Presentation on Causes of Nasal Obstruction & Management of DNS Prepared by;Muhammad Muzammil Sangani Muhammad Ali Yousuf Sajjad Hussain Bhatti Student of Final Year MBBS

Anatomy and Physiology of noseBy: Muhammad Muzammil Sangani

ANATOMY OF NOSE:Nose is primarily for breathing and Olfaction , design of its cavity results warming and moisturing the inspired air & cleaning it also. Ext.nose.

Nose broadly divided intocavity subdivided into

Nasal

Nasal cavity Right half Left half

[By nasal septum]

EXTERNAL NOSEIt projects forwards and Downwards from the face. Shape: Pyramidal shape.

PARTS: ROOT: Projects forwards from the upper end which continues with forehead. BASE: Lower part consisting two nostrils.

DORSUM: Sides of nose meet anteriorly to form it. Upper part- bridge Dorsum Lower part-tip ALA: It is lower flaccid part of side of nose.

SUPPORTING FRAMEWORK:Supporting framework of the nose is cartilages And bones. Cartilages [hyaline] Bones [nasal pair bones]

BONES: 1. NASAL BONES -Upper part of external nose supported byit. -It articulating posteriorly with maxilla & Above with frontal bone & inferiorly Overlap with lateral cartilages.

2. FRONTAL PROCESS OF MAXILLAE

CARTILAGES1. Lateral cartilages 2. Alar cartilage 3. Septal cartilage. Major Minor

SKIN OF EXTERNAL NOSEThinnest at upper part. Thickest at lower part containing abundant of sebaceous glands.

MUSCLES OF EXTERNAL NOSE1. Procerus. 2. Depressor septii. 3. Nasalis.

FACIAL EXPRESSIONSProcerus-frowning, Depressor septii-anger Nasalis-sadness.

BLOOD SUPPLY1. 2. 3. 4. Dorsal nasal artery- branch of ophthalmic artery. External nasal-branch of anterior ethmoidal. Lateral nasal Superior labial artery -branches of facial artery.

NERVE SUPPLY1. External nasal nerve-branch of anterior ethmiodal. 2. Infratrochlear branch of nasociliary nerve. 3. Nasal branch of infra orbital nerve.

NASAL CAVITYEXTENSION

Broader below & narrowed at top. Shape: Pyriform shape. Extends anteriorly anterior naris[nostrils] & posteriorly posterior nasal aperture [choana]

CHOANA -Which lies between vomer & COMMUNICATION

Medial pterygoid plate of sphenoid -Anteriorly communicates with environment. -Posteriorly communicates with nasopharynx.

DIVISIONNasal cavity subdivided into right & left half by nasal septum. Each half has Roof. Floor. Medial wall- septum. Lateral wall.

ROOF

Length-7 cm, Width-2cm. -It slopes downwards both in front & behind. -Anterior slope formed by nasal part of frontal Bone & nasal bone.

-Posterior slope formed by body of sphenoid. -Middle horizontal slope formed by cribriform Plate of ethmoid.

FLOORLength-5cm, Width-1.5cm. -Which forms the roof of oral cavity & floor of nasal cavity. -Which is formed by horizontal plate of palatine bone & palatine process of maxilla. -It concaves from side to side.

MEDIAL WALL OR NASAL SEPTUMIt is divided into three parts. Bone Cartilage Cuticular part.

It articulates above with sphenoidal body

BONY PART1. Vomer. Forms posterior border of septum 2. Perpendicular plate of ethmoid bone. It articulates with vomer superiorly.

CARTILAGE

a)

Septal cartilageUnossified part of ethmoid perpendicular plate forms the anterosuperior part of septum

b)

Septal process of inferior nasal cartilage.

