explore nasal cavity

1. THE NOSE
BY MR OSEKU ODELE AGAPITO
DCMCH, BCP, MPH, MME
Clinical Anatomy
• Consists of bony parts (nasal and maxillary bones)
• Cartilaginous parts
• Septum dividing the nose to give the left and the right
canals
• Three turbinates ( inferior, middle, superior)
• Three meati corresponding to the three turbinates
(lacrimal gland, PNS drainage)

2. Blood supply to the lateral wall of the nasal canal
cf: epistaxis and achieving haemostasis

3. The blood supply to the septum
(note the central attention to the Little’s area)

4. Physiology
1) Olfaction by the cribiform plate of about 1 sq. cm on
each side of nasal canal
2) Filtration
-through adhesion of dust, bacteria, and other particles to
the mucous membrane
-particles removed by ciliary movements backwards and
swallowed with secretions
3) Humidification
-optimum for air reaching the lungs is 40% but varies b/n
10% - 95% depending on atm. humidity

5. 4) Warming or cooling the air reaching the lungs
5) Phonation cf rhinolalia aperta/clauda
6) Self cleansing
- By ciliary action
- Over action of the cilia results in copious
secretion
- Impaired action may result in post nasal drip
due to thickened mucus e.g. drying,
inflammation, unsuitable drugs

6. Examination
• Follows full history and social background of patient i.e.
main complain, mode of onset, time/season of
occurrence, associated symptoms, general health, family
history etc
• Clinical exam of the nose done through nares and/or
choanae
- anterior rhinoscopy using nasal speculum
- posterior rhinoscopy using tongue depressor and a small
post-nasal mirror
- seen will be; nasal cavities and contents, choanae,
adenoids, eustachian tube openings

7. Symptoms of nasal diseases
• Nasal obstruction the most common
- may be due to anatomical abnormality
mucosal membrane abnormality
polyp or increased secretion
allergies and vasomotor
control abnormalities
• Nasal discharge
- common in nasal sinus diseases

8. - may be thin and watery as in colds
- thick as in ciliary dysfunction conditions
- purulent as in sinus bacterial infections
- unilateral and foul smelling as in cases of
Foreign bodies (FB) in the nose
- thick and blood stained as in cases of
carcinoma (ca)

9. • Nasal pain
- less common and present in several ways
* burning sensation and irritation
* severe & localized as in furuncles
* referred as in dental pain
* non-localized - in trigeminal neuralgia
• External nasal deformities
-may be congenital, result from facial trauma,
syphilis/TB infections or from carcinoma effects

10. Diseases of the external nose
• Injuries resulting from fractures of facial structures
• Lacerations secondary to RTA, fist fights etc
• From improper FB removal attempts
Diseases of nasal septum
-haematoma secondary to trauma
-septal abscess secondary to haematoma or hair
root/sweat gland infections
NB may result in cavernous sinus thrombosis

11. • Septal deviation (in cartilaginous or bony parts)
resulting from trauma or may be developmental
- may exacerbate epistaxis from Little’s area
• Septal perforation
- may result from trauma, septal operations septal
haematoma/infections, bilateral cauterization of
Little’s areas

12. Diseases of the vestibule
- dermatitis and boils due to infections of the skin
appendages (hair follicles, sweat glands)
(to prevent cavernous sinus syndrome infection
site should not be squeezed)
- tumours in form of warts, ulcers or fissures may
be seen in the nasal vestibules

13. Diseases of the nasal cavity
A) Infectious diseases
1. Acute rhinitis/coryza/common cold
- Caused by rhinovirus
- more common in children
- cause rhinorrhoea, nasal obstruction, sneezing,
pharyngitis, cough and malaise for 5 – 7 days
- during acute phase, ciliary activities are great
and copious secretions are cleared

14. - during the obstruction phase, the cilliary
activities are diminished, destroyed
membranous cells accumulate and produce
thick yellow secretion difficult to eliminate
Treatments
• Isolation, bed rest, increased intake of warm
fluids
• Nasal decongestants, antihistamines,
• ABC only in elderly and children to avoid
possible sinusitis and lower RTI
• Prophylaxis suggested but not recommended

