EARS, NOSE & THROAT (ENT)

Topic: Diseases of the Nose and Paranasal Sinuses

Lecturer: Dr. Hernandez, Josefino

OUTLINE Lecture Discussion: Lateral Nasal Wall

I. Anatomy We can see here the different turbinates (also called concha). We have here
II. Diseases the:
A. External Nasal Diseases  Inferior turbinate  underneath it is the inferior meatus into
 Nasal Vestibulitis which the nasolacrimal canal drains through the valve of Hasner
 Nasal Furunculosis  Middle turbinate  underneath it is the middle meatus  it is a
B. Rhinitis space into which the frontal sinus, maxillary sinus and anterior
 Allergic Rhinitis ethmoids drain
 Viral Rhinitis  Superior turbinate  underneath it is the superior meatus where
 Non-Allergic Rhinitis the posterior ethmoids drain
 Atrophic Rhinitis
 Rhinitis Medicamentosa The inferior turbinate and middle turbinate can be visualized anteriorly
when examining the nasal cavity
C. Rhinosinusitis Superior turbinate can be visualized posteriorly
D. Tumors of the Nose and Paranasal Sinuses
 Nasal Polyps Sphenoid Sinus – seen more posteriorly than the superior turbinate. Has an
 Inverting Papilloma ostium at the sphenoethmoidal recess
 Carcinoma
AIRFLOW PATTERNS
NOSE
 Aside from contributing significantly on how we look, the nose
subserves the sense of smell, prepares inhaled air for use in the lungs,
furnishes the air resistance necessary for normal functioning of the
lungs, and exerts certain reflex effects upon the lungs

Nose
 Turbinates
Are bony structures attached to the lateral nasal wall
 Septum  You can see here that the cribriform plate separates the nasal cavity
Divides the nose into 2 from the orbit and through small openings, the olfactory nerve endings
 Mucosa pass through to reach the upper third of the nasal cavity which is the
With erectile tissue covered with Pseudostratified ciliated columnar olfactory area. As we sniff more air, it reaches that area so that we can
epithelium  significant for mucociliary clearance which propels smell the substance or particle we try to sniff
mucous from anterior going posteriorly into the nasopharynx

PARANASAL SINUSES
 Paired:
o Frontal
o Maxillary
o Ethmoids
 Anterior
 Posterior
o Sphenoid

 When breathing in normally, we can see here that air flow is

Maxillary and Ethmoid sinuses are present at birth concentrated inferiorly but some of the air will still reach the olfactory
area. So anything that would result or prevent the substance or particle
Lateral Nasal Wall from reaching the olfactory area, will result in anosmia or hyposmia.
This can be secondary to nasal congestion or masses or tumors that will
obstruct or prevent the substance/particle from reaching the olfactory
area

Ostium of sphenoid sinus

Sphenoidal sinus

 When we exhale we can note that the air flow is more turbulent

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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

Ethmoidal Bulla, Endoscopy Mucociliary Clearance continued…..

 This is the mucociliary clearance involving the frontal sinus. So you can
have secretions moving up superiorly, medially and eventually going
lateral then medially, inferiorly and exits the natural ostium into the
 This is the image we see when we do endoscopy. From the front we can
frontal recess. But take note that some of the secretions will revert back
see here S – septum. Mt – middle turbinate that is attached superiorly
to the mucociliary pathway
to the cribriform plate. It – inferior turbinate. Between the two
turbinates is the space ~ middle meatus  where you find the UP –
Drainage:
unicinate process as well as the B – ethmoidal bulla which is part of the
 Inferior meatus
ethmoid air cells
o Nasolacrimal canal through the valve of Hasner
When a patient cries, some of the tears will enter the
Ethmoidal Infundibulum
punctum and nasolacrimal canal  exits into the nose

 Middle meatus
o Frontal sinus: 4-7 ml
o Maxillary sinus: 15 ml
o Anterior ethmoid air cells
 Superior meatus
o Posterior ethmoid air cells
 Sphenoethmoidal recess
o Sphenoid: 7 ml

NASAL PATENCY TEST

Glatzel’s mirror test
 A 3D space extending from HSL antero-inferiorly to the LNW, with the  Patient is allowed to exhale onto the mirror and misting is compared on
maxillary ostium in its floor each side
 Lateral to the uncinated process  Difference in misting may indicate obstruction

