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OTOLARYNGOLOGY)–)HEAD)AND)NECK)SURGERY)
Lectured%by:%Cecile%C.%Capinpin,%MD,%FPOHNS%
%%%%%%February%9,%2016
FEUANRMF%Institute%of%Medicine%
%
NOSE,)PARANASAL)SINUSES,)NASAL)OBSTRUCTION)&)EPISTAXIS
)
I.)ANATOMY)&)PHYSIOLOGY)OF)THE)NOSE)
) )
NOSE% EXTERNAL)NOSE)
! Air%conditioner%of%the%body% ! PyramidalAshaped% structure% where% its% apex% is% positioned%
! Responsible% for% warming% and% saturating% inspired% air,% anteriorly%
removing% bacteria% and% particulate% debris,% and% conserving% ! Extends%the%nasal%cavities%into%the%front%of%the%face%
heat%and%moisture%from%expired%air% ! Nares%are%positioned%pointing%downwards%
! Prominent%cosmetic%feature%of%the%face% ! Upper% angle% of% the% nose% is% continuous% with% the% forehead%
! Lined% by% ciliated% pseudostratified% columnar% epithelium% between%the%openings%of%the%orbits%
with% goblet% cells% also% called% Schneiderian) Membrane/% ! Anterior%parts%of%nasal%cavities%located%within%the%nose%are%
Schneiderian)Mucosa% held%open%by%a%skeletal%framework%
- Has%lysozyme%and%IgA% - Similar%to%posterior%regions%
! Olfactory)Epithelium% - Composed%partly%of%bone%and%mainly%of%cartilage%
• Lines%superior%nasal%cavity;%at%the%roof%of%the%nose% ! Bony%parts%are%where%the%nose%is%continuous%with%the%skull%
• Where%transduction%of%olfactory%epithelium%occurs% ! Provides%support:%
• Includes% several% distinct% cell% types,% the% most% - Nasal%bones%
important%of%which%is%Olfactory)Bipolar)Neurons% - Parts%of%the%maxilla%and%frontal%bones%%
- Axons% of% these% neurons% synapse% with% the% - Septal%cartilage%in%the%midline%(forms%the%anterior%part%
st
olfactory% bulb% (1 % relay% station% in% the% olfactory% of%nasal%septum)%
pathway)% - Major%alar%and%3%or%4%minor%alar%cartilages%%
- Lateral% processes% of% septal% cartilages% anteriorly% on%
both%sides%
! Divided%into%3%parts:%
a. Bony)Vault)
- Most%superior)
- Composed%mainly%of%the%paired%nasal%bones%and%
the%ascending%processes%of%the%maxilla)
- Additional% support% from% nasal% process% of% the%
frontal% bone% and% the% perpendicular% plate% of% the%
ethmoid)
b. Cartilaginous)Vault)
% - Located%in%the%middle)
! Nasal)Breathing% - Slightly%movable)
- Important%for%optimal%pulmonary%function% - Composed% of% the% upper% lateral% cartilages% and%
% quadrangular%septal%cartilage)
ANATOMY)OF)THE)NOSE)AND)PARANASAL)SINUSES) c. Nasal)Lobule)
) - Lowest% movable% part% supported% by% the% lower%
lateral%cartilages)
)
INTERNAL)NOSE)
! Nasal% cavity% extends% from% the% os% internum% (limen% nasi% or%
nasal% valve% of% Mink)% as% far% back% as% the% soft% palate,% where%
the%posterior%choana%opens%into%the%nasopharynx)
! Roof)
- Adjacent%to%the%anterior%cranial%fossa)
• Cribriform)Plate)
- Contains%numerous%tiny%perforations)
- Transmit%sensory%fibers%to%the%olfactory%bulbs)
• (Posteriorly)% slants% downward% →% anterior% wall% of% the%
sphenoid%sinus)
)
) ! Sensation%of%smell%is%limited%in%man%to%a%very%small%area%of%
) mucosa%in%the%superior%recess%of%the%nose)

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! Lateral)Wall) - Both% from% the% maxillary% artery% and% facial% artery%
- Composed% of% 3% (sometimes% 4)% bulbous% projections% which% gives% off% the% superior% labial% and% angular%
(superior,)middle)and)inferior)turbinates)) arteries%
! External%nose%
• Superomedially% supplied% by% the% angular% artery% from%
the%facial%artery%
• Sellar% and% dorsal% regions% supplied% by% the% maxillary%
artery% (specifically% the% infraorbital% artery% and% the%
ophthalmic%artery)%
! Internal%Nose%
• Lateral%nasal%wall%supplied%by%
) - Anterior% and% posterior% ethmoid% arteries%
- Covered%by%erectile%mucosa) (superiorly):%ICA%
- Serve%to%increase%the%interior%surface%area%of%the%nose% - Sphenopalatine% artery% (inferiorly)% and% posterior%
→%heat%and%water%exchange) septal%artery:%ECA%
- Constantly% engorge% or% shrink% to% accommodate% • Septum%is%supplied%by%
changing%physiologic%requirements) - Sphenopalatine%artery%
- Are% the% chief% structures% involved% in% pathologic% - Anterior%and%posterior%ethmoid%arteries%
obstruction% - Superior%labial%artery%(anteriorly)%
- Greater%palatine%(posteriorly)%
• Kiesselbach’s)Plexus)or)Little’s)Area%
- Area% in% the% anteroinferior% third% of% the% nasal%
septum%
- Where% the% major% arteries% (sphenopalatine,%
anterior% ethmoid,% posterior% ethmoid,% greater%
palatine% and% superior% labial)% that% supply% the%
internal%nose%converge%
- Where% majority% of% epistaxis% occur% (around: 906
95%:which:can:be:controlled:by:digital:pressure):
%

%
(http://www8.1.drumons.com/wall/anatomy6of6lateral6wall6of6nose/):
:
Contains% inferior,% middle% and% superior% meati% (series% of%
!
