A. Anatomy and physiology
The nose functions primarily in respiration and olfaction. The external nose comprises the nasal bones superiorly and nasal cartilage anteriorly. The nasal septum comprises cartilage anteriorly and bone posteriorly. The inferior, middle, superior, and supreme turbinates are mucosa-lined bony prominences that project from the lateral nasal walls and serve to filter, warm, and humidify inspired air. The olfactory nerve penetrates the cribriform plate and is distributed along the superior aspect of the nasal vault. The nose is lined with a mucosa rich in mucous glands, nerves, blood vessels, and inflammatory cells.
The paranasal sinuses (frontal, maxillary, ethmoid, and sphenoid sinuses) are paired bony cavities of the skull that contribute to voice resonance, decrease the weight of the skull, and cushion cranial contents in the case of head trauma. Mucus produced in the sinuses drains into the nasal cavity through ostia by mucociliary flow.
B. Congenital disorders
Congenital midline nasal masses in children can be encephaloceles, gliomas, or dermoid cysts and may be present intranasally, extranasally, as a mass or pit. A magnetic resonance image (MRI) should always be obtained to rule out intracranial communication. Treatment is surgical excision.
Choanal atresia (CA) is persistence of the nasobuccal membrane, which prohibits communication between the nasal cavity and nasopharynx. CA is more common in females, is unilateral in approximately 70% of cases, and is often associated with other anomalies. Because infants are obligate nasal breathers, bilateral CA is often diagnosed shortly after birth. Inability to pass a catheter through the nose into the oropharynx confirms the diagnosis. Bilateral CA requires immediate surgical attention, whereas unilateral CA repair is often delayed to allow the operative site to enlarge.
C. Infectious/inflammatory disorders
- Rhinosinusitis is characterized by nasal congestion, excessive secretions, and postnasal drip. Rhinosinusitis has multiple etiologies that can be grouped into allergic, infectious, or drug induced.
- Acute bacterial rhinosinusitis (ABS) is characterized by facial and dental pain, sinus pressure, fever, and purulent nasal discharge. The most common pathogens are Streptococcus pneumoniae, M. catarrhalis, and H. influenzae. Treatment consists of a 14-day antibacterial regiment (amoxicillin/clavulanate or quinolones), decongestants, mucolytic agents, and humidification, with or without systemic corticosteroids. Surgical intervention is usually not necessary. Clinicians should be vigilant for intraorbital or intracranial complications of ABS.
- Chronic bacterial rhinosinusitis (CRS) is loosely defined as ABS symptoms lasting more than 6 weeks. The pathophysiology of CRS is thought to be multifactorial and includes mechanical obstruction of the paranasal sinus drainage at the osteomeatal complex, allergic inflammation, and infection (bacterial or fungal). However, the exact pathogenesis and treatment of CRS are under debate. Coronal computed tomography (CT) scan of the sinuses is the diagnostic study of choice and provides the surgeon with information regarding the bony and soft tissue anatomy, mucosal inflammation, and purulence within the sinus cavities. Patients should first be treated medically for 12 weeks with antibiotics, nasal saline washes, and nasal steroids . Patients that have failed medical treatment may be candidates for functional endoscopic sinus surgery (FESS). The objectives of FESS are to re-establish the patency of the sinus ostia, ventilate the sinuses, and remove diseased mucosa or polyps. Studies indicate that patients refractory to medical treatment benefit from FESS. Immunotherapy might provide another tool in treating CRS; however, data are lacking.
- Fungal sinusitis is most often caused by Aspergillus species. Invasive fungal sinusitis is more common in immunocompromised patients and requires intravenous antifungal medications and prompt surgical débridement. Antifungal treatment of chronic rhinosinusitis has not been shown to be successful (J Allergy Clin Immunol 2006;118:1149).
