THE NOSE AND

PARANASAL SINUSES
Dr. Mohamad S. Aziz
Otolaryngologist
CABMS (ORL-HNS)
ENT Dept, College of Medicine, University of Mosul

Undergraduate, The Nose, 2016/2017

Is bleeding per nose. It is a known
disease of unknown aetiology.
Epistaxis from Little’s area
Aetiology
The two most common causes of epistaxis are
idiopathy and trauma.
I. Local causes
1. Idiopathic.
2. Trauma: Direct injury as nose picking or nasal
operations.
3. Inflammatory: Acute rhinitis, sinusitis and allergy.
4. Anatomical and structural abnormalities: Septal
deviation may disturb air flow and causes
turbulence of airflow thereby resulting in mucosal
drying and epistaxis.
5. Neoplastic as angioma and carcinoma.
6. Environmental: Airconditioners and industrial
fumes.
• II. Systemic causes
– Cardiovascular as hypertension: Here the nasal
mucosa is often atrophic and cracks easily
which eventually leads to exposure of the
arteriosclerotic vessel producing severe
bleeding during a hypertensive episode.
– Haematologic: Haemophilia, leukaemia and
ITP.
– Drugs: Aspirin and anticoagulants as warfarin.
• II. Systemic causes
– Diseases of blood vessel as Osler’s
disease ( Hereditary haemorrhagic
telangiectasia). This is a hereditary
disease characterized by the formation of
abnormal capillaries in the mucous
membrane of the nose. It is treated by
radiation, Laser therapy and surgical
excision of the mucous membrane of the
nose with replacement of a split thickness
skin graft.
Osler Weber Rendu’s disease
Clinical Picture
1. Anterior epistaxis: It is the most common. It arises
from Little,s area to the anterior nares and occurs
in young and middle aged patients. Here the
bleeding is trivial, easy to stop and tends to recur.
2. Posterior epistaxis: Its less common. Arises far
back in the nose and may flow back to the pharynx
and occurs in elderly hypertensive patients. Here
the bleeding is profuse and extremely difficult to
stop.
Management
A-Arrest of haemorrhage.
R-Resuscitate the patient: A baseline Hb is
withdrawn and IV drip is commenced. If
necessary plasma and blood transfusion should be
given to restore the circulation.
T-Treat the cause.
Arrest of the Bleeding by
1-Pressure on the nostrils in a sitting position, the
mouth is kept open and swallowing is forbidden.
The patient is instructed to breath quietly through
the mouth with the head leant forwards.
2-Ice packs on the nasal bridge.
3-Cauterization of the bleeding point: Either
chemical cautery using silver nitrate or
trichloroacetic acid or electrical cautery. GA is
some times required to identify the bleeding point
and in children.
Correct Incorrect
4. If epistaxis can not be controlled and the bleeding
continues a pack may be needed.
a. Anterior packing: Using one inch ribbon
gauze impregnated with paraffin or
Vaseline. The pack may be left for 24-48
hours. The first part of the pack is inserted
along the floor of the nose as far
posteriorly as possible the next layer is
placed on top sequentially.
. Systemic antibiotics should be used to prevent
secondary bacterial infection as sinusitis and
otitis media. Sedation is necessary whenever a
nasal pack is in situ, not only because the pack is
uncomfortable, but the added anxiety of
epistaxis may elevate the blood pressure.
 Anterior pack

Modification from this picture- have both packing ends towards the front
 b. Postnasal packing: Continued haemorrhage
despite an anterior packing is probably a result
of bleeding from the posterior branches of the
sphenopalatine artery which necessitate the
insertion of a postnasal pack.
It is done under GA and prepared from a
piece of gause soacked wit paraffin or any
antiseptic solution. Tapes are taken anteriorly
through each nostril from the posterior pack
around the columella. Another tape is tied
around the middle of the pack and picked up
from the patient mouth.
 A further anterior pack is placed against the
posterior pack. The posterior pack stays in place
for 48 hours. Variation of the pack is to use a
urinary Foley’s catheter to fill the nasopharynx
which can be done without anesthesia.
Posterior pack
Posterior Pack
5. Surgical Treatment: If despite anterior and
posterior packing, the bleeding continues or
recurs , surgical intervention is indicated.
a-Submucosal resection of the nasal septum in case
of septaal spur to induce fibrosis at Little’s area.
b-Arterial ligation: The appropriate vessel is
clipped under GA depending on the area of
bleeding.
1. Anterior ethmoidal artery ligation for bleeding
from the superior part of the nasal cavity.
2. External carotid artery ligation for bleeding
from the inferior part of the nasal cavity.
3. Sphenopalatine ( best) or maxillary artery
ligation.
c- Embolization :unfit for surgery
 Management Protocol

Adapted from Marks SC: Nasal and sinus surgery

Pathology: Causes – Etiology of symptoms
1- Congenital
2- Traumatic Foreign body
Accident
Iatrogenic
3- Inflammatory Acute:
Chronic:
Specific:
Nonspecific:
4- Neoplastic Benign:
Malignant
Reda Kamel, M.D.
5- Others
 Benign
Epithelial CT. Tissue
Papilloma Osteoma Chondorma
Angioma Fibroma

