Oxford Handbook of ENT and Head and Neck Surgery (2 edn)
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Structure and function of the nose
Structure
The structure of the nose is made up of four parts:
The surface anatomy—
see Fig. 9.1.
The nasal skeleton—composed of the two nasal bones, the paired upper lateral and lower lateral cartilages and the nasal septum, covered in subcutaneous tissue and skin (Figs 9.2–9.4).
The internal anatomy—includes the septum of the nose which forms the medial wall of the paired nasal cavities. The turbinates, also called conchae (the Latin term for scroll, which describes their appearance neatly) are attached to the lateral wall.
The osteomeatal complex—a key functional area of the nose. Understanding its anatomy is essential in understanding the aetiology of sinus disease.
Diagram of the surface landmarks of the nose.
Diagram of the nasal skeleton.
Knowing the anatomical terms for parts of the nose helps you to describe the site of lesions accurately, and to document the findings of examinations accurately.
Function
The nose is the main route for inspired air, and its structure is related to this function. As the air passes over the large surface area of the turbinates, the inspired gases are warmed and humidified. Mucus on the mucosa of the nose removes large dust particles from the air as it is breathed in (as anyone who has blown their nose after a trip on the London underground knows!).
The voice resonates in the sinuses and nose and this provides character to the speech. Patients with very obstructed nasal passages have what is often described as a ‘hyponasal’ quality to their speech.
Pneumatization of the sinuses are air-filled spaces, which reduces the weight of the skull.
The specialized neuroepithelium in the roof of the nose is the sire of olfactory sensation.
Diagram of the internal structure of the nose.
Rhinitis
Rhinitis is an inflammation of the nasal lining. Rhinitis may be diagnosed if a patient has two out of the three symptoms for more than 1h every day for over 2 weeks.
Symptoms
Blocked nose
Running nose—including postnasal drip
Sneezing
This condition is very common. Approximately one in six adults suffers from rhinitis.
Causes
There are a multitude of factors which cause rhinitis. However, since it may be caused by several different factors, it is important to treat each different cause. The symptoms of rhinitis may also be part of systemic disease (Table 9.1).
| Common | Rare | ||
|---|---|---|---|
| Allergic | Infective | Other | Part of systemic disease |
Seasonal Perennial Occupational | Acute Chronic | Idiopathic NARES (non-allergic rhinitis with eosinophilia) Drug-induced beta-blockers Oral contraceptives Aspirin NSAIDs Local decongestants Autonomic Atrophic Neoplastic | Primary mucus defect Cystic fibrosis Young’s disease Primary ciliary dyskinesis Kartagener’s syndrome Immunological SLE Rheumatoid arthritis AIDS Antibody deficiency Granulomatous disease Wegener’s/sarcoidosis Hormonal Hypothyroidism Pregnancy Old man’s drip |
| Common | Rare | ||
|---|---|---|---|
| Allergic | Infective | Other | Part of systemic disease |
Seasonal Perennial Occupational | Acute Chronic | Idiopathic NARES (non-allergic rhinitis with eosinophilia) Drug-induced beta-blockers Oral contraceptives Aspirin NSAIDs Local decongestants Autonomic Atrophic Neoplastic | Primary mucus defect Cystic fibrosis Young’s disease Primary ciliary dyskinesis Kartagener’s syndrome Immunological SLE Rheumatoid arthritis AIDS Antibody deficiency Granulomatous disease Wegener’s/sarcoidosis Hormonal Hypothyroidism Pregnancy Old man’s drip |
The commonest forms of rhinitis are allergic and infective. Classification of the disease and its rarer forms are shown in Table 9.1.
History
It is important to take a full history to determine the cause of rhinitis. This includes asking the patient about any history of atopy or asthma, and any seasonal variation in the symptoms. Documenting the main symptoms—blockage, running, and sneezing—and noting which one is predominant will help in treatment selection.
The patient should be asked what medications are being used and about their smoking history—almost every smoker has a degree of rhinitis. The patient should be asked about any previous treatment for rhinitis, including its duration and effectiveness.
Investigations
Anterior rhinoscopy—looking for enlarged turbinates (a blue tinge often indicates an allergic rhinitis) or nasal polyps.
