Diseases of

Nose &
Paranasal
Sinuses

Dr / Amna Babikir Altahir Ahmed

ENT Specialist
MBBS Omdurman Islamic University
• Anatomy
• Physiology
• Pathology
• Miscellaneous
 Anatomy of the Nose
1. External nasal skeleton: nasal bone, frontal process of
the maxilla, upper and lower lateral nasal cartilages and
sesamoid cartilage.
2. Nasal septum: quadrilateral cartilage anteriorly+ bony
part posteriorly
3. Lateral nasal wall: superior, middle and inferior
turbinate
*inferior meatus nasolacrimal duct
*middle meatus maxillary, ant.ethmoid and
frontal
*superior meatus posterior ethmoid & sphenoid
 Physiology of the nose
Functions of the nose are classified into:
1- Respiration(natural pathway for breathing)
2- Conditioning of the inspired air: adjust the temp. and
humidity of the air before reaching the lungs
3- Protection of the lower airways
4- Vocal resonance
5- Nasal reflex function: reflex secretion of saliva,
nasopulmonary reflex and sneezing
6- Olfaction
 Anatomy of paranasal sinuses
• Anterior group: frontal, maxillary and anterior
ethmoid
• Posterior group: posterior ethmoid and
sphenoid
• Maxillary and ethmoid sinuses develops during
3rd & 4th gestational month and grow in size
until late adolescence
• Sphenoid sinus presents by 2 years of age
• Frontal sinus develops during 5 and 6 yrs.
 Physiology of the sinuses
*Ventilation of the sinuses is paradoxical
*Mucus secretion travel into the Ostia where it
propels into the nasal cavity by cilia from where it is
carried to the pharynx to be finally swallowed
*Function of the paranasal sinuses:
-Conditioning of the inspired air
-Resonance to the voice
-Lighten the skull bones
• Three key elements allow good function of the
paranasal sinus:
– Patency of the Ostia
– Function of the cilliary apparatus
– Quality of secretions
Diseases Of The External Nose And Nasal
Vestibule
 Congenital
Saddle nose:
depressed nasal dorsum due to destruction of the nasal
septum
Causes:
-trauma is the most common cause
-septal abscess
-granulomatous diseases(TB, syphilis, leprosy)
Management:
Cartilage or bone graft, Synthetic implants
Deviated nose:
Septum deviated to one side of the nose
Trauma is the usual cause
 Trauma
• Nasal bone fracture
• Is the most common facial fracture
• Direct trauma to the face
• Most fractures result from laterally applied forces
• Greater force is required to fracture the nose from front as
the nasal cartilages act as shock absorbent
• Clinical presentation :
• History of facial trauma, Epistaxis, CSF rhinorrhea
(associated cribriform plate fracture)
• Nasal deformity, Nasal obstruction
O/E: -tenderness and swelling makes assessment
difficult. In uncomplicated cases reassess after 5-
7days
- integrity of the nasal bone(Crepitus in case
of fracture)
- septum: hematoma, deformity, deviation
- ocular movement
- Vth nerve function (infraorbital sensation)
-Dental occlusion (maxillary fracture)
Investigations:
Not required in Simple uncomplicated case
X-ray nasal bone
CT scan facial bones in serious cases
Treatment :
Soft tissue injury: thorough cleaning and antibiotic cover
Nasal bone fracture: reduction
Septal hematoma: -aspiration if small
- incision and drainage if large
CSF leak: - close spontaneously pt coverer with anti-
pneumococcal antibodies
-surgical repair
 Diseases of the nasal vestibule
Nasal Furunclosis:
-Staphylococcalinfection of the hair follicle
Trauma by picking of plucking of vibrissae are usual predisposing factors
-May organize to form pus with central core (furuncle)
Clinical presentation:
Nasal swelling and pain
Edema, redness and tenderness of the nasal vestibule
Complication: septal abscess, chondritits and nasal collapse, cavernous sinus
thrombosis
Treatment:
May rupture spontaneously
Topical and systemic antibiotic
Incision and drainage if abscess formed
Nasal vestibulitis:
*Diffuse dermatitis of the nasal vestibule
*Nasal discharge coupled with trauma by handkerchief is the usual
predisposing factor
*Staph aureus is the causative organism
Clinical features:
Red, swollen tender , eroded vestibular skin with crusts, scales and fissures
Complication : vestibular stenosis
Treatment :
Cleaning
Topical steroid based antibiotic
Treatment of the underlying cause of nasal discharge
 Pathology of the nasal septum
Deviated nasal septum:
Etiology :
1- Trauma
2- Developmental
3- Racial -caucasian more than negros
4- Heridetary
Clinical features:
Nasal obstruction unilateral or bilateral
Headache
Sinusitis
Epistaxis
External deformity
Treatment: septoplasty to improve the function of the nose and to
correct the external appearance
Septal hematoma
*The nose is the most frequently injured facial structure
*The anterior nasal septum is a thin cartilage with closely
adherent perichondrium
*Collection of blood between the perichondrium and cartilage
results in septal hematoma
*Usually bilateral due to dissection of blood through the fracture
line
*Early diagnosis and treatment is important to prevent abscess
formation, septal perforation, saddle-nose deformity, and
potentially permanent complications
Diagnosis:
History of nasal trauma
Examination:
-Signs of external trauma(nasaldeformity, epistaxis)
-inspecting the septum with a nasal speculum or an otoscope. a
bluish or reddish swelling
-palpation by gloved small finger fluctuance along the septum.
Treatment:
-Incision and drainage under local anesthesia
-Staggered incisions to avoid through and through
perforation
-Tide dressing + systemic antibiotics
Septal abscess
Secondary infection of septal hematoma
Occasionally follows furuncle of the nose
Clinical features:
Bilateral nasal obstruction
Pain and tenderness over nasal bridge
Fever and chills
Treatment
Hospital admission
Incision and drainage +tide dressing + repeated opening
Systemic antibiotics for at least 10 days
Complications
Nasal collapse
Septal perforation
Septal perforation
Etiology :
-Trauma : is the most common cause either iatrogenic or habitual nose
picking
-Pathological:
Septal abscess
Granulomatous diseases
Neglected foreign body or rhinolith cause pressure necrosis
-Idiopathic
Clinical features:
Small perforation causes whistling sound
Large perforation crusts formation and nasal obstruction, epistaxis
Management:
Try to find the underlying cause by doing investigations
Treatment:
Treatment of the underlying cause
Acute inflammatory conditions
of the nose
 RHINITIS