Malignant
Epithelial CT.Tissue
squamous cell Ca Fibrosarcoma
AdenoCA Angiosarcoma
It arises either from the skin of the nasal vestibule 
squamous papillomas or from the respiratory mucosa
 inverted papilloma.
A. Squamous papilloma
It is a warty like growth either sessile or
pedunculated. It is removed by an elliptical incision
and the base is cauterized to prevent recurrence.
They can also be treated by cryosurgery or LASER.
B. Inverted Papilloma (transitional cell
papilloma, Ringertz tumour )
It arises from the lateral wall of the nose and
occasionally from the nasal septum. They expand the
containing bone but do not infiltrate. Extension to
the ethmoidal and maxillary sinus is common.
Pathology
It is histologically benign but has a great tendency to
recur. It is named so because microscopically
neoplastic epithelium is seen to grow towards
underlying stroma rather than on the surface
(transitional type of epithelium).
There is a coincidental malignancy (synchronous
malignancy) in 15% of cases and malignant
transformations of the tumour occur in about 8%.
Clinical Picture
Mostly seen between 40-70 years with male
predominance. The usual presentations are unilateral
nasal obstruction and recurrent attacks of sinusitis.
Examination
It arises from the lateral wall of the nasal cavity and
it is always unilateral. It presents as red or grey mass
simulating simple nasal polyp.
Investigations
1. Radiology: X.ray and CT scan.
2. biopsy.
Treatment
Adequate local excision (medial maxillectomy) by
lateral rhinotomy approach.
I. Localized Compact Osteoma: it is most
frequently found in the frontal sinus, but may be
seen in the ethmoidal region.
Clinical Picture
• They are frequently silent.
• If the frontonasal duct is obstructed, it leads to
frontal mucocele.
• Displacement of the eye.
• Pressure on the floor of the anterior cranial fossa
leads to CSF rhinorrhea and intracranial
infection.
Investigations
Radiology: X.ray and CT scan.
Treatment
Asymptomatic: observation.
Symptomatic: external frontoethmoidectomy.
• II. Fibro-osseous Dysplasia: This disease
commonly involves the maxilla and mandible. It
represents an arrest of the maturation of bone
formation at the stage of woven bone. It is
divided into two types: the multiple polyostotic
lesion and the monostotic lesion.
– Multiple polyostotic lesion which is a
systemic disease involving several bones.
– Monostotic lesion which is localized to the
maxilla and ethmoidal bone.
Fibrous dysplasia
Clinical Picture
It presents as a painless swelling around the orbit or
the cheek. This swelling become apparent during
childhood and increases in size, but often ceases to
expand after 20 years.
Investigations
Radiology by CT scan.
Treatment
1. Asymptomatic  observation as the lesion tends
to slow in progression during puberty.
2. Big (symptomatic)  surgical resculpturing
(shaving)
I. Capillary: the commonest site is the nasal septum
and here it is called a bleeding polyp of the septum.
Clinical Picture
Epistaxis and on examination a pedunculated friable
red lesion is seen which bleeds easily on touch.
Treatment
Excision with an adequate margin of the normal
mucosa to prevent recurrence.
II. Cavernous: which may involve the whole tip of
the nose.
Bleeding polyp of the septum
Cavernous Haemangioma
A rare tumor involving mainly the maxillary and
ethmoidal sinuses.
Aetiology
Unknown, but hardwood and nickel workers are
more liable to develop this tumour.
.
Clinical Picture
The average at presentation is 60 years.
1. Unilateral nasal obstruction.
2. Blood stained discharge.
3. Toothache or loosening of the teeth.
4. Extension to the orbit  proptosis and diplopia.
5. Facial swelling and skin involvement.
• Examination
• Fleshy polyp
• Investigations
• Radiology: CT and MRI.
• Biopsy through intranasal antrostomy.
• Metastasis
• Deep cervical lymph nodes and retropharyngeal
lymph nodes
• Treatment
• Combination of surgery and DXT.
Squamous cell carcinoma of the maxillary
sinus
 Sinonasal tumors: Classification
1- Benign:
A- Epithelial: -Papilloma -Inverted papilloma -Adenoma
B-Non-epithelial: -Hemangioma -Ostioma -Fibrous dysplasia
-Chondroma -nZeurofibroma
2- Intermediate:
A-Epithelial: -Ameloblastoma
B-Non-epithelial: -Giant cell tumor
3- Malignant:
A-Epithelial: -Squamous cell ca –Adenoid cystic ca
-Melanoma – Olfactory neuroblastoma
–Mucoepidermoid tumor –Anaplatic ca
B-Non-epithelial: -Osteosarcoma –Angiosarcoma –
Rhabdomyosarcoma -Fibrosarcoma
Reda Kamel, M.D.
Sinonasal tumors: Symptoms:
1-Benign:
• Nasal
• Extension
• Expansion

2-Malignant:
• Nasal
• Extension
• Erosion
• Lymph nodes
• Metastasis
Reda Kamel, M.D.
Sinonasal tumors: Symptoms:
A- Nasal:
• Obstruction
• Discharge
• Headache
• Pain
• Bleeding
• Bad odor

Reda Kamel, M.D.

 Sinonasal tumors: Symptoms:
B- Extension:
• Medial:nasal
• Inferior:oral
• Lateral:orbital,
fossa
• Superior:cranial
• Anterior:sublabial
• Posterior:
nasopharynx

Reda Kamel, M.D.

 Sinonasal tumors:
Investigations

• Endoscopy
• CT & MRI
• Biopsy

Reda Kamel, M.D.

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