2Nose is a prominent midline structure on the face. When viewed from lateral aspect, various landmarks are revealed. These landmarks are produced as a result of underlying bones, cartilages and soft tissues. The upper one-third of the nose is formed by bones and lower two-third which is mobile is formed by cartilages.
The nasal septum is formed by various cartilages and bones as shown.
3The lateral wall of the nose has three curved projections called turbinates or concha. Various paranasal sinuses open into the meati as seen in the diagram. The nasolacrimal duct opens under the inferior turbinate.
The nose has rich blood supply through the anterior and posterior ethmoidal arteries (internal carotid) and by the superior labial, sphenopalatine and greater palatine arteries (external carotid artery). The area of the vascular anastomosis between them is called Little's area. The Little's area is a common site for anterior epistaxis. This area is easily traumatized by nose picking.
Venous drainage of the nose is shown in Figure 1.7. Nasal infection can lead to cavernous sinus thrombosis which may get involved due to ascending infection from the nose and surrounding area. Thus, it should be treated with broad spectrum antibiotics.
The inspiratory currents pass directly into the nasopharynx while the expiratory currents aerate the paranasal sinuses.
Endoscopes required for examining the ear, nose and throat are shown.
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Fig. 1.12: Examination of nose: The vestibule of the nose is examined for fissure, vestibulitis or boil
External examination of the nose is performed to ascertain the symmetry, structural defect and other lesions. Vestibule is everted and examined for fissures or vestibulitis.
8Anterior rhinoscopy is done by reflecting deep penetrating light through a head mirror. The various turbinates, meati and nasal septum are checked.
Nasal endoscopy is now a standard OPD procedure for complete examination of nasal cavity as well as nasopharynx.
When necessary, the nasal cavities are examined after applying local anesthetic and decongestant.
10Posterior rhinoscopy reveals posterior edge of the nasal septum, posterior choanae and posterior ends of the turbinates. Eustachian tubes open in the lateral wall while the fossae of Rosenmuller lie posterosuperiorly. The adenoids are situated in the roof and posterior wall.
Fig. 1.18: Diagrammatic view of structures seen in posterior rhinoscopy (Nasopharyngoscopy can be done with nasal endoscope)
11Common symptoms of the nasal disease are blockage, discharge and disorder of smell. Since the nose is vascular, bleeding is a common complaint. Causes and symptoms of nasal blockage and discharge are illustrated.
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Nasal atresia can either be anterior or posterior. Acquired anterior nasal atresia case is shown.
12Choanal atresia can be unilateral or bilateral. Bilateral congenital atresia is an emergency requiring urgent intervention.
Fig. 1.20: Unilateral congenital posterior atresia. It can be demonstrated by a plain X-ray examination with a cotton ball soaked in radiopaque dye (arrow)
Unilateral cases may remain undiagnosed until adulthood. Bilateral cases present as acute respiratory distress in neonates. It can be demonstrated by an axial CT scan of paranasal sinuses as shown in Figure 1.21. In this patient, a nasal cannula was inserted through the partial atresia on right side. Complete bony atresia is seen on the left.
Vestibulitis is caused by staphylococci. It should be treated promptly as it may result in cavernous sinus thrombosis (refer to Figure 1.7 venous drainage of the nose).
New growths of the external nose are frequently seen. Nasal warts and rhinophyma cases are managed by radiofrequency ablation or laser.
Fig. 1.25: Basal cell carcinoma presenting as rodent ulcer involving nose and lower eyelid with cicatrization
Fig. 1.26: Histopathology of basal cell carcinoma: Microscopic picture of basal cell carcinoma (rodent ulcer) showing anastomosing cords of elongated tumor cells
Injury to the nose may cause loss of tissue or distortion of the shape of the nose as shown. The lost tissue is transplanted while distortion is corrected by remoulding the underlying nasal cartilages and bones.
Fig. 1.29: Coronal CT: Deviated nasal septum left and spur is in contact with inferior turbinate. Such a spur may cause contact headache. Also note right inferior turbinate hypertrophy on opposite side
Deviated nasal septum may be asymptomatic or may produce nasal obstruction and its consequent symptoms. It may also contribute to the external deformity of the nose. Symptomatic deviations need surgical correction, i.e. septoplasty or septorhinoplasty.
