NASAL DISCHARGE &

OBSTRUCTION

BY
PULEIYAAR
AHMAD ZAKARIA
NURUL AIN IZZATI
PICHOLAS PHOA
ANATOMY
 DISEASES OF EXTERNAL NOSE

1.CELLULITIS
 The nasal skin may be invaded by streptococci or
staphylococci leading to a red, swollen and tender
nose.
 Sometimes, it is an extension of infection from the
nasal vestibule.
 Treatment is systemic antibacterials, hot
fomentation and analgesics.
 2. NASAL DEFORMITIES
SADDLE NOSE
Depressed nasal dorsum may involve bony,
cartilaginous or both bony and cartilaginous
components of nasal dorsum.

CAUSES
 Nasal trauma
 Excessive removal of septum in submucous
resection
 Destruction of septal cartilage by haematoma or
abscess
 Sometimes by leprosy, tuberculosis or syphilis.
HUMP NOSE
 This may involve the bone or cartilage or both bone and cartilage.

CROOKED OR A DEVIATED NOSE

 In crooked nose, the midline of dorsum from frontonasal angle to
the tip is curved in a C- or S-shaped manner.
 In a deviated nose, the midline is straight but deviated to one side.

 Usually, these deformities are traumatic in origin.

 Injuries sustained during birth, neonatal period or childhood, but
not immediately recognized, will also develop into these deformities
with the growth of nose.
3. TUMOURS
Dermoid with a sinus.
 seen in infants/children

 represented by a pit or a sinus in the midline of the dorsum of nose

 Hair may be seen protruding through sinus opening.

 sinus track may lead to a dermoid cyst lying under the nasal bone in
front of upper part of nasal septum or may have an intracranial dural
connection.

 In those with intracranial extension, sinus tract passes through the

cribriform plate or foramen caecum and is attached to dura or has other
intracranial connection.

 Meningitis occurs if infection travels along this path.

 Treatment of such cysts may necessitate splitting of the nasal bones to

remove any extension in the upper part of the nasal septum.
 Meningoencephalocele
or encephalocoele
Herniation of brain tissue with meninges through a
congenital bony defect.

Types

• Nasofrontal - subcutaneous pulsatile swelling in the

midline at the root of nose.
• Nasoethmoid - swelling at side of nose.
• Naso-orbital - on the antero medial aspect of orbit.

Swellings show cough impulse & reducible.

b) BENIGN TUMOURS
 C) MALIGNANT TUMOURS
 Basal cell carcinoma
Most common malignant tumour
M:F = 1:1
Age group of 40-60.
Common sites: tip and the alar

Clinical presentation
-Cyst
-Papulo-pearly nodule
-Ulcer with rolled edges

Characteristics
-Very slow growing
-Remains confined to skin for a long time
-Underlying bone and cartilage may get invaded
-Nodal metastasis extremely rare
 Squamous cell carcinoma (epithelioma)
2nd most common malignant tumour -11%
M:F = 1:1
Age group of 40-60

Clinical features
-Infiltrating nodule
-Ulcer with rolled out edges
-Affecting side of nose or collumela
-Nodal metastases – 20%

 Melanoma
 DISEASES OF NASAL VESTIBULE

1. FURUNCLES / BOIL
 2. VESTIBULITIS

 It is diffuse dermatitis of nasal vestibule.

 Nasal discharge, due to rhinitis/sinusitis/nasal allergy, coupled

with trauma of handkerchief, is the usual predisposing factor.

 Causative organism is S. aureus.

 In acute form, vestibular skin is red, swollen and tender; crusts

and scales cover an area of skin erosion or excoriation.

 The upper lip may also be involved.

 In chronic form, there is induration of vestibular skin with painful

fissures and crusting.
 OVERVIEW

 A sense of blockage of the nose within the nose

 Is a common presenting symptom for the entire
range of pathological condition of the nose.
 Causes of Nasal obstruction

Growth and
Anatomic Mucosal disease Miscellanous
neoplasia
abnormalities
•Septal deviation
• Benign and •Viral infection •Septal
•Turbinate
malignant •Bacterial hematoma
hypertrophy
tumor of nasal infection •Septal
•Congenital choanal
cavity •Fungal abscess
atresia
• Nasal infection •Foreign
•Septal perforation
polyposis •Allergic rhinitis bodies
•Nasal valve collapse
 What to ask on the history?