Lecture Discussion: Ethmoidal Infundibulum

This is a coronal image cut along the level of the maxillary ostium. So we have
here the orbit, maxillary sinus, natural ostium. Middle part is the nasal
septum attached superiorly to the cribriform plate. We also have the inferior
turbinate, middle turbinate  these are bony structures. Sometimes the
middle turbinate may have pneumatization called concha bullosa, the larger
the concha bullosa is, it is possible that it may cause the unicinate process to
pushed laterally resulting into the development of maxillary sinusitis

MUCOCILIARY CLEARANCE

Cottle’s Maneuver
 The cottle’s maneuver is a test in which the cheek on the side to be
evaluated is gently pulled laterally with one to two fingers to open the
valve. This test is used to determine if the most significant site of nasal
obstruction is at the valve or farther inside the nasal cavity

 So secretions develop at the floor which move up laterally, medially, and

superiorly and it always exits through the natural ostium  this is
genetically predetermined so the natural ostium should always be
patent, otherwise rhinosinusitis will develop

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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

EXTERNAL DISEASES OF THE NOSE o It can also trigger asthma in asthmatic patients.
 Nasal Vestibulitis o If there is obstruction of the ostium, secretions cannot come
o Infection of the skin of the nasal out so there is impaired mucociliary clearance which will
vestibule eventually lead to bacterial overgrowth on the secretions
o Staphylococci is the most which will cause the patient to develop bacterial
common organism rhinosinusitis.
o Could be secondary to trauma or
frequent nasal manipulation Classification of Rhinitis:
Allergic Infectious Others
 Nasal Furunculosis  Can be intermittent  Can be acute or  Can be Non-allergic,
o Infection of the nasal hair follicle or persistent. chronic Non-infective,
oftentimes caused by Staphylococcus  Recurrent rhinitis idiopathic, NARES, etc
aureus due to an IgE
o Could be secondary to plucking of nasal mediated reaction
vibrissae (hair) of the nasal mucosa
to allergens
Infection of the external nose can progress to cellulitis or cavernous sinus
1. Allergic Rhinitis
thrombosis
 Allergic rhinitis is now classified as intermittent or persistent.
Treatment:  Intermittent allergic rhinitis
 Consists of analgesics, warm compress and antibiotics directed against o Involves having signs and symptoms less than 4 days per week
staphylococcus or less than 4 weeks.
o In intermittent type, either of the 2 given criteria is sufficient
to be able to diagnose a patient as having an intermittent type
RHINITIS
of allergic rhinitis.
 Simply means inflammation of the nose
 Inflammation of the lining mucosa of the nose characterized by one or
 Persistent allergic rhinitis
more of the following symptoms:
o Involves having signs and symptoms more than 4 days per
o Nasal congestion
These 4 are the cardinal signs week and more than 4 weeks.
o Rhinorrhea
and symptoms of rhinitis o For persistent allergic rhinitis, the 2 given criteria should both
o Sneezing
be present in order for a patient to be diagnosed as having
o Itchiness
persistent allergic rhinitis.
Nasal congestion must be differentiated from nasal obstruction.  Allergic rhinitis can be further classified as mild, moderate or severe.
o Nasal congestion may result to nasal obstruction but the  The infection will not affect the sleep as well as
problem is usually not permanent. Mild
daily activities (e.g. work or school) of the patient.
o Nasal obstruction is used to identify more permanent
 Will affect the daily activities of the patient
conditions such as nasal polyps and tumors as well as
 Sleep disturbance
septal deviation. Moderate
 Impairment of school or work
o Nasal congestion is applied to rhinitis and sinusitis.
 Troublesome symptoms
Rhinorrhea  nasal discharge that can be clear/watery or  Will affect the daily activities of the patient
mucopurulent  Sleep disturbance
o Clear/Watery  we attribute it to viral rhinitis, Severe
 Impairment of school or work
allergic rhinitis, non-allergic rhinitis
 Troublesome symptoms
o Mucopurulent  we attribute it to bacterial
infections (e.g. acute bacterial sinusitis)
 ARIA: The New Classification
 Rhinitis may appear to be a simple disorder, but it can lead to more
serious problems if overlooked and left untreated
 Sequelae of Rhinitis:
o If the rhinitis lasts longer than 10 days, the patient may
develop sinusitis.
o If the rhinitis persists, it may actually affect the Eustachian tube
connected to the middle ear so the patient will develop otitis
media.
There will be inflammation of the Eustachian tube mucosa
so air will not reach the middle ear and there will eventually
be fluid behind the middle ear prompting patient to
develop otitis media
Causes of Allergic Rhinitis:
o Mucopurulent discharge coming from the sinuses which  Allergic rhinitis can be provoked by exposure to allergens in the
contains bacteria can be propelled posteriorly and it will reach environment.
the oropharyngeal area and patient can develop  Examples of allergens are pollens (tree such as alder, hazel oak, elm and
tonsillopharyngitis. birch grass, weed), house and dust mites, animal danders, cockroaches
o This infection may further go down to develop laryngitis which and certain mold species.
presents with hoarseness.  These are the common causes of allergic rhinitis.