spaces;%overhanging%edge%of%turbinates)%)
• Inferior)Meatus)
- Located%inferiorly%to%the%inferior%turbinate)
- Contains%the%orifice%of%nasolacrimal%duct)
• Middle)Meatus)
- Located%inferiorly%to%the%middle%turbinate)
- Contains% the% semilunar% hiatus,% with% openings% of%
the% maxillary,% frontal,% and% anterior% ethmoidal%
sinuses)
• Superior)Meatus)
- Drains%the%posterior%ethmoid%cells)
! SphenoREthmoid)Recess%
- Contains%the%orifice%of%sphenoid%sinus%
% %
(http://medipicz.blogspot.com/2011/01/blood6supply6of6nasal6septum.html):
BLOOD)SUPPLY% VENOUS)DRAINAGE)
! Has%very%rich%blood%supply% ! Follows%the%arterial%pattern%
! Divided%into:% ! Lack%valves%
a. Branches%from%the%internal%carotid%artery%(ICA)) ! Have%a%direct%communication%with%the%cavernous%sinus%
- Ophthalmic% artery% with% the% anterior) and) )
posterior) ethmoid) arteries% as% the% terminal% LYMPHATIC)DRAINAGE%
branches% ! Through%the%
b. Branches%from%external%carotid%artery%(ECA)% - Facial%venous%drainage%
- Sphenopalatine%(branching%into%posterior)lateral) - Upper%or%Superior%Deep%Cervical%LN%
nasal)and)posterior)septal)arteries)% - Submandibular%LN%
- Greater)palatine)arteries) - Retropharyngeal%LN%

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%
NERVE)SUPPLY) FUNCTIONS)OF)THE)NOSE)
! CN) V1) (Ophthalmic)% and% CN) V2) (Maxillary)) supply% the% %
external%nose%and%the%nasal%cavity% A. OLFACTION%
! CN)1%provides%the%special%sensory%innervation%within%nasal% ! Perception%of%odors%is%essential%to%life%
cavity%related%to%olfaction% ! Odors%are%present%in%our%everyday%life%and%give%a%multitude%
! Superior) Salivatory) Nucleus% in% the% brainstem% of% event% (giving% pleasure% from% a% scent% of% perfume;% Giving%
(Parasympathetic)% and% Superior) Cervical) Ganglion) warning%to%the%danger%of%fire)%
(Sympathetic)%via%the%pterygopalatine%ganglion%supply%ANS% ! Process%by%which%odors%are%perceived%is%still%uncertain%but%
- ANS)to%control%diameters%of%veins%and%arteries%as%well% there%are%theories%that%may%explain%such%mechanism%%
as%mucus%production% • Chemical)Theory%
! CN)VII)supplies%the%muscles%of%external%nose% - Wherein% particles% of% odorous% substances% are%
distributed% throughout% the% air% by% diffusion% and%
cause% a% chemical% reaction% when% they% reach% the%
olfactory%epithelium%
• Undulation)Theory%
- Wherein%waves%of%energy%similar%to%light%impinge%
upon%the%olfactory%nerve%endings%
%
B. AIRWAY)RESISTANCE%
! Through% changes% in% the% erectile% tissue% in% the% turbinates%
and%septum%
! Smoothens%and%shapes%the%airstream%
% ! Regulates%air%volume%and%pressure%
(http://emedicine.medscape.com/article/826796overview):
! Controls% temperature% and% humidity% to% assure% optimal%
PARANASAL)SINUSES)
oxygen% absorption% and% in% reverse% optimal% elimination% of%
! AirAfilled,%mucosalAlined%cavities%% carbon%dioxide%
! Develop%in%facial%and%cranial%bones% ! Alternating% cycle% between% the% right% and% left% nose% occurs%
! Spaces%communicate%with%nasal%airway%
every% 2A3% hours% (due% to% alternating% congestion% and%
! Functions:%
decongestion%between%the%sides;%normally%not%perceived)%
- Decrease%the%weight%of%the%skull%
! Pressure%change%in%inspiration%and%expiration%
- Resonators%for%the%voice% ! Forced% inspiration% creates% suction% or% (A)% pressure% that%
! Four%types%divided%into%2%groups:%
promotes%transport%of%mucus%out%of%sinuses%
) Anterior)Group) Posterior)Group)
%
Sinuses) Frontal%Sinus% Posterior%Ethmoid%
C. AIR)CONDITIONING%
Anterior%Ethmoid%% Sphenoid%
Maxillary%% %
! Wherein%the%inspired%air%is%warmed%and%humidified%before%
Drainage) Middle%Meatus% SphenoAethmoidal% it%reaches%the%lungs%
Recess% ! Control%of%temperature%&%humidity%
% ! Nasal%mucosa/%turbinates%transfer%heat,%warm%&%humidify%
inspired%air%and%cool%expired%air%
%
%
D. AIR)PURIFICATION%
! Vibrissae%and%the%irregular%anatomy%of%the%nasal%passages%
all% contribute% to% Air) Filtration% resulting% in% deposition% of%
particulate% matter% (most% up% to% 4.5mm% in% size)% including%
viruses%and%bacteria%in%the%nose%and%nasopharynx%%
! Soluble% gases% are% removed% from% the% air% as% it% passes%
% through%the%nose%
%
! A%clear%understanding% of%the%anatomy%of%the%lateral%nasal% %
wall%is%of%utmost%importance%because%of%the%concept%that% E. MUCOCILIARY)FUNCTION%
inflammatory% disease% of% the% sinus% is% mainly% the% result% of% ! Transport%of%particles%deposited%in%inspired%air%posteriorly%
compromise% of% the% drainage% portals% (ostiomeatal% is% carried% out% by% the% action% of% cilia% moving% the% mucus%
channels/units)%of%each%sinus%cavities% blanket%or%film%
% ! Nasal% airflow% turbulence% provides% more% exposure% of%
