Dr.Hussein
L.2  Congenital & Traumatic diseases  of  the Nose and Paranasal Sinuses

Congenital Malformation:
A.   Facial cleft:
-   Cleft lip: result from failure of fusion of the maxillary process on one side with the median nasal process; it may be bilateral, or unilateral.
-   Cleft palate: result of the failure of the palatine processes to fuse with each other and with the nasal septum. Bifid uvula and submucous cleft represent minor degrees.
-   Bifid nose.
B.
Dermoid cysts and sinuses: This found in the midline.                                         
C. Aplasia of the sinuses: failure of pneumatization, often of frontal sinus.
D.
Atresia and stenosis of the anterior nares, atresia of the posterior nares (congenital choanal atresia): due to persistence of the primitive bucconasal membrane.
Types: 1. Bony, most commonly (90%) mostly thin bone easily perforated.
       2. Membranous (10%).
       3. Partly bony partly membranous.
    Degrees: 1. Complete unilateral atresia, most commonly.
              2. Complete bilateral atresia.
           3. Incomplete unilateral atresia.
              4. Incomplete bilateral atresia.
      Pathology:
 The partition is covered with mucous membrane, its thickness may vary    from    1-10 mm,   and females are more commonly affected than males.
     Clinical features: 1. 	Nasal obstruction.
                      2.	Excessive nasal discharge, tenacious.
                           3.  In   bilateral   atresia may be urgent and   cause death   from Asphyxia (the child is cyanosed when he is quite).  
    Diagnosis:
1. Plastic catheter cannot be passed  through the nose to nasopharynx.
2. CT scan.                                                                                        
3. Contrast   radiography,   when   radio   opaque    substance instilled                        into the nose, it does not reach the nasopharynx.
Treatment: Excision of the atretic segment, or perforation.                        

Trauma of the Nose:
A• Fractured Nasal Bone: 
Etiology:
Usually caused by blows to the front or side of the nose due to personal assault, sport injuries, RTA, personal accidents.                             
Clinical features:
                   1. Deformity: external    swelling, black eye (periorbital ecchymosis).
2. Pain.
3.Epistaxis                                                                                                    
4. Nasal obstruction.
Diagnosis:
         Clinical features and X-ray which is of medicolegal importance with little clinical value.
Treatment:                                                                                                              
1. Early: if the patient is seen early before swelling appears, reduce immediately.
2. Intermediate; when the swelling is marked, leave until the swelling has subsided, and give antibiotics and sedatives.
3. Late (7-14 days): after swelling has subsided, reduction under local or general anesthesia, external splint may be required.
4. Malunion: may require rhinoplasty.
Complications: 1. deviated nose 2. bleeding 3. septal haematoma 4. saddling 5. CSF leak.
B.    Fractures of the middle 1/3 of the face:
Fractures   involving   that   part   of the   face   between   the supraorbital ridge and the upper teeth, along Le Fort's lines of weakness, which may be unilateral or bilateral, and may involve the paranasal sinuses.   

Cerebrospinal Rhinorrhoea:
   It is flow of CSF from the nose (CSF rhinorrhea).
  Etiology:                                                                                                              1. Traumatic: from fractured base of skull      involving the anterior cranial fossa and tearing of the dura mater.
  2. Spontaneous: from destructive lesions.
Clinical features:     
1. Watery fluid drips from the nose, the fluid contains no mucous nor albumin, but contains glucose.
2. Meningitis may follow these drips.
 Investigations:                                                                                                        
1. Injection of radioactive tracer into the lumbar CSF and wool pled gets placed in the roof of both nasal cavities.
2. Gamma camera scanning of the head.
3. Simpler method by placing dextostix in the various sites to look for the   glucose in the CSF.
Treatment:                                                                                                         
1. Immediate: avoid meningeal infection by systemic ABs, avoid nose blowing, and avoid any local treatment like packing of the nose. 
2. Delayed:   if CSF   leak   persists   for   more   than   4   weeks, lumboperitoneal shunt to reduce CSF pressure, craniotomy and facial graft if this fails.

Barotraumatic Sinusitis:
Pathological changes in the nasal mucosa due to lowering of the pressure within the sinus compared with that of the surrounding atmosphere.
Etiology:
 
       Descent   in   non-pressurized   aircraft   in   the   presence   of obstruction   of the   sinus   ostium, and flying   with   respiratory   tract infection.
Clinical features:                                                                                                                  pain is felt during   descent in the frontal region or the cheek.
Treatment:                                                                                                                                                                                                                             Preventive:   avoidance   of flying with   URTI,   polyps, septal deviation.
      Symptomatic: analgesia, decongestant nasal drops, treatment of infection.
  
 Septal Deflections and Spurs:
Few adults have a completely straight septum; only gross deviation may lead to mechanical obstruction.

