Copyright 2008 Sara Arif

Full text

(1)Acute and Chronic Rhinosinusitits. Odontogenic maxillar sinusitis. Fracture of nasal bones. Epistaxis. Management of Epistaxis. Imaging studies in otolaryngology.. Copyright 2008 Sara Arif.

(2) Rhinitis  Rhinitis is the name given to a group of conditions that. are caused by inflammation of the lining of the nose.  There are a variety of types  All do, however, tend to cause a constant set of symptoms, whatever the cause.  These include nasal discharge, nasal obstruction, nasal itching, sneezing and post-nasal drip or phlegm.. Copyright 2008 Sara Arif.

(3) Rhinitis. Acute. Chronic. Copyright 2008 Sara Arif.

(4) Acute rhinitis  First stage (dry) – Itching (1-2 days,37. degree)  Second stage - serous rhinorrhea  Third stage – purulent rhinorrhea (4-5 days). Copyright 2008 Sara Arif.

(5) Chronic Rhinitis Catharal. Hypertrophi c. Vasomotor. Atrophi c. Limited. Allergic. Simple. Diffuse. Neurovegetative. Ozena. Copyright 2008 Sara Arif.

(6) Difference between CR and HR. After the spreading decongestant surface the turbinate  Reduced size significantly – catharal rinit  Size reduced not or less.. Copyright 2008 Sara Arif.

(7) Copyright 2008 Sara Arif.

(8) Atrophic rhinitis.  Atrophic Rhinitis - is an uncommon disorder in. modern societies.  While it occurs most commonly today in developing countries or arid climates, it is becoming more common as a sequelae of medical intervention.  Therefore, it is important for physicians who treat nasal disorders to be aware of the origins of the disease. Copyright 2008 Sara Arif.

(9)  … The excess removal of turbinate. tissue might lead to empty-nose syndrome. Excess resection can lead to crusting, bleeding, breathing difficulty (often the paradoxical sensation of obstruction), recurrent infections, nasal odor, pain, and often clinical depression. In one study, the mean onset of symptoms occurred more than 8 years following the turbinectomies.” Copyright 2008 Sara Arif.

(10) Empty nose syndrome (ENS), is an iatrogenic debilitating nasal disorder, which occurs when the nasal airway passages have been over enlarged in operations known as turbinectomies. These operations involve significantly reducing the size of the inferior or middle turbinates of the nose. Copyright 2008 Sara Arif.


(12) Mucosal changes  Analysis of the nasal mucosa has similar. findings in both primary and secondary diseases.  Normal nasal mucosa is lined with pseudostratified columnar epithelium, and has abundant mucous and serous glands.  In atrophic rhinitis, the epithelial layer undergoes squamous metaplasia, and subsequent loss of cilia. Copyright 2008 Sara Arif.

(13) cont  This contributes to loss of nasal clearance,. and failure to clear debris.  The mucous glands are severely atrophic or absent, which results in the common term “rhinitis sicca”.  There is also small vessel disease, endarteritis obliterans, which some consider a causative factor, and others consider a result of the disease process Copyright 2008 Sara Arif.


(15) Non-surgical treatment  Non-surgical treatments will not cure ENS, because it cannot restore the missing turbinates, but it can help control some of the symptoms and make the suffering more tolerable:  Daily nasal irrigations of regular saline are always recommended..  Sesame oil can help in cases of extreme dryness and crusts.  Sleeping with a cool mist humidifier..  Some patients respond well to orally taken vitamin A and D.  Acupuncture meant to improve nasal blood supply and. nerve functionCopyright 2008 Sara Arif.

(16)  Nasal irrigation and removal of crusts using alkaline . .   . . nasal douches 25% glucose in glycerine can be applied to nasal mucosa, this inhibits growth of foul smelling proteolytic organisms Local antibiotics like Kemicetine (Chloramphenicol) Ostradiol and Vit D2 Ostradiol spray Systemic streptomycin Oral potassium iodide placental extract injected in the submucosa Copyright 2008 Sara Arif.

