1.

2 Diseases of the Nose, Paranasal

Sinuses, and Face

Francisco Victoria, MD June 11 & 18, 2015

OUTLINE Bilateral choanal atresia

I. Malformation of the Nose, Paranasal Sinuses, and Face o acutely life threatening because neonate is an obligate
A. Choanal Atresia nasal breather (except when crying) until 6th week of life
B. Frontobasal Dysraphias o episodes of asphyxia at rest when mouth is closed
C. Dorsal Nasal Fistula during sleep and feeding
D. Cephalocele o leads to hypoxia manifested by cyanosis, bradycardia,
II. Nasal Deformities and erratic respiratory rate
A. Septal Deviation o paradoxical cyanosis: cyanosis present at rest and
B. Deformities of the External Nose S improves with exertion because of opposite of cyanosis
C. Septal Perforation S with cardiac cause
III. Epistaxis x Unilateral choanal atresia
IV. Foreign Body o purulent nasal discharge on affected side
V. Soft Tissue Injuries and Plastic Surgery CHARGE Syndrome: presentation of fully developed cases
VI. Fractures of the Nasal Pyramid and Lateral Midface o Coloboma
A. Nasal Pyramid Fracture o Heart disease
B. Lateral Midline Fracture o Atresia of choanae
VII. Fractures of the Central Midface and Anterior Skull Base o Retarded growth (development and/or CNS anomalies)
A. Central Midfacial Fractures o Genital hypoplasia
B. Frontobasal Fractures o Ear anomalies or deafness
VIII. Inflammations of the External Nose, Nasal Cavity, and  routine catheterization (w/ suction catheter) of both
Facial Soft Tissue D
choanae in newborns (immediate postnatal period)
A. Purulent Inflammations of the Hair Follicles x
 confirmation by a rigid or flexible endoscope
B. Erysipelas  intubation followed by perforation of atresia plate
C. Inflammations of the Nasal Cavity  Recurrent stenosis: prevented by stent insertion with
IX. Sinus Inflammations suture to prevent aspiration
A. Acute Sinusitis T
 Bilateral choanal atresia: definitive surgical repair at first
B. Chronic Sinusitis x
weeks or month of life
X. Dangerous Triangle of the Face  Unilateral choanal atresia: surgery can be postponed until
A. Cavernous Sinus Thrombosis school age (when anatomy is more similar to the adult)
XI. Nasal Polyposis
XII. Antrochoanal Polyp
A. Caldwell-Luc Procedure
B. Antral Lavage
C. Functional Endoscopic Sinus Surgery
XIII. Tumors of the External Nose and Face
A. Benign Tumors
B. Precancerous Lesions
C. Malignant Tumors
XIV. Tumors of the Nasal Cavity and Paranasal Sinuses
A. Benign Tumors
B. Malignant Tumors

MALFORMATIONS OF THE NOSE, PARANASAL SINUSES,

AND FACE
Fig. 2 Normal nasopharynx
CHOANAL ATRESIA (transnasal endoscopic view)
 Choanae: posterior openings that connect nasal cavity w/
nasopharynx
 Persistence of bony plate or membrane
 Embryonic failure of bucconasal membrane to rupture prior
to birth
 Develop between 3rd-7th embryonic weeks after rupture of
vertical epithelial fold between olfactory groove and roof of
primary oral cavity (pronasal membrane)
 Failure of rupture will result to stenosis (partial closure) or
E atresia (complete closure)
t
i
o
l Fig. 3 Stenosis of left choana and atresia of right choana
o (postrhinoendoscopic view)
g
y FRONTOBASAL DYSRAPHIAS
 analogous to a dermal sinus or spina bifida involving the
lumbar portion of the spine
 exposure to teratogenic agents:
Etiology

o 2nd or 3rd week of embryonic development (formation

of neural tube)
o 4th week (formation of cerebral ventricles and central
canal; separation of CNS from epidermis for migration to
Fig. 1 Rupturing oronasal membrane a deeper level)
Incidence: Incidence:
E
Epi

 5,000 to 1 in 10,000 births  1:20,000 to 1:40,000

p
i  unilateral>bilateral
 90% bony atresia cases vs 10% membranous atresia cases 1. 1. DORSONASAL FISTULAS
d
 fistulous tract lined by keratinized squamous
Morpho
epithelium

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 Diseases of the Nose, Paranasal Sinuses, and Face
 forms tiny opening on dorsum or tip of nose
 may terminate blindly or extend into cranial
cavity (creates an open communication with
subarachnoid space)
 fistulas that terminate blindly manifest
M clinically at older age due to inflammation around
a fistulous opening
SSx
n  fistulas that communicate with
i subarachnoid space may lead to cerebrospinal
f fluid leakage, meningitis, brain abscess
e  CT scan
s  MRI
t Dx  Diagnostic catheterization or contrast
a injection is contraindicated due to risk of
t intracranial complications
i  complete removal of fistulous tract may include
o excising dural defect and repair by duraplasty
n Tx
 incomplete removal will predispose to recurrent
infections
2. NASAL DERMOIDS
Fig. 4 Presentation of nasal dermoid L-R: Nasal tip, hair
follicles, nasal pit and infected dermoid (frontal view), nasal
pit and infected dermoid (lateral view)
Morpho  lined by keratinized squamous epithelium
 sites of predilection: dorsal nasal midline and
nasal flank (lesions present as cystic
protrusions)
Sx  may coexist with dorsal nasal fistula in rare
cases
 abscesses may develop as an inflammatory
complication
Dx & Tx  same as in Dorsonasal Fistula
3. CEPHALOCELES
 herniation of intracranial contents through a
Morpho
bony defect in skull
Etio  congenital>post-traumatic
SSx
1. Based on structures involved:
 Meningocele: congenital protrusion of
leptomeninx
 Meningoencephalocele: leptomenix and
Types
brain tissue
 Meningoencephalocystocele:
meningocele plus portions of ventricular
system
Diagnosis
 most manifest clinically during childhood
 Cephaloceles of anterior base skull:
1. Sincipital cephaloceles
o located near glabella, forehead, or orbit
o often associated with broad nasal
dorsum and hypertelorism
Manif
Treatment
Fig. 5 Sincipital cephalocele
2. Basal cephaloceles
o found mainly in nasal cavity or
Transcribers: CARLOS, DELA ROSA, GNILO, LATONIO, LAURILLA
1.2
nasopharynx
o Presents as an intranasal mass and
with associated nasal airway
obstruction
o closely resemble intranasal polyps
o considered in DDx of children with
suspected nasal polyps w/c are rare
in this age group
 CT scan
 MRI
Dx Fig. 6 Coronal CT with bone window setting
Fig. 7 Coronal CT with soft tissue window
 always surgical
 removal of cephalocele
Tx
 repair of dural defect and associated anomalies
of orbit and facial skeleton
4. FRONTONASAL EXTRACEREBRAL GLIOMAS
NASAL DEFORMITIES
SEPTAL DEVIATION
 A congenital or traumatically acquired bending or bowing of
the nasal septum
 almost everyone has some degree of bowing, spurring, or
ridging of cartilaginous or bony nasal septum
 may obstruct nasal breathing and can cause olfactory
impairment due to inadequate ventilation of olfactory
groove
 deficient nasal airflow may lead to paranasal sinus
sequelae such as headaches and recurrent sinusitis
 large septal spur that comes into contact with nasal
turbinates can cause epistaxis
 Septal subluxation
o anterior septal margin is displaced from medial plane
o readily identified by external inspection of nasal base
 Anterior rhinoscopy or endoscopy
o can verify morphologic changes in nasal septum
 Rhinomanometry
o objectively evaluates degree of nasal obstruction
 Olfactory testing should always be done prior to surgical
treatment for medico-legal reasons
Septoplasty
o straightening of deviated septum
o removal and reimplantation of deviated cartilaginous and
bony portions of septum, spurs, and ridges as needed
until septum is tension free in median plane
o indication: any septal deviation causing subjective
complaints with functional impairment of nasal breathing
o indiscriminate use in children and adolescents under 15-
17 years of age can damage growth zones of septum
o “Scoring” procedure; weeks after follow-up, deviation
may still exist
Submucous Resection [SMR] of the Nasal Septum
o No longer used except when harvesting [quadrangular]
cartilage for corrective surgeries.
o May c ause saddle-nose deformity later on
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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

NOSE BLEED (EPISTAXIS)