*Inflammation of the nasal mucosa

*Acute or chronic
*Infective or allergic
NB: nearly all smokers have a degree of rhinitis
 Acute rhinitis
Common cold:
Viruses are the primary pathogens
adenovirus and rhinovirus
Bacterial infection is often secondary to the viral
attack
pneumococci, streptococci and staph.
Mode of transmission : through air borne droplets
Pathophysilogy: initially Vasoconstriction of the
nasal mucosa causing dry feeling followed by
vasodilation that leads to edema ,nasal
obstruction and rhinorrhoea
Clinical features:
Burning sensation at the back of the nose
Nasal congestion
Rhinorrhea (profuse watery then thick mucopurulant
in secondary bacterial infection
Postnasal drip
Sneezing
Hyposmia
Treatment:
Bed rest
Plenty of fluid
Decongestant
Antibiotic (bacterial)
Influenza rhinitis
Influenza virus type A/B/C IS is the causative agent
Phathology :
Necrosis of the ciliated epithelium
Secondary bacterial invasion
Clinical features
More severe than common cold
Fever, malaise and joint pain
Rhinorrhea and nasal obstruction
May be complicated with severe morbidity and mortality
 Chronic rhinitis
Chronic inflammation of the nasal mucosa
1-Hypertrophic rhinitis
Characterised by thickening of mucosa, submucosa,
seromucinous glands, periosteum and bone
Marked on the turbinates particularly the inferior
turbinate
Etiology:
Recurrent nasal infection
Chronic irritation of nasal mucosa( smoking)
Prolonged use of nasal drops (rhinitis medicamentosa)
Symptoms:
Nasal obstruction
Thick nasal discharge
Anosmia and headache