 Onset of the nasal blockage - Sudden or gradual?

 Presence of precipitating factor –exposure to
perfume, wood dust(SCC), metal(adenocarcinoma)
 Localisation –bilateral or unilateral?
 Smell sensation – reduced or absence?
 including family history, past or present history
indicative of allergic disease, features of upper
respiratory tract infection and medication used.
 Presence of epistaxis
Differential diagnosis of nasal obstruction

Unilateral Bilateral

1) Structural: deviated nasal 1) Structural: deviated nasal septum

(DNS)
septum (DNS), inf.
turbinate hypertrophy 2) Infection: acute rhinitis, chronic
rhinosinusitis, atrophic rhinitis
2) Infection: unilateral
sinusitis 3) Allergy: allergic rhinitis
3) Polyp: antrochoanal polyp 4) Non-allergic, non-infective:
vasomotor rhinitis
4) Neoplasm : SCC 5) Trauma: septal hematoma
5) Congenital: choanal atresia 6) Ethmoidal polyposis
6) Trauma 7) Neoplasm
 NASAL POLYP

Definition : Nasal polyps are non-neoplastic masses

of oedematous nasal or sinus mucosa.They are
divided into two main varieties:
1. Bilateral ethmoidal polyp
2. Antrochoanal polyp
Bilateral ethmoidal polyps
D: Ethmoidal polyps are multiple, bilateral, painless, pearly white, grape like masses arising from the ethmoidal air
cells

Aetiology
 Inflammatory conditions of
nasal mucosa – rhinosinusitis
 Asthma – 7% shows nasal polyp
 Aspirin intolerance -36%
 Cystic fibrosis- 20% of patients
shows nasal polyp d/t abnormal
mucus
 Allergic fungal sinusitis
 Kartagener syndrome
Symptoms Signs

• smooth, glistening (shine), grape-

 nasal obstruction like structure, pale in colour, sessile
 broadening of external or pedunculated, insensitive to
nose probing
• multiple and bilateral
 partial or total anosmia
• no contact bleeding
 sneezing and watery
nasal discharge due
to associated allergy
 Mass protruding from
the nostril
Investigations
• Clinical examination
• Anterior rhinoscopy
• Nasal endoscopy
• CT scan of paranasal sinuses-
essential to exclude the bony
erosion and expansion suggestive
of neoplasia
Treatments
 Conservative
 antihistamine ,
 topical steroids (in case of people
who can’t tolerate antihistamine & there is
contraindication)
 Surgery
 polypectomy
 intranasal ethmoidectomy
 extranasal ethmoidectomy
 transantral ethmoidectomy
 endoscopic sinus surgery
Antrochoanal polyps
 D: benign lesions that arises from the mucosa of
maxillary antrum near its accessory ostium, comes out Antral: thin
of it and grows in the choana and nasal cavity Thus it stalk
has three parts.
Choanal:
 1. Antral, which is a thin stalk. round and
 2. Choanal, which is round and globular. globular
 3. Nasal, which is flat from side to side.
Nasal: flat
from side to
side
 AETIOLOGY

Exact cause is unknown. Nasal allergy coupled

with sinus
infection is incriminated. Antrochoanal polyps are
seen in children and young adults. Usually they are
single and unilateral.
Symptoms Signs

 unilateral nasal • smooth greyish mass covered with

obstruction nasal discharge

 bilateral obstruction if • soft, can move up and down with

probe
it grows into the
• may protrude from nostril
 nasopharynx and
obstruct the opposite • post.rhinoscopy show globular
mass filling the nasopharynx
choana.
• Examination of the nose with an
 nasal discharge mainly endoscope may reveal a choanal or
mucoid antrochoanal polyp hidden
posteriorly in the nasal cavity
Diagnosis
 Anterior and posterior rhinoscopy
 X-ray
 paranasal sinuses may show opacity of the
involved antrum
 lateral view reveals a globular swelling in the
postnasal space
 CT scan