Local Causes: Systemic Causes:
 mucosal hyperemia due to  vascular and circulatory
acute inflammation (rhinitis) diseases
 allergies (atherosclerosis,
 ambient conditions that dry arterial HPN)
mucosa  hemorrhagic diathesis
 increased fragility of (Osler disease)
intranasal vessels o coagulopathies
Fig. 8a. Nasal septum deviated Fig. 8b Bony septal spur that (airconditioning) o platelet disorders
towards left causing airway touches inferior turbinate  local manipulation or nose o vasopathies
obstruction causing epistaxis picking in Kiesselbach’s area  infectious diseases
DEFORMITIES OF EXTERNAL NOSE (richly vascularized area of (influenza, measles,
 congenitally or traumatically acquired septal mucosa at junction of typhus)
nasal cavity and vestibule)  endocrinopathies
Etio

 Virtually any bone and cartilaginous structures of the

external nose may be affected  congenital or acquired nasal (pheochromocytoma,
septum abnormalities (septal pregnancy, diabetes
1. CROOKED NOSE spurs or ridges mellitus)
 septal perforation

Etiology
o septal abscess: septal
fracture with superinfected
septal hematoma
o autoimmune disease:
Wegener granulomatosis
o previous septoplasty
leading to mucosal
perforation and cartilage
2. HUMPED NOSE necrosis
 change in nasal septum Fig. 9 Kiesselbach’s area
(perforation, traumatic, on the anterior septal
iatrogenic, inflammatory, mucosa (site at which
spurs, ridges) epistaxis typically occurs
 mucosal or vascular injuries due to a local cause)
(fpreign bodies, rhinoliths,
trauma, allergies, acute
rhinitis, traumatic aneurysm
Types

of internal carotid artery)

3. SADDLE NOSE  neoplasia
 idiopathic
 blood pressure measurement
 hemoglobin measurement
Diagnosis

 platelet count, bleeding time, thromboplastin time, partial

thromboplastin time or PTT, thrombin time (for exclusion
of coagulation disorders)
 ant. rhinoscopy or endoscopy following decongestion and
local anesthesia or mucosa
 Nostrils are compressed against the nasal
4. BROAD NOSE septum
 Patient is told not to swallow blood running
down the pharynx
 Patient is kept in an upright posture to
General
reduce blood flow to the head and inhibit
measures
the swallowing of blood
 Ice bag can be placed on the back of the
neck to induce reflex vasoconstriction
 Intravenous line should be placed if
bleeding is severe
 Inspection: identification of affected cartilaginous and bony  For mild epistaxis from Kiesselbach’s area
Treatment

structures  Opposing sites on the nasal septum should

 Anterior rhinoscopy or endoscopy: evaluate shape and Silver
not be cauterized due to the risk of septal
Dx

position of nasal septum nitrate

cautery perforation
 Photographic documentation: always obtained
preoperatively for medicolegal reasons
 Functional septorhinoplasty with correction of nasal  For severe epistaxis
septum and external nose  anterior nasal cavity packed with ointment-
 Bony nasal skeleton is osteomized at multiple sites to impregnated gauze strips or ready-made
foam packs that expand on contact with
Tx

achieve desired nasal shape and position

 For humped nose: Dorsal hump removal Nasal fluid
 For saddle nose: corrected by filling dorsal concavity with packing  Both nasal cavities should always be packed
cartilage graft taken from septum, auricle, or rib in order to produce adequate counter
pressure
SEPTAL PERFORATION  Packing should not remain in place for more
Majority is iatrogenic in nature or caused by doctors after than 2–3 days
Etio

septorhinoplasty
May also be caused by septal abscess
 Sometimes, larger perforation is better because in slit-like
Tx

perforation, the patient whistles every time he talks

 Perform reconstruction to repair the perforation

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

Fig. 12 Bleeding from edges of septal

Fig. 10 Nasal packing perforation
 Double-lumen balloon catheter:
introduced and inflated with water (air
sabi ni doc sa lecture) to produce local
compression in the nasal cavity and
nasopharynx.
 Posterior nasal pack (Bellocq pack):
If bleeding persists; must be used in
caution due to risk of aspirating pads in
Alternatives nasopharynx
to Nasal  Systemic complications of anterior and
Packing: posterior nasal packing:
o Arterial hypoxia: fall of oxygen partial Fig. 13 numerous punctate telangiectasias
pressure with pulmonary dysfunction in the left nasal cavity in Osler disease
due to an impaired nasopulmonary
reflux mechanism.
o Toxic shock: focal staphylococcal
infection develops within 24h after
nasal packing, with generalized shock
symptoms caused by bacterial toxins.
 only temporary
 coagulation or clipping of the
sphenopalatine artery (branch of the
maxillary artery), which is the most
common source of bleeding from the
posterolateral part of the nasal cavity
 ligation or angiographic embolization of a
larger arterial trunk may be considered as
a last recourse
 source of the bleeding must be accurately
identified since the nasal lining is supplied
by various arteries

Vascular
ligation or
embolizatio
n

Fig. 11 Vascular ligation for severe epistaxis

 Indications: septal spurs, ridges, and
perforations
 Septoplasty or closing of septal
perforation: implantion of an auricular
cartilage graft and using local mucosal flap
Surgical
advancement
prevention
 surgical laser: for diseases that are
of recurrent
associated with vascular changes, such as
epistaxis
Osler disease.
 Saunders dermoplasty: telangiectatic
septal mucosa is resected and replaced
with a free skin graft (from the
supraclavicular area)
FOREIGN BODY
 when removal anteriorly is not possible, don’t push the foreign
body posteriorly
 may go to the airway and lodge into right bronchus because it
is shorter and more vertica
 Dx: direct visualization (anterior rhinoscopy)
RHINOLITH
 A calculus in the nasal cavity
E  usually forms around the nucleus of a small exogenous
t foreign body, blood clot or secretion by slow deposition of
i calcium and magnesium salts.
o  May cause pressure necrosis of the nasal septum or
lateral wall of nose
T  Endoscopic guided removal
x  Lateral rhinotomy

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

SOFT TISSUE INJURIES AND PLASTIC SURGERY noticeable

 Common occurrence in recreational and traffic accidents
 Imaging studies: biplane skull films, standard sinus
projections, and computed tomography (CT) scans
Dx

 smear: bite wounds

 tetanus immunization: if with facial injuries
 Bite wounds: reduce microorganism counts and prevent
infections (tetanus, rabies) prior to surgical treatment
 maximum tissue preservation: only definitely necrotic
tissue are debride Repair of tissue defects:
 never reapproximate wound margins under tension (may  Soft-tissue defects (traumatic or post-tumor resection)
result in aesthetic and functional deficits such as often cannot be adequately managed by primary wound
incomplete eyelid closure) closure with reapproximation of the skin margins
 soft tissue injuries to nose: primary reapproximation and
suturing of wound margins LEGEND:
 Scar Camouflage
o Two fundamental local principles:
1. Relaxed Skin Tension Lines (RSTLs)
 when there are no soft-tissue or skin defects
 only direct closure is required
 scars are easier to camouflage when oriented
along RSTLs
2. Aesthetic units
 repair of smaller tissue defects
o useful in revising a functionally and/or aesthetically
 inadequate for extensive defects of external
objectionable result (lengthening a heavily contracted
nose (tumor, dog bite)
scar)
Closure of facial soft tissue wounds:
 techniques of scar revision can also be used in primary
wound care
 wound area should be broadly undermined to eliminate
tension on the reapproximated wound margins
 colored dots mark the original and transposed location of
the skin areas
 solid lines represent the wound margins
 broken lines indicate auxiliary incisions

LEGEND:

T 1. Z-plasty
x  When a wound margin runs perpendicular to the Fig. 14 Bilobed flap: butterfly-shaped
RSTLs, it can be reoriented with a single or advancement flap used to close a defect
multiple Z-plasty and lengthened in the direction
of the scar axis

Local
flap

Fig. 15 Rhomboid flap: used on the nasal flank,

as illustrated, or on the cheek
2. W- plasty
 principal effect of this technique is to lengthen the
scar

Fig. 16 Island flap: skin between the defect and

3. Broken-line closure superficial flap is under- mined, and the island
 effect of this technique is to “optically disperse” flap is pulled into the defect on its sub-
the scar, making it more irregular and less cutaneous pedicle

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

Fig. 19 Pedicled flap (myocutaneous pectoralis

major flap)

 Microvascular free transfer/flap:

autologous tissue is removed with its supply
vessels, which are anastomosed to
Fig. 17 Horizontal advancement flap: small corresponding arteries and veins at the
“burrow triangles” are excised at the ends of the recipient site
incisions, allowing the two rectangular flaps to be  very extensive defects in nasal region (tumor
advanced for defect closure resection)
 Complex flap transfers from scalp (multiple
sittings)
 Converse scalp flap:
o based on the superficial temporal artery
o One of its applications is for total nasal
reconstruction
o Backing material (costal or auricular
cartilage) should be added to the flap when
Scalp it is mobilized and inset in order to obtain
flap proper nasal height