Signs:
Diffuse hypertrophy of the turbinate mucosa
Investigation:
Nasal endoscopy
CT Nose and paranasal sinuses
Treatment :
Medical treatment:
Saline douche
Topical steroids
Antibiotics in acute bacterial exacerbation
Surgery
Partial or total turbinectomy
Submucosal electrocautery
Submucus resection of turbinate bone
Laser
2-Atrophic rhinitis:
*Characterized by progressive atrophy of the nasal mucosa
and underlying turbinate bones
Two types:
1-Primary atrophic rhinitis:
*The exact cause is unknown
*Hormonal theory as it affects young adolescent female
*Nutritional deficiency(Iron)
*Hereditary
2-Secondary atrophic rhinitis:
*Chronic rhinitis
*Chronic granulomatous diseases of the nose
Klebsiella ozaenae has been isolated from the nasal secretion
Pathology:
Squamous metaplasia of the nasal mucosa
Atrophy of the glands and nerves
Endatrteritis
Clinical features:
-Foul smelly brown greenish nasal crusts
-Thick purulent nasal discharge
-Anosmia (Merciful anosmia)
-Headache
-Epistaxis
-Nasal obstruction(mechanical and neurological)
O/E: Fetor, widening of the nasal cavity, maggot infestation in
the nose
Diagnosis:
-Clinical
-Investigations: to exclude secondary cause
*Nasal swab to rule out acid fast bacillus infection
*Serology for syphilis
*complete haemogram
* Serum proteins and iron
Radiological inv.
Chest X-Ray
CT nose and paranasal sinus
Treatment:
-Nasal irrigation
- Periodic nasal cleaning
-Rifampicin 600mg O/D for 12 weeks
Surgery :
Young`s operation

Modified Young`s operation

3- Compensatory hypertrophic rhinitis
Seen in cases of marked deviation of septum to
one side.
The roomier side of the nose shows hypertrophy of
inferior and middle turbinates
Treatment
-Septoplasty
-Treatment of hypertrophied mucosa and bone as
in hypertrophic rhinitis
 Vasomotor rhinitis

Chronic inflammation associated with nasal block and

rhinorrhea due to imbalance in the autonomic system
with parasympathetic over activity
 Allergic rhinitis
IgE mediated immunological response of nasal mucosa to
aeroallergen
Type I hypersensitivity reaction
Types :
Seasonal
Perennial
Occupational
Predisposing factors:
*Age : any age but young patients are more affected
*Environmental pollution
*Genetic predisposition plays a significant role
Pathogenesis:
-Sensitization: initial exposure to the allergen
captured by denderitic cells (APC)
production of specific antibodies IgE
gets fixed to the mast cells and basophils
-early phase: degranulation of mast cells
release of chemical mediators
-late phase: ingress of the inflammatory cells eosinophils are
predominant
Clinical features:
Sneezing
Itching –nose, throat and eyes
Running nose
Nasal obstruction
Investigation:
*Skin prick test and RAST to identify sensitivity to aeroallergen
eg grass pollen, house dust mite cat and dog dander
*Blood test: allergen specific antibodies
*Nasal smear (large number of eosinophils)
-CT scan
Treatment :
*Allergen avoidance
*Steroids topical nasal spray
systemic in severe cases
*Antihistamines during acute attack
* Decongestants topical and systemic
*Antileukotrienes – montelukast- mast cell stabilizer
Allergic rhinitis treatment cont.
• Saline douche to wash the secretions
• Desensitization or immunotherapy
-injection of purified allergen in hope to produce
blocking IgG antibodies
-duration of treatment is 3 years
-risk of anaphylaxis
- more recently sublingual immunotherapy
Surgery :
Marked septal deviation septoplasty
Bony turbinate enlargement turbinectomy
Functional Endoscopic Sinus Surgery
 Special cases
Rhinitis and pregnancy:
*Pregnancy can exacerbates rhinitis
*De novo in pregnancy due to high circulating
oestrogen level.
*No medication considered completely safe in
pregnancy for treatment of allergic rhinitis
*Topical steroid and occasionally use of topical
decongestant to aid sleep
Paediatric rhinitis:
*Diagnosis is difficult( 6-8 colds per year)
Few treatments are available
*Sedating antihistamines should be
avoided?????
Coz. It Impairs the cognitive function
The licened intranasal formulation is sodium
cromoglicate, saline nasal drop and spray
*Corticosteroid has an age limit of use ?????
Risk of growth suppression years after
administration
Miscellaneous conditions