) inspired%air%to%the%epithelium%with%its%Mucus)Film;%consists%
Ostiomeatal)Complex/) of%2%layers:%%
%
Unit))
(OMC/OMU)) %
) %
% %

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• Upper)Gel)Layer% F. PULMONARY)CORRELATIONS)
- More%viscous% ! Normal% pulmonary% function% is% dependent% on% nasal%
- Rich%in%glycoproteins% breathing%
- Provides% an% environment% that% traps% foreign% ! Bronchial% tone% is% dependent% on% Nasopulmonary) Reflexes%%
particulates% →% cleared% though% the% action% of% the% (via% hypothalamus)→% cause% changes% in%the% resistance% and%
cilia% perfusion% of% the% lungs;% influences% both% nasal% airway%
• Lower)Sol)Layer% resistance%&%pulmonary%compliance%
- Inner%serous%layer% %
- Facilitates%ciliary%and%gel%layer%movement% G. SPEECH)MODIFICATION)
! Mucociliary)Clearance% ! Speech%production%
- Critical%host%defense%mechanism%of%the%airways% - Multiplex%system%
- Effective% mucociliary% clearance% requires% appropriate% - Lungs%acting%as%the%power%source%
mucus%production%and%coordinated%ciliary%activity% - Larynx%as%a%sound%generator%
- Ciliary% action% affected% by% temperature,% dehydration,% - Lips,%tongues,%teeth%etc.%acting%as%articulators%
medications,%smoke,%foreign%body%and%pH% - Nose%&%paranasal%sinuses%acting%as%resonators%
% ! Resonance%
% - Intensification,% prolongation% and% filtration% of% sound%
% by%induction%of%sympathetic%vibration%
%
II.)DISEASES)OF)THE)NOSE)AND)PARANASAL)SINUSES)
! Fundamental% in% the% diagnosis% of% the% diseases% of% the% nose% and% • Ancillary%tests%are%useful%in%the%diagnosis%and%management)
paranasal%sinuses% - Culture%and%Sensitivity%for%infection)
- Good%clinical%history% - Smears%for%eosinophil)
- Thorough%examination%of%the%nose% - Skin%testing%for%allergy)
! Appearance%of%the%external%nose%should%be%noted% →% give%clues% )
to%the%patient’s%condition% INFLAMMATORY)DISORDERS)
! Edema%under%the%eyes%→%Allergy,%crepitation% )
! Nasal%deformity%→%Nasal%bone%fracture% A. VIRAL)RHINITIS)
! Tenderness%on%palpation%→%Infection% ! “Common)Cold”)
% ! Caused%by%more%than%200%viruses%especially%adenoviruses,%
EXAMINATION)OF)THE)NOSE) rhinoviruses,%parainfluenza,%influenza%
! Adequate% lighting% through% a% head% mirror% with% a% light% source,% ! SelfAlimiting;%Symptoms%last%for%only%3A5%days%
headlight,%penlight%or%an%otoscope) ! Symptoms%
! Intranasal% examination% begins% with% inspection% of% the% nasal% - Nasal%congestion%
vestibule) - Excessive%nasal%discharge%with%some%sneezing%
! Nasal%tip%can%be%slightly%lifted%to%see%the%internal%nose%and%the% - Coughing%with%or%without%headache%
septum%can%be%inspected%for%any%deviation) - Normal%or%slight%fever%
! Nasal%speculum) - Body%malaise%
- Allows% visualization% of% the% inferior% and% middle% turbinate,% ! Course%
nasal%septum%and%color%of%the%nasal%mucosa) • First%stage%
- Normal%mucosa%→%pink%and%not%swollen%or%congested) - 3%to%5%days%
- Held%with%the%left%hand%leaving%the%right%hand%free%to%move% - Secretions:%watery%→%mucoid%→%viscid%→%profuse%
the%patient’s%head%and%use%other%instruments) →%scanty%
- Performed%without%causing%any%discomfort%to%the%patient) • Secondary%bacterial%infection%%
! Topical%vasoconstrictors%(ex.%oxymetazoline)) - If%common%cold%progresses%
- Applied%in%spray%or%on%cotton%placed%intranasally) ! Management)(supportive))
- Can%be%used%for%decongestion%to%improve%visualization) - Antipyretics%
! Endoscopic%techniques%using%rigid%or%flexible%instruments) - Decongestants%
- Standard%in%the%examination%of%the%nasal%cavity) - Antihistamine%(if%there’s%a%history%of%allergic%rhinitis)%
- Allowed%thorough%evaluation%of%any%pathology%in%portions% - Antibiotics%(for%secondary%bacterial%infection)%
of% the% nose% and% nasopharynx% that% is% difficult% to% do% using% - Increased%fluid%intake%
traditional%methods) - Bedrest%
! Other)Methods) %
• Transillumunation% of% the% sinuses% –% useful% but% has% poor% B. BACTERIAL)RHINOSINUSITIS)
reliability) ! If%the%symptoms%of%viral%rhinitis%have%not%improved%or%have%
• CT%scan%of%the%paranasal%sinus%(coronal%and%axial)%or%an%XA worsened%in%7A10%days%(manual))
ray%(Water’s,%Caldwell%and%lateral%views)) ! Have%not%improved%after%10%days%or%have%worsened%after%5%
- Provides% further% information% as% to% presence% or% absence% to%7%days%(powerpoint/lecture))
and%severity%of%sinus%disease) ! Pathophysiology)(4)Stages))
) )

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a. Inciting)Stage%(Viral%Infection/%Allergic%Rhinitis)% Complications) Orbital%Cellulitis%% Mucus%Retention%Cyst%
- Reversible%mucosal%lesions% (MC:–:Ethmoid:bec.:of:its: Mucocoele%