(17) Surgical treatment The underlying rational of surgery. is to restore the inner nasal geometrical structure of the nasal passages of air (the inferior, middle and superior meatuses).. Copyright 2008 Sara Arif.

(18) Ozena  Ozena, also known as atrophic rhinitis,. is a rare chronic inflammatory disease that affects the lining of the nasal cavity.  This condition is characterized by a wasting away or an atrophy of the bony ridges and the mucus membranes inside of the nasal cavity. Copyright 2008 Sara Arif.

(19) Etiology  Klebsiella ozaenae.  tends to occur after a long period of. nasal swelling, such as with a cold or other viral infect.  lack of essential vitamins and items in the diet and, possibly to hormonal deficiencies. Copyright 2008 Sara Arif.

(20) Symptoms  The symptoms of ozena also include.  nasal crusting,  discharge,.  bad odor.  Hypoosmia.  Bleeding  Hearing impairment Copyright 2008 Sara Arif.

(21) Clinic features  The nasal cavities become roomy and are. filled with foul smelling crusts which are black and dry .  Microorganisms are known to multiply and this produces a foul smell from the nose, though patient is not aware of this because his/her nerve aliments (responsible for the perception of smell) have become atrophied. Copyright 2008 Sara Arif.

(22) cont.  Bleeding from the nose, also called epistaxis. may occur when the dried discharge (crusts) are removed  Atrophic rhinitis is also associated with similar atrophic changes in the pharynx, larynx producing symptoms pertaining to these structures.  Hearing impairment can occur due to Eustachian tube blockage causing middle ear effusion. Copyright 2008 Sara Arif.

(23) Treatment antibiotics  vitamin therapy  systemic estrogens geared toward. reducing the crusting and eliminating the odor.  topical ointments  nasal sprays that may be utilized. Copyright 2008 Sara Arif.

(24) Surgery.  In severe cases, surgery may be required to. narrow the nasal passages in order to reduce the amount of air flow through the cavity contributing to the malodorous crusting..  The decreased air flow produced by the. surgery will help prevent the drying out of the mucous membrane.. Copyright 2008 Sara Arif.

(25) Allergic rhinit.  An allergy occurs when the body reacts to. substances like tree pollen or dust mites,are called environmental antigens or allergens, and are normally, harmless.  But the immune system of a person with allergies viewes the allergens as harmful.  Allergic rhinitis(hay fever)is an inflamattion or irritation of the mucous membranes, that line the nose. Copyright 2008 Sara Arif.

(26) Pathogenesis  Allergic rhinitis happens when an. allergen, such as pollen, causes your body to defend itself by producing antibodies. – this is called sensitation.  The antibodies then bind to mast cells.  These mast cells then release chemicals such as histamine. Copyright 2008 Sara Arif.

(27) The binding causes dilatation of nasal blood vessels  inflamation of the mucous. membrane which result in common allergy symptoms.. Copyright 2008 Sara Arif.

(28) Allergic rhinitis. Hay fever. Copyright 2008 Sara Arif. Perennial.

(29)  The type that. occurs during only the spring or summer, is called seasonal allergic rhinitis, the medical term for hay fever Copyright 2008 Sara Arif.

(30) The most common causes of hay fever are:  tree pollen such as elder, elm, hazel and especially. birch (spring hay fever)..  grass pollen (summer hay fever).  mugwort and hybrids such as chrysanthemum. (autumn hay fever)..  house dust mites and mould fungus - particularly. associated with perennial allergic rhinitis.. Copyright 2008 Sara Arif.


(32) Symptoms of hay fever Itchy and watery eyes. Frequent sneezing, a bunged up or. runny nose. Itching on the roof of the mouth. Coughing Wheezing or a burning sensation in the throat. Copyright 2008 Sara Arif.

(33) What can cause hay fever  The pollen to which you are allergic.  Genetic predisposition associated with other. atopic diseases, eg eczema or asthma Hay fever sufferers are more vulnerable to other allergic respiratory diseases, eg asthma, and sleeping difficulties that can lead to chronic fatigue (because of blocked nasal passages and snoring). Copyright 2008 Sara Arif.