Rhinolith
Rhinolith
Stone formation in the nasal cavity
More common in adults
Usually forms around a nucleus of foreign body or blood
clot by slow deposition of calcium and magnesium salts
Clinical features
Nasal obstruction, foul smelling nasal discharge are the
usual presentation
Frank epistaxis and neurologic pain due to mucosal
ulceration
Treatment
Removed under general anesthesia
Paranasal sinuses
conditions
 Rhinosinusitis
• Inflammation of nasal cavity and PNS
• Classified into acute, subacute and chronic
• Acute RS: duration of up to 4 weeks
• Subacute RS: 4-12 weeks
• Chronic RS: more than or equal to 12 weeks
• Recurrent acute RS
• Acute exacerbation of chronic RS
 Causes
• Allergic
• Bacterial : S.pneumoniae, H.influenzae and
M.catarrhalis
• Viral : Rhinovirus, parainfluenza, influenza,
RSV and adenovirus
• Fungal : Aspergillus species , mucorales.
 Diagnosis
• Major criteria: facial pain/pressure, nasal
obstruction/blockage, nasal discharge/ purulence/
discolored postnasal discharge,
hyposmia/anosmia, purulence in nasal cavity and
fever (acute).
• Minor criteria: headache , fever(all nonacute),
halitosis, fatigue, dental pain, cough and ear pain/
pressure/ fullness.
• Strong history 2 majors OR 1 major and
minors
 Investigations
• Plain X-rays
• CT scan
• Culture and sensitivity: indicated for failed
medical management, complicated sinusitis
(sepsis, orbital infection, intracranial
extension), immunocompromised patients.
 Treatment
• Treat underlying cause
• Adjunctive measures: saline nasal sprays,
analgesia and decongestants.
• Antibiotic therapy 10days- 2weeks
• Recommended drugs includes amoxicillin
/clavulaunate, cefuroxime and cefpodoxime
• Penicillin-allergic : macrolides, doxycycline
• Respiratory quinolone (levofloxacin),ceftrixone or
combination therapy
• Surgery rarely required in acute cases
• Consider if orbital or central nervous system
complications or failure of maximal medical
therapy, sinus mucocele or pyocele, fungal
sinusitis, nasal polyps (massive ),neoplasm or
suspected neoplasm
• Functional endoscopic sinus surgery (FESS)
 Complications of sinusitis
Extra cranial complications:
1-Orbital complications:
The orbit is closely related to the ethmoid, frontal and
maxillary sinuses
Most of the complications follow ethmoid sinus infection
(lamina papyracea)
Infection spreads by osteitis or thrombophlebitis
It includes:
- Periorbital cellulitis
-Orbital cellulitis
-Subperiostial abscess
- Orbital abscess
• 2-Mucocoele
• 3-Pott`s puffy tumor(fore head abscess)
• Intracranial complications
• 1- meningitis and encephalitis
• 2- extradural abscess
• 3- subdural abscess
• 4-Brain abscess
• 5- Cavernous sinus thrombosis
 Fungal sinusitis
*Common species is Aspergillus.
*Involve multiple or single sinus.
*There is four different varities of fungal infection of sinuses.
1-Fungal ball: Implantation of fungus into otherwise healthy
sinus, no bone erosion or expansion.