Epistaxis has multiple etiologies, including trauma, tumors, coagulopathies, and granulomatous diseases (Wegener, tuberculosis, sarcoidosis, etc.). Most epistaxis is minor; however, due to the significant vascularity of the nose, hemorrhage can be life-threatening. Always address the ABCs first (airway, breathing, circulation). The patient should be instructed to pinch his or her nose until examined by a clinician. If bleeding persists, pledgets soaked with vasoconstrictors (lidocaine with epinephrine, or cocaine) can be inserted into the nasal cavity. Visualization of the nasal cavity allows for localization of the bleeding (anterior vs. posterior) and allows for cauterization of active bleeding with silver nitrate or electrocautery. The anterior nose can be packed using epistaxis balloons or gauze. Posterior nasal packing can be achieved by passing a Foley catheter through the nares past the choana. The catheter is then inflated and pulled anteriorly until it rests snugly in the posterior choana. Arterial embolization is reserved for refractory cases.
E. Nasal-sinus trauma
- Nasal fractures are the result of blunt facial trauma. Epistaxis and airway management are the first priority. Reduction of nasal fractures is recommended between days 3 and 10. This timing allows for resolution of swelling but avoids bony healing. Closed reduction is usually sufficient for most fractures.
- Midface fractures with cosmetic or functional deformities require open reduction and internal fixation. Control of the airway is important in the acute setting. Midface fractures are classified according to the Le Fort system (Fig. 28-1). Le Fort I fracture separates the bone containing the maxillary dentition from the rest of the craniofacial skeleton. Le Fort II (pyramidal fracture) extends up through the maxilla, across the orbital floor and nasal bones, and down the other side of the face in similar fashion. Le Fort III fracture represents a true separation of the facial bones from the cranium by involving both zygomas, orbits, and nasal bones.
F. Nasal septum
- Nasal septal deviation (NSD) results from nasal trauma or differential growth during postnatal development. The role of NSD in sinus disease is controversial . Most surgeons correct NSD (septoplasty) in connection with the FESS procedure (see Section III.C.3) if nasal obstruction and sinus disease are present.
- Nasal septal hematomas may occur with any nasal trauma. Blood collects between the mucoperichondrium and cartilage of the nasal septum. Because the cartilage relies on the overlying tissues for its blood supply, the hematoma can cause cartilage necrosis and septal perforation. Treatment is incision and drainage.
- Nasal septal perforations (NSPs) are usually located anteriorly in the cartilaginous portion of the septum. NSPs are most commonly caused by trauma (prior surgery, facial trauma, digital trauma), intranasal cocaine use, or vasculitis. Though NSP is not a life-threatening condition, it can cause substantial morbidity due to continual crusting, bleeding, nasal obstruction, and “whistling” while breathing. Most NSP are not repaired due to the high failure rates of local mucosal flap advancement.
G. Nasal foreign bodies
Nasal foreign bodies are generally found in children or adults with mental retardation. Unilateral, foul-smelling nasal discharge in a child is considered a foreign object until proven otherwise. In adults with similar symptoms, neoplasms must be ruled out. Most foreign bodies can be removed in awake patients. However, conscious sedation or general anesthesia with airway protection may be necessary in younger children. Batteries in the nose, ear, trachea, or esophagus constitute a medical emergency requiring urgent removal.
H. The adenoids
The adenoids are lymphoid tissue present in the posterior nasopharynx that hypertrophy during childhood and then usually atrophy with age. Adenoid hypertrophy can cause recurrent otitis media, snoring, and nasal obstruction, resulting in mouth breathing. Adenoidectomy is often performed in connection with tonsillectomy.
I. Nasal polyps
Nasal polyps are pendulous, edematous, hyperplastic regions of nasal mucosa that often cause sinus drainage obstruction. The etiology of nasal polyps is unknown, but they are commonly associated with systemic diseases (cystic fibrosis, allergies, chronic rhinosinusitis, or the clinical triad of aspirin sensitivity, asthma, and nasal polyposis). Nasal polyps are usually treated with nasal steroids and surgical debulking, although the effectiveness of surgical treatment is controversial and requires further investigation (Health Technol Assess 2003;7:1).