(34) Perennial alergic rhinitis. Perennial allergic rhinitis is a. similar allergy that occurs all year round and is caused by things such as house dust mites and pets. However the predominant allergen changes from time to time. Copyright 2008 Sara Arif.

(35) Perennial rhinitis is common, and ski prick testing will show if. obvious allergy is cause.  Symptoms often come and go, and sufferers may think they are getting frequent colds, the medical term for which is viral rhinitis. Copyright 2008 Sara Arif.

(36)  The symptoms of chronic rhinitis will often. come and go, whether or not allergy is the cause, and frequent attacks of sinusitis are common.  For this reason many sufferers do not realise that this is their problem, preferring to blame colds, a condition that is more correctly called a viral rhinitis.  This distinction is often difficult, even for a doctor, as a cold is simply a short episode of rhinitis that is caused by a virus.  Skin prick testing may be useful to show if allergic rhinitis may be the cause. Copyright 2008 Sara Arif.

(37) Skin tests Cases with skin tests positive are. similar to hay fever, and the results of such tests may show allergy to a number of common items such as house dust mite, cats dogs and other pets, and fungal spores. Copyright 2008 Sara Arif.

(38) Rhinitis with positive skin tests In order to find out which patients. with rhinitis are suffering from allergy a good clinical history needs to be combined with skin prick testing for the common inhalant allergensm Copyright 2008 Sara Arif.

(39) These help to confirm the causative allergen and the results are immediately available. Showing the patient the "weal and flare" reaction is a useful way of demonstrating to the patient the inflammatory nature of allergic rhinitis. Copyright 2008 Sara Arif.

(40) Rhinitis with negative skin tests.  Some patients have all the symptoms of nasal. allergy, but the standard allergy tests prove negative.  In the past it was convenient to refer to this condition as non-allergic rhinitis although in view of recent developments suggesting that many of these cases may turn out to be due to a type of allergy after all the alternative name idiopathic rhinitis is probably better.  Idiopathic simply means that the causes are at present unknown. Copyright 2008 Sara Arif.

(41) Rhinosinusitis  Sinusitis refers to inflammation of the. lining of the paranasal sinuses.  Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition (Lanza, 1997). Copyright 2008 Sara Arif.

(42) Anatomy of the paranasal sinuses. Copyright 2008 Sara Arif.

(43) Classification By definition,  symptoms of acute rhinosinusitis last less than 3 weeks,  symptoms of subacute rhinosinusitis last 21-60 days,  symptoms of chronic rhinosinusitis last more than 60 days. The Agency for Healthcare Research and Quality accepted this terminology in 1999. Copyright 2008 Sara Arif.


(45) Coronal computed tomographic scan showing normal osteomeatal complex. Patent ostia are visible on both sides, and sinuses are well ventilated.. Copyright 2008 Sara Arif.

(46) Coronal computed tomographic scan showing rhinosinusitis with a blocked osteomeatal complex and secondary infection in the maxillary sinuses.. Copyright 2008 Sara Arif.

(47) Classification Rhinosinusitis may be further. classified according to the anatomic site maxillary ethmoidal  frontal sphenoidal Copyright 2008 Sara Arif.



(50) Classification pathogenic organism Bacterial. Viral. Copyright 2008 Sara Arif. Fungal.

(51) Classification Associated factors. Nasal polyposis. Immunosuppression. Copyright 2008 Sara Arif. Anatomic variants.

(52) Viral cause The vast majority of rhinosinusitis episodes are caused by viruses. Most viral upper respiratory infections are caused by  rhinovirus,  coronavirus,  influenza A and B,  parainfluenza,  adenovirus,  enterovirus are also causative agents Copyright 2008 Sara Arif.

(53) The pathophysiology of rhinosinusitis is related to 3 factors obstruction of sinus drainage pathways (sinus ostia)  ciliary impairment, mucus quantity and quality. . Copyright 2008 Sara Arif.