- Transudate%formation% close:proximity): %
- Stimulated%serous%production% Osteomyelitis%% )
(Pott’s%Puffy%Tumor)%
- Mucosal%hyperemia%and%swelling%
Intracranial%
b. Ostial)Obstruction)Stage) Cavernous%Sinus%Thrombosis%
- Poor%drainage,%retained%secretions% Meningitis%
- Poor%aeration,%oxygen%absorption% Abscess%
- CO2%accumulation% %
- Favorable%environment%for%facultative%anaerobes% ACUTE)
c. Bacterial)Stage) No: recent: antibiotic: use: in: the: past: With:recent:antibiotic:use:in:the:past:
- Heavy%bacterial%growth% 466:weeks: 466:weeks:
- Increased%granulocyte%immigration% % %
st
- Oxygen%depletion%(Impaired%granulocyte% 1 %line:% %
bactericidal%action%and%secondary%growth%of% - AMOXICILLIN% - HIGH%DOSE%AMOXICILLIN%
- Amoxicillin/Clavulanate% - Amoxicillin/Clavulanate%
anaerobes)%
- Cefpodoxine% - Ceftriaxone%
d. Irreversible)(Chronic)%Stage) - Cefuroxime% - Gatifloxacin%
- Mucus%membrane%fibrosis% % - Levofloxacin%
- Ciliary%injury% % - Moxifloxacin%
- Loss%of%local%immune%mechanism% % %
- Persistent%ostial%obstruction) Alternative,%if:patient:is:allergic:to:B6 Alternative,%if:patient:is:allergic:to:B6
! Diagnosis% lactam:: lactam::
- History% - TMPASMX% - Gatifloxacin%
- Doxycycline% - Levofloxacin%
- Anterior%Rhinoscopy/Endoscopy%
- Azithromycin% - Moxifloxacin%
- Transillumination%(maxillary,%frontal)%–%Poor:reliability% - Moxifloxacin%
- Palpation% - Clarithromycin%
- Imaging%(Request:for:Open:Mouth:Water’s:View:to:be: - Erythromycin%
able:to:appreciate:sphenoid:sinus;:Sinuses:normally: CHRONIC)
appear:radiolucent;:If:Radiodense,:consider:retention: - Initially% managed% maximally% with% medical% therapy,% up% to% 3% months;%
of:secretion:or:mass)% nasal%douche%
- Cultures% - Topical%Steroids%
! MC:involved:in:rhinosinusitis:is:Maxillary:Sinus: - Surgery% is% an% option% for% refractory% cases;% Functional: Endoscopic: Sinus:
! SUBACUTE:6:In:between:the:duration:of:acute:and:chronic: Surgery:(FESS):is:usually:done%
) Others:)
- Topical%Decongestants%
) ACUTE)BACTERIAL) CHRONIC)RHINOSINUSITIS)
- Mucoevacuants%
RHINOSINUSITIS)(ARBS)) (CRS))
- Saline%Steam%Inhalation%
Duration) %<%4%weeks) %>3%months) - Antihistamines)
Etiologic) Adult):: Anaerobes:%(MC)% Clinical:Practice:Guidelines:(CPG):of:the:Philippine:Society:of:Otolaryngology:–:Head:and:Neck:Surgery:
Agents) *S.:pneumonia) Bacteriodes%sp.%Anaerobic% (PSO6HNS),:2006:
*H.:influenza) Gram%(+)%cocci% %
*M.:catarrhalis) Veillonella% C. FUNGAL)RHINOSINUSITIS)
Anaerobes% Fusobacterium% ! Refers% to% a% broad% group% of% immune% and% pathologic%
S.:pyogenes: Aerobes:%% responses%including%invasive,%chronic,%granulomatous,%and%
Children) S.:viridans:
allergic%disease)
*H.:influenza) H.:influenza:
*S.:pneumonia) ) ! MC%pathogen%is%the%Aspergillus:Spp.)
*M.:catarrhalis: ! Rhizopus:oryzae,:Candida(
(Memorize:*MC)) ! Includes:)
Symptoms) *Purulent%nasal%discharge) Same%as%ABRS) a. Fungus)Ball)
*Nasal%congestion%/% Including%dull%aches%and% • PNS% is% filled% with% a% ball% of% fungal% debris,% mostly%
obstruction) pains,%ET%obstruction%and% the%maxillary%sinus)
*Facial%pressure/pain) dacryocystitis) • Symptoms)
Periorbital%pain) Usually%persists%3%months%
- Fullness)
Postnasal%drip) or%longer%together%with%
Anosmia/%hyposmia) documented%inflammation% - Pressure)
*Fever) either%physically%or% - Nasal%discharge)
Cough) radiographically) • Treatment)
Fatigue) ) - Surgical%removal%of%fungal%element)
Dental%pain) )
Ear%pressure/%fullness) b. Allergic)Fungal)Rhinosinusitis)
Foul%breath%
• Patients% will% have% a% golden% yellow,% rubber%
*Major:criteria::
(atleast:2/4)(
cementAlike% sinus% secretions% which% contain%
eosinophils%and%fungal%elements)
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%
• Treatment) • Imaging%
- Surgery% +% long% term% systemic% and% topical% - Plain%sinus%xArays%
corticosteroids%and%antifungals) - CT%Scan%
) ! Grading%according%to%its%size%is%of%utmost%importance%for%proper%
c. Acute)Fulminant)Fungal)Rhinosinusitis) management%
• aka%Rhinocerebral%mucormycosis%or%mucor) Grade% Description%
• Occurs%when%the%fungi%invade%the%sinus%tissue%in% 0) Absence%of%polyp%
immunocompromised%individuals) 1) Polyps%do%not%prolapse%beyond%the%middle%turbinate%(MT)%
• Patients% will% have% areas% of% necrotic% tissue% that% 2) Polyps%extend%beyond%the%MT%
are%invaded%by%the%fungi% →% invade%the%eyes%and% 3) Massive%polyposis%
brain%within%hours) )
• Treatment) ! Management)
- Surgical%removal%of%dead%tissues) MEDICAL) SURGICAL)
- Systemic%antifungal) (Intranasal/%Systemic%Steroids)%
) - Grade%1%and%2%polyps% - Medical%treatment%failure%
- Grade% 3% polyps% (in% - Grade%3%polyp%
