KAU Rabigh School of Medicine Department of Otolaryngology

KAU Rabigh School of Medicine Department of Otolaryngology, Head and Neck Surgery

Tutorial 6 By Razan A. Basonbul, MBBS NASAL OBSTRUCTION

Objectives • • • Definition Differential diagnosis History Examination Investigation Common issues: • Mucosal Swelling • Septal deviation • Collapse of nasal valves • Nasopharyngeal obstruction: • • • Adenoids Choanal atresia Nasal polyps Cephalocele Tumors, JNA

Definition • Nasal obstruction is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral). There are four main subdivisions: • • Mucosal swelling Septal deviation Collapse of the nasal valves Nasopharyngeal obstruction

Differential Diagnosis KITTENS Method (K) congenital • • • Neurogenic tumors. Conginital Nasopharyngeal cysts. Teratoma Choanal atresia. Nasoseptal deformaties Infectious & Idiopathic • • Infectious Rhinitis Rhinoscleroma Chronic Sinusitis Adenoid Hyperplasia • • • Endocrine • • • Diabetes Hypothroidism Pregnancy Neurologic • Vasomotor rhinitis Toxins & Truma Tumor ( Neoplasia) Nasal & septal Fractures Medicatios side effects ( Rhinitis medimentosa) Synechia Environmental irritants Septal Hematoma Foreign bodies • • systemic • • Granulomatous diseases Vasculitis Allergy Cystic fibrosis • • Papillomas Nasal Polyps Hemangiomas Pyogenic granulomas Juvenile nasopharyngeal angiofibromas Malignancy

History • Character of Nasal Obstruction: Onset and duration. Constant VS intermittent. Unilateral VS Bilateral. Associated mouth breathing, Snoring, anosmia/hyposmia/taste disturbance • Tearing ( Nasolacrimal Duct Obstruction or Allergy). • • • Contributing Factors: • • Toxin and Allergen exposure. Known Drug Allergies Medications Hx of Asthma Rhinosinusitis Sleep Disturbance Facial Trauma or Surgery Common Drugs that cause Nasal Congestion • • • Antihypertensive, Asprin OCP Chronic Nasal Decongestants Cocaine, Marijuan Tobacco Antithyroid Medication

• Associated Symptoms and signs: • Allergic component: • • Sneezing Itching Watery eyes Clear Rhinorrhea • Sinus Involvement: • Facial Pain • Headaches • Acute Infection: • Fever • Malaise • Purulent or odorous nasal discharge • Pain • H&N: • • Sore throat. Postnasal drip Cough Ear complaints Halitosis Ocular pain hoarseness

Examination • External Nasal Exam: • External deformities: ( firmness, tenderness on palpation) • Nasal flaring • Nasal airflow • Anterior Rhinoscopy/ Nasal endoscopy: • • • Examine twice ( with and without topical decongestion) Quality of turbinates ( hypertrophic, pale, blue) Quality of nasal mucosa, Septum. Osteometal complex obstruction Foreign body, Nasal Masses, Choanal opening • Quality of Nasal Secretions: • Purulent and thick ( infectious) • Watery and clear ( Vasomotor rhinitis, Allergy) • Salty and clear ( CSF leak)

• H & N exam: • • • Facial Tenderness Tonsil and adenoid hypertrophy Cobblestoned posterior pharynx Cervical lymphadenopathy Otologic exam

Investigations • Allergy Evaluation • CT/MRI of Paranasal Sinus: • CT is Indicated if Obstruction secondary to; • Nasal Masses • Nasal Polyps • Work up for Chronic rhinosinusitis • MRI is preferred if; • Suspected Tumors • Intracranial involvement • Complicated rhinosinusitis • Biopsy: For any mass suspecious of malignancy, avoid biopsy of vascular neoplasms or encephaloceles. • Ciliary Biopsy and mucociliary Clearance Tests: Electron microscopy and ciliary motility studies for ciliary defects. • Nasal secretion protien, Glucose or B 2 -transferrin: For CSF leak.