Nasal endoscopy—examining the middle meatus for mucus or polyps.
Skin prick allergy tests—tiny amounts of test substances are placed on the skin and a pin prick is made—a positive result leads to a small raised, red, itchy patch.
RAST tests—a blood test which indicates if patients are allergic to a range of test substances.
Peak flow—many patients with rhinitis also have asthma—their peak flow test may be reduced.
Types of rhinitis
Medical treatment of rhinitis
The treatment of rhinitis is related to the underlying aetiology of the condition. Medical treatment is given if the patient feels their symptoms are bad enough.
Allergen avoidance
If the patient’s rhinitis is caused by an allergy, skin prick testing can identify the allergens to be avoided. It gives a visual feedback to the patient to confirm the diagnosis. Following a positive skin prick test, the patient can be given allergen avoidance information both verbally and on information sheets.
Pharmacological treatments
Each of the different medications has different effects on symptoms (Table 9.2).
Steroids—should ideally be delivered topically to the nasal mucosa using sprays or drops.
Oral steroids—can be very effective but their systemic effects limit their long-term use. A short course can be ideal for an important summer event such as an exam or a wedding, e.g. prednisolone PO od 0.5mg/kg for 1 week.
Antihistamines—non-sedating antihistamines are effective against sneezing, itching, and watery rhinorrhoea, e.g. cetirizine 10mg od PO. Used systemically they can be effective for other atopic problems such as watery eyes. They are not useful for symptoms of blockage.
Nasal decongestants—are only useful in the short term at the start of other therapy or when flying, since prolonged use can produce the intractable rhinorrhoea of rhinitis medicamentosa. For example, oxymetazoline 0.5% 2 drops bd into both nostrils for 2 weeks.
Ipratropium bromide—is an intranasal preparation and is effective for watery vasomotor-type rhinitis, e.g. ipratropium bromide 0.03% 2 sprays qds into both nostrils.
Sodium cromoglicate—is a mast cell stabilizer and is useful for allergic rhinitis. Sodium cromoglicate 4% 2 sprays each nostril qds.
| Sneezing | Discharge | Blockage | Anosmia | |
|---|---|---|---|---|
Cromoglicate | ++ | + | + | − |
Decongestant | − | − | +++ | − |
Antihistamine | +++ | ++ | ± | − |
Ipratropium | − | ++ | − | − |
Topical steroids | +++ | ++ | ++ | + |
Oral steroids | ++ | ++ | +++ | ++ |
| Sneezing | Discharge | Blockage | Anosmia | |
|---|---|---|---|---|
Cromoglicate | ++ | + | + | − |
Decongestant | − | − | +++ | − |
Antihistamine | +++ | ++ | ± | − |
Ipratropium | − | ++ | − | − |
Topical steroids | +++ | ++ | ++ | + |
Oral steroids | ++ | ++ | +++ | ++ |
Surgical treatment of rhinitis
The role of surgery is limited in the treatment of rhinitis. Surgery to improve nasal function may be a useful adjunct to other treatments.
Even if a surgically correctable problem is found it is worth a trial of medical therapy alone in the first instance. There is often a high rate of symptom resolution.
It is worth obtaining a CT scan of the paranasal sinuses if surgery is considered to review the need for sinus surgery.
Turbinate reduction
The turbinates often hypertrophy in all types of rhinitis but particularly in allergic rhinitis. Their hypertrophy often obstructs the airway to such a degree that it is impossible to deliver topical medication. Reduction can be achieved by several means:
Surface linear cautery—burning the surface
Submucous diathermy—burning under the surface
Cryotherapy—freezing
Outfracture—pushing out of the airway
Submucosal conchopexy—changing the shape of the turbinate
Trimming or cutting the turbinate
These techniques are effective in improving the airway for 18 months, but additional medical therapy is needed to prevent recurrence of the hypertrophied mucosa. The technique of trimming has a better long-term result, but has the potential for severe postoperative haemorrhage. Surgeons undertaking this type of surgery are known as turbinate terrorists!
Septal surgery
A deviated septum may need to be corrected to improve nasal function and help medication delivery.