(54) Obstruction of the natural sinus ostia  Obstruction of the natural sinus ostia. prevents normal mucus drainage..  Edema, inflammation, polyps, tumors,. trauma, scarring, anatomic variants (eg, concha bullosa [pneumatized middle turbinate], septal deviation), and nasal instrumentation (nasogastric tubes or packing) can result in decreased patency of sinus ostia Copyright 2008 Sara Arif.

(55) Ciliary impairmnet Hypoxia within the obstructed sinus is thought to cause ciliary dysfunction and alterations in mucus production, further impairing the normal mechanism for mucus clearance . Ciliated columnar epithelial cells propels the sinus contents toward the natural sinus ostia. Any disruption of the ciliary function results in fluid accumulation within the sinus. . Copyright 2008 Sara Arif.

(56) Poor ciliary function can result from the loss of ciliated epithelial cells;  high airflow; viral,  cold air;  bacterial,  environmental ciliotoxins;  inflammatory mediators;  contact between 2 mucosal surfaces;  scars;  primary ciliary dyskinesia (Kartagener. Syndrome).. Copyright 2008 Sara Arif.

(57) Sinonasal secretions  Sinonasal secretions play an important role. in the pathophysiology of rhinosinusitis.  The mucus that lines the paranasal sinuses is composed of a. thin periciliary layer, which enables ciliary mobility, b. thick gel layer, which anchors the tips of the cilia Copyright 2008 Sara Arif.

(58) Secretion  This mucous blanket contains  mucoglycoproteins,  immunoglobulins,  inflammatory cells.. Alterations in the water content of the mucous blanket can impair ciliary mobility. Overproduction of mucus resulting in retained secretions within the sinuses. Copyright 2008 Sara Arif.

(59) Symptoms of acute bacterial rhinosinusitis include the following:  Facial pain or pressure (especially unilateral)  Hyposmia/anosmia  Nasal congestion  Nasal drainage  Postnasal drip  Fever  Cough  Fatigue  Maxillary dental pain  Ear fullness Copyright 2008 Sara Arif.

(60) Physical  Purulent nasal secretions  Purulent posterior pharyngeal secretions  Mucosal erythema.  Periorbital edema  Tenderness overlying sinuses.  Air-fluid levels on transillumination of the. sinuses (60% reproducibility rate for assessing maxillary sinus disease)  Facial erythema Copyright 2008 Sara Arif.

(61) Causes The most common pathogens isolated from maxillary sinus cultures in patients with acute bacterial rhinosinusitis include  Streptococcus pneumoniae,  Haemophilus influenzae,  Moraxella catarrhalis.  Streptococcus pyogenes,  Staphylococcus aureus,  anaerobes are less commonly associated with acute bacterial rhinosinusitis. Copyright 2008 Sara Arif.

(62) Symptoms Major factors: Facial pain/pressure*. Minor factors: Headache. Facialcongestion/fullness. Fever. Nasalobstruction/blockage Halitosis. Nasal discharge/purulence/ discolored nasal drainage. Fatigue Dental pain. Decreased or no sense of Cough smell Pus in nasal cavity on examination Copyright 2008 Sara Arif Ear pain/pressure/ fullness.

(63) Chronic rhinosinusitis(CRS) CRS with nasal polyps. Nonpolypoid rhinosinusits. Eosinophilic Neutrophilic Astma Allergic Aspirin sensitivy AFS NAFS superantigen. Antral choanal polyp Cystic fybrosis Ciliary dismotility Kartagener syndrome Copyright 2008 Sara Arif.

(64) Requirments for diagnosis of CRS  Physical Findings. 1. Discolored nasal discharge, polyps or polypoid swelling on anterior rhinoscopy 2.Edema or erythema in middle meatus on nasal endoscopy 3. Generalized or localized edema, erythema or granulation tissue in nasal cavity. If it does not envolve the middle meatus ,imaging is required for diagnosis. 4. Imaging confirming diagnosis. Note; plain film without any of other findings is not diagnostic. Copyright 2008 Sara Arif.




(68) Endoscopic Picture of an Ethmoid Polyp in the Left Middle Meatus. Copyright 2008 Sara Arif.