d. Chronic)Invasive)Fungal)Rhinosinusitis)
preparation%for%surgery)% - Antrochoanal%polyp%
• Invasion% of% the% sinuses% occurs% over% weeks% to% - Recurrent%polyp%
months% - Patients% with%
• Present%with%eye%swelling%and%blindness% contraindication% for%
• Treatment) steroids%
Clinical:Practice:Guidelines:(CPG):of:the:Philippine:Society:of:Otolaryngology:–:Head:and:
- Surgical%removal%of%dead%tissues) Neck:Surgery:(PSO6HNS),:2006:
- Systemic%antifungal) %
) ALLERGIC)RHINITIS)
e. Granulomatous)Fungal)Rhinosinusitis) ! Common%nasal%disorder%
• Specific% long% term% inflammatory% response% to% ! Affects%about%20%%of%the%local%population%
fungal% organism% that% has% invaded% the% sinus% ! Caused%by%type%1%IgE%mediated%hypersensitivity%reaction%
tissues% ! Prone:to:develop:nasal:polyp:
% :
NASAL)POLYPS)
! Definition%
- Common%benign%lesions%that%arise%from%the%nasal%mucosa%
at% the% area% of% the% ostiomeatal% complex% (OMC)% in% the%
middle%meatus%
- Appear% smooth,% gelatinous,% pale% white,% grayish% or% semiA
translucent,%cystic%masses%
- Frequently%bilateral%
! Epidemiology%
- <5%%in%general%population%
- 1A5%%among%asthmatics%and%allergic%patients%
- High%recurrence%
! Etiology%
- Unknown%
- Several% theories% consider% polyps% as% a% consequence% of%
chronic%inflammation%and%edema%
- Have% strong% associations% with% asthma,% allergy,% aspirin%
intolerance%and%cystic%fibrosis%
! Diagnosis%
• Symptoms%
- Nasal%obstruction%
- Rhinorrhea%
- Anosmia%
- Sometimes%pain%
• Physical%Examination%
% Polyp% Turbinate%
Location% Osteomeatal%% Entire%nasal%wall%
Moves%on%probing% (+)% (A)%
Shrinks%with%decongestion% (A)% (+)%
Bleeds%with%manipulation% (+/A)% (+)%
% %
% %

Joan%Marie%Sales% 6%
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%
! Symptoms% )
• Mast%Cell%% ! Management)
→%Immediate%rhinitis%% - Most: important: is: environmental: control,: advise: the:
- Itching% patient: to: avoid: or: at: least: minimized: the: exposure: to:
- Frequent% sneezing% (usually: in: the: morning: because: it: allergen:
is:the:time:when:pollens:are:more:concentrated)%
- Watery%nasal%discharge%
- Nasal%congestion%
• Eosinophil%%
→%Chronic%Ongoing%
- Nasal%blockage%
- Loss%of%smell%
- “Nasal%hyperreactivity”%
• Other:
- Allergic:salute:
- Nasal:crease:
- Allergic:Shiners::
(Purplish:discoloration:under:the:eyes):
- Increase:lacrimation:
- Post:nasal:drip:
- Sore:throat: :
- Itchy:ears: )
- PE::pale:congested:turbinates:
! Triggers%
- Allergens:% fleas,% pet% dander% (enzyme: in: their: saliva: that:
triggers: allergic: attack: not: the: fur: exactly),% dead%
cockroaches%
- Pollutants:%cigarette%smoke,%industrial%pollution%
! May%affect%both%children%and%adults%
! CoAmorbidities%such%as%asthma,%otitis%media%and%sinusitis%create%
a% big% impact% on% the% quality% of% life% of% patients% including% the%
financial% burden% because% of% the% substantial% cost% of% the%
treatment%
! Diagnosis%
- History%+%PE%of%the%nose%(ENT%exam%using%endoscope)%
- Confirmatory% tests% can% be% done% if% one% is% to% avoid% specific%
allergens%
- Allergy%Tests%%(In:developed:countries)%
• Skin%prick%test%(MC%used%method)%
• Radioallergosorbent%Assay%(RAST)%
- Detects%specific%IgE%Abs)%
• Paper%Radioimmunosorbent%Test%(PRIST)%
- Detects%total%serum%IgE%B%
)
CLASSIFICATION)OF)ALLERGIC)RHINITIS))
(ARIA%2007%GUIDELINES)%

)
)
NONRALLERGIC)RHINITIS)(NAR))
! Form% of% chronic% rhinitis% which% presents% impact% on% society%
because%of%its%frequency)
! Pathophysiology% is% quite% complex% and% numerous% factors% affect%
the% nasal% physiology% including% sensory% innervation,%
parasympathetic,% and% sympathetic% nerves% and% various%
inflammatory%cascades)
! Diagnosis)
- Most%important%is%a%complete%history)
- Details% must% be% covered% on% the% symptoms,% triggers,%
) medication%use,%or%presence%of%systemic%disorders)
Joan%Marie%Sales% 7%
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%
! Examples:) h. Atrophic)Rhinitis%
a. NAR)with)Eosinophilia)(&)Basophilia)) • aka%Ozena%
• Complex%with%perennial%symptoms%of:) • Unknown%etiology%
- Watery%rhinorrhea) • Has%been%associated%with%Klebsiella:ozaenae,%vitamin%
- Itchiness) A% deficiency,% hereditary% factors% or% autoimmune,% C.:
- Sneezing) diphtheria,%PeterAHofer%Bacillus%
- Epiphora%with%negative%or%irrelevant%to%common% • Signs)&)Symptoms%
allergens%on%skin%or%in%vitro%testing) - Nasal%obstruction%
• Cytologic%examination%shows%eosinophilia) - Anosmia%
) - Offensive%foul%odor%
b. MedicationRInduced) - Epistaxis%(sometimes)%
• Several%medications%may%have%side%effects) • On%examination,%nasal%cavity%paradoxically%will%appear%