Functional endoscopic sinus surgery
This surgery is aimed at the osteomeatal complex—it aims to remove blockage in the critical area and restore the normal function and drainage of the sinuses. It could benefit patients with sinusitis who do not respond to medical treatments.
Sinusitis
Sinusitis is a common inflammation of the sinuses. It is now regarded as a continuation of the spectrum of rhinitis.
The work of Messerklinger has shown that effective sinus drainage occurs through the area known as the osteomeatal complex ( see Fig. 9.4). Obstruction in this area due to anatomical or mucosal problems impairs sinus drainage and leads to obstructed outflow. This can occur as an acute phenomenon ( see ‘Acute sinusitis’, p. 170) or as a chronic condition ( see ‘Chronic sinusitis’, p. 172).
The osteomeatal complex.
Other theories of sinusitis are especially relevant to surgical failures (10–30%) where the sinus outflow tracts are open and the patient clinically still has mucopurulent secretions coming from their sinuses.
Fungal sinusitis
Fungi can be inhaled into the sinus tracts and can promote a prolonged chronic inflammation that causes sinus symptoms. This is mediated by an IgE response. Fungi can be isolated from the sinuses in almost 100% of patients, so the causality is doubted.
Biofilm production
Free-floating organisms form a biofilm by becoming anchored to a mucosal surface. The organisms then become more organized and progressively more difficult to remove from the surface. This facilitates further organism attachment. The expanding biofilm may destroy cilia and goblet cells of the normal sinus mucosa. This can lead to sinusitis and antibiotic resistance. Some studies have shown a very high percentage of biofilms in patients with sinusitis.
Superantigens
Colonization by Staphylococcal aureus with the production of enterotoxin can generate a potent immune response. These are known as ‘superantigens’. This leads to activation of the immune cascade and can lead to the development of chronic sinusitis. IgE antibodies to S. aureus enterotoxin have been isolated in 50–90% of patients with nasal polyposis.
Acute sinusitis
It is thought that everyone will suffer from an episode of sinusitis at some time in their life. It is caused by an acute bacterial infection which often develops after a preceding viral illness, such as a cold.
Signs and symptoms
Preceding URTI
Nasal obstruction
Severe facial pain over the sinuses, particularly the maxillae/cheeks
Pain, which is worse on bending down or coughing
A swelling on the face is usually caused by a dental abscess rather than by sinus disease. Tenderness over the sinuses is an overemphasized sign.
Investigations
Anterior rhinoscopy—to examine the inside of the nose
Nasal endoscopy—often shows the presence of pus in the middle meatus or oedematous mucosa
Treatment
In previously healthy adults, medication alone is usually effective:
Antibiotics may be given—co-amoxiclav 625mg PO tds 1/52
Decongestant—xylometazoline 0.1% drops 2 drops tds 1/52
Anti-inflammatory betamethasone drops—2 drops bd into both nostrils
If sinus symptoms do not resolve, consider sinus washout or endoscopic sinus surgery after CT to confirm the diagnosis.
In immunocompromised patients, consider a sinus washout to obtain microbiology for more effective antimicrobial treatment. Also, seek advice from local microbiologists for other appropriate therapy.
Tip: A pledget soaked in 5% cocaine solution placed in the middle meatus under endoscopic guidance may relieve the obstructed osteomeatal complex due to its intense vasoconstriction.
Recurrent acute sinusitis
Patients presenting with a history of recurrent sinusitis are often difficult to diagnose. This is because in the absence of an acute infection there may be no abnormal physical signs. Even CT scans may be entirely normal.
If the history is good, functional endoscopic sinus surgery (FESS) is appropriate if the number of episodes of infection is sufficient to cause disruption to the person’s lifestyle.
To avoid misdiagnosis, patients can be given an open appointment to turn up when their symptoms are severe. Endoscopic examination at this time may reveal pus in the middle meatus. When a patient is symptomatic a CT scan can also be helpful, but this depends on a co-operative radiology department who will allow rapid access.
Differential diagnosis of sinusitis
Migraine—typical or non-classical migraine symptoms may mimic sinus symptoms
Dental problems—abscess or temporomandibular joint disorders
Trigeminal neuralgia
Neuralgias of uncertain origin
Atypical facial pain
Remember that the CT paranasal sinus scan may be normal unless the patient is symptomatic.