Treatment: Surgery(FESS).
2-Allergic fungal sinusitis: Allergic reaction to the causative
fungus. Presents with sinonasal polyposis, no invasion of
sinus mucosa with fungus, more than one sinus involved on
one or both sides, there may be bone erosion or sinus
expansion due to pressure.
• Treatment: FESS with or without antiallergic
drugs
3-Chronic invasive fungal sinusitis: Fungus
invade into the sinus mucosa with bone
erosion by fungus. Pt may have intracranial
or intra orbital invasion.

• Treatment: FESS with antifungal therapy.

4-Fulminant fungal sinusitis: (acute invasive)
*Acute presentation, life threatening condition seen in
immunocompromised or diabetics.
*Caused by Mucor or Aspergillus.
*Cause ischemic necrosis involving inferior turbinate,
palate or sinus and spread to face, eyes, skull base and
brain.
Treatment:
*Hospital admission
*Control of underlying cause
*Surgical debridement of necrotic tissue
*I/V antifungal under ICU monitoring
 Nasal Polyp
Definition:
Edematous Sino-nasal mucosa prolapsing into the nasal
cavity.
Divided into two varieties:
1-Simple nasal polyp
2-Antrochoanal polyp
Simple nasal polyp
*part of spectrum of chronic rhino-sinusitis
*formed by the sino-nasal lining becoming progressively
more inflamed and thicker and then pedunculating into the
nasal cavity.
Etiology:
Unknown
Factors contribute to polyp formation:
-allergy
-inflammatory
-genetic: aspirin intolerance, late onset asthma and
nasal polyp (Sampter`s triad)
-Pediatric polyp:
*polyp is rare in healthy child
*investigate for cystic fibrosis, Kartagener`s syndrome ,
immunodeficiency and celiac disease
NB: Unilateral nasal polyp should be considered
neoplastic until proved otherwise.
Differential diagnosis of unilateral polyp:
*Sinonasal malignancy
*Nasopharyngeal carcinoma
*Inverted papilloma
*Fungal sinusitis
*Antrochoanal polyp
 Antrochoanal Polyp
• Unilateral inflammatory polyp arising from the
maxillary sinus and prolapsing through the accessory
ostium into the nasal cavity and posterior choana.
• Clinical features:
• *Tends to occur in young adults
• *Unilateral nasal obstruction
• *Nasal discharge
• *Snoring
• *Glue ear
Investigations:
CT scan nose and paranasal sinuses
Biopsy to exclude neoplasia
Treatment:
Medical: topical steroid
Surgery: FESS
GRANULOMATOUS DISEASES
Definition
Group of conditions causing chronic inflammation in
the nasal cavity and paranasal sinuses characterized
by granuloma formation .
Granuloma is a tumor- like mass of nodular
granulation characterized by accumulation of
macrophages, epithelioid cells and multinucleate
giant cells.
Divided into :
*specific (known cause) TB, Syphilis and leprosy
*non specific (unknown cause) no specific causative
agent. Eg: Wegener granulomatosis and sarcoidosis
 TUBERCULOSIS
*Primary tuberculosis of nose is rare. More often it is
secondary to lung tuberculosis.
*The causative organism in the nose is almost invariably
Mycobacterium tuberculosis
*Nasal septum and the anterior part of the inferior turbinate
are the sites commonly involved
Lupus vulgaris
A low-grade tuberculous infection commonly affecting nasal
vestibule or the skin of nose and face.
characteristically as brown, gelatinous nodules called
"apple-jelly" nodules.
Perforation may occur in the cartilaginous part of nasal
septum.
Diagnosis
Biopsy and special staining for acid fast bacilli
Treatment: anti tuberculour drug
 SYPHILIS
Sexually transmitted disease
A spirochete Treponema Pallidum is the causative agent
Classified as acquired and congenital
Primary: It manifests as primary chancre of the vestibule of nose. It
is rare.
Secondary. Rarely recognized. It manifests as simple rhinitis with
crusting and fissuring in the nasal vestibule.
Tertiary. This is the stage in which nose is commonly involved.
Typical manifestation is the formation of a gumma on the
nasal septum. Later, the septum is destroyed causing a saddle nose
deformity.
 Congenital. It occurs in two forms: early and late.
 Early form. It is seen in the first 3 months of life and manifests
as "snuffles".
 Late form. Usually manifests around puberty in the form of
Syphilis
Diagnosis:
*Serological tests:
nonspecific screening VDRL (Venereal Disease Research
Laboratories),
specific FTA-ABS (Fluorescent Treponemal Antibody-Absorption
Test )
*smear from the ulcer examined by dark field illumination
microscopy
*biopsy of the tissue with special stains to demonstrate Trep.
pallidum.
Treatment:
Penicillin is the drug of choice.
 LEPROSY
Tropical, Chronic granulomatous disease
Mycobacterium leprae (acid fast bacillus) is the causative organism
Initially manifests between the ages of 10 and 20

