Nose / Sinus

Key Points

The nose is the commonest site traumatized on the face due to its prominence.

A nasal septal hematoma is a feared complication that should be picked up as soon as possible and the hematoma should be evacuated within 12 hours due to the potential of septal cartilage necrosis.

Nasal septal cartilage necrosis can result in a saddle nose deformity with nasal obstruction.

Nasal trauma can result in a nasal fracture with nasal obstruction and/or cosmetic deficits such as a saddle nose or crooked nose.

The critical window for a closed nasal reduction for treatment of nasal fracture is before 2 weeks in adults and before 1 week in the pediatric patient.

The treatment for persistent nasal deformities beyond 1 month after injury may require a functional septorhinoplasty.

The nose is frequently traumatized in facial injuries and this often results from motor vehicle accidents, sports-related injuries and altercations. When the injury is significant, this can result in nasal fractures with its accompanying nasal deformity. There are 2 main problems that nasal trauma can result in: a nasal septal hematoma or nasal fracture with nasal obstruction or nasal deformities.

A nasal septal hematoma is one of the most feared complication that can occur with nasal trauma. Though uncommon, a septal hematoma can lead to complications such as septal abscess, septal perforation, cartilage necrosis with potential saddle nose deformity. A nasal septal hematoma can be usually diagnosed with a careful clinical examination using a good light source with a nasal speculum. A fluctuant reddish-blue swelling can be noted on the anterior part of the nasal septum drainage of the hematoma should be performed urgently to prevent complications as mentioned above.

Exposed vessels on Little’s area in the nose can be easily traumatized resulting in nosebleeds. This can be treated easily with silver nitrate cautery.

Exposed vessels on Little’s area in the nose can be easily traumatized resulting in nosebleeds. This can be treated easily with silver nitrate cautery.

 

Epistaxis from trauma to exposed vessels on septum and inferior turbinate

Epistaxis from trauma to exposed vessels on septum and inferior turbinate

 

Exposed vessels treated with Silver Nitrate Cautery

Exposed vessels treated with Silver Nitrate Cautery

 

A nasal fracture can be diagnosed clinically if there is gross deviation of the nose from its pre-injury appearance. An x-ray though frequently performed may not be always necessary as it does not change the management.

First aid measures:

  • If the nose is bleeding, digital pressure over the soft fleshy part of the nose on its lower half can be applied for 15 minutes to slow down bleeding.
  • The head should be tilted forward during this time to prevent aspiration of the blood into the lungs.
  • Place ice wrapped in a cloth or a bag of frozen peas over the nose for about 15 minutes at a time. This process can be repeated hourly throughout the day. Using ice packs at the time of injury and for 1-2 days afterward helps to reduce pain, swelling and reduce nose bleeds. Take breaks between applications, and do not apply the ice directly to the skin.
  • Take paracetamol or NSAIDS to reduce pain. The pain is usually worse in the first 5 days after the injury.
  • Nasal decongestant such as oxymetazoline can be used to help with the nasal obstruction. However these should not be used beyond 5 days.
  • Elevate the head, especially when sleeping, to avoid increased swelling of the nose. Prop the head up with pillows or lift the head of the bed by placing large blocks or phone books under the mattress.
  • A closed nasal reduction can be attempted within 3 hours of injury before swelling sets in or between 3 days to 14 days when the swelling has improved. This helps in the evaluation of the precise nasal deformity the patient is suffering from. This procedure can be performed under local anaesthesia and is frequently painless. (Figure 1) A satisfying “click” can usually be felt or even heard when the nasal fracture is pushed back in place. There is usually increased swelling over the nose and some periorbital bruising may sometimes occur post nasal reduction. Some small amount of nose bleeds is usually expected in the first 48 hours after a nasal reduction. A nasal cast is usually applied for the next 1 week to protect the reduced nasal fragments. It is important that the patient avoids all contact sports (eg basketball, football) for the next 6 weeks following a closed nasal reduction till the nasal fragments are healed in place.