15. 2. Chronic rhinitis
• May result from acute form or from unsuspected sinusitis
• From prolonged exposure to dust, fumes or unsuitable
weather conditions
Symptoms
• Presents with reddening/swelling of mucosal membrane,
nasal obstructions, but no fevers
• Freq headaches, mouth breathing, snoring
• Mucopurulent nasal D/C
• Reduced hearing due to eustachian tube dysfunction

16. Treatments
- antihistamines
- topical decongestants (cf ephedrine can
give rebound effect – rhinitis
medicamentosa)
- steam inhalation/ nasal douching
- turbinate surgery (cryotherapy,
turbinectomy, electrocautery)

17. 3. Purulent (bacterial) rhinitis
- rare but usually sever
- may follow viral infections
- show nasal obstruction, purulent discharge,
facial pain, fever
Treatments
Are the same as for viral rhinitis plus antibiotics

18. 4. Atrophic rhinitis
- result from conditions that cause prolonged
drying of nasal mucosal membrane
e.g. post operative conditions, occupational
chemical factories
- endocrine dysfunction
- undiscovered sinus infection
• Ciliated mucosa changed to cuboidal one hence
impairing ciliary clearance
• Glands are atrophied & vessels are obliterated

19. Symptoms
- dryness in the nose, pharynx, larynx
- false sensation of nasal obstruction (fully patent
nasal canal) due to loss of air flow because the
mucosa is dry and insensitive
- crusts may actually block the nasal canal
- is referred to as rhinitis sicca in elderly or those
working in hot, dry, dusty conditions
NB no decongestants, avoid probable causes

20. • Is referred to as Ozeana as is seen in young
females where offensive smell from the nose
ensues even before the crusts have formed in
the nasal canals
- the mucous membrane is dark coloured
- membrane is very dry
- crust is usually yellow
Treatments involve
*canal douching several times daily
*parotid duct transplanted into nasal cavity to
prevent drying in extreme cases

21. B) Inflammatory Diseases
1. Allergic rhinitis
• Affects about 10% world population
• Has strong family predisposition
• Is classically an IgE – mediated Gel and
Coomb’s type I hypersensitivity reaction
(NB check the other hypersensitivity reactions II,
III, IV)

22. • Inhalants are the most common group of
allergens in nasal atopy
e.g. plant pollen, dust mites, dander from
carpets, drapes, pets, molds, soil, fungus
• May be seasonal (pollen) or perennial (the
rest)
• May occur after ingestion of some foods or
drugs

23. Mechanism
• Mast cells in nasal mucosa have IgE (reagenic
antibody)
• When reagenic antibody reacts with antigen the
mast cell degranulates releasing histamine and
other mediators of anaphylaxis (serotonin, slow
reacting substance of allergy), platelet activating
factor-PAF
• Eosinophiles are attracted to the site of
degranulation to try to neutralize the released
mediators (engorgement and pruritus)

24. Symptoms
- rhinorrhoea, postnasal drip, pruritus (nasal,
ocular, palatal, aural), nasal obstruction
- others are anosmia, sneezing, sinus pain,
headache, oedema of the turbinates, tearing
-upward stoking of the nose may result in ‘allergic
salute/allergic shines’ appearance of the nose
Diagnosis is based on history and clinical findings
without need for specific testing

25. Examples of specific allergic tests are
- scratch test
- skin prick test
- intradermal dilution test
- invitro testing using serum
-nasal cytology

26. Treatments
1. Avoidance of allergen when known
2. Suppression of allergic reaction using antihistamines
and steroids
3. Local treatment with local decongestant give
temporary relief
4. Specific locally acting inhalers esp in non-specific
rhinitis with no identified allergen
5. Specific hypo sensitization when allergen known (to
induce a ‘blocking Ab’ that intercepts Ag before it
reacts with IgE-bound mast cells
6. Correct nasal conditions (sinusitis, nasal polyp, etc)

27. 2. Vasomotor Rhinitis
• Inflammatory nasal condition unrelated to
allergy, infection or other etiology
• Due to sensitivity to cold, dry air, perfumes, paint
fumes, cigarette smoke or other chemicals
• Patients experience predominantly either
rhinorrhoea or congestion
• Rx same as for allergic form (decongestants,
anti-cholinergic and desensitizers)
• Vidian nerve section (parasympathetic nerve
section) considered on pats with severe forms