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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

Signs and Symptoms of Allergic Rhinitis: Management of Allergic Rhinitis:

 Sneezing  Allergen avoidance
 Nasal itchiness  Pharmacotherapy – antihistamines, intranasal corticosteroids, topical,
 Clear, watery rhinorrhea nasal and systemic steroids, leukotriene receptor antagonist
 Nasal congestion (Montelukast)
 Pale and boggy turbinates  Decongestants may or may not be used depending on the severity of
 Redness of the eyes the congestion.
 Allergic shiners  Immunotherapy – if pharmacotherapy fails
o Infraorbital dark circles probably related to venous plexus
engorgement Pharmacologic Treatment of Allergic Rhinitis (ARIA Guidelines)
 Nasal salute
o Patient actually tries to take out the watery nasal discharge

 Linea nasalis
o Dorsal crease develops due to nasal salute
 Dennie’s line
o An accentuated line or atopic pleat of the lower eyelid  Take note: as an individual drug, the best medication is intranasal
corticosteroids followed by oral antihistamines
Pathogenesis of Allergic Rhinitis:
 For nasal obstruction – best drug is intranasal decongestant
 Sometimes may need more than 1 medication to improve their condition

 Initially, an allergic patient is sensitized.

 If the patient is not allergic, even if he is exposed to the allergen the
patient will not develop the infection.
 When the patient is exposed, the allergen combines with the IgE and
this combination will result in mast cell degranulation.
o When the mast cell degranulates, it will release the pro-
inflammatory mediators (histamine, leukotrienes,
prostaglandin) and this will affect the eyes and the nose
resulting in immediate allergic reaction.
 In the early phase reaction, there is involvement of the eyes (itchiness,
redness) and nasal symptoms (itchiness, watery nasal discharge,
sneezing and congestion.
o This is an immediate allergic or early phase reaction.
 Few hours later, the patient will develop late phase reaction.
o It develops 2-4 hours after the exposure to allergens.
o There will now be involvement of eosinophils.
o These eosinophils will go to the site of allergic reaction and the
major complaint of the patient will be chronic nasal blocking.
o There will be nasal obstruction.
LTRA*  in particular, in patients with asthma
 For mild intermittent, antihistamines can simple be given.
 For moderate severe intermittent up to moderate severe persistent,
intranasal corticosteroids may be given.
o Intranasal corticosteroids are usually given together with
antihistamines.
 Allergen avoidance should always be discussed with the patient.
 If medical management fails, patient can be referred for
immunotherapy for desensitization.
 Antihistamines are a mainstay in the treatment of allergic rhinitis.
o Antihistamines are inverse agonist since they occupy histamine
receptors.

Diagnosis is done by getting a good history and definitive diagnosis can be

achieved by skin testing  less expensive, more sensitive, technically easier to
perform, and results can be interpreted immediately

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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

Effects of Antihistamines Effects of Nasal Steroids Comparison of Common Colds and Allergic Rhinitis:
 Relieve pruritus  Degree of inhibition of early phase
 Prevent sneezing reaction
 Decrease thin secretions  Primary effect on suppression of late
 Does not improve phase reaction
congestion  Reduction of non-specific activity
 Inhibition of effects of cytokines