- AntiAinflammatory%drugs%(NSAIDs%and%aspirin)) spacious% with% atrophied% turbinates% with% severe%
- AntiAhypertensive%drugs%(Beta%blockers%and%ACEi)) crusting%and%a%foul%odor%
- Hormones%(OCPs)) • Treatment%
- AntiAplatelet%Agents%(Clopidogrel)) - Antibiotics%
- Psychotropic%Agents%(Chlorpromazine)) - High% dose% vitamin% A% (reversing% nutritional%
) deficiency)%
c. Rhinitis)Medicamentosa) - Saline%(more%helpful%if%with%sodium%bicarbonate)%
• Unique%condition) irrigations%
• Rebound% congestion% after% prolonged% use% of% topical% - Surgery%(Close:the:nostril:for:the:mucosa:to:heal):
nasal% decongestants% (such: as: Oxymetazoline)% or% i. Others)
cocaine) • EndRstage)vascular)atony)of)chronic)allergic)rhinitis/)
% sinusitis)
d. Hormonal) • Recumbency)Rhinitis)
• Increased% hyperactivity% of% the% mucus% glands% →% • Paradoxical)nasal)obstruction)&)nasal)cycle)
increased%rhinorrhea) - 2.5A3%hours%
• Metabolic% diseases% like% hypothyroidism% and% - Septal%deviation%
acromegaly%→%hormonal%imbalances%→%rhinitis) • NonR)airflow)Rhinitis))
• Fluctuating% hormones% during% puberty,% menstruation% - Laryngectomy%
and%pregnancy%→%rhinorrhea%and%congestion) - Tracheostomy%
• Possible% cause% for% this% could% be% the% direct% effects% in% • Choanal)Atresia)Rhinitis)
the%nasal%mucosa%of%changes%in%the%level%of%estrogen,% • Adenoid)Rhinitis)
progesterone,% prolactin% and% placental% growth% • Compensatory)Hyperthropic)Rhinitis)
hormone) - Septal% deviation% (Compensatory: hypertrophy: on:
) the:other:side:→:congestion):
e. Irritation)and)Environmental) • SVC)Syndrome)
• Temperature%changes) • Horner’s)Syndrome)
- Sudden%changes%stimulate%congestion) )
• Barometric%pressure%changes) STRUCTURAL)DEFORMITIES)
• Certain%foods%(stimulation:of:trigeminal:nerve:endings)( )
• Inhaled%irritants) A. CONGENITAL)DISEASES)
) ! Whether%internal%or%external,%inherited%or%acquired)
f. Emotional)Causes) ! Can% range% from% isolated% deformities% to% those% associated%
• Anxiety% with%multiAorgan%system%syndromes)
• Frustration% )
• Resentment% a. Cleft)Lip)&)Palate)(Hypertrophied:turbinates))
) )
g. Idiopathic)or)Vasomotor)Rhinitis) b. Nasal)Dermoid)Cysts)
• MC)form) • NonAcompressible,%nonApulsatile%masses)
• Diagnosis%of%exclusion%wherein%no%other%cause%can%be% • Evidenced%by%a%pit%on%the%nasal%dorsum)
identified% and% there% is% no% cytologic% evidence% of% • Contain% all% the% elements% of% the% skin% (hair,% hair%
mucosal%inflammation) follicles,%sweat%glands,%sebaceous%glands))
• Due% to% an% imbalance% of% the% autonomic% nervous% • Diagnosis)–)CT%scan)
system,% either% excessive% parasympathetic% • Treatment)–)Excision)
(vasodilation)% or% reduced% sympathetic%% )
(vasoconstriction)%nerve%activity) c. Nasal)Gliomas)
) • Rare%lesions)
) • Similar% to% encephalocoeles% (both% are% composted% of%
) extradural%glial%tissue))
Joan%Marie%Sales% 8%
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%
• Solid,% nonAcompressible,% nonApulsatile% gray% or% purple% • Common%signs)
mass%) - Depression%or%displacement%of%the%nasal%bone)
• (A)%Transillumination) - Edema)
• (A)%Furstenberg)Sign)(enlargement%on%compression%of% - Epistaxis)
the%jugular%vein)) - Displacement%of%the%septal%cartilage)
• Diagnosis)–)CT%and%MRI) • Treatment)
• Treatment)–)Surgical%Excision) - Incision%and%drainage)
) - Placement%of%a%drain%to%prevent%reAaccumulation%
d. Encephalocoeles) of%hematoma)
• Connected% to% the% CNS,% unlike% gliomas,% thus% a% cranial% - Application% of% nasal% dressing% to% compress% the%
defect%is%always%present% nasal%mucosa)
• Usually%bluish,%compressible,%pulsatile% - Antibiotic%therapy%to%prevent%infection)
• May%transilluminate% - Closed% reduction% can% be% done% under% local%
• (+)%Furstenberg)Sign% anesthesia% immediately% after% the% trauma% or%
• Diagnosis%–%CT%&%MRI% within%3A7%days%following%resolution%of%edema)
• Treatment%–%Neurosurgical%Intervention% - If% closed% reduction% does% not% yield% a% satisfactory%
% result% or% if% the% injuries% are% severe,% an% open%
e. Choanal)Atresia) reduction%may%be%required)
)
• Thought% to% occur% when%
b. Neoplasms)
the%bucconasal%membrane%
(separating%the%mouth%and% • Both%benign%and%malignant%are%not%frequently%seen)
nose% during% fetal% • Symptoms%are%not%specific%but%commonly%presents%as%
development)% persists% nasal% obstruction) with% epistaxis% or% bloodAtinged%
after%birth) mucus)
• Results% in% the% presence% of% • Benign)
a% bony% plate% (90%)% or% 1. Inverting)Papilloma)
membrane%(10%)%obstructing%the%posterior%choana) - MC% benign% tumor% of% the% nose% and% the%
• Bilateral% choanal% atresia% is% considered% an% airway% paranasal%sinuses)