Clinical types:
*Tuberculoid leprosy; -
-solitary lesions in the form of hypo pigmented anesthetic cutaneous patches
with involvement of sensory or motor nerves with possible paralysis of muscles
-no mucosal involvement
-skin of nasal vestibule can be involved
*Lepromatous leprosy;
- diffuse infiltration of the skin, nerves and mucosal surfaces
-histologically :damaged and infiltrated nasal mucosa
-clinically: nasal obstruction
crusts formation
blood stained nasal discharge containing infectious bacilli
septal perforation and saddle nose deformity late stage
Borderline leprosy:
Patient may convert to Lepromatous or Tuberculoid leprosy depending on the
immunological status.

Diagnosis:
*Clinical
*Demonstration of the mycobacterium leprae on microscopy of:
-nasal discharge
-scraping of the nasal mucosa
*skin biopsy
Treatment :
-triple therapy: To reduce relapse and prevent drug resistance
Dapsone, Rifampicin and Isoniazid for several years
-nasal irrigation to remove the crusts
-reconstructive surgery when the disease is inactive
 Leishmaniasis

 is a protozoal infection, is classified as visceral,

cutaneous or mucocutaneous.
 Transmission is by the sandfly, often around the
nose, are followed by a small papule that ulcerates
and heals leaving a scar.
 Poplypoid growths are typical and extensive soft
tissue and cartilaginous destruction may ensue.
Diagnosis : Leishman-Donovan bodies.
Treatment : pentavalent antimony /
pentamidine.
 Non specific
Wegener granulomatosis
-Systemic disorder of unknown etiology
-Involves the upper airway, lungs, kidneys and skin
Clinical features:
*Clear or blood stained nasal discharge
*Persistent cold or sinusitis
*lung: cough and hemoptysis
Signs:
*Nasal crusting
*Granulation tissues
*Septal perforation and saddle nose
*Destruction may involve eye, palate, oropharynx
*Middle ear may be involved
WG..cont.
Renal failure is the usual cause of death
Diagnosis:
Biopsy from the nose: epithelioid granuloma, necrotising vasculitis
Serology: cANCA is diagnostic
ESR: raised
RFT: elevated serum creatinine level
X-Ray chest: single or multiple cavities
Urine exam.: red cells, casts and albumin
Treatment:
systemic steroid and cytotoxic drugs
 Sarcoidosis
Systemic disease of unknown etiology
Involves lungs, lymph node, eyes and skin
Resembles tuberculosis in history with absence of caseation
Nose manifestations:
Nodular infiltration of the septum or inferior turbinate
Nasal obstruction
Crusting
Epistaxis
Diagnosis:
Biopsy of the lesion
X-ray chest: diffuse pulmonary infiltration and hilar
lymphadenopathy
Treatment : systemic and topical steroid
 References
1- Scott Brown`s otolaryngology head and neck
surgery 7th edition
2- PL Dinghra text book of otolaryngology
3- Oxford specialist handbook in surgery
4- Key topics in otolaryngology head and neck
surgery
STAY SAFE