(69) Picture of left antrochoanal polyp hanging into the oropharynx. Copyright 2008 Sara Arif.

(70) Endoscopic photograph of right nasal cavity showing an antrochoanal polyp arising from the middle meatus and blocking the right posterior choana.. Copyright 2008 Sara Arif.

(71) Coronal CT scan image showing the above antrochoanal polyp arising from the right maxillary antrum and extending into the right nasal cavity through the widened natural ostium of the sinus. Copyright 2008 Sara Arif.

(72) ACUTE MAXILLARY SINUSITIS Maxillary sinuses are located behind. the cheek bones. They are present at birth and continue to develop as long as teeth erupt. Tooth roots, in some cases, can penetrate the floor of these sinuses. Copyright 2008 Sara Arif.



(75) Acute symptoms.  Pain across the cheekbone, under or around. the eye, or around the upper teeth; may occur on one or both sides of the face.  Area over the cheekbone is tender and may be red or swollen.  Possibly tooth pain.  Symptoms are worse when the head is upright and improve when patient reclines.  Nasal discharge or postnasal drip.  Fever. Copyright 2008 Sara Arif.

(76) Chronic symptoms  Discomfort or pressure below the eye.  Chronic toothache..  Symptoms become worse with colds,. flu, or allergies.  Discomfort increases during the day.  Coughing increases at night.. Copyright 2008 Sara Arif.

(77) ETHMOID SINUSITIS.  Ethmoid sinuses are. located between the eyes. They resemble a honeycomb and are vulnerable to obstruction. This is a common location for sinusitis in children Copyright 2008 Sara Arif.

(78) Acute Symptoms  Nasal congestion.  Nasal discharge or postnasal drip.  Pain or pressure around the inner corner of the eye or.        . down one side of the nose. Headache in the temple or surrounding the eye. Symptoms worse when coughing, straining, or lying on the back and better when the head is upright. Fever. Symptoms of maxillary sinusitis often occur. Symptoms indicating medical emergency : Increasing severity of symptoms. Fever, swelling and drooping eyelid, loss of eye movement (possible orbital infection, which is in the eye socket). Fever, vision changes, pupil fixed or dilated. Symptoms spreading to both sides of face (may indicate blood cloT) Copyright 2008 Sara Arif.

(79) Chronic symptoms  Chronic nasal discharge, obstruction,. and low-grade discomfort usually across the bridge of the nose.  Symptoms worse in the late morning or when wearing glasses.  Chronic sore throat and bad breath.  Sinusitis also can recur in other sites. Copyright 2008 Sara Arif.

(80) Frontal sinusitis  Frontal sinuses are. located on both sides of the forehead. These sinuses are late in developing, so infection here is uncommon in children. Copyright 2008 Sara Arif.


(82) Acute symptoms  Severe headache in the forehead.  Fever (common but not always present).  Symptoms are worse when lying on the. back and when pressing against the area over the eye on the side closest to the nose.  Symptoms are better when the head is upright.  Nasal discharge or postnasal drip. Copyright 2008 Sara Arif.

(83) •Symptoms indicating medical emergency: •Increasing severity of symptoms, particularly severe headache, altered vision, mild personality or mental changes (may indicate spread of infection to brain). •Fever, vision changes, fixed or dilated pupil. Symptoms spreading to both sides of face (may indicate blood clot). •Headache, fever, along with a soft swelling over the bone (may indicate bone infection Copyright 2008 Sara Arif.

(84) Chronic symptoms Persistent, low-grade headache in. the forehead. History of physical injury or other damage to the sinus area.. Copyright 2008 Sara Arif.

(85) SPHENOID SINUSITIS Sphenoid sinuses are located. behind the eyes. They usually are present by age 3 and are fully developed by age 12. Copyright 2008 Sara Arif.


(87) Acute symptoms.  Deep headache with pain in many places,. including the back and top of the head, across the forehead, and behind the eye.  Fever.  Symptoms are worse when lying on the back or bending forward.  Nasal discharge or postnasal drip.  Symptoms indicating medical emergency:  Increasing severity of symptoms, particularly severe headache, altered vision, mild personality or mental changes (may indicate spread of infection to brain). Copyright 2008 Sara Arif.

