Trauma, Drugs as ASA or Idiopathic. Management by:
Drainage and pressure Dressing.. Slide 19 Collapse of the nasal
valves Normally on breathing in through the nostrils there is a
small amount of collapse of the nostrils. Often this collapse stops
if the mucosal swelling is treated. Occasionally the problem is
primarily due to a floppy valve or side wall of the nose
collapsing. Treatment using external nasal splints can sometimes be
help at night. Surgery is an option in case of bothersome issue.
Slide 20 Nasopharyngeal obstruction Adenoids : Most common cause of
nasal obstruction in children reaching maximum size between the age
of 3-5 years old and then reduce in size often by the age of 7 and
can hardly be seen by the late teens. Snoring alone is not an
indication for adenoid removal but if the child also develops apnea
(stops breathing for more than 10 seconds regularly without a cold)
then adenoidectomy and tonsillectomy may be helpful. Slide 21
Choanal atresia Incidence of 1 in 5000 to 1 in 10,000 births and is
more often unilateral than bilateral. The atresia is bony in 90% of
cases and membranous in only 10%. The choana develop between the 3
rd and 7 th embryonic weeks. Symptoms: Bilateral choanal atresia is
an acutely life threatening emergency! The resulting hypoxia is
manifested by cyanosis that is present at rest and improves with
exertion is called paradoxical cyanosis. Unilateral choanal atresia
may be manifested by a purulent nasal discharge on the affected
side. Slide 22 Diagnosis: Both choanae in newborns should be
routinely catheterized in the immediate postnatal period (e.g.,
with the suction catheter) to exclude choanal atresia. Rigid or
flexible endoscope. Treatment: Bilateral: intubation followed by
perforation of the atresia plate. Recurrent: stenosis is prevented
by inserting a stent and securing it with a suture (to prevent
aspiration). The definitive surgical repair of bilateral choanal
atresia is performed during the first weeks or months of life.
Unilateral: Surgery can be postponed until school age. Slide 23
Coanal Atresia Slide 24 Nasal Polyps Defined as benign swelling of
most commonly ethmoid sinus mucosa of unknown cause. Histology:
waterlogged stroma infiltrated with inflammatory cells and
eosinophils. They rise from each ethmoid air cells and hang down
inside the nasal cavity. Polyps can arise from other sinuses as a
single large polyp arising from the maxillary sinus called
antrochoanal polyp, this prolapse done the nasopharynx. Associated
with: Asthma, Aspirin Sensitivity and Cystic fibrosis. Samters
Triad: Nasal Polyposis, Aspirin Allergy and Asthma. Slide 25 Hx:
Nasal obstruction, watery rhinorrhea, sinus infection, anosmia. Ex:
Pale, Semitransparent gray mass. Mobile. Insensitive when palpated.
( differentiate it for hypertrophied turbinate) May prolapse out of
the nose if left untreated. !! Role out Malignancy in Adults with
unilateral polyp. !! Role out Meningocoele or encephalocoele By CT
TTT: Topical Steroids spray Surgery Slide 26 Nasal polyps ALL
POLYPS SHOULD BE SENT TO HISTOPATHOLOGY! Slide 27 Cephalpcele
Cephaloceles are herniations of intracranial contents through a
bony defect in the skull. Types: Meningocele. Meningoencephalocele.
Meningoencephalocystocele (meningocele + portions of the
ventricular system) Etiology: Most cephaloceles are congenital.
Rare cases are post-traumatic (e.g., after a frontobasal fracture)
Presentation: Closely resemble Nasal Polyp. But have to be role out
in Unilateral nasal polyp in children. Slide 28 Diagnosis: CT or
MRI can supply information on the location and extent of the mass
and the associated bony defect. Treatment: Always surgical and
consists of removing the cephalocele and repairing the dural defect
Slide 29 Tumors Of the Nasal Cavity Unilateral nasal blockage,
discharge and bleeding are often the presenting symptoms of nasal
or sinus tumors. Osteomas are often asymptomatic. Transitional cell
papilloma is the most common benign tumor ( may undergo malignant
changes) Squamous cell carcinoma is the most common malignant
tumor. 50% of Sinonasal cancer arise from lateral nasal wall, 33%
in Maxillary antrum. Slide 30 Juvenile angiofibroma (JNA) A benign
tumor that arise adjacent to the sphenopalatine foramen, tends to
bleed and occurs in the nasopharynx of prepubertal and adolescent
males. Epidemiology: 0.05% of all head and neck tumors. Occurs in
MALES. Affects age 7-19 years. Presentation: Nasal obstruction
(80-90%) Epistaxis(45-60%) unilateral sever bleeding. Headache
(25%) Slide 31 Diagnoosis: Vascular unilateral nasal mass. CT and
MRI showing the extent of the tumor growth. Angiography shows
branches of external carotid that feeds the tumor. Treatment:
Hormonal: Testosterone receptor blocker Surgical Resection and
Radiotherapy. Slide 32 Foreign Bodies of the Nose Mostly are self
inserted by children. Organic materials present early by Purulent
Discharge Inorganic materials may remain for ages. Presentation:
unilateral, foul smelling nasal Discharge blood Management:
Forceps: Pieces of paper or cotton swabs. blunt hook: for Rounded
objects, pass it deeper than the object then try to bring it out by
dragging it over the floor of the nose. Removal under General
Anastasia might be required, make sure to protect the airway!
Complications: Nasal infection and sinusitis. Rhinolith formation.
Inhalation into the tracheobronchial tree. Slide 33 Nasal Foreign
body removal Slide 34 Foreign body removal by balloon catheter
Slide 35 Be aware ! In children with a blocked nose on one side and
a one sided nasal discharge, a foreign body may be in the nose.
Nasal polyps are rare in children and further tests should be done.
Nasal obstruction of one side of the nose in adults, with or
without bleeding, needs to be REFERED to be examined carefully by
an otolaryngologist. Instruct the patient to Avoid the long-term
use of nasal medication purchased over the counter unless
specifically prescribed. Slide 36 Thank you References: Clinical
Otolaryngology online (COOL)
http://www.entnet.org/EducationAndResearch/cool.cfm
http://www.entnet.org/EducationAndResearch/cool.cfm Under the
American Academy of otolaryngology, Head and Neck Surgery The
British Association of Otolaryngology Head and Neck Surgery
http://www.entuk.org/patient_info/nose/obstructions_html
http://www.entuk.org/patient_info/nose/obstructions_html
Otolaryngology head and neck surgery by Raza Pasha,MD Primary care
otolaryngology www.emedicine.medscape.com Bailey and Love Short
practice in surgery 25 th edition. Oxford Handbook of clinical
specialties.