     Mladina’s classification of septal deformities:
        Type 1: is characterized by a vertical, unilateral ridge in the region of the nasal valve,    but without a direct contact with the valve, hence not compromising it’s function.
         Type 2: is characterized by a vertical, unilateral ridge that is in contact with the nasal valve area, thus compromising it’s function.
         Type 3: is characterized by a unilateral vertical ridge, next to the head of the middle turbinate i.e. at the junction of the quadrangular cartilage and the perpendicular plate of ethmoid bone.
        Type 4: is characterized by bilateral vertical ridges, one in the valvular region on one side, and the other in the region of the middle turbinate on the contra lateral side of the nose (S – shape septum).
        Type 5:  is characterized by an almost flat septum on one side or deviated and a basal, horizontal spure on the other side.
        Type 6:  is characterized by a deep horizontal gutter in the basal segment of the anterior septal region on one side and a ridge formed from a wing of intermaxillary bone on the contra lateral side. 
       Type 7:  is characterized by a combination of more than one type, so called: crumpled septum.        
Type 6:  is characterized by a deep horizontal gutter in the basal segment of the anterior septal region on one side and a ridge formed from a wing of intermaxillary bone on the contra lateral side. 
       Type 7:  is characterized by a combination of more than one type, so called: crumpled septum.

  Anterior cartilaginous:             types 1,2,6
   Posterior bony:
types 3,4,5
  Vertical deformity:
types 1,2,3,4
  Horizontal deformity:
types 5,6

        Etiology:
               1. Trauma is the commonest cause.
2. Errors of development produce either bending or spurs.
3. Compression of the nose during birth.
      Pathology:                                                                                                                                Deflections may involve cartilage and/or bone, either simple or sigmoid (double bend).
Spurs: are isolated thickenings found at the junction of the bone and cartilage, which may impede drainage of sinuses and lead to sinusitis, and epistaxis due to vessels on their convex side.
        Clinical features:                                                                                                                          1. Nasal obstruction.
2. External deformity.
3. Pressure headaches: result from contact of the deflected septum with structures of the lateral wall of the nose.
4. Nose bleeding.
Treatment:  1. No treatment is required in minor degrees.
                    2. Submucous resection (SMR), or septoplasty.

Haematoma of the Septum:
       Collection of blood beneath mucoperichondrium of the septum.
          Etiology:                                                                                                                                           1. Traumatic, nearly always, either because of blovvs or fails, or operations            like SMR.
2. Sometimes rarely blood dyscrasias.         Clinical features:
1.  Nasal obstruction, usually bilateral.
2. Septal soft swelling.
Complications:                                                                                                            1. Septal abscess due to secondary infection of the haematoma.
2. Cartilage necrosis and saddling of the nose.
3. Permanent thickening of the septum due to fibrosis.
Treatment:                                                                                                                                               
1. Simple aspiration in small haematoma.
2. Incision and drainage is more effective with insertion of drainage tube.
3. Nasal packing to prevent recurrence of haematoma.
4. Antibiotics and sedatives.

Septal Abscess:
Occur   due   to    secondary    infection    of   haematoma, or
spontaneously following measles or scarlet fever, furuncolosis.
C clinical   features:.	   
1. Pain may be severe and throbbing.
2. Nasal obstruction.
3. Pyrexia.
4.  Septal swelling.
Complication:                                                                                                        1. Cartilage necrosis and saddling of the nose.
2. Meningitis and cavernous sinus thrombosis.
Treatment:                                                                                                      Incision and drainage with systemic antibiotics.

  Perforation of Septum:
           Etiology: -                                                                                                                                          A. Traumatic:
1. Septal operations.
2. Pick ulcers; result from picking of the septum.
3. Chronic perforation, which is an occasional condition
4.  Snuff takers perforation in cocaine addiction.
5. F.Bs. placed through the septum like safety pins. B.Pathological:
1. Lupus.
2. Syphilis involves the bony septum.
3. Haematoma or abscess.
4. Malignant granuloma (Wagener's granuloma).
5. Rhinitis sicca and rhinitis caseosa.
6. Pressure from F.Bs. or rhinoliths. 
       C. Idiopathic:                                                                
                Clinical features:
                   1. Irritation in the nose and crusts formation.
2.  Epistaxis.
3. Whistling.
4. Pain and foeter.
               Investigations: 
               1. Serological test for syphilis.
               2. ESR.
               3. Biopsy.

Treatment:                                                                                                                          1.  Alkaline douche, glucose 25%   in glycerin to separate crusts.
2. Chlorhexidine cream 0.5% is applied.
3.  Silver nitrate may be used in bleeding.
 
4. Closure of the perforation.

  Foreign Bodies in the Nose:
Etiology:
More common in children, either through the anterior nares, or food through the posterior choanae, or penetrating wounds. The F.Bs. may be organic or inorganic, papers, beads, buttons, or cotton pieces.                      
           Clinical features:
            1. History of introduction of a F.B. may be not obtained.
2. Unilateral nasal discharge, foul smelling.
3.  Nose bleeding.
                               4. Pain.
5. Sneezing.
         Treatment:                                                                                                          Removal of the F.B. through the anterior nares, which might be done under G.A. in young children.

 Rhinoliths
           Nasal concretions are formed around the F.B., blood, mucous may be friable or hard, and it is radopaque in x-ray.
Treatment:
Removal, through anterior nares under G.A...... .