(88) Chronic symptoms Low grade, general headache. (although not always present).. Copyright 2008 Sara Arif.

(89) Symptoms in Children  Children are most likely to develop infection in the. ethmoid sinuses, located between the eyes. Children with sinusitis are also less likely to experience facial pain over the affected sinus and headache, which are the primary signs in adults. Symptoms of bacterial sinusitis may be less specific than in adults and include:  Persistent nasal discharge (of any type) and day time cough for more than 10 days, or  Severe symptoms last for at least 3 - 4 days in a row and include thick, greenish nasal discharge plus a fever Copyright 2008 Sara Arif.

(90) Odontogenic sinusitis.  Sinusitis of odontogenic origin can. arise from a periapical abscess, chronic apical or extensive marginal periodontitis, or after dental extraction.. Copyright 2008 Sara Arif.

(91) Anatomical Relationship Between the Dental Region and the Maxillary Antrum Maxillary sinus is bounded inferiorly. by the dento-alveolar portion of the maxilla. Copyright 2008 Sara Arif.

(92) cont  In dentate individuals, the continued. pneumatization and expansion can occur such that only the sinus mucoperiosteum (Schneidarian membrane) is left..  In edentulous individuals, continued. expansion may leave only the alveolar bone between the sinus and oral cavity (as a result patients may need an alveolar ridge augmentation prior to dental implants).. Copyright 2008 Sara Arif.

(93) The roots of the second molars are closest to the maxillary sinus, followed by the first and third molars, the second and first premolars, and canine. As a result, odontogenic infections commonly present with soft tissue vestibular/fascial infections, and rarely sinusitis. Copyright 2008 Sara Arif.


(95) Axial CT images shows a expansive lucency with root resorption (arrow),) in the alveolar process.. Copyright 2008 Sara Arif.

(96) Superiorly, the process occupies and expands the entire maxillary sinus (arrow).. Copyright 2008 Sara Arif.

(97) Venous drainage. Copyright 2008 Sara Arif.

(98) The. Copyright 2008 Sara Arif.

(99) The rich vascular supply of the nose originates from the ethmoid branches of the internal carotid arteries , the facial and internal maxillary divisions of the external carotid arteries. Although nasal circulation is complex epistaxis usually is described as either anterior or posterior bleeding. This simple distinction provides a useful basis for management. Copyright 2008 Sara Arif.

(100) Epistaxis.  Most cases of epistaxis occur in the anterior part of the. nose, with the bleeding usually arising from the rich arterial anastomoses of the nasal septum (Kiesselbach's plexus). Posterior epistaxis generally arises from the posterior nasal cavity via branches of the sphenopalatine arteries.8 Such bleeding usually occurs behind the posterior portion of the middle turbinate or at the posterior superior roof of the nasal cavity.. Copyright 2008 Sara Arif.

(101) Etiology of epistaxis Local Trauma – digital,fractures Nasal spreys Inflammatory reactions Anatomic deformaties Foreign bodies Intranasal tumars. Chemical irritatants Nasal prong O2 Copyright 2008 Sara Arif. Systemic Hipertansion Vascular disorders Blood dyscrasias Hematologic malignancies Allergies Malnutrition Alcohol Drugs.

(102) Treatment Epistaxis.  Observation.  Antiseptic cream  Barrier ointment  Cautrization  Nasal packing: Ant packing, Postnasal packing, nasopharyngeal balloon  Ptergopalatine fossa block.  Laser photocoagulation  Pharmacologic  Surgical arterial ligation.  Angiographic embolization Copyright 2008 Sara Arif.  Surgical reconstruction.

(103) Typical contents of an epistaxis tray. Top row: • nasal decongestant sprays •local anesthetic, silver nitrate cautery sticks, • bayonet forceps, •nasal speculum, • Frazier suction tip, • posterior double balloon system and • syringe for balloon inflation. Bottom row: • Packing materials, •including nonadherent gauze impregnated with petroleum jelly and 3 percent bismuth tribromophenate •(Xeroform), Merocel, Gelfoam, • and suction cautery. Copyright 2008 Sara Arif.

