Disease of external nose deviated nasal septum, fb in nose 02.05.16, dr.bini mohan

1. DISEASES OF EXTERNAL EAR
DEVIATED NASAL SEPTUM
FOREIGN BODY NOSE

2. DISEASES OF EXTERNAL NOSE

3. Cellulitis: nasal skin may be invaded by
streptococci or staphylococci leading to
red, swollen and tender nose. It may be
infection spreading from nasal vestibule.
Rx: systemic antibacterial,hot fomentation
and analgesics

4. cellulitis

5. NASAL DEFORMITYn
• SADDLE NOSE
• HUMP NOSE
• CROOKED NOSE OR DEVIATED NOSE

6. • SADDLE NOSE: Depressed nasal dorsum
may involve bony,cartilaginous or both
component of the nasal septum.
Aetiology: - Nasal trauma
-Excessive removal of septum in
SMR
-Destruction of septal cartilage
by haematoma ,abcess
-Leprosy, TB or syphilis

7. Treatement :Augmentation rhinoplasty by
filling the dorsum with cartilage ,bone,or
synthetic implant.

8. Hump nose: may involve bone or cartilage or
both.
• Corrected by reduction rhinoplasty
(removal of hump and narrowing of the
lateral wall)

9. HUMP NOSE

10. CROOKED NOSE OR DEVIATED
NOSE:-
• In Crooked nose the midline
of dorsum from fronto-nasal
angle to the tip is curved in a
C or S shaped manner.
• In Deviated nose, the midline
is straight but deviated to one
side.
• These deformities are usually
traumatic in origin.
• TREATMENT :-
Septorhinoplasty or
Rhinoplasty

11. TUMOURS
• 1. Congenital
• 2. Benign
• 3. Malignant

12. Congenital Tumour
1)DERMOID CYST.
2)ENCEPHALOCELE or
MENINGOENCEPHALOCELE.
3)GLIOMA

13. Congenital
1) Dermoid cyst: 2 types
• a)simple dermoid : it occur as a midline
swelling under the skin but in front of the
nasal bones
-have no external opening

14. b)Dermoid with a sinus:
- seen in infants and children
- represented by a pit or a sinus in the midline
of the dorsum of nose .
- hair may be seen protruding through the
sinus opening .
- in these cases ,the sinus track may lead to a
dermoid cyst lying under the nasal bone in
front of upper part of nasal septum or may
have an intracranial dural connection.

16. - In those with intracranial extension sinus tract
passes through the cribriform plate or
foramen caecum and is attached to dura or
has other intracranial connection.
- Treatment :splitting of the nasal bones to
remove any extension in the upper part of the
nasal septum.
- Combined neurosurgical otolaryngologic
approach is required in case with intracranial
extension

17. 2)Encephalocele or meningoencephalocele:
herniation of brain tissue along with its
meninges through a congenital bony defect.
- An extranasal meningoencephalocele
presents as a subcutaneous pulsatile
swelling in the midline at the root of
nose(nasofrontal),side of nose(nasoethmoid
variety) or on the anteromedial aspect of the
orbit(naso orbital variety)

18. • Swelling show cough impulse and may be
reducible .
• Treatement :neurosurgical
removing the tumour stalk from the
brain and repairingthe bony defect through
which herniation has taken place.

19. 3)Glioma:
• It is a nipped off portion of encephalocele
during embryonic development.
• Most of them (60%) are extranasal and
present as firm subcutaneous swelling on the
bridge, side of nose or near the inner canthus
• 30% purely intranasal ,while 10% are both
intranasal and extranasal.
• Extranasal gliomas are encapsulated and can
be easily removed by extranal nasal
approach.

20. BABY WITH
GLIOMA

21. BENIGN TUMOURS
• They arise from the nasal skin and include
• A) PAPILLOMA
• B) HAEMANGIOMA
• C) SEBORRHOEIC KERATOSIS
• D) NEUROFIBROMA
• E) TUMOUR OF SWEAT GLAND

22. • Rhinophyma: or potato tumour is a slow
growing benign tumour due to hypertrophy of
the sebaceous glands of the tip of nose often
seen in cases of long standing acne rosacea
• Presents as a pink, lobulated mass over the
nose with superficial vascular dilation.
• Mostly affects men past middle age .
• Due to large size of the tumour it cause
unsightly appearance, obstruction to
breathing and vision.