CUTICULAR PARTFormed by fibro fatty tissue covered by skin Lower margin of septum is called the columella It has four borders Superior Inferior Anterior Posterior It has two surfaces right and left

Nasal Septal Blood Supply

LATERAL WALL It is mainly formed by maxilla It separates the nose From orbit above (Intervening with ethmoidal air sinuses) From maxillary sinus below From lacrimal groove and naso lacrimal canal infront PARTS It has three parts:Vestibule Atrium of middle meatus Chonchae-Space seperating chonchae called meatus

VESTIBULE Small depresed area in anterior part It is lined by modified skin containing short, stiff, curved hairs called VIBRISSAE ATRIUM Atrium bounded above and anteriorly by a ridge called agger nasi (contains few ethmoidal cells) Lateral wall of nose is made up of bone cartilage and soft tissue

Choncae or TurbinatesInferior Turbinate:

An inferior infolding of the lateral nasal wall. 60 mm in anterior to posterior direction. Forms an important component of the nasal valve.

Middle Turbinate

Lies medial to the anterior ethmoid air cells, the maxillary sinus ostium, the nasofrontal duct, and the uncinate process. Length of 40 mm and mean height of 14.5 mm anteriorly and 7 mm posteriorly.

Superior Turbinate

Meatus drains the posterior ethmoid air cells.

HistologyThree layers of Turbinates

Medial thin mucosa Bone Lateral thick mucosaFrom: Berger: Laryngoscope, Volume 111(12).December 2000.2100-2105

HistologyMucosa

Pseudostratified columnar ciliated respiratory epithelium Goblet cells produce salts, glycoproteins, polysaccharides, lysozymes. Complex array of arteries, veins, and venous sinusoids. Lamina Propria contains the above tissue.

MeatusInferior Meatus:It runs along the whole length of the lateral wall Nasolacrimal duct opens in its anterior part

Middle Meatus:It runs posterior half of lateral wall. In the middle meatus is a rounded bulge called bulla ethmoidalis which is due to middle ethmoidal air cell which opens on or above it. Below and in front of the bulla is a gap called hiatus semilunaris Which leads into a funnel shape space called ethmoidal infundibulum Frontal and Anterior ethmoidal sinuses open into the infundibulum. Maxillary sinus open into the posterior part of infundibulum

Superior Meatus:It is limited to posterior third of lateral wall Posterior ethmoidal sinuses open into it

Sphenoethmoidal recessIt lies above the superior turbinate and receives the opening of the sphenoid sinus

Nerve Supply of nose

Physiology of Nose

Function of the NoseThe only externally visible part of the respiratory system that functions by: Providing an airway for respiration Moistening and warming the entering air Filtering inspired air and cleaning it of foreign matter Serving as a resonating chamber for speech Housing the olfactory receptors

Respiratory mucosaLines the balance of the nasal cavity Glands secrete mucus containing lysozyme and defensins to help destroy bacteria

Inspired air is:Humidified by the high water content in the nasal cavity Warmed by rich plexuses of capillaries Ciliated mucosal cells remove contaminated mucus

Superior, medial, and inferior conchae:Protrude medially from the lateral walls Increase mucosal area Enhance air turbulence and help filter air Sensitive mucosa triggers sneezing when stimulated by irritating particles

During inhalation the conchae and nasal mucosa:Filter, heat, and moisten air

During exhalation these structures:Reclaim heat and moisture Minimize heat and moisture loss

Sinuses in bones that surround the nasal cavitySinuses lighten the skull and help to warm and moisten the air

Olfactory Function of nose

REASONS FOR OLFACTIONSAFETY

ASSESS QUALITY OF AIRAVOID DANGEROUS ENVIROMENTS AVOID DANGEROUS FOODS

PLEASURE

DETERMINES FLAVOUR OF FOOD AND BEVERAGES OTHER AESTHETICS

INTRANASAL CHEMOSENSATIONCN I (OLFACTORY)

Mediates smellprovides flavour Aggregate of 40 nerve bundles that course from olfactory epithelium through cribiform plate to brain Large number of receptor cells Dispersed throughout nasal mucosa Mediate: chemical and non chemical stimuli Somatosensory sensations (irritation, burning, cooling, tickling) Induces reflexes (e.g. mucous secretion, inhalation cessation) to prevent /minimize injury to nose/lungs

CN V (TRIGEMINAL)

THE OLFACTORY NERVE

Neuroepithelium is located on the cribiform plate, superior septum and superior and middle turbinates