Fig. 18 Sliding flap: if you undercut the skin at

the edges of a wound, you may be able to slide
the skin edges across to cover it
 for covering larger defects of nose
 after first reconstructing the nasal skeleton
with cartilage and bone grafts
 reconstruction with a forehead flap based on Fig. 20 Converse scalp flap
the supraciliary and supratrochlear arteries
 if the graft must also provide a degree of
stability (alar cartilage of the external nose)
 harvested from the auricle from the costal or
septal cartilage
Forehead flap

Composite graft

a. The skin surrounding the defect is

circumscribed, mobilized, and turned downward
to provide intranasal lining.
b. Next the forehead flap is raised and partially
backed with cartilage (composite graft) for
coverage of the external defect.
c. The forehead defect can usually be closed
directly
 uses autologous transfer
 for extensive defects of external nose
 Myocutaneous pectoralis major flap:
o frequently used in the head and neck Fig. 21 The nasal alar defect is repaired with a
Recons
o useful for repairing large defects in the facial composite graft of cartilage and skin from the
tructiv
region auricle to restore adequate stability to the nasal
e
o based on the thoracoacromial artery, the vestibule
proced
flap is composed of skin, subcutaneous soft
ure
tissue, and portions of the pectoralis major FRACTURES OF NASAL PYRAMID AND LATERAL MIDFACE
muscle  Common in sports and traffic accidents
o it is mobilized, swung into the tissue defect,  Most of the injuries are closed fractures
and sutured into place  The initial findings may be deceptive, due to hematoma-
induced soft-tissue swelling

NASAL PYRAMID FRACTURE

 Predisposed to fractures because of its exposed location

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

 Classified as open or closed on the basis of concomitant

Etio
soft-tissue injuries  Blunt trauma
Inspection
 Obvious deviation of external nose Depressed fracture of zygoma:
 Simple depression of the lateral nasal wall  Presents with facial asymmetry
 Swelling of the surrounding soft tissues (caused by
hematoma)
Diagnosis

Depressed fracture of zygomatic arch:

 Do intranasal inspection to check for concomitant  Causes limited mouth opening
mucosal injuries and to evaluate the nasal septum
Palpation Fractures of orbital floor:
 Crepitus confirms the suspicion of a fracture  Can cause diplopia in upward gaze (due to entrapment of
Radiographs inferior rectus muscle)
 Excludes bony involvement of lateral midface
 Lateral projection and standard sinus projections Direct/indirect fracture-induced lesion of infraorbital
nerve:
 Subperichondrial hemorrhage with hematoma  Causes sensory disturbances involving the cheek,
formation ipsilateral upper lip, and lateral nasal wall
 The hematoma may become infected, giving rise to a  The nerve enters the buccal soft tissues below the
septal abscess S
infraorbital margin and is commonly involved by fractures
 Cartilage necrosis with loss of the nasal septum and x
of orbital floor
C dorsal saddling
o  Infection may spread to the cranial cavity by the vascular
m route, causing meningitis
p
l
i
c
a
t Signs and symptoms of lateral midline fracture.
i (left)unilateral periorbital hematoma: The periorbital
o hematoma in this patient is the superficial sign of a lateral
n midfacial fracture. (right) facial asymmetry caused by a
s depressed fracture of the zygoma
Figure 22. Complications of septal fracture:
(left) Symmetrical sites of boggy swelling over the nasal
Inspection
septum following a septal fracture, with subperichondrial
 Swelling due to subcutaneous hemorrhage (periorbital or
bleeding under the intact mucosa. (right) Septal abscess
“monocle” hematoma)
with symmetrical bulging and erythema of the mucosa, with
 If depression of zygoma or zygomatic arch:
a purulent.
o Asymmetry of affected facial half
Surgical Treatment
 If involvement on orbital floor:
 Indicated due to the potential for permanent nasal
o Enopthalmos (posterior discplacement of eye)
deformity
o Caused by the herniation of orbital contents
For open fractures:
 Requires immediate surgical care+ tetanus prophylaxis/
Palpation
tetanus booster
 Difficult/impossible due to swelling
For Displaced and closed fractures:
 The following areas should be examined:
 Safely reduced during the initial week after the injury
o Frontozygomatic suture (upper part of the lateral
 Displaced or depressed bone fragments can be reduced
orbital rim)
manually or with the aid of a special instrument
o Infraorbital margin (anterior bony margin of the
 After the reduction, the nasal cavities should be packed
orbital floor)
to provide “internal splinting,” and a plaster cast is
o Zygomatic arch (often difficult to evaluate due to soft-
applied externally
tissue swelling)
Tx

Sensory Testing
 Wisps of cotton used to test sensory function on the
D healthy and affected sides
x Radiographs
 Standard sinus radiographs should be obtained
o occipitomental and occipitofrontal projections
o to define the extent of the bony discontinuity or
displacement
Figures 23 reduction of nasal pyramid structure.  “bucket handle” view
(upper)Laterally displaced fragments are reduced by o added when a concomitant zygomatic arch fracture is
external digital pressure. (lower) If the nasal pyramid is suspected
depressed, the fragments have to be elevated with an
instrument from within the nasal cavity.

LATERAL MIDLINE FRACTURE

 Caused by blunt trauma to the side of the face
 Affected structures of the bony facial skeleton are:
o Maxillary sinus
o Orbit (a) Sinus radiograph demonstrates the displaced bone
o Zygoma or zygomatic arch fragments (arrows). (b) Sinus radiograph of a blow-out
 Blow out fracture fracture shows a typical soft tissue density (arrow) caused
o A lateral midline fracture that is isolated in the orbital by herniated orbital contents (“hanging drop” sign). (c)
floor with partial herniation of the orbital contents into the Coronal computed tomogram of a blow-out fracture.
maxillary sinus.

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

(a) Depressed fracture of the zygomatic arch (arrows),

demonstrated by the bucket-handle view. (b) axial CT scan.
CT scans
 to obtain a more discriminating view of the fracture
 Fractures of the central midface and frontal skull base
to exclude an involvement of the anterior skull base
generally occur in:
Surgical treatment: o Multiply injured patients (usually vehicular
 Unnecessary if: accidents) – most common
o Undisplaced, asymptomatic fractures o “Trivial” trauma
 Indicated if: o Surgical procedure (e.g., endoscopic sinus surgery)—
o Displaced fractures since some bony portions of the anterior skull are
Treatment

o Positive neurological symptoms E quite thin

o Restricted jaw opening t  Frontobasal fractures
o Facial asymmetry i o Usually an “indirectly open” injury that creates a
 Treatment consists: o communication between the cranial cavity and the
o Reduction of and fixation of bone fragments—using l environment
miniplates, interosseous wiring or both o o Ascending infection can occur (via the adjacent
 In ALL cases—patient is advised to avoid nose g paranasal sinuses in frontobasal fractures)
blowing y  Leading to life-threatening intracranial
complications (e.g. meningitis, brain abscess)
 The dura along the fracture line tends to become torn at
FRACTURES OF THE CENTRAL MIDFACE AND ANTERIOR
sites where it is firmly adherent to the bone of the skull
SKULL BASE
base
CENTRAL MIDFACIAL FRACTURES
o E.g., Cribriform plate, Sphenofrontal suture, Sellar
tubercle, Spheno-occipital synchondrosis

 Unilateral or bilateral periorbital hematoma

 Dish face
o Seen in combined fractures (Le Fort II–III, Escher III)
where the midface has been separated from the skull
base and displaced inward
 Cerebrospinal fluid (CSF) rhinorrhea
o reliable sign of anterior skull base fracture with
associated dural injury
o If occurs with petrous bone fractures: CSF leakage
Central midfacial fractures (Le Fort Classification) occurs via Eustachian tube
 Le Fort I: isolated detachment of the alveolar process. o In fresh head injuries: CSF leak from a dural tear may
 Le Fort II: pyramidal fracture with detachment of the maxilla. be obscured by heavy bleeding or contained by bone
 Le Fort III: craniofacial dysjunction fragments, prolapsed brain tissue, swollen mucosa, or
foreign bodies
Sx