Management
 Easily remove by avulsion (separation)
through nasal/oral route
 Differences between antrochoanal and
ethmoidal polyp

Anthrocoanal polyp Ethmoidal polyp

Age Children Adults

Aetiology Infection Allergy
Number Solitary Multiple
Laterality Unilateral Bilateral
Origin Maxillary sinus near Ethmoidal sinuses,
the ostium uncinate process,
middle turbinate,
middle meatus

Growth Posteriorly to the Anteriorly to nostril

choana
Recurrence Uncommon Common
 TUMOR OF NASAL CAVITY
BENIGN MALIGNANT
 Squamous papilloma • Carcinoma
 Inverted papilloma • Squamous cell carcinoma
 Pleomorphic adenoma • Adenocarcinoma
 Schwannoma
• Malignant melanoma
 Meningioma
 Haemangioma • Esthesioneuroblastoma
 Chondroma • Haemangiopericytoma
 Angiofibroma • Lymphoma
 Encephalocele • Solitary plasmacytoma
 Glioma • Various types of sarcoma
 Dermoid

SQUAMOUS PAPILLOMA
Verrucous lesions similar to skin warts can arise from the nasal vestibule
or lower part of nasal septum.
 They may be single or multiple, pedunculated or sessile. Treatment is
local excision with cauterization of the base to prevent recurrence. They
can also be treated by cryosurgery or laser.
 Inverted papilloma (Transitional cell
papilloma or Ringertz tumour or
Schneiderian papilloma).
 A tumour of the nonolfactory mucosa of nose (Schneiderian membrane)
and paranasal sinuses.
 Most common site of origin is lateral wall of nose in the middle meatus;
 It is so named because hyperplastic papillomatous tissue grows into the
stroma rather than in exophytic manner (Figure 39.3).
 Human papilloma virus is thought to be responsible for its aetiology.
 Clinically, men are affected more than women in the age group of 40–
70. It is almost always unilateral and presents with nasal
obstruction, nasal discharge and epistaxis.
 It can invade sinuses or orbit. Orbital involvement causes proptosis,
diplopia and lacrimation.
Squamous cell carcinoma

 Arises from vestibule, anterior part of nasal septum or

lateral wall of nasal cavity
 Commonly :Men, >50 years old
 Vestibule:
arises from lateral wall of nasal
vestibule extend into columella,
nasal floor, & upper lid with
metastases to parotid nodes
 Septal
 mucocutaneous junction
 cause burning & soreness in
the nose. “nose-picker’s cancer”
 low grade malignancy

 Lateral Wall
 most common site
 easily extend into ethmoid or maxillary sinus
 grossly – polypoid mass
 rarely metastases
 treatment – radiotheraphy + surgery
 Tumors Of Paranasal Sinuses
Benign Malignant

Osteoma Carcinoma of maxillary

sinus

Fibrous dysplasia Ethmoid sinus

malignancy
Ossifying fibroma Frontal sinus
malignancy

Ameloblastoma Sphenoid sinus

malignancy
Osteoma

 Benign slow growing

tumour of mature bone
 Frontal sinus > ethmoid
sinus > maxillary sinus
 Symptoms (may also be
asymptomatic)
 Obstruction to sinus osteum
 Mucocele formation
 Pressure symptom like headace
 Treatment (usually when it
is symptomatic)
 Analgesics – aspirin, paracetamol etc.
(temporary relieve)
 Resection by surgery Osteoma of the frontal sinus
seen on x-ray
Carcinoma of the maxillary sinus

 Clinical features:
Early:
 Usually no symptoms(seldom diagnosed until

spread to surrounding structures)

 Blood stained nasal discharge
 Increasing unilateral nasal obstruction
Late
 Swelling of the cheek

 Epiphora (involve nasal

lacrimal duct)