THE OLFACTORY NERVENeuroepithelium: Pseudostratified columnar epithelium Comprised of 6 different cell types including the receptor cell (Bipolar Cell) First cell (Bipolar cell): Bipolar receptor cell Projects from nasal cavity into brain without an intervening synapse Cilia have transmembrane receptors that interact with odorant ligands Provides major rout of viral, fungal and bacterial invasion into CNS 1000 types of receptors are present within the epithelium Synapses with dendrites of second order neurons within a glomerulus

http://www.leffingwell.com/olf2.gif

Glomerulus Decreased number with age Location of synapse between bipolar cells and second order neurons (mitral and tufted cells) Olfactory bulb Olfactory tract olfactory cortex (primary and secondary)

OLFACTORY CORTEXJUST REMEMBER THAT ITS COMPLEX

http://www.nature.com/nature/journal/v444/n7117/images/nature05405-f2.2.jpg

OLFACTIONDefinition:

Sense of smell Anosmia: loss of sense of smell Hyposmia: reduced sense of smell Dysosmia: olfactory distortion Presbyosmia: olfactory loss, sensorineural in nature, related to aging

Other terminology:

CAUSES OF OLFACTORY LOSSCONDUCTIVE

Airflow to olfactory receptor cells is blocked Usually treatable Damage to olfactory receptors or to central neural structures Usually untreatable Combination of conductive and sensorineural

SENSORINEURAL

MIXEDhttp://upload.wikimedia.org/wikipedia/commons/3/3a/Head_olfactory_n erve.jpg

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Causes of Nasal ObstructionBy: Muhammad Ali Yousuf

Nasal Obstruction Definition: Obstruction to the nasal airway. Itmay be:

Bilateral, unilateral, or positiondependent. Partial or complete. Continuous or intermittent. Acute, chronic or recurrent

Nasal obstruction may be:1. Structural : due to an obstructing lesion ,e.g., adenoids or deviated nasal septum. 2. Mucosal: due to mucosal swelling and congestion, e.g. acute rhinitis and allergy. 3. Mixed: due to a mucosal disease that caused an obstructive lesion, e.g., rhinitis complicated by polyps or hypertrophied turbinates.

Causes:Almost all nasal diseases may cause nasal obstruction. Common cold is the commonest cause of nasal obstruction. Allergy is the second common cause of nasal obstruction in general, and the commonest cause of chronic or recurrent nasal obstruction. Common causes of chronic nasal obstruction in children are : allergy ,rhinosinusitis, and adenoids.

Causes (Contd):I. Causes in Nose. II. Causes in the Sinuses. III. Causes in the Nasopharynx.

Causes (Contd):A- Causes in the Nose:1. Congenital choanal atresia. 2. Trauma, e.g. septal hematoma, foreign bodies, irritant fumes. 3.Rhinitis: i. Acute, e.g. common cold (commonest cause) ii. Chronic: a. Non-specific: hypertrophic, atrophic (primary or secondary). b. Specific (granulomata), e.g. scleroma

Causes (Contd):5. Nasal Polyps. 6. Deviated nasal septum. 7. Nasal allergy and vasomotor rhinitis. 8. Tumors: e.g. inverted papilloma or carcinoma.

B. Causes in the Sinuses:1. Acute rhinosinusitis. 2. Chronic rhinosinusitis. 3. Tumors

Causes (Contd):C- Causes in the Nasopharynx:

1. Adenoids (Children). 2. Nasopharyngeal angiofibroma (young adult males). 3. Nasopharyngeal carcinoma (old males).

Causes of chronic nasal obstruction:1. 2. 3. 4. 5. 6. 7. 8. Adenoids (in children). Allergic and vasomotor rhinitis. Chronic rhinitis. Chronic rhinosinusitis. Hypertrophied inferior turbinate. Deviated septum. Nasal Polyps. Tumors.

Causes of Unilateral Nasal Obstruction:1. 2. 3. 4. 5. 6. Unilateral congenital choanal atresia. Trauma, e.g. foreign bodies and fractures. Deviated septum. Antrochoanal polyp. Dental maxillary sinusitis. Tumors.