Side Effects of Glucocorticoids

 Growth retardation in children and adolescent
 Suppression of HPA- axis
 Osteoporosis
 Aseptic necrosis of the bone
 Hypertension
 Peptic ulcer
 Centripetal obesity
 Glaucoma
 Cataract
 Diminished immune response
 Impaired wound healing
 Diabetes mellitus
 Mental disturbance
 Proximal myopathy
 Cushing’s syndrome
Differential Diagnosis of Allergic Rhinitis:
1. Acute Rhinitis
Viral Rhinitis
 Common colds
 Peaks on the 2nd day and gradually
improves in 7-10 days
 Clear watery discharge 7-10 days 
in duration
 Presents with nasal congestion,
clear watery to mucoid nasal
discharge and may have mild sore
throat and low grade fever
 Commonly caused by a cold virus
which is well over a hundred
rhinoviruses
 Most cases are caused by
Rhinoviruses (comprising about
40% of the incidence)
 Respiratory Syncytial virus
 Influenza virus
 Adenoviruses
 Treatment: supportive –
decongestants, analgesics
3. Non-allergic and Non-Infective Rhinitis
 This also presents with recurrent rhinitis.
 It is not governed by allergic mechanisms.
 It is not IgE mediated.
 It may be idiopathic.
 Non-allergic rhinitis with eosinophilia (NARES)
 Occupational rhinitis – people working in chemical factories develop
rhinitis upon exposure to various chemicals.
 Hormonal rhinitis – common among pregnant women where estrogen
is elevated and this triggers development of rhinitis
Bacterial Rhinitis
 Drug induced rhinitis
 Presents with mucopurulent
 Food
discharge
 Streptococcus pneumoniae  Emotional
H. influenzae  Primary atrophic rhinitis
4. Idiopathic Rhinitis
 Better term than vasomotor rhinitis.
 Non-allergic and non-infective rhinitis
 Presents with nasal hyperresponsiveness to non-specific triggers such
as strong smells (perfumes, bleach, solvents), irritants (such as tobacco
smoke an exhaust fumes) and changes in environmental temperature
and humidity.
 When a person develops rhinitis during cold weather, it falls under non-
allergic rhinitis.
 The exact mechanism is unknown.
 Definitely, antihistamine is not the drug of choice for this case.
 Common causes of non-allergic rhinitis are changes in the temperature,
tobacco smoke, perfumes and pollution.
 Management: Intranasal corticosteroid, decongestants

2. Chronic 5. Atrophic Rhinitis

 Mycobacterium tuberculosis  There is atrophy of the nasal mucosa.
 Mycobacterium leprae  The patient will still complain of nasal obstruction.
 Klebsiella rhinoscleroma  It is a chronic inflammation of the nose characterized by a progressive
 Treponema pallidum atrophy of the nasal mucosa and the turbinates resulting in widened
 Fungi nasal passages, excessive crusting and a foul odor (ozena and anosmia).
 Incidence is quite rare  It is usually idiopathic.
 The cause is unknown.
 Common organisms implicated are Coccobacillus foetidus ozaena and
Klebsiella ozaena.
 It presents with nasal obstruction, atrophied turbinates, excessive
crusting and widened nasal cavity.
 Although there is good airway exchange the patient will still complain
of nasal obstruction.
 Therapy consists of buffered nasal saline irrigation twice daily and
vitamin A

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Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