FRONTOBASAL FRACTURES
 Bony injuries to the anterior skull base and adjacent Severe craniocerebral trauma result in:
paranasal sinuses (frontal and sphenoid sinuses, ethmoid  Vision loss caused by ocular destruction/ optic nerve
labyrinth) injury
 Escher classification  Diplopia due to oculomotor palsy from damage to CNs
o Escher I: high fracture III, IV or VI
o Escher II: central fracture o Rare; occurs if fracture runs through cavernous sinus
o Escher III: low fracture  Cerebral prolapse—extensive injuries with sites of bone
o Escher IV: latero-orbital fracture dehiscence
 Anosmia result from:
o fracture of cribriform plate with avulsion of fila
olfactoria, or
o damage to more central structures in cerebral
concussion or contusion

 Patient’s vital functions should be stabilized first

 Preliminary testing of hearing and balance
o only if the patient is conscious and responsive to
verbal commands
 Olfactory testing
o To exclude anosmia
D o Often cannot be performed in the acute stage but
x should be done at a later time
o For medicolegal reasons, it should always precede
surgical treatment
 Palpation and Inspection of:
o nasal cavity by rhinoscopy or endoscopy; and then,
o oral cavity and oropharynx
 Profuse bleeding from soft tissue injuries in acute stage:

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

o Difficult to evaluate 1. Fracture of the anterior skull base

o Not possible at this time to confirm CSF leak in o Should be treated surgically in operable patients,
injured patients regardless of (+) or (-) CSF leak
 Otoscopy/otomicroscopy: o The patient is instructed not to blow the nose
o Performed to exclude a concomitant petrous fracture
 If (+) for clear, watery nasal discharge, suspect CSF leak. 2. Isolated central midfacial fracture that does not
Detection of CSF by: involve the anterior skull base
1. Glucose test o should be provided by a maxillofacial surgeon to
o A dipstick is used to test the glucose content of the ensure the restoration of normal occlusion
discharge 3. Frontobasal fracture indications for surgical
o (+) blood in the sample can give a false-positive treatment:
reading (since blood has twice the sugar content of
CSF)
o Very nonspecific
2. The immunoelectrophoretic determination of β2-
transferrin
o A more accurate method.
o This protein is normally present only in CSF
o Advantage:
 Noninvasive,
 Supplies result within 24 hours
 Can be repeated as needed (for follow-up)
o Disadvantage:
 Relatively costly
 Complex
 CT scan:
o Supplies additional information on location and extent
of injuries
o Bone-window CT scan—can reliably evaluate
fracture
1. Axial scans – evaluate:
o Anterior and posterior walls of the frontal sinuses
o Sphenoid sinus
2. Coronal scans – evaluate:
o Ethmoid roof and cribriform plate

INFLAMMATIONS OF THE EXTERNAL NOSE, NASAL

CAVITY, AND FACIAL SOFT TISSUES

PURULENT INFLAMMATIONS OF THE HAIR FOLLICLES

 occur at almost any age
 common purulent inflammations
Two Forms:
1. Folliculitis: if the disease is confined to the hair follicles
2. Furuncle: if the infection spreads to deeper tissues and
CT exam of frontobasal fractures. forms a central core of purulent liquefaction.
(a) Axial CT scans demonstrate a fracture of the anterior
and posterior walls of the frontal sinuses (arrows);
 Staphylococci
Etio

(b) and a clivus fracture (arrow) that extends anteriorly into

the sphenoid sinus;
 Painful, tender, erythematous swellings about the nasal
(c)The coronal scans show air in the cranial cavity;
tip and nares
(d) and a fracture of the ethmoid roof (arrow)
 Concomitant edematous swelling of the upper lip.
Sx

 Surgical procedure depends on location

 Confined to the outer skin and do not involve the mucosa
 Fever (sometimes)
 TOC: high-dose parenteral administration of an antibiotic
that is active against staphylococci (flucloxacillin
sodium or dicloxacillin sodium) + local application of
an antibiotic-containing ointment (chlortetracycline
HCl).
Tx

 Upper lip should be moved as little as possible

 Patient should be placed on a liquid or semisolid diet
T  Speak as little as possible.
x  An essential goal of these measures is to prevent the
potentially lethal complication of intracranial spread.
 Hematogenous spread to intracranial structures
o veins of the nose and upper lip  angular and
ophthalmic veins  cavernous sinus.
 Thrombophlebitis of the angular vein
Cx

o Suspected If there is tenderness in the medial canthus

of the eye
o Tx: vessel should be surgically ligated and divided.
3 main surgical approaches for anterior skull base fracture.

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

ERYSIPELAS o nasal obstruction due to mucosal swelling, which mainly

 Principal causative organisms: beta-hemolytic group A
streptococci.
 Less common pathogens: streptococci of other groups,
Staphylococcus aureus, and gram-negative rods (e.g.,
Etio
involves the turbinates
 Viral damage to the mucociliary transport system 
hampers the normal clearing of secretions  profuse
nasal discharge  inflammatory changes about the

Klebsiella pneumoniae) nasal vestibule.

gain entry to the skin through minor injuries (usually on  Viral damage to the epithelium  bacterial colonization
the face and limbs)  inflammation spreads diffusely into  alteration of the consistency of the clear nasal
the skin and subcutaneous tissue. discharge  mucopurulent discharge
 begins with high fever and a feeling of tension in the soft
tissues
 followed rapidly by broad areas of erythema and swelling
Sx

(which are sharply demarcated from unaffected skin)

 tissue is warm to the touch
 small blisters form (occasionally)
 TOC: parenteral administration of penicillin
 Moist compresses soaked in an antiseptic solution
Tx

(locally).
 Intracranial involvement by hematogenous spread of the Mucopurulent secretion
causative organisms The local and systemic symptoms usually subside in about a
week.
Cx

o If facial erysipelas spreads lateral to the nose and about

the eyelids (as with a nasal furuncle)  Decongestant nose drops.
o Should be used no longer than absolutely necessary
(generally no more than one week) due to the risk of
INFLAMMATIONS OF THE NASAL CAVITY
tachyphylaxis with severe rebound swelling of the nasal
Treatment
*from batch 2015 ENT trans but not included sa book. mucosa.
 Other options: chamomile steam inhalation, “light
*VESTIBULITIS baths,” and infrared therapy.
 infection of the sebaceous glands  Antibiotics: patients with bacterial superinfection or
paranasal sinus involvement.
 Self-limiting
Etio

 Staphylococcus aureus
NONSPECIFIC CHRONIC RHINITIS
 warm compress  Recurrent acute inflammations with progressive damage
Tx

 incision and drainage to the mucosa

 antibiotics [cloxacillin]  Can develop due to
o Anatomic changes (e.g., marked septal deviation,
Etiology

*SEPTAL ABCESS septal spur)

 secondary to blunt injury with hematoma formation on o other lesions of the nasal cavity (polyps, tumors) and
nasopharynx (adenoids)
Etio

the septum that was not seen on regular examination or

left unattended  Environmental factors
o sustained extreme temperatures or air pollutants)
 manifested as bulging of the septum
 unilateral foul-smelling nasal discharge  Obstructed nasal breathing
Sx

 Classic history: “Merong mabahong lumalabas dito pero  Mucous nasal discharge
Sx

sa isang side lang ho eh…”  Frequent throat clearing

 Occasional hoarseness.
Course

 usually very short yung history, about 3-5 days  Eliminate the cause by removing chronic irritants from the
 after that you can develop rhinolith around the foreign environment
Treatment

body kung hindi napansin ng parents  By surgically correcting any intranasal pathology (e.g.,
septoplasty)
 blood is a very good medium for bacterial route  will  Supportive measures for temporary benefits
(decongestant nose drops or nasal irrigation with saline
Cx

later develop septal abscess  if left a long time, will lead

to resorption of the cartilage saddle-nose deformity solution)

 management of ordinary or usual abscess formation:

Tx

incision and drainage Viral Bacterial

 rhinovirus  Pneumococcus
ACUTE RHINITIS (COMMON COLD) Etio  coronavirus  Staphylococcus
 Streptococcus
 most prevalent infectious disease
 does not confer postinfection immunity  assumed major  transient signs and  follow viral
Epid

epidemiologic and economic significance symptoms infection (after

 self-limiting, with more than 5days)
 Rhinoviruses and coronaviruses
Course local and systemic
o comprise almost half of the causative organisms
symptoms usually
 Other pathogens: influenza viruses and adenoviruses.
subsiding in about a
 Bacterial pathogens: follows viral infection
Etiology

week
(pneumococcus, staph, strep)
 MOT: airborne route (droplet infection). Involvement  both sides  may be one side
 Cold exposure and other environmental factors: increase Discharge  watery and clear  thick, yellow-green
the susceptibility of the host to infection.  congested
Turbinates
 Incubation period: 3–7 days.  congested turbinates turbinates and
and mucosa
1. Dry stage mucosa
o Characterized by malaise (lethargy, headache, fever)  usually not given  antibiotics are
S and local discomfort in the nose and nasopharynx prophylactic warranted
x (burning, soreness). antibiotics  available for
Tx
2. Catarrhal stage o there is only a relieving the
o marked by a watery, initially serous nasal discharge small chance that discomfort of acute
bacterial infection rhinitis:

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

would follow o chamomile

o if given- may only o steam inhalation MALLEUS
lead to resistance o “light baths”  A rare infectious disease that is transmitted to humans from
o infrared therapy horses and occasionally from house pets.
Etiology: Pseudomonas mallei
SPECIFIC CHRONIC RHINITIS Symptoms:
TUBERCULOSIS  inflammatory swelling
 Can involve the nasal mucosa as a primary infection following  pustule formation
the inhalation of infectious droplets, forming a primary  Ulceration with a viscous nasal discharge containing blood and
complex approximately 6 weeks after infection. pus.
 Lupus vulgaris
o The most common postprimary form of cutaneous FUNGAL INFECTIONS
tuberculosis.  Aspergillosis
o Ulcerative cases are marked by increasing necrosis within o The most common fungal infection causing chronic specific
the tubercular granulomas  mutilating destruction of nasal rhinitis, with fungal colonization occurring mainly in the
skin and cartilaginous structures. paranasal sinuses.
o May also arise from the nasal mucosa itself  contiguous o Immunocompromised patients
destruction of nasal structures from the inside.  Take an aggressive, fulminating course with the
destruction of surrounding structures, resulting in a very
SARCOIDOSIS high mortality.
 Common, granulomatous systemic disease of unknown  Mucormycosis
etiology o Resembles aspergillosis in its symptoms and course.
 Predominantly women; < 40 y/o o The invasive form of mucormycosis still has a relatively
 Nasal symptoms may be the initial manifestation of the high mortality rate despite the availability of systemic
disease although URT involvement are rare. antimycotics
 Lupus pernio o Mainly affects patients with a weakened immune status.
o Involvement of the external nose  Rhinosporidiosis
o Called so because the characteristic skin changes resemble o Very rare disease caused by the spore-forming fungus
chilblains (pernio) Rhinosporidium seeberi.
 Painful inflammation of small blood vessels in your skin o Highly vascular, friable granular lesions develop in the
that occur in response to sudden warming from cold anterior portions of the nose and may spread to involve the
temperatures. It can cause itching, red patches, swelling paranasal sinuses and nasopharynx.
and blistering on extremities, such as on your toes,
fingers, ears and nose. ALLERGIC RHINITIS
o Involvement of the nasal mucosa mainly affects the Nasal Hyperreactivity
septum and inferior turbinate, which develop  Heightened reactivity of the nasal mucosa to:
yellowish, submucous nodules that have the gross o allergen
appearance of intramucosal granulomas. o pollutants (cigarette smoke, dust, fumes)
o position changes or exertion
RHINOSCLEROMA  Marked by:
 Chronic inflammatory disease o signs of inflammation
 Extremely rare o disturbances of autonomic nervous regulation
 Manifested in the nose, oral mucosa, and upper respiratory o altered response of the associated receptors on vessels,
tract. nerves, and glands of the mucosa
 Etiology: Klebsiella pneumonia subs. Rhinoscleromatis
 Symptoms:
o presents the features of atrophic rhinitis
o fetid nasal discharge  An immediate, IgE-mediated reaction of the immune
Etio

o dry mucosa system.

o crusting
 Nasal mucosa w/ inflammatory infiltrates  may progress to
granulations  involve the nasal vestibule. 1. Seasonal allergic rhinitis (Hay Fever)
o Central Europe
ACTINOMYCOSIS o Causative allergens: pollens from alder, hazel,
Etiology: Actinomyces israelii (g+; anaerobe); usually in birch, grasses, rye, mugwort, and plantain.
immunocompromised patients. o Clinical symptoms appear between February and
September, depending on the individual allergen
Symptoms: spectrum of the patient, and disappear at the end of
C
 Nose and paranasal sinuses involvement is uncommon. the pollen season.
l
 If involved, firm infiltrates in the nasal mucosa that resemble a
a nasal furuncle. *from upper batch trans /sabi ni Doc:
s
 Granulations forming on the nasal mucosa and in the o in the Philippines, some experts say that the peak of
s
paranasal sinuses. pollen usually appears between October to February
i
Complications: Untreated, the inflammation can spread and o however, unlike in the Western countries, we don’t
f
cause severe tissue destruction with a fatal outcome. have a seasonal allergic problem, but what we have is a
i
perennial allergic problem because most of the
c
SYPHILIS pollens from the Philippines will be coming from the
i
ordinary “talahib” or wild grass
 Nasal involvement by syphilis occurs mainly in the tertiary a
stage of the disease. t
2. Perennial allergic rhinitis
Symptoms: i
o Caused by year-round allergen exposure that incites a
 Isolated gummata or by diffuse gummatous infiltration of the o
permanent inflammation of the nasal mucosa.
nasal cavity. n
o Causative allergens:
 Congenital syphilis
 Mainly by house dust, pet dander, and molds.
o Purulent and sometimes bloody nasal discharge, which may
 certain foods (e.g., strawberries, nuts, eggs, fish)
be mistaken for “normal” infant rhinitis.
 Occupational exposure to allergens (e.g., bakers and
Complications:
hairdressers).
 progressive destruction of the surrounding tissue
- Latex: new occupational allergen, especially
 eventual bone destruction
prevalent in health workers, which is used to

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

manufacture disposable gloves. - A protracted course of treatment (Lately, however,

there have been efforts to design a “brief
“there is no more seasonal (Oct-Feb) or perennial, but immunotherapy” that will shorten the duration of
instead you have your intermittent, persistent, and mild to treatment)
moderate” – Dr. Victoria - Significant percentage of nonresponders.
o you can have a mild intermittent, a moderate-severe  SCIT (Subcutaneous immunotherapy)
intermittent, or a moderate-severe persistent - Provides symptomatic relief
- Modifies allergic disease
- Safety & efficacy established
 SLIT (Sublingual immunotherapy)
- Safety & efficacy to be considered by US FDA
- Much safer than SCIT
- Boosts tolerance to antigen
o Surgical treatment
 If the response to conservative treatment is
unsatisfactory and the principal complaint is nasal
obstruction (i.e., hyperplasia of the nasal mucosa)
 reduce the size of the turbinates by:
 Obstructed nasal breathing and sneezing attacks - coagulation (turbinate cautery)
 A watery clear nasal discharge (rhinorrhea) - laser treatment
 Itching of the nose and eyes (conjunctivitis). - mucotomy (resecting a tissue strip from the lower
edge of the inferior turbinate).
 Concomitant septoplasty
- if septal pathology is also present (septal deviation,
septal spur or ridge)
 Endoscopic sinus surgery
- Required if with associated sinus complaints
 May be reversible spontaneously (Victoria)
S
x

Fig.32 Typical endoscopic appearance of the nasal mucosa

in allergic rhinitis.

 boggy and pale turbinates

 localized to nose and affects both sides
 in allergic rhinitis, you would see the cavity as grayish,
dirty-looking, or pale turbinates and nasal mucosa
 the presence of hyperemic mucosa and turbinates
signifies more of an acute rhinitis rather than an allergic
rhinitis
 Detailed allergy history (do the symptoms present year-
round or only during contact with certain animals or
plants; do they disappear during vacation?).
 Seasonal allergic rhinitis: inspection of the nasal cavity
D typically reveals a bluish-purple discoloration of the
x mucosa
 Perennial rhinitis: mucosa is bright red and shows
inflammatory changes.
 Careful allergy testing is necessary to identify the
antigens involved.
 condition may still recur even with treatment
o especially for patients with nasal polyps, grade II,
practically grade III, sometimes they would respond
very well to one type of steroid and sometimes they
will respond very well to another type of steroid
C
o Doc: I have a patient now who is currently under my
o
treatment who has undergone 3 surgeries here, under
u
different surgeons through the years. Now again, he
r
has this huge polyp, practically grade III. I started him
s
on budesonide and he is responding very well.
e
Practically, I can see now the good space underneath
the polyp. I can see the floor down to the posterior
pharyngeal wall. Table 1: Pharmacologic Treatment for Allergic Rhinitis
 each patient should be treated on a case-to-case
basis VASOMOTOR RHINITIS
 The best treatment strategy is to avoid contact with
 Resembles allergic rhinitis in its clinical features, but there is
the allergen or eliminate allergenic irritants from the
T no evidence that the patient has been previously sensitized.
environment (which is not always possible)
r  Involve neurovascular autonomic disturbances in
 Pharmacologic treatment: (at the table below.)
Patho

e regulating the tonus of the nasal mucosal vessels.