CausesCongenital choanal atresia repaired cleft palate tumours

CausesAcquired(without discharge)

-

trauma polyps neoplasms

CausesAcquired(with discharge)

-

mucosal inflammation - viral - bacterial - chemical - allergy - foreign body(unilateral, foul-smelling)

CausesCongenital choanal atresia(uni- or bilateral, soft-tissue or bony) ~ presents at birth ~ bilateral is problem as neonate is obligate nose breather ~ airway must be provided as emergency

CausesCongenital repaired cleft palate~ before repair - common airway ~ after repaired maxillary crest may occlude nose ~ provide oral airway ~ surgical correction

CausesCongenital tumours~ meningo-encephalocoele !! biopsies in nose !! ~ nasal glioma

CausesAcquired(without discharge)

-

trauma

Nasal traumaMay be part of more extensive injury to face, skull, skull-base, neck and chest.

CausesAcquired(without discharge)

-

trauma~ deviated septum - unilateral

Deviated septumDevelopmental as well as Traumatic The convexity of the septum is usually to the obstructed side while the concave side often has enlarged (compensatory) inferior and middle turbinates.

Septal deviationsA truly straight septum is rare deviations, deflections and spurs occur and, if severe, can cause obstruction. Perceptions of abnormality are subjective as some patients with minimal loss of airflow complain while complete obstruction is often an incidental finding in others.

Septal deviation

SymptomsUsually unilateral Obstruction - convex side - septum itself - concave side - turbinate Facial pain / - enlarged turbinate sinusitis

Clinical appearanceExternal appearance of the nose gives idea of symmetry. Inspection (anterior & posterior rhinoscopy) - deflection(s) - caudal dislocation - spur(s) - compensatory turbinate enlargement

External deformity

TreatmentDepends on degree of symptoms / discomfort Is surgery is indicated, choice is between septoplasty and submucosal resection Aim is to straighten or remove the deviated section and reposition it in the midline, while retaining adequate support of the nasal dorsum Turbinates may be trimmed or realigned

CausesAcquired trauma~ septal haematoma - bilateral Surgical correction haematoma as emergency

(without discharge)

Septal haematoma

ManagementSeptal haematoma(collection of blood beneath mucoperichondrium causing bilateral complete obstruction) - aspirate if small - usually incise and drain with a quilt suture to prevent re-collection - appropriate antibiotic cover

Management

If septal haematoma is missed or not treated adequately, septal abscess may follow and result in cartilage necrosis and saddle deformity

Saddle deformity

CausesAcquired(without discharge)

- nasal polyps

represent edematous glistening masses in the nasal and paranasal cavities mostly originating from the mucosal linings of the sinuses and prolapsing into the nasal cavities.

CausesAcquired(without discharge)

-

neoplasms- inverted papilloma - juvenile angiofibroma - malignancies

Surgical excision

CausesAcquired masses(without discharge) ~ adenoids (commonest in children)

-

Post Nasal Space

~ carcinoma / lymphoma ~ angiofibroma

Surgical removal

CausesAcquired(with discharge)

-

mucosal inflammation - viral~ clear rhinorrhoea ~ chills, fever

- bacterial~ purulent rhinorrhoea Symptomatic + antibiotics if indicated

Symptomatic treatmentDecongestants - systemic - antihistamine - topicalpseudo-ephedrine

Antipyretics Antibiotics - 2 bacterial infection? always in children from lower socio-economic groups

Steam inhalations

CausesAcquired inflammation(with discharge)

mucosal - chemical~ nose drops (rhinitis medicamentosa) - inflamed mucosa - clear rhinorrhoea

CausesAcquired(with discharge)

-

mucosal inflammation - allergy~ atopy history ~ seasonal or perennial ~ obstruction, rhinorrhoea, itching

Allergen avoidance antihistamines topical nasal steroids

CausesAcquired(with discharge)

-

mucosal inflammation - foreign body~ unilateral, foul-smelling rhinorrhoea in a child is a foreign body until disproven.

Visualise and remove local anaesthetic

Conclusion common senseIdentify cause Remove cause Treat any underlying / residual problems Reassurance

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