 Proptosis and diplopia

 Pain(distribution of 2nd
division of CN5 or other
branches to ear,head or
mandible)
swelling of the right maxilla
causing gross asymmetry of
face
Investigations
 Plain xray of sinus-
opacity of the sinus
 CT scan- assess the
extent of invasion and
bone erosion
 Biopsy-
 when spread to nasal
cavity
 antrum:obtained via
antronasal wall Coronal CT scan showing
right maxillary sinus
opacification.
Treatment
 Surgery + radiotherapy
 Maxillectomy(removal of orbit if
involve)
 Fenestration of the hard palate
 allow drainage and access for inspection of
the antral cavity
 Poor prognosis:
 30% surviving to 5 years
 Septal pathology & management

 Deviated nasal septum

 Septal perforation
 Deviated nasal septum

 Congenital or traumatic dislocation of the septal

cartilage into one nasal fossa. Causes unilateral nasal
obstruction.

 Complication (if marked obstruction)

-recurrent sinusitis

 Treatment Deviated nasal septum into the

-Septoplasty columella. An obvious deformity is
coupled with nasal obstruction
 Septoplasty

 Surgical procedure to
correct a deviated
septum.
 Nasal septum is
straightened and
repositioned in the
middle of nose.
 Require the surgeon to
cut and remove parts of
the nasal septum
 Reinserting them in the
proper position.
 Septal perforation
 Defect in any portion of the cartilaginous or bony septum. It
provides direct communication between the right and left nasal
cavities.

 Sign & Symptoms :

-usually asymptomatic. Some may present with a history of
nasal obstruction, crusting, intermittent episodes of
epistaxis, malodorous discharge from the nose, cacosmia, or
a whistling sound during nasal breathing.
 Diagnosis :
-ARS
-Nasal endoscopy
Causes
 Treatment

 Medical therapy
 Surgical therapy
 Medical therapy

 Medical treatment aims to reduce symptoms rather than

correct the perforation.
- Treatments aimed at keeping the nose moist.
- Daily application of petroleum jelly (Vaseline) on a cotton-tipped
inside the nose
- Application of a nasal emollient such as Ponaris oil, or nasal
irrigations.
- In addition, a humidifier in the home may benefit the patient.
 Surgical therapy
Nasal Septal Prosthesis
 Placement of a nasal-septal
prosthesis is a conservative
intervention that may act as a
temporary or long-term
solution.
 Available in various materials
(eg, acrylic, plastic, silicone)
Surgical repair
 Surgical repair may provide a
definitive solution though is
accompanied by increased
potential morbidity and
failure.
 Repair techniques can be
classified broadly into several
groups, from the most
conservative to the most
radical. These techniques
include local flaps, various
autologous and biocompatible
grafts, 2-stage procedures,
and free-flap repair.
 Turbinate Hypertrophy

Turbinate hypertrophy is a condition

characterized by chronic swelling of
the nasal turbinates
-Sinus Center of Atlanta
 Introduction

 Nasal turbinates (nasal concha) are normal

structures that are attached to the sidewall of
internal nasal cavities.
 Inferior, middle and superior turbinates (in each nostrils)
 Functions:
 Warm and humidify the air

 Filter out airborne irritants

 Etiology

 Allergic rhinitis
 Vasomotor rhinitis
 URTI
 Passive smoking
 Chemical irritants
 Drugs (overuse of topical/oral decongestants,
“rhinitis medicamentosum”)
 Hormones (progesterone)
 Clinical Features

 Congested/block nasal breathing

 Postnasal drainage
 Midfacial headaches/facial pain
 Nasal headache (when in contact with septum or
lateral nasal wall)
 Breathing trouble at night → snoring → sleeping with
mouth open → dry mouth upon awakening
 Examination

1. Anterior rhinoscopy (until middle turbinate)

2. Nasoendoscopy (until nasopharynx)

Turbinate?
Polyp?
 Investigation

1. Sinus CT Scanning
 To determine extent of disease in Coronal CT
patients who have underlying through middle
chronic rhinosinusitis or acute portion of the
inferior turbinate
recurrent rhinosinusitis.
 Preferred – coronal plane