6. Rhinitis Medicamentosa Findings:

 A form of idiopathic rhinitis characterized by worsening rebound  Paranasal sinus series or CT Scan of the PNS may reveal haziness, an air-
congestion following prolonged use of topical decongestants. fluid level or total opacification of the sinuses, but imaging studies are
 Medicamentosa means it is related to use of medications. NOT recommended for the routine diagnosis of ABRS
 Topical decongestants are advised continuous use not longer than 10 Treatment:
days.  Therapy would include appropriate antibiotics (7-10 days).
 If patients use topical decongestants for more than 10 days, instead of  Decongestants can be given if there is severe congestion.
the congestion being relieved by the medications, there will be more
 If the discharge is quite thick, mucolytics can be given.
development of congestion.
 Nasal saline irrigation will be of help.
 Rhinoscopy reveals congested and swollen turbinates.
 Intranasal corticosteroids can be used
 It is treated by discontinuing the use of nasal decongestants.
 Antihistamines are NOT INDICATED in the management of acute
 A shift to topical nasal steroids and systemic decongestants is bacterial rhinosinusitis.
necessary
Recommended Antibiotic Therapy for ABRS:
2. Rhinosinusitis  First-line antimicrobial regimen:
 Is an inflammatory condition involving the paranasal sinuses, as well as o Amoxicillin-clavulinic acid 625 mg q 8
the lining of the nasal passages o Amoxicillin 500 mg q 8
 Bacterial infection complicates only 0.5 to 2 % of viral URTIs, bacteria is  Use if patient is Penicillin allergic:
present in only 60% ARS cases and in most instances resolve o Doxycycline (among adults)
spontaneously o Levofloxacin (among adults)
o Azithromycin, Clarithromycin
1. Acute Rhinosinusitis  Cefuroxime remains an option in ABRS treatment
 The most important factor in the pathogenesis of rhinosinusitis appears
to be impaired mucociliary clearance and narrowing or obstruction of If unresponsive to medical management, CT scan of the paranasal sinuses
the sinus ostium. could be requested, patient may warrant Endoscopic sinus surgery
 Viral infection results in the loss of cilia and ciliated cells, reaching a
maximum around 1 week after the infection. 2. Chronic Rhinosinusitis
 Ciliary action is the most effective natural defense against acute  If signs and symptoms of acute rhinosinusitis persists longer than 3
rhinosinusitis months, it is already chronic rhinosinusitis.
Inflammation of the nasal cavity and paranasal sinuses and/or
Diagnosis: underlying bone that has been present for at least 12 weeks
 In general, a diagnosis of acute bacterial rhinosinusitis (ABRS) may be
made in adults with symptoms of a viral UTRI that has not improved  The most common predisposing factor is an untreated or poorly treated
after 10 days or worsened after 5 to 7 days lasting up to 4 weeks acute rhinosinusitis usually of more than 3 months duration.
 Other predisposing factors include trauma, structural deformities of the
Microorganisms of Acute Rhinosinusitis: nose, allergy and presence of nasal polyps.
Bacteria Viral  The signs and symptoms of chronic rhinosinusitis is more or less similar
Strep. pneumonia 31% Rhinovirus to the symptoms of acute rhinosinusitis except that the signs and
H. influenza 21% Influenza virus symptoms for chronic rhinosinusitis are LESS SEVERE
M. catarrhalis 2% Parainfluenza virus CRS can be divided to:
Anaerobes 6%  CRS without nasal polyps
Staph. Aureus 4%
 CRS with nasal polyps
Staph. Pyogenes 2%
Diagnosis of CRS:
Signs and Symptoms:  Based on the following criteria:
 Mucopurulent nasal and postnasal discharge o Presence of two or more of the following symptoms, one of
 For viral rhinitis, the discharge is watery to mucoid. which should be either:
 For bacterial rhinosinusitis, the discharge is mucopurulent yellowish to a) Nasal blockage/obstruction/congestion or
greenish nasal discharge. b) Nasal discharge (anterior/posterior nasal drip)’
 Usually, the discharge goes posteriorly hence the term post nasal drip. c) Facial pain/pressure; and
 Secretions will only come out of the nose if the patient blows his nose. d) Reduction or loss of smell
 Congestion o AND presence of any of the following:
 Pain a) Mucopurulent discharge
 Pressure b) Nasal polyps
c) Edema/Mucosal obstruction
 Heaviness and tenderness over the sinuses
d) Radiographic imaging showing mucosal changes
 Fever higher than 38.3 degrees
within ostiomeatal complex/sinuses
 Maxillary dental pain
 Hyposmia/Anosmia  A distinction should be made if there is acute exacerbation of CRS
 Fever The signs and symptoms are similar to the signs and symptoms of
 Rhinoscopy and endoscopy reveal purulent nasal discharge coating acute bacterial rhinosinusitis BUT the signs and symptoms of CRS
congested nasal mucosa are less severe. If the signs and symptoms will worsen again (fever,
mucopurulent discharge, tenderness on pressure)  indicates
exacerbation