 Long-term tx options:
a  Exact cause is unknown (Victoria)
o Immunotherapy or hyposensitization therapy
t
 A specially prepared antigen is administered SQ to  obstructed nasal breathing
m
induce a systemic tolerance to the foreign protein.  watery nasal discharge
e
 Used for desensitization before steroid use S  sneezing
n
 Disadvantages: x  History shows that the symptoms are related to:
t
- adverse effects, (mild local reactions to severe o Temperature change
systemic symptoms) o consumption of hot liquid or alcohol

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 Diseases of the Nose, Paranasal Sinuses, and Face
o “emotional stress”
 Inspection: appearance of the nasal mucosa is similar to
that in allergic rhinitis.
 Use of antihistamines or corticosteroid-containing nasal
sprays.
 Kneipp system of therapy
o Ice-cold water is sniffed up the nose as a way of
“training” the neuroautonomic regulation of the blood
supply to the nasal mucosa.
Treatment
 Surgical reduction of the turbinates
o the last recourse for intractable vasomotor rhinitis
o by electrocoagulation, laser ablation, or mucotomy
o Especially in cases with pronounced inferior turbinate
hyperplasia.
- Septoplasty: if significant septal deviation is
present
 Avoid triggers (Victoria)
ATROPHIC RHINITIS
 Primary atrophic rhinitis: unknown.
 Secondary forms:
o extensive prior tumor resection
o excessive use of nose drops
Etio
o drug abuse (cocaine)
o previous radiotherapy for nasal and sinus tumors
o Iatrogenic causes (botched septoplasty or an excessive
turbinate reduction (conchotomy).
 Pronounced dryness of the nasal mucosa.
 Fetid nasal odor
o not perceived by the patient due to degeneration of the
olfactory epithelium (for severe cases, especially with
secondary bacterial colonization)
Sx
 Endoscopic examination: broad nasal cavity lined with
dry, crusted mucosa
 Crusting, atrophic nasal organs and turbinates. Crust
easily bleeds when removed
 Should begin with conservative, symptomatic measures
(saline “nasal douche,” soothing mucosal ointments).
 Under NO CIRCUMSTANCES should decongestant
nose drops be used
o As the vasoconstriction would exacerbate the patient’s
symptoms.
Tx
 Submucous implantation of cartilage grafts
o If conservative treatments prove inadequate
o reduce the nasal cavity surgically
o This creates a relative increase in surface area in
relation to the volume of the nasal cavity.
HORMONAL RHINITIS
 AKA: pregnancy-associated rhinitis (occurs mainly during
pregnancy)
 Cause: estrogen-induced swelling of the mucosa with nasal
airway obstruction
 Symptoms diminish as term approaches and disappear after
the delivery
RHINITIS MEDICAMENTOSA
 Rebound vasodilation secondary to prolonged use of
sympathomimetic decongestant nose drops and nasal spray
[oxymetazoline]
o Initial vasoconstriction  vasodilation  excessive mucous
secretion  nasal obstruction
o most common = oxymetazoline or xylometazoline
o decongestants should not be used for more than 3 days
o patients tend to abuse it because of the relief
o Doc: I seldom prescribe nasal decongestants. I only
prescribe it in acute middle ear problem, especially during
the stage of hyperemia to decongest the pharyngeal end of
the Eustachian tube for easier drainage
 Side effect from long-term use of decongestant nose
drops
Etio
 antihypertensive drugs (rauwolfia alkaloids, beta-
blockers, ACE inhibitors)
 oral contraceptive use - vasoactive estrogen effect
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1.2
 obstructed nasal breathing
Sx
 dry mucosa
 occasional olfactory disturbances
 there are huge turbinates obstructing the nasal cavity
Dx
(narrowed cavity) but sinuses are clear
 for the pediatric age group advise the parents very well
regarding the use of decongestants
Tx
 decongestants can be substituted with topical steroids
(mometasone, budesonide, fluticasone, ciclesonide) after
discontinuation
INFLAMMATION OF THE FACIAL SOFT TISSUE
Differential diagnosis of facial soft-tissue swelling:
 Lupus erythematosus (LE)
o most common form of cutaneous LE
o inflammatory dermatosis that frequently affects the face,
spreading in a butterfly-shaped pattern over the cheeks,
forehead, and nose
 Allergic contact dermatitis
o may be induced by cosmetics, toilet articles, sun creams, or
exposure to airborne plant pollens
o In strongly sensitized patients, even a single contact can
incite a severe, acute allergic reaction with erythema and
edematous swelling of the facial soft tissues
 Angioedema
o associated with facial swelling that chiefly affects the
eyelids and lips
SINUS INFLAMMATIONS (SINUSITIS)
 generally develop in association with rhinitis
“rhinosinusitis”
o inflammation of mucosa, of the nose, and paranasal
sinuses; characterized by severe nasal discharge
o Lasts up to 4 weeks (28 days)
 rhinitis  blocks drainage  sinusitis
o there is no isolated rhinitis
 the mucosa is continuous from the nose the sinuses and
what’s practically dividing them is only the ostiomeatal
complex where most of these sinuses drain
 it can be acute, an inflammatory condition involving the
paranasal sinuses, as well as the nasal passages
 common pathogens: S. pneumoniae, H. influenza
 X-ray findings
o Acute
 Presence of air-fluid level (request for upright Water’s
view to see this finding)
o Chronic
 Mucosal thickening
 Mucosal opacification (no more air spaces on the entire
sinus involved, usually the maxillary sinus or frontal
sinus)
ACUTE SINUSITIS
 In children: affects the ethmoid cells due to incomplete
pneumatization of the other sinuses
 In adults: affects the following sinuses in descending
order of frequency:
o Maxillary Sinus
o Ethmoid Cells
o Frontal Sinus
o Sphenoid Sinus
 Pansinusitis – inflammation of allparanasal sinuses
E
 Results from intranasal inflammation (rhinitis) since the
t
mucosa of the paranasal sinuses communicates with that
i
of the nasal cavity (rhinogenic sinusitis)
o
 Etiology:viruses, Haemophilusinfluenzae and
l
Streptococcus pneumonia
o
 The extent of the inflammation in the sinus system and
g
the associated symptoms depend on various factors:
y
o Individual functional anatomy
o Individual immune status
o Specific virulence of the causative organism
 Dentogenic Sinusitis
o arising from a dental root infection, an apical granuloma,
or a maxillary sinus fistula following a tooth extraction
 inflammation and edema  increased secretion of
underlying mucosa  retention of secretion in the sinuses
 secondary bacterial infection severe purulent, foul-
Page 13 of 18
 Diseases of the Nose, Paranasal Sinuses, and Face
smelling nasal discharge
 features of acute rhinitis combined with a variable degree
of headache, which is exacerbated by bending over
 classic history: “Mayroonpoakongnaamoynamalansa…”
in this instance, suspect that the patient may already be
suffering from chronic rhinosinusitis
 Pain is most intense over the affected sinuses
SINUS PAIN LOCATION
 over the maxillary sinus
Maxilla
 adjacent midface and temple
ry
 near the canine teeth
Ethmoi  over the bridge of the nose
d  medial canthus of the eye
S  over the anterior wall and floor
x of the frontal sinus, with pain
Frontal
radiating toward the medial
canthus
 fairly nonspecific
 marked by a dull, aching
Spheno
pressure located at the center of
id
the skull and radiating to the
occiput
o not all occipital headaches are secondary to
hypertension
 you must ask the patient very well because he
may have an acute sphenoid sinusitis
COURSE lasts up to 4 weeks (28 days)
 Rhinoscopy Or Nasal Endoscopy
o reveals pus tracking along the middle meatus of the
nasal cavity but a purulent track may not be seen if the
mucosa is greatly swollen.
o Sphenoid Sinusitis – pus may be found about the
ostium in the anterior wall of the sphenoid sinus or on
the posterior wall of the pharynx
Etio
 Sinus Radiographs
D o may show partial opacification of the affected sinus due
x to mucosal swelling or may demonstrate a fluid level if
the sinus contains free pus
Patho
Symp
 Ultrasonography
o alternative to radiography, especially for follow-up and
in children and pregnant women, which avoids radiation
exposure
 Surgery
o necessary when the complaints of acute sinusitis do not
T drainage in the nasal cavity itself (e.g., tumors)
respond to conservative treatment modalities and in
x  Imaging Studies:
cases with persistent sinus empyema
 Conservative Therapy
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1.2
o Ventilation and drainage of the paranasal sinuses can be
improved by the use of decongestant nose drops, nasal
spray, or by inserting a cotton pack soaked with nose
drops into the middle meatus.
o with fever and significant malaise: antibiotics(e.g.,
amoxicillin)
o Heat therapy(electric light bath) and the inhalation of
chamomile or sage are recommended as adjuncts.
 Surgical Therapy
o Maxillary sinusitis- treated by maxillary sinus
puncture following decongestion and topical anesthesia
of the nasal mucosa.
o Two approaches available:
1. “Sharp Puncture”
 through the inferior meatus, passing the needle
below the inferior turbinate
 significant risk of complications due to air
embolism if air is inadvertently injected into the
sinus
 perforation of the lateral sinus wall, resulting in a
buccal abscess or perforation of the sinus roof
causing infection of the orbital contents
2. “Blunt Puncture”
 via the natural maxillary sinus ostium in the
middle meatus
 Beck Puncture
o for frontal sinus empyema, frontal sinus irrigation
o patient faces the risk of meningoencephalitis or frontal
brain abscess
o Procedure:
 the skin and subcutaneous soft tissues are divided at
the medial border of the eyebrow, and the anterior
wall of the frontal sinus is opened with a drill
 Secretions and pus are aspirated from the frontal
sinus, and the sinus is irrigated with decongestant
nose drops and an antibiotic solution
CHRONIC SINUSITIS
 All can lead to chronic sinusitis (at least 12 weeks –
Victoria):
o intranasal anatomic changes such as septal deviation
and septal spurs
o chronic inflammatory, allergic, traumatic or neoplastic
nature
 most common predisposing factor: untreated or poorly
treated acute sinusitis
o usually because of discontinued medications due to cost
 predominantly a mixed infection with gram-positive,
gram-negative and anaerobes
 Impaired Ventilation of the Ostiomeatal Unit
o due to stenosis or obstructionhampers drainage of the
dependent sinus systems (adjacent maxillary sinus and
anterior ethmoid cells)mucosa becomes swollen
(especially in the narrow anatomical passages of the
ostiomeatal unit)  initially leads to recurrent bouts of
acute inflammation eventually culminates in a
persistent, chronic sinusitis
 frequently affects the maxillary sinus and ethmoid
cells, while the frontal and sphenoid sinuses are less
commonly involved
 pain is variable: a feeling of pressure to persistent or
recurrent headaches
 classic history:“Meronhongmabigat e. ‘Pagtumutungo ho
akomabigat.” or “Para pong tinutulakangmatako…”
 yellowish or greenish nasopharyngeal drainage (postnasal
drip),obstructed nasal breathing
 Rhinoscopy, Endoscopy
o changes in the nasal septum
o turbinates (turbinate hyperplasia, pneumatized middle
turbinate, concha bullosa)
D o appearance of the ostiomeatal unit (mucosal swelling,
x polyps,tumors, etc)
o exclude other causes of impaired ventilation and
o Computed Tomography
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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