Beware of operating on patients where there is no good evidence of sinus disease on a CT scan or on endoscopic examination—the results of surgery in this group are disappointing.
Chronic sinusitis
Chronic sinusitis is an inflammation of the sinuses lasting more than 6 weeks. Diagnosing chronic sinusitis, like diagnosing acute sinusitis, may be difficult, as it may be mimicked by other causes of facial pain.
Signs and symptoms
Pressure in the face—which gets worse on bending over
Pain when flying—in particular when descending
A feeling of nasal obstruction
Rhinitis—runny or blocked nose and sneezing
Investigations
Nasal examination—to check the patency of the airway
Anterior rhinoscopy—to examine the septum and nasal cavity
Posterior rhinoscopy with rigid endoscope—to examine the middle meatus and look for nasal polyps
Treatment
Some 80% of patients respond to medical therapy. This will involve one or more of the following medications for at least 3 months:
Intranasal steroid—mild inflammation/oedema in the nose, e.g. fluticasone two sprays od into both nostrils. For gross oedema a higher concentration of steroids is needed—for example betamethasone drops, 2 drops bd into both nostrils.
Oral antihistamine—e.g. cetirizine hydrochloride 10mg od PO.
If medical treatment fails, the following treatments may be considered:
A CT scan—to provide a surgical road map
FESS—extent dictated by disease process at surgery
Septoplasty—may be necessary in addition to the above
Surgery for chronic rhinosinusitis
Indications
Failed medical therapy
Surgically treatable sinus disease
Methods
FESS (functional endoscopic sinus surgery)
Most sinus surgery is now carried out with the use of Hopkins rod endoscopes and based on the original theories of Messerklinger. Obstruction at the osteomeatal complex is relieved by surgically enlarging the common drainage pathway of the sinuses. Thus it is functional surgery—opening up the natural drainage pathways.
The extent of the sinus surgery depends on the distribution of disease and the abilities of the surgeon. A progressive approach would be to carry out the following procedures:
Uncinectomy
Middle meatal antrostomy
Opening of the bulla ethmoidalis
Anterior and posterior ethmoidectomies
Sphenoidotomies
Opening of the frontal recess and ensuring drainage of the frontal sinuses
Complications
Rare—orbital ecchymosis, orbital haemorrhage, CSF leak, orbital damage including optic nerve injury.
Extended procedures
The following are often used to treat extensive polypoid disease or recurrent disease:
Canine fossa puncture
—here a sublabial incision enables access to the front wall of the maxillary sinus. A trocar passed through the bone of the maxilla enables passage of instruments to access the front inner face of the maxillary sinus. The procedure can lead to numbness of the upper lip and cheek.
Modified Lothrop procedure
—this is performed for the treatment of persistent frontal sinusitis and usually reserved for revision cases. Image-guided surgery equipment is used and the frontal recess is widened anteriorly in a U-shape fashion, including removal of the top part of the septum. This provides drainage of the frontal sinuses.
Balloon sinuplasty
—is a new treatment which uses the principles of Messerklinger’s theories. A balloon is passed into the sinus to be treated using a guidewire technique. This is particularly useful for the frontal sinus. The balloon is then inflated to widen the sinus outflow tract. Irrigation catheters can then be placed into the sinus for delivery of topical steroids or antibiotics. However, the technique does not treat the mucosal inflammation in the ethmoidal sinuses. Balloon techniques can dilate obstructed frontal, maxillary, and sphenoid sinuses.
Ethmoidal implants, e.g. Stratos™
—a patented drug delivery system for the ethmoid has been developed. This implant is inserted under radiological control and positioned in the anterior and posterior ethmoid anterior to the face of the sphenoid sinus. It can be filled with long-acting steroid (triamcinolone) which is released over a period of 30 days.
Complications of sinusitis
Mucociliary damage
Long-standing or chronic sinusitis can lead to mucociliary failure. This means that the sinus cannot drain properly, even if it is anatomically ventilated. Cigarette smoke will also paralyse cilia action, so smoking should be avoided by those with sinusitis.
