“DISEASES OF EXTERNAL NOSE & NASAL VESTIBULE”.

CELLULITIS• The nasal skin may be invaded

by streptococci or staphylococci

• leading to red, swollen and tender nose.

• infection from the nasal septum.

• T/t:-Systemic anti-bacterial’s, hot fomentation and analgesics.

NASAL DEFORMITIES:-

• SADDLE NOSE

• HUMP NOSE

• CROOKED NOSE OR DEVIATED NOSE

SADDLE NOSE:-• Depressed nasal dorsum may

involve bony, cartilaginous or both.

• Nasal trauma causing depressed fractures is the common cause. Also results from excessive removal of in S.M.R, haematoma or abscess.

• T/t:-Augmentation rhinoplasty (Autograft or synthetic implant).

HUMP NOSE:-

• This may also involve the bone or cartilage or both bone and cartilage.

• T/t:-Reduction rhinoplasty.

CROOKED NOSE OR DEVIATED NOSE:-

• In Crooked nose the midline of dorsum from fronto-nasal angle to the tip, is curved in a C or S shaped manner.

• In Deviated nose, the midline is straight but deviated to one side.

• These deformities are usually traumatic in origin.

• T/t:-Septorhinoplasty or Rhinoplasty

TUMOURS

• 1. Congenital

• 2. Benign

• 3. Malignant

1.Congenital Tumour

• DERMOID CYST.

• ENCEPHALOCELE or MENINGOENCEPHALOCELE.

• GLIOMA

DERMOID CYST:-

• a. Simple dermoid cyst: - It occurs as a midline swelling under the skin but in front of the nasal bones.

• b. Associated with sinus: - It is seen in infants and children and is represented by pit or sinus.

Encephalocele or meningoencephalocele :-

• It is hernition of brain tissue with meninges through a congenital bony defect.swellings show cough impulse and may be reducible.

• T/t:-Neurosurgical(severing the tumour stalk from the brain and repairing the bony defect though which herniation has taken place).

GLIOMA:-

• It is a nipped off portion of encephalocele during embryonic development. Most of them are extranasal and present as firm subcutaneous swellings on the,side of the nose or near the inner canthus.

2.BENIGN TUMOURS

• They arise from the nasal skin and include papilloma, hemangioma, pigmented naevus, seborrhoeic keratosis, neurofib

• T/t:-Excision and Skin grafting.

3. Malignant tumours :-

• Basal cell carcinoma (rodent ulcer).

• Squamous cell carcinoma (epithelioma).

• Melanoma.

Basal cell carcinoma

• Most common malignant tumour involving skin of nose (87%)

• Equally in males and females of age group 40-60.

• Common sites on nose are tip and the ala.

• It may present as a cyst or papulo-pearly nodule or an ulcer with rolled edges.

• It grows slowly and is confined to skin, underlying bone or cartilage may get invaded.

• Nodal metastases is rare.

• Treatment depends on the size, location and depth of the tumour. Early lesions can be cured by cryosurgery, irradiation or surgical excision with 3-5mm of skin around palpable borders of the tumour.

• If lesions which are recurrent, extensive or with involvement of cartilage or bone are excised and closed with local or distant flaps or prosthesis.

Squamous cell carcinoma (epithelioma).

• It’s the second most common malignant tumour (11%).• Equally affecting both sexes (40-60yrs).• Occurs as an infiltrating nodule or an ulcer with rolled out

edges affecting side of nose or columella.• Nodal metastases are seen in 205 of cases.• Early lesions respond to radiotherapy, advanced lesions

exposed to bone or cartilage require surgical and plastic repair of the defect.

• Enlarged regional lymph nodes will require block dissection.

Melanoma.

• It’s the least common variety.

• Clinically it is superficially spreading type or nodular invasive type.

• Treatment is surgical excision.

Diseases of nasal vestibule

• Furuncle or boil.

• Vestibulitis.

• Stenosis and atresia of the nares.

• Tumours.

Furuncle or boil :-• It is an acute infection of the hair

follicle by staphylococcus aureus.• Trauma from picking of the nose or

plucking the nasal vibrissae, is the usual predisposing factor.

• The lesion is small,painful and tender.• Inflammation may spread to skin of

nasal tip and dorsum which becomes red and swollen.

• The furuncle may rupture in nasal vestibule.

• Treatment consist of warm compresses, analgesics to relieve pain, and topical and systemic antibiotics directed against staphylococcus.

• In case of fluctuant area incision and drainage can be done.

• The furuncle should not be squeezed or prematurely incised because of the danger of spread of infection to cavernous sinus through venous thrombophlebitis.

• A furuncle of nose may complicate into cellulitis of the upper lip or septal abscess.

Vestibulitis :-• It is a diffuse dermatitis of nasal vestibule.• Nasal discharge due to any cause such as rhinitis, sinusitis or

nasal allergy, coupled with trauma of handkerchief, is the usual predisposing factor.

• Causative organism is staphylococcus aureus.• It may be acute or chronic.• In acute form, skin is red, swollen and tender, crust and scales

cover an area of skin erosion. Upper lip may be involved.