• Culture and Sensitivity: Direct Nasal Swabs or Surgically obtained cultures may be indicated of r complicated acute rhinosinusitis and resistant chronic rhinosinusitis. • Pulmonary Function test: Considered if suspected coexisting reactive airway disease process.

Nasal obstruction Children Adults *Large Adenoids *Deviated Nasal Septum *Choanal Atresia *Rhinitis *Postnasal space tumors (angiofibroma) *Foreign body *Rhinitis, Sinusitis *Polyps *Granuloma ( wegner’s) *Topical vasoconstrictors Refer to ORL urgently: Refer to ORL in the same day if: Unilateral obstruction ± foul or bloody discharge. Numbness, tooth pain, bleeding, unilateral obstruction, tumor suspected

Mucosal swelling • Autonomic rhinitis Clear mucus production is the primary problem with less nasal obstruction. This is due to over activity of the glands in the nose. It is not common and usually occurs in the over 60 s. • Rhinitis medicamentosa Overuse of some decongestant nasal sprays (Otrivine, Sinex). These can help decongest the nose for a few hours if you have a cold but should not be taken for more than a 5 days as they damage the lining of the nose. • Chronic infection It is associated with a mucky discolored production of green mucus through the day. • Idiopathic rhinitis Where neither allergy nor infection can be found yet the lining of the nose is swollen.

Turbinate Hypertrophy

Turbinate Hypertrophy With lower two showing management with coblation

Septal deviation • Septum is bent or deviated over to one side and this blocks the air passage of the nose. • Septal deviation may be associated with a visibly deformed nose and a history of nasal trauma although it is not necessary as the cartilage may bend and deform as the nose grows. • Nasal obstruction is the predominant symptom, usually on one side. However, if other symptoms are present other disease processes must be excluded. • Management depends on the severity of nasal obstruction. Surgery to correct the deformity can be undertaken if the nose is blocked or unsightly.

Deviated nasal septum

Septal Hematoma • Occurs following Trauma, Drugs as ASA or Idiopathic. • Management by: Drainage and pressure Dressing. .

Collapse of the nasal valves • Normally on breathing in through the nostrils there is a small amount of collapse of the nostrils. Often this collapse stops if the mucosal swelling is treated. • Occasionally the problem is primarily due to a ‘floppy’ valve or side wall of the nose collapsing. • Treatment using external nasal splints can sometimes be help at night. Surgery is an option in case of bothersome issue.

Nasopharyngeal obstruction Adenoids : • Most common cause of nasal obstruction in children • reaching maximum size between the age of 3 -5 years old and then reduce in size often by the age of 7 and can hardly be seen by the late teens. • Snoring alone is not an indication for adenoid removal but if the child also develops apnea (stops breathing for more than 10 seconds regularly without a cold) then adenoidectomy and tonsillectomy may be helpful.

Choanal atresia • Incidence of 1 in 5000 to 1 in 10, 000 births and is more often unilateral than bilateral. • The atresia is bony in 90% of cases and membranous in only 10%. • The choana develop between the 3 rd and 7 th embryonic weeks. • Symptoms: • Bilateral choanal atresia is an acutely life threatening emergency! The resulting hypoxia is manifested by cyanosis that is present at rest and improves with exertion is called paradoxical cyanosis. • Unilateral choanal atresia may be manifested by a purulent nasal discharge on the affected side.

• Diagnosis: • Both choanae in newborns should be routinely catheterized in the immediate postnatal period (e. g. , with the suction catheter) to exclude choanal atresia. • Rigid or flexible endoscope. • Treatment: • Bilateral: intubation followed by perforation of the atresia plate. • Recurrent: stenosis is prevented by inserting a stent and securing it with a suture (to prevent aspiration). • The definitive surgical repair of bilateral choanal atresia is performed during the first weeks or months of life. • Unilateral: Surgery can be postponed until school age.

Coanal Atresia

Nasal Polyps • Defined as benign swelling of most commonly ethmoid sinus mucosa of unknown cause. • Histology: waterlogged stroma infiltrated with inflammatory cells and eosinophils. • They rise from each ethmoid air cells and hang down inside the nasal cavity. • Polyps can arise from other sinuses as a single large polyp arising from the maxillary sinus called antrochoanal polyp, this prolapse done the nasopharynx. • Associated with: Asthma, Aspirin Sensitivity and Cystic fibrosis. • Samter’s Triad: Nasal Polyposis, Aspirin Allergy and Asthma.