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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino
Management:
 CRS with and without Nasal Polyps, being an inflammatory disease
should be primarily treated with intranasal corticosteroids
 Nasal saline irrigation is recommended
 CRS in acute exacerbation should be treated with short term antibiotics
 Surgical management is recommended if there is failure of medical
management of 1-3 months
 Multi-slice high resolution CT scan is done for patients who failed
medical management
 Plain sinus X-rays have a limited role in the diagnosis of CRS and is not
recommended
Management Key points:
 Drug of choice is intranasal corticosteroids combined with nasal
saline irrigation.
 Antibiotics are only given if there is exacerbation of the signs and
symptoms.
 Intranasal corticosteroids are given at 2 sprays twice a day.
 If patients present with thick discharge, mucolytics can be given.
 Referral to an otorhinolaryngologist can be done if the problem is
not adequately controlled.
 Endoscopic sinus surgery can be done if indicated.
 On CT scan, the maxillary sinus should present as a dark area but if
there is an opacified area in CT scan, it could indicate that there is
mucopurulent discharge in that area.
 Mucopurulent discharge can lead to opacification
TUMORS OF THE NOSE AND PARANASAL SINUSES
1. Inverting Papilloma
 A unilateral bulky deep red to gray lateral nasal wall lesion which may
appear like a polyp with gross translucency.
 Patients present with unilateral nasal obstruction, epistaxis and post
nasal drip.
 If the lesion is unilateral, malignancy must be considered.
 Malignant transformation is considered to be less than 2% of all cases.
 It usually develops into squamous cell carcinoma.
 Histology shows epithelium of the lesion inverting into the underlying
stroma.
 It can also affect the maxillary sinus
 Three characteristics make this tumor very different from other
sinonasal tumors:
a) A relatively strong potential for local destruction
b) High rate of recurrence
c) A risk of carcinomatous evolution
Management:
 Management involves complete excision via endoscopic sinus surgery
or lateral rhinotomy with medial maxillectomy
2. Nasal Polyps
 The most common mass in the nasal cavity
 No definite etiology exists.
 Certain risk factors are associated with the condition.
 Usually bilateral
Risk Factors:
 Chronic infection – infection causes inflammation of the nasal mucosa
prompting the patient to develop nasal polyps in the future.
 Allergies
 Trauma
 Metabolic disease
 Aspirin intolerance
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Signs and Symptoms:
 Patients present with nasal obstruction because polyps can obstruct the
airway.
 They may also present with discharge.
 Polyps can obstruct the ostium and sinusitis may develop.
 Patients also present with anosmia.
 The particles inhaled does not reach the olfactory epithelium.
 Rhinoscopy reveals presence of translucent, grayish white cystic
masses.
Management:
 If the polyps reach the oropharyngeal area, it warrants surgery.
 Most polyps are initially managed medically by giving intranasal
corticosteroids for about 4-6 weeks.
 It is a spectrum between medical and surgical management with the
ultimate aim of making the patient symptom free (no nasal obstruction
and no mucopurulent nasal discharge).
 If the polyps regress through medical management, even if there are
still small polyps left, it will not warrant any surgery as long as it does
not cause obstruction.
 It will only warrant surgery if there is nasal obstruction and there is
mucopurulent discharge after about 4-6 weeks of medical
management.
 A combination of topical as well as short term oral steroids can improve
the signs and symptoms thereby surgery is not anymore needed.
 Antibiotics, mucolytics and decongestants may be given when there is
exacerbation of the signs and symptoms.
MALIGNANT TUMORS OF THE NOSE AND SINUSES
 Carcinoma of the nose can present with nasal obstruction and nasal
discharge
 It can be mistaken for rhinosinusitis.
 Carcinoma of the paranasal sinuses presents with one or more of the
following:
o Unilateral nasal obstruction
o Epistaxis
o Nasal mass
o Maxillary bulge
o Loose teeth
o Bulging palate
o Diplopia and blurring of vision
 A patient presenting with unilateral nasal obstruction, epistaxis and is
elderly must be screened to rule out the possibility of malignancy or
inverting papillomas.
 An early case may progress to a late case of CA thus the management
will be more difficult.
 If the lesion involves the anterior maxillary wall, there could be
maxillary bulge.
 If it involves the gingiva, there might be loosening of the teeth.
 Diplopia, bulging palate and blurring of vision happens when the lesion
affects the floor of the orbit which is the roof of the maxillary sinus.
 Maxillary carcinoma is the most common.
 Radiographs will reveal radioopacity of the nose and sinus as well as
bone destruction.
 The most common histopathologic feature is squamous cell carcinoma.
Diagnosis:
 CT scan of the paranasal sinuses – presents with bone destruction
 Malignant tumors invade the bone while benign tumors push the bone
away.
 Biopsy: incisional via gingiva-buccal approach or biopsy of nasal
extension
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 EARS, NOSE & THROAT (ENT)
Topic: Diseases of the Nose and Paranasal Sinuses
Lecturer: Dr. Hernandez, Josefino

Management:
 Wide excision of the carcinoma or maxillectomy
 There must be a margin
 We want to catch patients with malignancy early. Early diagnosis should
result in better prognosis
 Modalities of treatment:
o Surgery
o Radiotherapy
o Chemotherapy
Surgery and postoperative radiation therapy may result in improved
local control, absolute survival, and complications when compared
with radiation therapy alone

SUMMARY
 Disorders of the Nose and Paranasal Sinuses result in congestion and
obstruction of the nasal cavity which can result in problems in olfaction

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