Orbital complications
An unresolved episode of acute ethmoid or pansinusitis may lead to orbital complications, as shown in Figs 9.5 and 9.6. Infection under pressure in the ethmoid sinuses can traverse the thin bony plate of the medial orbital wall. This can lead to oedema formation and abscess formation. The management of this problem is dealt with in the Emergencies section of this book ( see ‘Periorbital cellulitis’, p. 380). The Chandler classification of orbital complications is shown in Fig. 9.5.
Chandler classification of orbital complications.
Pathways of spread for intracranial complications.
Intracranial complications
Infection under pressure in the frontal sinus can lead to stasis of blood in the diploeic veins which traverse the skull. Infection can travel back through the posterior table of the frontal sinus into the cranial cavity. This can lead to meningeal irritation, cerebral oedema, and frontal lobe abscess formation.
Pott’s puffy tumour
Ongoing frontal sinusitis can lead to osteomyelitis of the frontal bone. A soft boggy swelling then appears on the skin of the forehead. It was given this colourful name by Percival Pott.
Nasal polyps
Simple nasal polyps are part of the spectrum of rhinosinusitis as the lining of the nose becomes inflamed and thicker. These polyps are oedematous sinus mucosa, which prolapse to fill the nasal cavity to a variable extent. They are common, and their cause is unknown.
Signs and symptoms
Variable symptoms—with the season or with URTI
Rhinitis—blocked or runny nose and sneezing
Sinusitis—due to osteomeatal obstruction
Nasal obstruction
Appearance of the polyps at the anterior nares
Investigations
Diagram of nasal polyp showing features compared with inferior turbinate.
Polyp size can be graded.
Treatment
For small nasal polyps—give topical steroids, e.g. betamethasone drops: 2 drops bd for 2 weeks, followed by fluticasone 2 sprays od into both nostrils for 3 months
For large nasal polyps—give oral steroids 30mg od for 1 week, followed by fluticasone 2 sprays bd for 3 months
If medical treatment fails, the following should be considered:
Surgical removal for obstructive polyps—if the patient is sufficiently symptomatic
A CT scan to provide a road map prior to more advanced surgery
FESS—using a microdebrider for atraumatic polypectomy
Postoperative intranasal steroids to prevent recurrence
Samter’s triad associated polyp
This is the association of:
Aspirin sensitivity—making patients wheezy when they take aspirin
Late-onset asthma
Nasal polyps
It is caused by a defect in leukotriene metabolism. Polyps in this condition are florid and recur frequently
Treatment
Diet—refer patient to a dietician for advice on a low salicylate diet. This is very bland and difficult to maintain.
Intranasal steroids—patients often elect to use betamethasone drops long term despite their risk of systemic side effects.
Repeat surgery as for nasal polyps above—the microdebrider is the atraumatic instrument of choice.
Leukotriene antagonists, e.g. montelukast—aim to reduce polyps, results may vary.
Danger signs
A unilateral polyp must be regarded as a malignancy until proven otherwise by a biopsy.
Unusual nasal polyps
Antrochoanal polyps
These originate from the maxillary sinus and often present as a unilateral pendulous mass in the nasopharynx (Fig. 9.9). The uncinate process directs the polyp posteriorly as it emerges from the maxillary sinus. They are uncommon and their cause is not known.
An antrochoanal polyp and its anatomical relations. a = maxillary sinus attachment; b = maxillary ostium; c = osteomeatal complex; d = posterior choana; e = nasopharynx.
Macroscopically, the polyp is formed from a nasal component which is similar in appearance to a common nasal polyp.
The maxillary antral component is a thin fluid-filled cyst. A small fibrous band joins the two components as it passes out through the expanded sinus otium.
Treatment
CT scan—to confirm the diagnosis.
Endoscopic removal of the polyps—from its point of attachment in the maxillary sinus.
Caldwell–Luc approach for recurrent problem—an open sinus operation accessing the sinus via a cut in the mouth under the top lip.
Childhood polyps
Polyps presenting in childhood are very unusual. They are usually associated with an underlying mucociliary abnormality such as cystic fibrosis or primary ciliary dyskinesia syndrome.