(104) Packing of the anterior nasal cavity using gauze strip. .. . A. Gauze is gripped with bayonet forceps and inserted into the anterior nasal cavity. B. With a nasal speculum (not shown) used for exposure, the first packing layer is inserted along the floor of the anterior nasal cavity. Forceps and speculum then are withdrawn. C. Additional layers of packing are added in an accordion-fold fashion, with the 2008positioned Sara Arif nasal speculum used to Copyright hold the layers down while a new layer is.

(105) Complications of epistaxis management Complicatio n •Septal perforation • Apnea, hypoxia. Avoidance. Limited cautery, PPS/baloon inflation Post pack size and placement, avoid •Hypovolemic shock bilateral packs •Aspiration of packing Intravenous fluids as needed Adequate placement and securing of •Recalcitrant bleeding nasal packs Identify the bleeding site, •Infection inadequate size pack •Neurovascular insult Prophylactic oral and topical Copyright 2008 Sara Arif antibiotics.

(106) Kiesselbach’s plexus. Copyright 2008 Sara Arif.



(109) Posterior nosebleed: More rarely, a nosebleed can begin high and deep within the nose and flow down the back of the mouth and 2008 Sarais Arifsitting or standing throat even if theCopyright patient.

(110) Posterior packs. Copyright 2008 Sara Arif.

(111) Fracture of the nasal bones, resulting in external nasal deformity and nasal airway obstruction from a deviated fractured septum. It is important to correct the septal deviation when reducing the fracture.. In addition to the nasal fractures, these coronal CT scan slices show the severe soft tissue deformity and the deviation of the Copyright 2008 Sara Arif nasal septum. fractured.

(112) Symptoms of a broken nose include  Nose pain..  Swelling of the nose.  A crooked or bent appearance.  Bruising around the nose or eyes..  A runny nose or a nosebleed.  A grating sound or feeling when the nose is touched or. rubbed.  Blocked nasal passage Copyright 2008 Sara Arif.

(113) Possible complications of a broken nose include  Infection of the nose, sinuses, or facial bones.  Permanent breathing difficulty.  Persistent drainage from one or both nostrils. This may. be caused by cerebral spinal fluid draining from the brain into the nose (CSF rhinorrhea) and can occur after head injury or after surgery on the nose or ears.  Change in the appearance of the nose or the tip of the nose.. Copyright 2008 Sara Arif.

(114) Complications  Crooked (deviated) nasal septum. The nasal septum is. the structure that divides the nose into two parts. See an illustration of a deviated nasal septum.  A hole in the nasal septum (septal perforation).  An accumulation of blood in the nasal septum (nasal septal hematoma).  A change in or loss of sense of smell.. Copyright 2008 Sara Arif.

(115)  Minor and major traumas to the nose are frequent injuries that may cause injury to the nasal septum.  Nasal septal abscess resulting from nasal trauma is an uncommon complication of nasal trauma.  . Nasal septal abscess resulting from trauma usually develops in a pre-existing septal haematoma  Nasal septal abscess results from a collection of purulent material between the cartilaginous or. bony nasal septum and its normally applied mucoperichondrium or mucoperiosteum Copyright 2008 Sara Arif.

(116) Direct injury to the nose causes tearing of blood vessels in the mucoperichondrium. Blood then collects between the mucoperichondrium and the septal cartilage, forming septal haematoma. The haematomas separating the mucoperichondrium from the septal cartilage deprive the cartilage of its blood supply.. Copyright 2008 Sara Arif.

(117) Etiology Nasal septal abscess arises after  nasal trauma.  nasal surgery  furuncles of nasal vestibule  sinusitis  dental infection.  an immunocompromised patient.[. Copyright 2008 Sara Arif.

(118) Symptoms  The time interval between the nasal injury and the       . presenting symptoms is 5–7 days. nasal obstruction nasal congestion. nasal pain swelling erythema over the nasal skin headache, fever, and malaise. Aspiration by puncture of the swollen nasal septum will reveal purulent material. Copyright 2008 Sara Arif.