23. • Treatment consists of paring down the
bulk of tumour with sharp knife or carbon
dioxide laser and the area allowed to
reepithelialize.
• Tumour is completely excised and the raw
area skin grafted.

24. RHINOPHYMA

25. Malignant tumours :-
• Basal cell carcinoma (rodent ulcer).
• Squamous cell carcinoma (epithelioma).
• Melanoma.

26. a)Basal cell carcinoma:
-most common malignant tumour
involving skin of nose(87%).
-equally affecting males and females in
the age group of 40-60yrs.
-common sites on the nose are the tip
and the ala
-present as a cyst or papulo pearly
nodule or an ulcer with rolled edges.

27. - Very slow growing and remains confined
to the skin for a long time.
- Underlying cartilage or bone may get
invaded.
- Nodal metastases are extremely rare.
- Treatment depends on the size ,location
and depth of the tumour.
- early lesion can be cured by cryosurgery

28. • Squamous cell carcinoma(epithelioma):
- second most common malignant
tumour(11%).
-equally affecting both sexes in 40-60age
group
-occurs as an infiltrating nodule or an ulcer
with rolled out edges affecting side of nose
or columella.
- nodal metastases are seen in 20%of
cases

29. • Early lesion respond to radiotherapy
• More advanced lesions or those with
exposure of bone or cartilage require wide
surgical excision and plastic repair of the
defect.
• Enlarged reginonal lymph nodes will
require block dissection

30. c) melanoma: least common variety.
-it is superficially spreading type or
nodular invasive type.
treatment: surgical excision

31. Deviated nasal septum

32. 2.DEVIATED NASAL SEPTUM
Aetiology
1. Trauma
2. Developmental errors
3. Racial factors
4. Hereditary factors

33. TRAUMA
• A lateral blow on the nose may cause
displacement of septal cartilage from the
vomerine groove and maxillary crest
• A crushing blow from the front may cause
buckling , twisting ,fractures and crushing of
nasal septum
• Trauma during delivery

34. 2 . DEVELOPMENTAL ERRORS
• Nasal septum is formed by the tectoseptal process
which descends to meet the two halves of developing
palate in the midline
• During primary and secondary dentition further
developments takes place in palate
• Unequal growth between palate and base of skull may
cause buckling of nasal septum
• In mouth breathers-high arched palate and DNS
• In cleft palate,cleft lip,dental abnormalities

36. Types of DNS

38. ANTERIOR DISLOCATION

39. SEPTAL SPUR

40. Effects of DNS
1. Compensatory hypertrophy of turbinates of
opposite side
2. External deformity
3. Impairment of drainage to sinus
4. Secondary atrophic rhinits

41. Clinical features
1 . NASAL OBSTRUCTION
• Sites
1. Vestibular
2. At the nasal valve
3. Attic
4. Turbinal
5. Choanal
• Bilateral/unilateral obstruction

42. COTTLE TEST
• Used in nasal obstruction due to abnormality
of nasal valve
• In this test ,cheek is drawn laterally while
patient breathes quietly.If the nasal airway
improves on test side,the test is positive and
indicates abnormality of vestibular
component of nasal valve

44. 2. HEADACHE
3. SINUSITIS
4. EPISTAXIS
5. ANOSMIA
6. EXTERNAL DEFORMITY
7. MIDDLE EAR INFECTION

45. TREATMENT
• Minor degrees of septal deviation require no
treatment
• If produces mechanical nasal obstruction or
other symptoms, an operation is indicated

46. 1.SUBMUCOUS RESECTION OPERATION
• Generally done in adults under local
anaesthesia
• Elevating the mucoperichondrial and
mucoperiosteal flaps on either side of the
septal framework by a single incision made on
one side of the septum
• Removing the deflected parts of bony and
cartilaginous septum
• Repositioning the flaps

47. 2.SEPTOPLASTY
• Conservative surgery
• Only most deviated parts are removed
• Rest of the septal framework is corrected and
repositioned by plastic means.
• Mucoperichondrial or mucoperiosteal flap is
generally raised only in one side of the septum
retaining the attachment and blood supply of
the other