Investigations
Consider a sweat test—the diagnostic test for cystic fibrosis
Histology—send samples for histology to exclude a tumour
Fresh sample of nasal lining—for special tests of ciliary function
Sample for electron microscopy—to check ciliary structure
Treatments
Medical treatment with steroids, e.g. prednisolone 1mg/kg for 1 week
Surgical removal
Septal problems
The nasal septum provides an important mechanical support for the external nasal skeleton.
Problems with the nasal septum can lead to both a cosmetic and functional disturbance of the nose. The nose may look bent to one side and/or the nasal airway may be restricted.
Septal deviation
The causes of septal deviation can be either congenital or traumatic. A traumatic septal deviation could be the result of a broken nose. Congenital septal deviation can occur after birth trauma to the nose, or the differential growth of the nasal septum compared to the rest of the skull.
Almost all nasal septae are deviated to some extent. Most people do not experience any problems, but some find their airway has become restricted.
Acoustic rhinomanometry and computer flow modelling has shown that deviations at the area of the nasal valve cause most functional impairment to airflow. This area is situated about 1cm posterior to the nares. It is bounded superiorly by the overlap of the upper and lower lateral cartilages. Laterally is the origin of the anterior part of the inferior turbinate; inferiorly, the floor of the nose; and medially, the nasal septum. Changes in the relative position of any of these structures causes a change in the area of the nasal valve.
Investigations
Anterior rhinoscopy—to exclude other problems, e.g. rhinitis
Cottle’s test—to exclude alar collapse
Nasendoscopy—to exclude sinusitis
Treatment
Medical—3-month trial of an intranasal steroid, e.g. betamethasone nasal spray 2 drops bd into both nostrils.
Surgical—septoplasty or a submucous resection (SMR) is an operation on the nasal septum to improve nasal airflow.
Septal perforation
There are several reasons why a patient’s septum may be perforated. These include:
Trauma or accident
Postseptal surgery
Nose picking
Granulomatous disease—must be excluded before treating perforation ( see ‘Granulomatous conditions’, p. 183).
Wegener’s
Sarcoidosis
TB
Syphilis
Cocaine addiction
Signs and symptoms
Whistling—if there is a small anterior perforation
Bleeding from the nose
Crusting of the nose at the site of the perforation
Treatment
Patient applies a lump of petroleum jelly, on the end of their little finger, twice daily to the edge of the perforation.
Epistaxis treated using silver nitrate cautery. Often occurs from the posterior edge of the perforation.
Septal button—this is a plastic prosthesis fitted into the hole in the septum. Only half of patients find it tolerable and continue using it long term.
Surgical septal repair—the results of surgery are variable even in experienced hands.
Granulomatous conditions
These are an uncommon group of diseases which are classified together because of their histological appearance—all of which form granulomas.
These conditions include:
Wegener’s granulomatosis—is a multisystem disease characterized by perivascular granuloma formation, which most often affects the respiratory system and the kidneys.
Sarcoidosis—its cause is unknown.
Syphilis—a sexually transmitted disease which can affect the nose.
Signs and symptoms
The patient may present with systemic symptoms, e.g. sarcoid with chest problems.
Patients may have isolated nasal symptoms, such as septal perforation (posterior in syphilis) or crusting on the nasal septum.
Investigations
FBC
U+Es
ESR
Syphilis serology
ANCA
CXR
Nasal biopsy
Treatment
Involve the medical team who deal with the condition in hospital, such as the chest or renal teams. They can assess the patient for signs of systemic disease.
Further medical treatment is managed by the appropriate medical team, often with immunosuppressants.
Sinonasal malignancy
Sinonasal malignancy is not a common condition.
The common types of malignancy are:
Squamous cell carcinoma
Malignant melanoma
Adenocarcinoma of the ethmoid
Olfactory neuroblastoma
Symptoms
Nasal polyp with obstruction
Epistaxis
Cacosmia = unpleasant smell from the nose experienced by patients
Cranial nerve palsies
Proptosis
Assessment
Nasal endoscopy
CT scan
MRI scan—helps to detect intracranial spread
Angiography—for assessment and possible embolization prior to surgical resection
Treatment
Following tumour staging a treatment plan is formulated by the MDT in the skull base clinic. The team involves ENT, neurosurgery, and plastic surgeons.
Craniofacial resection is standard care.
Endoscopic combined resection is becoming more widespread.
