KAU Rabigh School of Medicine

KAU Rabigh School of MedicineDepartment of Otolaryngology, Head and Neck SurgeryNasal obstructionBy Razan A. Basonbul, MBBSTutorial 6

ObjectivesDefinitionDifferential diagnosisHistoryExaminationInvestigationCommon issues:Mucosal SwellingSeptal deviationCollapse of nasal valvesNasopharyngeal obstruction:AdenoidsChoanal atresiaNasal polypsCephaloceleTumors, JNADefinition Nasal obstruction is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral). There are four main subdivisions:Mucosal swellingSeptal deviationCollapse of the nasal valvesNasopharyngeal obstructionDifferential DiagnosisKITTENS Method(K) congenitalInfectious & IdiopathicToxins & TrumaTumor ( Neoplasia)Neurogenic tumors.Conginital Nasopharyngeal cysts.TeratomaChoanal atresia.Nasoseptal deformatiesInfectious RhinitisRhinoscleromaChronic SinusitisAdenoid HyperplasiaNasal & septal FracturesMedicatios side effects ( Rhinitis medimentosa)SynechiaEnvironmental irritantsSeptal HematomaForeign bodiesPapillomasNasal PolypsHemangiomasPyogenic granulomasJuvenile nasopharyngeal angiofibromasMalignancyEndocrineNeurologicsystemicDiabetesHypothroidismPregnancyVasomotor rhinitisGranulomatous diseasesVasculitisAllergyCystic fibrosisHistoryCommon Drugs that cause Nasal CongestionAntihypertensive, AsprinOCPChronic Nasal DecongestantsCocaine, MarijuanTobaccoAntithyroid MedicationCharacter of Nasal Obstruction:Onset and duration.Constant VS intermittent.Unilateral VS Bilateral.Associated mouth breathing, Snoring, anosmia/hyposmia/taste disturbanceTearing ( Nasolacrimal Duct Obstruction or Allergy). Contributing Factors:Toxin and Allergen exposure.Known Drug AllergiesMedicationsHx of AsthmaRhinosinusitisSleep DisturbanceFacial Trauma or SurgeryAssociated Symptoms and signs:Allergic component: SneezingItchingWatery eyesClear RhinorrheaSinus Involvement:Facial PainHeadachesAcute Infection:FeverMalaisePurulent or odorous nasal dischargePain

H&N:Sore throat.Postnasal dripCoughEar complaintsHalitosisOcular painhoarsenessExaminationExternal Nasal Exam:External deformities: ( firmness, tenderness on palpation)Nasal flaringNasal airflowAnterior Rhinoscopy/ Nasal endoscopy:Examine twice ( with and without topical decongestion)Quality of turbinates ( hypertrophic, pale, blue)Quality of nasal mucosa, Septum.Osteometal complex obstructionForeign body, Nasal Masses, Choanal openingQuality of Nasal Secretions:Purulent and thick ( infectious)Watery and clear ( Vasomotor rhinitis, Allergy)Salty and clear ( CSF leak)

H & N exam:Facial TendernessTonsil and adenoid hypertrophyCobblestoned posterior pharynxCervical lymphadenopathyOtologic examInvestigationsAllergy EvaluationCT/MRI of Paranasal Sinus:CT is Indicated if Obstruction secondary to;Nasal MassesNasal PolypsWork up for Chronic rhinosinusitisMRI is preferred if;Suspected TumorsIntracranial involvement Complicated rhinosinusitisBiopsy: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.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.Mucosal swellingAutonomic rhinitisClear 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 medicamentosaOveruse 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 infectionIt is associated with a mucky discolored production of green mucus through the day.Idiopathic rhinitisWhere neither allergy nor infection can be found yet the lining of the nose is swollen.Turbinate Hypertrophy

Turbinate Hypertrophy

With lower two showing management with coblationSeptal deviationSeptum 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.Deviated nasal septum

Septal HematomaOccurs following Trauma, Drugs as ASA or Idiopathic.Management by: Drainage and pressure Dressing..

Collapse of the nasal valvesNormally 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.Nasopharyngeal obstructionAdenoids :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.

Choanal atresiaIncidence 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 3rd and 7th 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.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.Coanal Atresia

Nasal PolypsDefined 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.

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 CTTTT:Topical Steroids spraySurgery

Nasal polyps

ALL POLYPS SHOULD BE SENT TO HISTOPATHOLOGY!CephalpceleCephaloceles 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.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

Tumors Of the Nasal CavityUnilateral 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.

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%)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 blockerSurgical Resection and Radiotherapy.

Foreign Bodies of the NoseMostly are self inserted by children.Organic materials present early by Purulent DischargeInorganic materials may remain for ages.Presentation:unilateral, foul smelling nasal Discharge bloodManagement: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.

Nasal Foreign body removal

Foreign body removal by balloon catheter

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. Thank you References:Clinical Otolaryngology online (COOL) http://www.entnet.org/EducationAndResearch/cool.cfmUnder the American Academy of otolaryngology, Head and Neck SurgeryThe British Association of Otolaryngology Head and Neck Surgery http://www.entuk.org/patient_info/nose/obstructions_htmlOtolaryngology head and neck surgery by Raza Pasha,MDPrimary care otolaryngologywww.emedicine.medscape.comBailey and Love Short practice in surgery 25th edition.Oxford Handbook of clinical specialties.