49. Foreign body nose

50. What is foreign body?
• An object is considered a "foreign body" if the
object is in a location in the body where it does
not belong

51. • Commonly encountered in emergency
department
• In children (2-4years)
• Seen in adults who are mentally retarder
or psychiatric illness
• Foreign body nose harbors potential for
mortality if the object is dislodged into
airway

52. Frequently encountered foreign
bodies:
• Pebbles
• Slate pencils
• Beads
• marbles
• peas
• Beans
• nuts
• button batteries
• paper wads

53. Types of foreign body
• ANIMATE:
1. Maggot
2. Worms
INANIMATE:
1. Vegetable FB :paes ,beans
2. Mineral FB : metal , plastic
toys
3. Post surgical : swabs , packs
4. Sequestra : syphilis ,
neoplasms

54. Button batteries:
• result in severe destruction of
the nasal septum.
• These are composed of various
types of heavy metals: mercury,
zinc, silver, nickel, cadmium,
and lithium. Liberation of these
substances causes various
types of lesions depending on
the localisation,
• it causes intense local tissue
reaction and liquefaction
necrosis.
• As a result they can cause
septal perforations, synechiae,
constriction, and stenosis of
the nasal cavity.

55. Consequences:
Inert Foreign body
Infection and inflammation of
mucous membrane
Granulation tissue formation
and ulceration of mucosa
Necrosis of bone or cartilage
Vegetable foreign body
Absorb water and swell
evoke brisk inflammatory
response

56. Symptoms:
• Unilateral foul smeling
discharge: mucopurulent or
blood stained
• u/l nasal obstruction
• Pain
• Nasal bleed
• Excoriation of nasal
vestibular skin

57. local examination:
• Main diagnostic tool
• Object mostly found
beneath inferior
turbinate or anterior to
middle turbinate
• Erythema ,edema
• Bleeding ,fetid nasal
discharge

58. Rhinoliths
• Foreign body buried in granulations or firmly
impacted. Receives a coating of calcium,
magnesium phosphate , carbonate .
• Usually at the floor
• Radiopaque
• O/E : Brown , greyish nasal mass near the floor.
• Stony hard / gritty
• Xray

60. Removal of rhinolith:
• Done under general anaesthesia
• If very large –it is removed by lateral
rhinotomy

61. NASAL MYIASIS (maggots in nose)
• Larval forms of flies (chrysomyia)
• Attracted by foul smelling
discharge (atropic rhinitis ,
syphilis , leprosy , infected
wound)
• Patient presents with intense
irritation , sneezing , lacrimation
, headache ,epistaxis , foul smell
• Maggots can cause extensive
damage to nose , sinuses ,soft
tissue of face ,palate and eyeball
• Death can occur from meningitis

62. Investigations
• Nasal endoscopy
• X-ray may reveal
radiopaque FB
• CT nose and PNS

63. MANAGEMENT:
ANIMATE FOREIGN BODY (Maggots)
• Isolation and broad spectrum antibiotics and
analgesics
• Good nourishment
• Tablet vitamins and iron
• Inj . Tetanus
• Manual removal of maggots after placing cotton
pledgets soaked in 25% chloroform and
terpentine oil(4:1)
• Alkaline douchings
• Primary causative factor is taken care of

64. Inanimate FB removal:
• Child is restrained in
upright position
• Add few drops of nasal
decongestant
• Proper suctioning to
visualise FB
• Curved hook is passed
beyond FB and gradually
drawn forward and
removed completely

65. Indications for general anaesthesia
• Uncooperative and very apprehensive
patients
• If troublesome bleeding is anticipated
• If the FB is posteriorly placed with a risk of
pushing it back in to nasopharynx
• If a foreign body is strongly suspected but
cannot be seen in anterior rhinoscopy and
radiolucent

66. Removal of FB under general
anaesthesia:
• Patient is anaesthetised with cuffed ET tube
• Pharyngeal pack placed
• If FB is placed posteriorly , patient positioned
in rose position and mouth gag applied.
• Palate is generally retracted with a catheter
which is placed through unaffected nasal
cavity
• FB is pushed from anterior nares in to the
nasopharynx and pick up with foreps

67. Thank you