• Hx: • • Nasal obstruction, watery rhinorrhea, sinus infection, anosmia. • Ex: • Pale, Semitransparent gray mass. • Mobile. • Insensitive when palpated. ( differentiate it for hypertrophied turbinate) • May prolapse out of the nose if left untreated. • !! Role out Malignancy in Adults with unilateral polyp. • !! Role out Meningocoele or encephalocoele By CT • TTT: • Topical Steroids spray • Surgery

Nasal polyps ALL POLYPS SHOULD BE SENT TO HISTOPATHOLOGY!

Cephalpcele • Cephaloceles are herniations of intracranial contents through a bony defect in the skull. • Types: • Meningocele. • Meningoencephalocystocele (meningocele + portions of the ventricular system) • Etiology: • Most cephaloceles are congenital. • Rare cases are post-traumatic (e. g. , after a frontobasal fracture) • Presentation: Closely resemble Nasal Polyp. But have to be role out in Unilateral nasal polyp in children.

• Diagnosis: • CT or MRI can supply information on the location and extent of the mass and the associated bony defect. • Treatment: Always surgical and consists of removing the cephalocele and repairing the dural defect

Tumors Of the Nasal Cavity • Unilateral nasal blockage, discharge and bleeding are often the presenting symptoms of nasal or sinus tumors. • Osteomas are often asymptomatic. • Transitional cell papilloma is the most common benign tumor ( may undergo malignant changes) • Squamous cell carcinoma is the most common malignant tumor. • 50% of Sinonasal cancer arise from lateral nasal wall, 33% in Maxillary antrum.

Juvenile angiofibroma (JNA) • A benign tumor that arise adjacent to the sphenopalatine foramen, tends to bleed and occurs in the nasopharynx of prepubertal and adolescent males. • Epidemiology: • 0. 05% of all head and neck tumors. • Occurs in MALES. • Affects age 7 -19 years. • Presentation: • Nasal obstruction (80 -90%) • Epistaxis(45 -60%) unilateral sever bleeding. • Headache (25%)

• Diagnoosis: • Vascular unilateral nasal mass. • CT and MRI showing the extent of the tumor growth. • Angiography shows branches of external carotid that feeds the tumor. • Treatment: • Hormonal: Testosterone receptor blocker • Surgical Resection and Radiotherapy.

Foreign Bodies of the Nose Mostly are self inserted by children. Organic materials present early by Purulent Discharge Inorganic materials may remain for ages. Presentation: • unilateral, foul smelling nasal Discharge ± blood • Management: • Forceps: Pieces of paper or cotton swabs. • blunt hook: for Rounded objects, pass it deeper than the object then • • try to bring it out by dragging it over the floor of the nose. • Removal under General Anastasia might be required, make sure to protect the airway! • Complications: • Nasal infection and sinusitis. • Rhinolith formation. • Inhalation into the tracheobronchial tree.

Nasal Foreign body removal

Foreign body removal by balloon catheter

Be aware ! • In children with a blocked nose on one side and a one sided nasal discharge, a foreign body may be in the nose. • Nasal polyps are rare in children and further tests should be done. • Nasal obstruction of one side of the nose in adults, with or without bleeding, needs to be REFERED to be examined carefully by an otolaryngologist. • Instruct the patient to Avoid the long-term use of nasal medication purchased over the counter unless specifically prescribed.

• References: • Clinical Otolaryngology online (COOL) http: //www. entnet. org/Education. And. Research/cool. cfm Under the American Academy of otolaryngology, Head and Neck Surgery • The British Association of Otolaryngology Head and Neck Surgery http: //www. entuk. org/patient_info/nose/obstructions_html • Otolaryngology head and neck surgery by Raza Pasha, MD • Primary care otolaryngology • www. emedicine. medscape. com • Bailey and Love Short practice in surgery 25 th edition. • Oxford Handbook of clinical specialties. T h a n k y o u