PDF: Article on Nasal Fracture

Subsequently, post-traumatic nasal deformity is one of the most common reasons that patients seek consultation in the doctor’s clinic. Depending on the type of nasal deformities, this can result in functional impairment and aesthetic problems. Two challenging problems to be addressed in the post-traumatic nose are the crooked nose deformity and the saddle nose deformity. The only definitive treatment for these conditions would be a functional septorhinoplasty if it troubles the patient.

nasal deformA closed nasal reduction being performed in the clinic with the patient awake with nose deviated to left. An elevator is used on the right side and digital pressure is simultaneously applied on the left to reduce the fracture.

Thick mucopus from the right nasal cavity with postnasal drip. The patient also complained of halitosis “Bad breath

Thick mucopus from the right nasal cavity with postnasal drip. The patient also complained of halitosis “Bad breath”

Sinusitis is an inflammation, or swelling, of the tissue lining the sinuses. Normally, sinuses are filled with air. But when they become blocked and filled with fluid, germs (bacteria, viruses, and fungi) can grow and cause an infection.

Conditions that can cause sinus blockage include the common coldallergic rhinitis (swelling of the lining of the nose), nasal polyps (small growths in that lining), or a deviated septum (a shift in the nasal cavity). Patients with sinusitis frequently present with yellowish-green nasal discharge with nasal congestion, fever, headaches or even facial pain.

 

 

Balloon Sinuplasty (BSP) is a safe and effective sinus procedure for chronic sinusitis patients seeking relief from uncomfortable sinus pain symptoms. In selected cases, these can be performed in the clinic.

 

Right nasal polyp grade 3 arising from the sphenoethmoidal recess. This eventually turned out to be an inverted papilloma

Right nasal polyp grade 3 arising from the sphenoethmoidal recess. This eventually turned out to be an inverted papilloma

Huge right nasal polyp extruding from the right nostril

Huge right nasal polyp extruding from the right nostril

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Mucopus from right nasal cavity from fungal sinusitis

 

Nasal polyps are benign lumps in the nose that can result in anosmia (loss of smell) or hyposmia (decreased sensation of smell). Anosmia/hyposmia can result in sensation of taste whilst eating and this can result in a decrease in quality of life for the individual. These polyps can be safely removed via a functional endoscopic sinus surgery under IGS (Image Guided Surgery) to improve the safety and greatly reduce complication rate.

MRI showing skull base polyps resulting in loss of smell (anosmia)”

MRI showing skull base polyps resulting in loss of smell (anosmia)”

Postoperative MRI cleared of skull base polyps via FESS (Functional endoscopic sinus surgery)” He recovered his sense of smell though this may not be possible in all situations.

Postoperative MRI cleared of skull base polyps via FESS (Functional endoscopic sinus surgery)” He recovered his sense of smell though this may not be possible in all situations.

This is a common reason for nasal congestion in Singapore. The high humidity results in high prevalence of house dust mites which stimulate an allergic reaction resulting in swollen inferior turbinates.

Right inferior turbinate size 1 month after an inferior turbinoplasty

Right inferior turbinate hypertrophy with nasal obstruction

Right inferior turbinate size 1 month after an inferior turbinoplasty

Right inferior turbinate size 1 month after an inferior turbinoplasty

Nasal tumors can be either benign or malignant. The commonest benign nasal tumor is an inverted papilloma. Though benign, this tumor is locally invasive ( and thus can erode into the surrounding vital structures such as the eye and brain) and has a 10% chance of turning malignant (cancer). If it occludes the opening of the sinus ostium, it can also result in recurrent infections (sinusitis).

This tumor will have to be removed completely and the stalk of the tumor traced to ensure its completely eradicated.

Inverted papilloma in the right nasal cavity

Inverted papilloma measuring 4cm in length removed en-bloc from the nasal cavity.

Inverted papilloma measuring 4cm in length removed en-bloc from the nasal cavity.

 

Although tumors of the nasal cavities are equally divided between benign and malignant types, most tumors of the paranasal sinuses are malignant. Approximately 55% of sinonasal tumors originate from the maxillary sinuses, 35% from the nasal cavities, 9% from the ethmoid sinuses, and the remainder from the frontal and sphenoid sinuses. Squamous cell carcinoma is the most common malignant histologic type (approximately 70-80%) followed by adenoid cystic carcinoma and adenocarcinoma (approximately 10% each)

The treatment for this will be more aggressive and usually includes a combination of surgery, radiotherapy or chemotherapy.

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