Fig. 1.30: Septal perforation has varied etiology. Its presence can be confirmed by a probe as demonstrated
Figs 1.31A and B: Bilateral septal swelling: Septal abscess should be drained urgently to prevent complications like septal perforation or saddle deformity
Acute inflammation of the mucous membrane of the nose is called acute rhinitis or coryza. It results in blockage of the nose and rhinorrhea. Etiology of coryza is varied as charted below: The viruses are the chief causative organisms.
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18Allergic rhinitis is the manifestation of an antigen-antibody reaction in the nasal mucosa. A variety of allergens are known to cause this. Vasomotor rhinitis is due to autonomic instability and clinically presents with similar symptoms.
Fig 1.32: HPE of allergic rhinitis slide showing characteristic edema and infiltration of the mucosa predominantly by eosinophils
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Atrophic rhinitis usually presents with nasal obstruction, epistaxis and depressed bridge of nose. A variety of causes are responsible for the same. The changes in the nasal cavity can be minimal to marked crusting along with a fetid odor (ozena),which at times is repulsive to others, but patient being anosmic is unaware of it. Alkaline nasal douching is recommended to keep the nasal cavity clean.
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Fig. 1.34: Rhinolith specimen from right nasal cavity of an eleven-year-girl who presented with intermittent right side epistaxis
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Fig. 1.35: Fungal rhinosinusitis: Repeated polyp formation may result in expansion of the nasal bridge or even proptosis when associated with rhinitis caseosa as seen in this patient
Fig. 1.36: Antrochoanal polyp: Pedunculated mass of the nasal mucosa as sequelae of allergy and/or infection is termed as nasal polyp. Ethmoidal polyps are multiple while antrochoanal polyp is usually single as shown
Fig. 1.37: Coronal CT: Left antrochoanal polyp: Nasoantral component in scan above and choanal component in scan below
Fig. 1.38: Axial CT: Left antrochoanal polyp of same patient as in Figure 1.37
Fig. 1.39: Antrochoanal polyp specimen: The antrochoanal polyp has small antral, narrow elongated nasal and rounded nasopharyngeal parts
Nasal polyps are removed by endoscopic sinus surgery.
Fig. 1.45: Instruments for endoscopic sinus surgery (ESS). Microdebrider assisted ESS preserves nasal mucosa and is less traumatic
Nasal foreign bodies can be removed by a curved probe (Eustachian catheter) in the OPD itself.
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28Epistaxis is a symptom and may result from variety of causes. The common site for epistaxis is Little's area. Epistaxis may vary from just spotting to severe bout of bleeding.
An outdoor procedure to stop epistaxis is to pinch the nostril for three minutes as shown.
Fig. 1.53: Anterior nasal packing: Epistaxis is controlled by anterior nasal packing as shown or by endoscopic cauterization of bleeding points or by ligating the artery in severe refractory cases
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30Rhinoscleroma can be presented as an infiltrative lesion causing granulomatous lesion of the external nose.
Fig. 1.56: Histopathology showing Mikulicz cells and macrophage with vacuolated cytoplasm. Microscopically, this lesion consists of infiltration of connective tissue by inflammatory cells. The characteristic Mikulicz cell of scleroma is a large macrophage with vacuolated cytoplasm
Fig. 1.57: Fungal granuloma in left nasal cavity: Rhinosporidiosis is a fungal granuloma affecting the nasal mucosa and produces a polypoidal granular mass which bleeds on touch
Microscopically, the fungal spores in various stages of maturation can be seen in the mucosa.
Fig. 1.60: Histopathology of lupus nose: Microscopically, granulomas consist of lymphocytes, epithelioid cells and Langhans giant cells and they are present in the dermis
Fig. 1.61: Nasal tumor. Nasal tumors produce blockage, epistaxis and distortion of the nasal anatomy. Photograph shows a large nasal tumor occupying the nostril. The most common nasal tumor is squamous cell carcinoma
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34Symptomatic cases of deviated nasal septum are corrected by septoplasty. Those cases of DNS with external deformity undergo septorhinoplasty.
Fig. 1.62: Markings for septorhinoplasty: Rhinoplasty may be reconstructive or cosmetic. Esthetic realignment and restructuring the components of the nose constitutes cosmetic rhinoplasty
Fig. 1.67: Indian nose: In northern India, people have long, pointed and well-defined nose with large dorsoventral and anteroposterior dimensions of the nasal septum
Fig. 1.68: Indian nose: In central India, people have prominent nose with amorphous dorsum and wider septoalar angle and thicker subcutaneous covering
Fig. 1.69: Indian nose: In eastern India, the nose of people is rather flat and small with short septum, smaller alar cartilages and short columella