 only acceptable modality for imaging the paranasal

sinuses if chronic sinusitis is suspected
 Conventional sinus radiographs: very limited value in
diagnosing chronic sinusitis due to artifacts from
superimposed structures.
NASAL POLYPOSIS
 Can arise from infection, allergy
 Presence of bilateral (if unilateral, usually an inverting
papilloma), smooth, semitranslucent, pearly white to pinkish,
pedunculated masses arising from the mucosa
o looks like a peeled grape inside the nasal cavity
 surround the ostiomeatal complex

 Conservative Treatment (for symptoms only)

Modified Mackay Classification
o decongestant nose drops (for no more than one
week), heat therapy(electric light cabinet, Grade absence of polyps
microwaves, infrared), and broad-band antibiotics 0
(e.g., amoxicillin) for acute exacerbations of sinusitis polyps do not prolapse cannot be seen
with fever and malaise. beyond the most anterior part using nasal
T o Mucolyticsfor supportive therapy. Grade I of the middle of the turbinate speculum exam but
x o Allergic etiology: antiallergic therapy can be seen on
 Sinus Surgery (only definitive treatment) endoscopy
o performed intranasally under endoscopic or microscopic  polyps extend below the can be seen using
Grade
control middle turbinate nasal speculum
II
 Principle: to enlarge the tight passages in the middle  does not touch the floor exam
meatus and ostiomeatal unit including the natural ostia of  polyps are massive and No need to use
the maxillary sinus and, if necessary, the frontal sinus. Grade occlude the entire nasal instrument to see
III cavity polyp
 complete obstruction seen
DANGEROUS TRIANGLE OF THE FACE
 in cases of grade III polyps, it is alright to administer locally-
 any inflammatory condition in this area should be treated
acting nasal steroids but most likely, you will recommend
aggressively because of possible intracranial
that the patient undergo surgery (functional endoscopic sinus
complications like cavernous sinus thrombosis, meningitis,
surgery)
or epidural and intracranial abscess; as well as other
 you have to differentiate between nasal polyps, turbinates,
rhinosinogenic complications including orbital cellulitis
and tumor:
and osteomyelitis
Turbinate Polyp Tumor
After use of
does not
decongesta Shrinks does not shrink
shrink
nt
After use of
metal Painful Painless Less painful
applicator
Does not bleed
bleeds easier
Easily (unless
Bleeding than
bleeds hemangiomatou
turbinates
s polyp)

ANTROCHOANAL POLYP
 polyp at nasal cavity that is already occupying the
Figure 33. Dangerous triangle of the face oropharynx
 starts to grow from the maxillary sinus, exits into the nasal
CAVERNOUS SINUS THROMBOSIS cavity, and protrudes out of the nasal choana
 usually unilateral
 Staphylococcus aureus  seldom will you find these kinds of polyps now, probably
Etio

 Streptococcus pneumonia because there are more ENTs now

 fever
Etio  secondary to an infectious type of polyp formation
 chemosis
 proptosis and edematous eyelids  surgery
 visual change and orbital pain o better if removed by endoscopic sinus surgery
Sx
o formerly done by Caldwell-Luc procedure,
SSx

especially if endoscopic surgery

CALDWELL-LUC PROCEDURE
 intraoral procedure for entering the maxillary antrum through
the canine fossa above the maxillary premolar teeth
 involves gingivobuccal incision opposite the canine area
 loss of vision – 10% through the periosteum, while preserving the infraorbital
 ischemia of other organs nerve
Cx

 intracranial complications (meningitis, brain abscess)  indications:

 30% mortality o to drain fluid from maxillary sinus

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

o get a biopsy for a possible tumor  other malignant neoplasms, precancerous lesions, and benign
o correct a herniated orbital content after blunt trauma tumors – much less common
to the orbit
o correcting maxillofacial fractures BENIGN TUMORS
o NO LONGER DONE FOR CHRONIC MAXILLARY SINUSITIS
RHINOPHYMA
 after the procedure, create a nasoantral window (will serve
 most important benign facial tumor
as drainage) using a Foley catheter to serve as hemostasis
 hyperplastic or overactive sebaceous glands
 wound is closed by 1 layer of suture from the mucosa to the
periosteum  seen almost exclusively in older men

Etio
 Post-surgical complication: may have numbness of the face  seldom seen among Filipinos
for several weeks or even months
 however, even if a clean Caldwell-Luc procedure is done and  connective-tissue and sebaceous hyperplasia with

Symp
a huge nasoantral window is created, the normal excretion of
the discharge coming from the sinuses will still follow the
normal pattern of going into the ostiomeatal complex
(instead of going out into the nasoantral window to be
angiectatic changes occurring over the cartilaginous nose
 most patients have preexisting rosacea  concomitant
erythema usually present
 cutaneous manifestations of lymphatic leukemia

DDx
drained)  cutaneous T-cell lymphoma
 sarcoidosis
 surgical ablation of the hyperplastic tissue in layers,