28. 3. Nasal Polyp
• Are grayish, pedunculated masses seen in nasal
canals
• Result from idiopathic perennial, reactive
inflammatory conditions of the mucous
membrane of the nose & paranasal sinuses –
PNS
• Most arise from the lateral aspect of the middle
meatus
• Seen usually during ant rhinoscopy
• Bilateral (unilat. – R/o ca or inverting papilloma)

29. • Are pale, grape-like masses with oedematous
membrane seen in nasal canals
• Cause symptoms of nasal obstruction and D/C -
mucoid means polyp of nasal origin
- purulent means polyp of sinus origin
• Other symptoms: hyposmia & anosmia
Rx
-topical corticosteroids (medical polypectomy) esp
for small ones
-surgical polypectomy with freq post op review

30. C) Other condition of nasal canal
1. FB
• -Especially in children where seeds, pebbles, rubber,
sponge, beads, toys stones, are common objects
found
• -symptoms of obstruction and/or foul smelling
unilateral nasal discharge
• -rhinolith may form in adults after plugging the nose
due to epistaxis
• -removal using FB hooks may require GA
*FB search may result in inhalation hence FB bronchus*

31. 2. Epistaxis
• Physiologic demands on nasal mucosa -
warming, moistening, filtering air – require vast
blood supply and this increases the potential for
haemorrhage
Causes
• Any condition that injures or causes hyperaemia
of nasal mucosa predisposes to epistaxis
e.g. drying under air conditioning, trauma, nose-
picking, sneezing nose blowing

32. • Sinusitis, URTI, allergy increases mucosal
vascularity and friability
• Neoplasms may present with epistaxis
• Bleeding disorders, ca chemotherapy HIV,
hereditary teleangiectasy
• Nasal decongestants
• 95% of bleeds occur in the ant. Part – the Little’s
area esp. in young and middle aged individuals
• In elderly, bleeding occurs in deep posterior
areas of nasal canal (cf HT, atherosclerosis)

33. Treatments
• Pinch & hold nostril for 5 – 10 mins
• Lignocain – adrenaline pack for 15 mins
• Chemical cautery (one side only) using silver
nitrate or chromic acid 25%
• Electro-cautery
• Petroleum embedded anterior nasal pack for 3 –
5 days
• If adequate ant pack fails then posterior pack
• Ethmoidal or maxillary artery ligation

34. Layer placement of nasal pack/sponge. First layer comes
on the floor of the canal. (? Instruments used?)

35. Examples of nasal canal balloons for intra –canal and post
nasal packing.

36. Both anterior and posterior packing using appropriate
balloon

37. Suitably placed post-nasal balloon for post nasal packing

38. 3. Disorders of smell
• Closely associated with disorders of taste
(check mechanism of smell & taste)
• Anosmia – loss of sense of smell
• Dysosmia – impaired sense of smell esp in elderly
• Parosmia – distorted sense of smell
• Phantosmia – smelling non-existent odour
• Parosmia & phantosmia are associated with post URTI
olfactory loss, trauma, aging, temporal lobe
lesion,epilepsy, & olfactory hallucination of schizophrenia
• Hyperosmia – increased sensation (Addison’ Disease)

39. Causes of anosmia
-obstructive nasal disease, post viral infection
-head trauma, toxic drugs
-congenital, aging, neoplastic
-psychologic
-idiopathic
Rx
Condition specific where possible
Concurrent evaluation of taste should be done

40. Tumours in nasal canal
• Benign tumours comprise of
-warts (sq papilloma) in vestibule
-fibroangioma originating from medial aspect of canal
• Malignant tumours include
-sq. cell ca fairly common
-adeno-ca, malignant melanoma, sarcoma
• Rarely originate from nasal canal
Rx: depend on tumour type
NB: check on rhinophyma, rhinosporidiosis
rhinescleroma, granulomatosis, sarcoidosis

41. Trauma to the nasal structures

42. Approximate boundary between thicker and thinner
portions of the nasal bone

43. Look out for maxillo-facial fractures with or without involvement of the nasal
structures (cf: Le Fort I, II & III)