(119) Physical examination reveals • tender, • erythematous, • swollen nasal bridge. Anterior rhinoscopy typically demonstrates tenderness and fluctuation by palpation of unilateral or bilateral swelling of the nasal septum that narrows the nasal cavity. Copyright 2008 Sara Arif.

(120)  Coronal CT scan. image showing expansile swelling of the septum.  Notice the complete bilateral nasal airway obstruction. Copyright 2008 Sara Arif.

(121) Treatment A patient with septal haematoma and abscess should be referred immediately . to otorhinolaryngologist for surgical treatment. Incision and complete drainage of the collection with bilateral nasal packing is the initial treatment. Systemic antibiotics based on culture and sensitivity Copyright 2008 Sara Arif.

(122) On incision and drainage, thick yellow pus was recovered. Copyright 2008 Sara Arif.

(123) A drain was left inside the abscess cavity and nasal splints were placed bilaterally to compress the septum. Copyright 2008 Sara Arif.

(124) Complication.  Delayed diagnosis and management of nasal septal. abscess results in a compromised vascular supply to the cartilaginous nasal septum and suddle nose deformity as a final cosmetic complication.. Other serious complications are  sepsis,  meningitis,  orbital cellulitis,  cavernous sinus thrombosis,  intracranial abscess.. Copyright 2008 Sara Arif.

(125)                . REFERENCES 1. Pollice PA, Yoder MG. Epistaxis: a retrospective review of hospitalized patients. Otolaryngol Head Neck Surg 1997;117:49-53. 2. Petruson B. Epistaxis. A clinical study with special reference to fibrinolysis. Acta Otolaryngol Suppl 1974;317:1-73. 3. Schaitkin B, Strauss M, Houck JR. Epistaxis: medical versus surgical therapy: a comparison of efficacy, complications, and economic considerations. Laryngoscope 1987;97:1392-6. 4. Rubin Grandis J, et al. The management of epistaxis. 3d ed. Alexandria, Va.: American Academy of OtolaryngologyHead and Neck Surgery Foundation, 1999. 5. Tan LK, Calhoun KH. Epistaxis. Med Clin North Am 1999;83:43-56. 6. Cassisi NJ, Biller HF, Ogura JH. Changes in arterial oxygen tension and pulmonary mechanics with the use of posterior packing in epistaxis: a preliminary report. Laryngoscope 1971;81:1261-6. 7. Lucente FE. Thanatology: a study of 100 deaths. Trans Am Acad Ophthalmol Otolaryngol 1972;76:334-9. 8. Koh E, Frazzini VI, Kagetsu NJ. Epistaxis: vascular anatomy, origins, and endovascular treatment. AJR Am J Roentgenol 2000;174:845-51. 9. Pond F, Sizeland A. Epistaxis. Strategies for management. Aust Fam Physician 2000;29:933-8. 10. Smith JA. Nasal emergencies and sinusitis. In: Tintinalli JE, Ruiz E, Krome RL, eds. Emergency medicine: a comprehensive study guide. 4th ed. New York: McGraw-Hill, Health Professions Division, 1996:1082-93. 11. Adornato SG. Epistaxis: new approach [Letter]. Otolaryngol Head Neck Surg 2000;123:524. 12. Frazee TA, Hauser MS. Nonsurgical management of epistaxis. J Oral Maxillofac Surg 2000;58:419-24. 13. Lethagen S, Ragnarson Tennvall G. Self-treatment with desmopressin intranasal spray in patients with bleeding disorders: effect on bleeding symptoms and socioeconomic factors. Ann Hematol 1993;66:257-60. 14. Toner JG, Walby AP. Comparison of electro and chemical cautery in the treatment of anterior epistaxis. J Laryngol Otol 1990;104:617-8. 15. Corbridge RJ, Djazaeri B, Hellier WP, Hadley J. A prospective randomized controlled trial comparing the use of Merocel nasal tampons and BIPP in the control of acute Copyright 2008 Sara Arif.

(126)

No results found