2. Acoustic rhinometry
Coronal CT
3. Eosinophilic infiltration of showing normal
mucosal membrane turbinates
 Management
Medical Therapy
 Topical decongestants
(oxymetazoline, phenylephrine)
 Oral decongestants
(pseudoephedrine,
phenylephrine)
 Anti-histamines
 Intranasal steroid spray
 Leukotrine receptor antagonist
(montelukast)
Surgical Therapy
• Reserved for symptomatic
patients with persistent
hypertrophy of turbinates, who
are not responding or
contraindicated to medical
therapy
• Complications – bleeding,
prolonged nasal dryness with
crusting (ozena)
 Choanal Atresia

Choana atresia is a congenital

abnormality described as a narrowing
of the anterior or posterior nasal
apertures, affecting the newborn.
Dr. Baharudin Abdullah, 2006
 Introduction

 Choanae are the posterior

openings that connect the
nasal cavities with the
nasopharynx.
 They develop between the
3rd-7th embryonic weeks,
following rupture of the
vertical epithelial fold
between the olfactory
groove and the roof of the
primary oral cavity
(oronasal membrane)
 Etiologies

Etiology (4 theories)
1. Persistence of
buccopharyngeal membrane
from the foregut
2. Abnormal persistence of the
nasobuccal membrane
3. Abnormal location of
mesoderm forming
adhesions in the choanal
region
4. Misdirection of neural crest
cell migration
 Incidence

 Incidence 1 per 8000 births

 Membranous (10%) or bony (90%)
 Unilateral more common than bilateral (3:2)
 Females affected twice as often as males (2:1)
 May be an isolated case, but usually 60-70% associated
with other congenital defects
 “CHARGE” - colobomatous blindness, heart dzs, atresia of choanae,
retarded growth/development, genital hypoplasia in male, ear
deformities & deafness
 Treacher Collins, Crouzon’s
 Polydactyly, craniosynostosis, cleft lip/palate, nasal/palatal
deformities
 Types

Unilateral Bilateral
Present later in life Neonatal emergency
Complete unilateral blockage, snoring and mucoid discharge Present at birth with a severe respiratory distress and
at affected side cyanosis lead to asphyxia and suffocation, require
resuscitation
Rarely causes respiratory distress Symptoms of severe airway obstruction - usage of acc.
muscle, alae nasi dilated, lips are sucked inwards
Cyclical change in oxygenation, infants will breathe if mouth
is opened during crying or if an artificial airway is inserted,
and cyanosed during quiet period.
Other manifestations – feeding difficulty, respiratory
collapse, failure to thrive
 Examination

 Inability to pass
catheter/NG tube
 Absent/diminished
fogging in cold spatula
test
 Lack movement of cotton
placed under nostrils while
mouth closed
 Investigation

 CT scan
 Nasal endoscopy
 Acoustic rhinometry

Axial
 Management

Immediate management in bilateral choanal atresia:

 Oxygenation
 McGovern nipple
 Oral intubation
 Tracheostomy (if definitive surgery needs to be delayed dt
health concerns)
 Gavage feeding
 Management

Definitive management
1. Trans-nasal
2. Trans-palatal
3. Trans-septal (occasionally used for older pt with
unilateral atresia)
4. Trans-antral (historical importance only)
 Management
Trans-nasal
 Simpler, safe, quicker, minimal tissue
handling
 Limited operative field to see and work
within
 Preferrable in membranous atresia, or
when body plate is thin
Trans-palatal
 Most commonly practiced, better
visualisation during atretic bone removal
 Longer operating time, greater blood loss,
may stunt palate growth, crossbite
deformity (52%), palate flap necrosis and
fistula, high rate of restenosis
 Preferrable when atresia is thick, pt aged
>5yo (most palatal growth has finished)
 References

 Dr. Baharudin Abdullah; Transnasal Endoscopic

Repair for Bilateral Choanal Atresia; 2006,
Malaysian Journal of Medical Sciences.
 Choanal Atresia: Diagnosis, Management and
Association with CHARGE syndrome by Matthew
Yantis, MD Dept of ORL, 2014.
 Sandford M Archer; Turbinate Dysfunction; 2018,
Medscape
 https://www.atlantasinus.com/turbinate-
hypertrophy/