Tx
allowing the wound area to heal by spontaneous
epithelialization

PRECANCEROUS LESIONS
 generally rare
 should be watched closely (may progress to a malignant
tumor)
 includes the following:
o Actinic keratosis
o Bowen’s disease - a chronic skin inflammation caused by
carcinoma in situ
ANTRAL LAVAGE o Cutaneous horn
o Malignant lentigo
 a minor procedure done under local anaesthesia to
 attributed to chronic sun exposure
evacuate fluid from the sinuses
 grows slowly
 no longer done at present
 may progress to malignant melanoma
 performed by inserting a gauge 16 needle either via:
o the inferior meatus
 problem: inserting needle through the inferior MALIGNANT TUMORS
meatus may reach the orbital cavity and may injure  most common facial malignancies – of epithelial origin
the eyeball o predominantly basal cell carcinomas and squamous cell
o the anterior maxillary wall carcinomas (spindle cell carcinomas)
 safer route  melanomas, sarcomas, lymphomas, and cutaneous
 done every 3 or 4 days infiltration by leukemia – relatively rare in the facial region
o if after the 3rd session there is still purulent discharge
coming out, perform the Caldwell-Luc procedure (inject BASAL CELL CARCINOMA (BASALOMA)
the mucosa with local anesthesia  puncture the  peak incidence: 60 to 70 years of age
Epid

anterior maxillary wall)  may be seen in patients as young as 40

 most common malignant tumor of the external nose
FUNCTIONAL ENDOSCOPIC SINUS SURGERY (FESS)  uncertain
 creates a wider opening for a clean ostiomeatal  appear to have causal significance:
Etio

complex in order for all the rest of the sinuses to drain o genetic predisposition
properly o prolonged sun exposure in people with very sun-
 termed functional because of minimal distortion of the sensitive skin
anatomy of the nasal cavity
o path of drainage is not altered, as opposed to the
Caldwell-Luc procedure
 done under local anesthesia
 allows for easier monitoring of possible complications
 one hand is holding the scope while the other is holding a
microdebrider
 disadvantage: instruments are very costly

S
S  classified as malignant BUT has no tendency to
x metastasize
 vary greatly in their morphologic features
 solid basalomas
o particularly rare in the facial region
o show central crusting and a string-of-beads
margin
 sclerodermiform basaloma
o often has ill-defined gross margins  leads to
problems of surgical excision (size of defect is often
underestimated preoperatively)
D
TUMORS OF THE EXTERNAL NOSE AND FACE  confirmed by biopsy
x
 majority of facial tumors – malignancies (basal cell
carcinomas and spindle cell carcinomas)

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

 surgical excision with frozen-section control of all  many are detected incidentally on x-ray films of the
margins skull

Dx
Tx

 the surgical defect is then reconstructed in the same  computed tomography

sitting o imaging modality of choice for accurate localization
 surgical removal

Tx
o as soon as osteoma becomes symptomatic
SPINDLE CELL CARCINOMA (SPINALOMA)  otherwise, no need for therapeutic intervention
 second most common malignant tumor of the external
Epid

nose
ANGIOFIBROMA
 tends to occur in older individuals
 a benign tumor that originates in the nasal chamber near
 uncertain nasopalatine foramen
Etio

o exposure to ultraviolet rays very likely has causal  highly vascular (“bloodiest”), as opposed to nasal polyp
significance which has no blood vessels
 a “classic” malignant tumor can metastasize to Epid  Usually in young males (9-25 years)
SSx

regional lymph nodes  Originates in the nasal chamber near nasopalatine

Etio
foramen
 surgical tumor removal  severe epistaxis (DO NOT PALPATE, DO NOT BIOPSY)
SSx
 various plastic reconstructive techniques used,  nasal obstruction
depending on the location and size of the defect  Diagnosed more through clinical examination,
Dx
o reconstruction via median forehead flap or making history, CT
 if with intracranial extension, mass at cranium is not
Tx

use of prosthesis Tx
 patients with regional lymph-node metastases should anymore removed
undergo the ff. in the same sitting: MALIGNANT TUMORS
o neck dissection  Far more common than benign masses
o postoperative radiotherapy  majority (>80%) – tumors of the epithelial series
o squamous cell carcinoma
TUMORS OF THE NASAL CAVITY AND PARANASAL o adenocarcinoma
SINUSES o adenoid cystic carcinoma
 benign tumors – relatively rare  much less common:
 malignancies o neoplasms of mesenchymal origin
o occur mainly in older patients  osteosarcoma
o develop in pre-existing cavities  may remain  chondrosarcoma
asymptomatic for years o malignant lymphoma
 occasionally found – metastases from other malignancies
o primary tumor residing in the kidney, lung, breast, testis,
BENIGN TUMORS
or thyroid gland
 may arise from smooth muscle, peripheral nerves, or blood
 main sites of predilection (most common to least common):
vessels
o nasal cavity and maxillary sinus
o ethmoid cells
INVERTED PAPILLOMA o frontal bone
 a benign, locally aggressive tumor o sphenoid sinus
 may transform to squamous cell carcinoma
 usually unilateral
 may resemble nasal polyp but may contain areas of
Epid

 patients over 50 years of age

carcinoma
o causes local bone erosion versus nasal polyp which only
conforms with normal anatomy
 inverts into the surface epithelium
 growth characteristics resemble those of virus-induced
cutaneous and mucosal lesions (e.g. warts, condylomas,
Etio
 often do not produce clinical manifestations until they
have reached advanced stage
 symptoms suspicious for malignancy:
o sudden onset of obstructed nasal breathing
o bloody rhinorrhea

laryngeal papillomas) o fetid nasal odor

 viral etiology has been discussed but remains unproved o unilateral sinusitis that is refractory to
 nonspecific treatment
 nasal airway obstruction S  advanced tumor stages:
SSx

 occasional epistaxis S o swelling of the buccal soft tissues

 polyp-like appearance x o swelling at the medial canthus of the eye
o headache
 nasal endoscopy
o facial pain
 histologic examination
o hypoesthesia or numbness of the cheek – due to
o the only test that can establish the diagnosis in many
Dx

infraorbital nerve involvement

cases
 orbital infiltration can lead to:
 imaging (computed tomography)
o displacement of the orbital contents
o helpful in defining tumor extent
o diplopia
 surgical removal (modified maxillectomy)
T o proptosis
 special growth characteristics of this tumor require
x  endoscopic inspection of the nasal cavity
adequate exposure to allow complete removal
 bimanual palpation of the cervical soft tissues
o to search for regional lymph-node metastases
OSTEOMAS  computed tomography and/or MRI
 benign bone tumors that may occur as isolated masses, D o should always be performed since sinus tumors often
especially in the ethmoid cells and frontal sinus x invade the nasal cavity secondarily
 may form extensive masses that grow along the skull base o endoscopy alone provide little information on the
extent of the mass
 often do not become symptomatic until they obstruct o should cover the cervical soft tissues to check for
drainage tracts to or from the paranasal sinuses, nodal metastases
SSx

leading to:
o headaches
o recurrent bouts of sinusitis

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 Diseases of the Nose, Paranasal Sinuses, and Face 1.2

 individualized according to the histology and extent of

the malignant tumor
 surgery and postoperative radiation
o since the great majority of lesions are squamous cell
carcinomas
 Goal of radical tumor removal may require:
o a very extensive procedure with partial or
Tx

complete removal of the maxilla or partial

resection of the anterior skull base
 Neck dissection with postoperative radiotherapy
o necessary only in patients who have clinically positive
cervical lymph nodes
o only about 20% of sinonasal malignancies
metastasize to regional lymph nodes

ESTHESIONEUROBLASTOMA
 rare neurologic malignancy
 arises from the sensory cells of the olfactory region
 may form extensive masses that grow along the skull base
Epid

 generally occurs in adults

 uncertain
Etio

 it is believed that some cases are embryogenically

induced
 remains asymptomatic for some time
o due to its location in the olfactory groove between the
upper portions of the nasal septum and the
attachment of the middle turbinate
 when advanced, the tumor causes:
o obstructed nasal breathing
o recurrent epistaxis
SSx

o hyposmia or anosmia
 some become symptomatic only after invading the
cranial cavity or orbit, causing:
o headache
o visual deterioration
 cervical lymph node metastases are the primary
manifestation of the disease in a few cases
 endoscopy
 computed tomography or magnetic resonance
Dx

imaging
o only these modalities can accurately define the tumor
extent
 combination of tumor resection and postoperative
Tx

radiotherapy

NASOPHARYNGEAL CARCINOMA
 will manifest symptoms depending on the area of extension:
 obstruction
Nasal Cavity  sanguineous or blood-streaked
discharge
 deafness
Ear
 pain
 proptosis
Eye
 diplopia
 neck mass
Other symptoms  neurological symptoms
 facial pain
 usually grows from the inferolateral nasopharyngeal wall
o can even extend to the sphenoid sinus or the pharyngeal
part of the Eustachian tube
 any patient seen with blood-tinged nasal discharge should
be suspected to further examination
 examine the nasopharynx very well in any middle-aged
adult male complaining of recurrent middle ear
effusion because it may not be otitis media but a
nasopharyngeal carcinoma.
 Treatment may be through chemotherapy, radiation therapy,
or a combination of both.
___________________________________________________

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