• In chronic there is a in-duration of vestibular skin with painful fissures and crusting.

• Treatment consists of cleaning nasal vestibule of all crusts and scales with cotton applicator soaked in hydrogen peroxide and application of antibiotic-steroid ointment.

• Chronic fissure can be cauterized with silver nitrate.

Stenosis And Atresia Of The Nares.

• Accidental or surgical trauma to the nasal tip or vestibule can lead to web formation and stenosis of anterior nares.

• Destructive inflammatory lesions of nose also cause stenosis.

• Earlier vestibular stenosis resulted from smallpox.

• Congenital atresia of anterior nares due to non canalization of epithelial plug is a rare condition.

Stenosis of nares corrected by reconstructive plastic procedures.

– Naso-alveolar cyst presents a smooth bulge in the lateral wall and floor or nasal vestibule. The cyst can be excised by sublabial approach preserving the integrity of vestibular skin.

– Papiloma or wart may be single or multiple, pedunculated or sessile. Treatment is surgical excision under local anaesthesia.

– Squamous cell carcinoma arises from the lateral wall of the vestibule and may extend into nasal floor, columella and upper lip. Treatment is surgical excision or irradiation.

Trauma of nose: fractures of noseTypes of nasal fractures:

Depressed

•Due to frontal blow

•Collapse of nasal septum

•Widening of nasal dorsum

Angulated•Lateral blow

•Fracture of nasal bone and septum with deviation of nasal bridge.

Nasal fractures- often accompanied by injuries of nasal septum. Septal hematoma may form.

Clinical features

• Swelling of nose• Periorbital ecchymosis• Tenderness• Nasal deformity• Crepitation and mobility of fractured fragments.• Epitaxis• Nasal obstruction due to septal injury or

hematoma.• Lacerations of nasal skin, exposure of nasal bones

and cartilage.

DiagnosisPhysical exam and x-ray

Treatments• Treatment should be started during the 1st hrs following injury.• Arrest bleeding from injuried tissues• Tetarus antitoxin should be administered to prevent infection.• If there is concussion of brain => neurogical treatments should be given.• Primary surgical treatment of wound: wound margins are not excised, and only

non-viable tissues should be removed. Face wounds usually heal quickly due to intensive blood supply.

• Treat with H2O2 and dry the wound• Join margins of the wound with shortly spaced sutures using fine synthetic

ligatures.Primary suturing should be done during the course of 24 hrs following the injury.• Repositioning of displaced bone ragments.

Laterally displaced – using digital finger, thumb, no anaesthesia, only Novocain can be injected.Posteriorly displaced – using nasal elevators. (volkov)Fixing by anterior tamponade.Paraffin tampon.

Injuries to paranasal sinuses• Frontal sinuses injuries are nore common, next maxillary

sinuses and ethmoidal labyrinth.• Sphenoidal sinuses are rarely injuried.

Clinical features:

concussion syndrome, nasal syndrome.Injuries to paranasal sinuses with penetration into skull: loss of the consciousness, dizziness, psychic disturbance, vomiting, congestive changes in funds of eye and cardio vascular disfunction.

Changes of sinus

• Accumulation of blood in injuried sinus.• Subcutaneous emphysema of orbit cyclid, cheek,

forehead (bone fracture) during fracture of ethmoid bone.

• Injury to ethmodial labyrinth : hypoosmia / asnomis.

Treatment:

• Arrest bleeding and eliminate shock.• Complete primary treatment including reposition of

bone fracture• Suturing wound• Administering antiteranic serum.

Nasal bleeding(EPISATAXIS)

Causes of episataxis :

• local (trauma, infections-viral, foreign body, neoplasm etc.)

• General- (hypertension, arteriosclerosis, disorder of the blood and blood vessels, liver diseases etc)

• idiopathic

Sites of episataxis

• Liltle’s area- anterior inferior part of nasal septum- kiesserbach’s plexus

• Above level of middle turbinate – from anterior and posterior ethmoidal vessels

• Below level of middle turbinate – from artery sphenopalatina.

• Posterior part of nasal cavity – blood flows directly into pharynx.

• Diffuse – both from septum and lateral nasal wall.

• Nasopharynx.

Classifications

Anterior episataxis

• More common• Mostly from liltles area or

anterior part of lateral wall• In childrens/ youngs• Mostly trauma• Mild bleeding • Blood flows out from front

of nose in sitting position.

posterior episataxis

• Less common • From posterior superior

parts of nasal cavity • 40 years• Spontaneous, hypertension• Severe bleeding • Blood flows back into

throat.

Clinical features:

• Prodormal disorder : headache, noise in ears, dizziness, itching

• Blood can enter pharynx and is swallowed : profuse haematemesis : decrease in B.P and increase heart rate.

Diagnosis : rhinoscopy, pharyngoscopy and inspection of other organs.

Treatment:• Arrest nasal bleeding – for ex- bleeding at

liltle’s area, pinch the nose with thumb and index for 5 min. and cold compress.

• Transfusion of erythrocytes, correction of protein, electrolyte and acid base balance of body.

• Antibiotics to prevent sinusitis.• Maintain hemodynamics .