emergency% since% newborns% are% obligate% nasal% - Mostly%originate%from%the%lateral%nasal%wall%
breathers) and%may%appear%similarly%to%a%nasal%polyp)
- Unilateral% nasal% mass% that% grossly% appears%
• Treatment)
as%a%polyp;%(nasal%polyps%occur%bilaterally))
- Insert%oral%airway)
- Once%the%infant%is%stable,% transnasal%airway%may% • Treatment)
be%established) - Surgical% excision% due% to% its% aggressive%
) behavior%and%high%recurrence%rate)
B. ACQUIRED)DISEASES) 2. Juvenile)Angiofibroma)
a. Trauma) - Triad:)
Obstruction%
• Nasal)Bone)Fracture%–%MC%bone%trauma)
Mass%
Recurrent%epistaxis%
- Males,%mean%age%is%15%(adolescent)%
- Origin:% Poterior% lateral% &% Superior% nasal%
cavity%
• Malignant)
) 1. Squamous)Cell)Carcinoma%)
• Septal)Hematoma) - MC%malignancy%in%the%head%and%neck)
- Nasal% trauma% →% blood% dissects% the% - Maxillary%sinus)
mucoperichondrium% off% the% septal% cartilage% from% one% 2. Nasopharyngeal)Carcinoma)(NPCA))
or%both%nose%→%abscess%formation% →%resorption%of% - 18%%of%all%malignant%tumors%among%chinese%
the%cartilage%→%SaddleRNose)Deformity) - MC%sign%and%symptom:%HL%and%Lump%in%the%
(All% nasal% injuries% must% be% evaluated% to% prevent% neck%
this)% - Initial:symptoms:such:as:HL,:ear:fullness:and:
- Treatment:%I%&%D% middle:ear:effusion:
• Septal)Perforation) - Risk:factors::
EBV:Infection:
Nitrosamine:found:in:Tocino:
- Treatment:%High%dose%Radiation%
)
)
) )

Joan%Marie%Sales% 9%
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%
c. Foreign)Bodies) )
• Common% cause% of% nasal% obstruction% especially% in% C. SYSTEMIC)AND)IMMUNOLOGIC)DISEASES)
young%children) ! The% nose% and% the% paranasal% sinuses% can% be% affected% by%
• Usually%presents%as%a%unilateral%foul%nasal%discharge) systemic%diseases)
st
• Majority%are%lodged%either%in%the%anterior%part%of%the% ! In% some% cases,% symptoms% in% the% nose% may% be% the% 1 %
vestibule%or%along%the%floor%of%the%noses%in%the%area%of% indication%of%a%systemic%disorder)
the%inferior%meatus% )
• Treatment) a. Granulomatous)Diseases)
- Prompt% removal% to% prevent% complications% such% • Several%have%predilection%to%involve%the%airways%wich%
as%infection%or%burns%and/or%necrosis%in%cases%of% is% often% characterized% by% local% inflammatory%
toxic%materials%like%disc%batteries) responses;)Included%are:)
d. Rhinolith) - Wegener’s%Granulomatosis)
• In%adults% - ChurgAStrauss%syndrome)
• Insoluble%salts% - Sarcoidosis)
% - )
e. Rhinophyma) b. Neoplastic)Diseases)
• Thickening% of% nasal% tip% with% hyperthrophy% of% • TRcell)Lymphoma)
sebaceous%glands%associated%with%acne%rosea% - Most%notable%disease%that%may%affect%the%nose)
• MCC%in%male% • Symptom)
• Unknown%etiology% - Usually% start% with% nasal% obstruction% →% purulent%
• Treatment) rhinorrhea% →% mucosal% ulceration% extending% to%
- Excision% the%palate,%maxillary%sinus%and%upper%lip)
- Dermabrasion% )
- Laser% )
EPISTAXIS
% %
! Definition) ! Etiology)
- Greek%word%“Epistazein”%meaning%to%flow%“drop%by%drop”% • MC)Local)cause)
- Acute% hemorrhage% from% the% nostril,% nasal% cavity% or% A Anterior%
nasopharynx% A Spontaneous%
! Classified% on% the% basis% of% the% primary% bleeding% site% as% anterior% A Usually%in%children%
or%posterior% • MC)Systemic)cause)
• Anterior) A Posterior%
- MC% A Hypertension%
- Originating%from%the%nasal%septum%(80%)% A Usually%in%elderly%
- Kiesselbach’s%plexus% • Idiopathic)(80%))
- Anterior% bleeding% may% also% originate% anterior% to% • Trauma%
inferior%turbinate% - Minor%trauma%
- Nasal%fractures%
- Iatrogenic%
• Inflammatory%
- Infective%and%atrophic%rhinitis%
- Sinusitis%
• Neoplastic)
- SCCA)
- Juvenile%angiofibroma)
• Systemic)
- Systemic%hypertension%
- Hematological%abnormalities%
% - AntiAcoagulation%
• Posterior) ! Risk)Factors)
- Originates% from% branches% of% the% sphenopalatine% • Hot%dry%indoor%climate%→%delicate%nasal%skin%to%crack%and%
artery%in%the%posterior%nasal%cavity%or%nasopharynx% bleed%
! Incidence) • Deviated% septum% →% one% side% of% the% nasal% septum% to%
- No%sex%predilection% become%dry%and%cracked%→%increasing%the%risk%of%bleeding%
- Bimodal%incidence%exists%with%peaks%in%those%aged%2%to%10% • Cold%and%Allergies%
years%and%50%to%80%years% - URTI% and% allergies% →% inflammation% in% the% nose% →%
- Causes%are%different%in%the%two%age%groups% increase%the%risk%of%bleeding%
% - More% congestion% →% blood% vessels% to% dilate% →% more%
% vulnerable%to%injury%
Joan%Marie%Sales% 10%
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%
- Strenuous%nose%blowing%to%clear%the%nose%→%bleed% - Prophylactic% antibiotics% should% be% used% if% pack% in%
• Exposure%to%irritating%chemicals% place%for%more%than%48%hours%%
- Cigarettes% - Anterior)Nasal)Packing)
- Sulfuric%acid% Traditional%(Vaseline%gauze)%packing%%
- Ammonia%etc% Compressed%sponge%(Merocel)%%
• Medical%conditions% Anterior%epistaxis%balloons%%
- Thrombocytopenia%
- Increase%blood%pressure%
- Hemophilia%
• Heavy%alcohol%use%
• Medications%that%interfere%with%blood%clotting%
- Anticoagulants%
- NSAIDS%
! Prevention)
- Do%not%pick%nose%
- Be%gentle%whenever%blowing%the%nose% %
• Posterior)Epistaxis)
- Do%not%smoke%
- Often%cannot%be%controlled%with%local%measures%%
- Use%a%humidifier%if%indoor%climate%is%dry%
- May% require% insertion% of% a% balloon% or% posterior% nasal%
- Use%saline%nasal%spray%to%moisturize%the%nasal%cavity%
pack%%
- Apply% a% dab% of% petroleum% jelly% to% the% nasal% cavity% before%
- If%fails%to%control%bleeding%need%to%consider%surgery%%
bedtime%%
- Posterior)Nasal)Packing)
- Avoid%facial%trauma%%
Posterior%epistaxis%balloons%
- Use% protective% equipment% to% avoid% breathing% irritating%
Foley%catheter%
chemicals%at%work%%
! History)
- Controlling%significant%bleeding%or%hemodynamic%instability%
should%take%precedence%over%obtaining%a%lengthy%history%
- Duration%and%side%of%bleeding%%
- Previous%epistaxis,%HPN,%other%systemic%disease%%
- Easy% bruising% or% prolonged% bleeding% after% minor% surgical%
procedures%%
- Use%of%medications%(aspirin,%NSAIDs,%warfarin,%or%heparin)%
!
! Physical)Exam))
- Perform% a% thorough% and% methodical% examination% of% the% %
nasal%cavity% %
- Approximately% 90%% of% epistaxis% can% be% visualized% in% the% ! Laboratory%Studies%
anterior%portion%of%the%nasal%cavity%% - Blood%count%
- Posterior% source% is% suggested% by% failure% to% visualize% an% - Clotting%screen%
anterior% source,% and% by% visualization% of% blood% draining% in% - Possibly%cross%match%
the%posterior%pharynx%% ! Imaging)Studies))
! Management)) - Sinus%films%are%rarely%indicated%)
- Airway,%Breathing%and%Circulation% - Other%Tests%)
- Patients% should% be% instructed% to% grasp% and% pinch% their% • CT% scan/% Nasopharyngoscopy% may% be% performed% if% a%
entire% nose,% maintaining% continuous% pressure% for% at% least% tumor%is%suspected%%
10%minutes%% • Angiography%is%rarely%indicated%%
- Gowns,%gloves,%and%protective%eyewear%should%be%worn%% ! Further)Inpatient)Care)
- Adequate%lighting%% - Admit%patients%with%posterior%packing%%
- Patients% should% be% positioned% comfortably% in% a% seated% - Elderly%patients%or%patients%with%cardiac%disorders%or%COPD%
position,%holding%a%basin%under%their%chin%% should%receive%supplemental%oxygen%and%be%admitted%to%a%
- Insert% pledgets% soaked% with% an% anestheticAvasoconstrictor% monitored%setting%%
solution% into% the% nasal% cavity% to% anesthetize% and% shrink% - Significant% or% uncontrolled% bleeding% from% a% posterior% site%
nasal%mucosa% may%require%operative%management%%
• Anterior)Epistaxis) ! Further)Outpatient)Care)
- Apply%pressure% - Patients% discharged% with% anterior% packing% should% receive%
- Anesthetize:% Vasoconstrictor% solution% applied% to% followAup% care% with% an% ENT% specialist% within% 48A72% hours%%
Little's%area%% and% prescribed% with% penicillin% or% firstAgeneration%
- Consider%cautery:%Silver%nitrate%stick%&%Electrocautery%% cephalosporin%&%oral%analgesics%
- Anterior% nasal% packing% should% be% considered% if% - Advise% patients% to% avoid% aspirin,% aspirinAcontaining%
bleeding%persists%% products,%and%NSAIDs%%

Joan%Marie%Sales% 11%
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%
! Nasal)Packing)Complications) )
- Sinusitis%% )
- Septal%hematoma/%perforation%% )
- External%nasal%deformity%% )
- Mucosal%pressure%necrosis%% )
- Vasovagal%episode%% )
- Balloon%migration%% )
- Aspiration%% )
! Prognosis%is%excellent%with%proper%treatment% )
! Patient’s)Education) )
- For%reAbleeding%or%future%nosebleeds,%patients%should%be% )
instructed%to%firmly%pinch%their%entire%nose%for%10A15% )
minutes% )
- Ice%packs%do%not%help.% )
% )
% )
% )
% %
% )
% )
% )
% )
% )
% )
% )
% % )
% )
% )
) )
) )
) )
) )
) )
) )
) )
) )
) )
) )
) )
) Sources::
) ! Otolaryngology:–:Head:and:Neck:Surgery:
) A:Textbook:for:Medical:Students:First:Edition:2015::
) - Anatomy: and: Physiology: of: the: Nose: and: Paranasal:
) Sinuses:(pp59665):
) - Diseases:of:the:Nose:and:Paranasal:Sinuses:(pp67677):
) ! Lecture/:Recording:
) ! Powerpoint::
) ! DR.)ROBIN)RAMIREZ)<3):
) :
) :
) :
) 02626616:
) THANK)YOU)FOR)ENCODING)JYLE)CHITO)VILLONES!)
) HAPPY)BIRTH)ANNIVERSARY)")
) )
) - Chut,)Karen,)Kate)&)I)
) )
) )
) )
)
)
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%