NOSE: Table of Contents

Nose .............................................................................................................................................................. 3
Anatomy ........................................................................................................................................3
Nasal septum ........................................................................................................................................ 3
Physiology of the nose....................................................................................................................8
Misc ...............................................................................................................................................9
Symptoms of nasal diseases ......................................................................................................... 10
Epistaxis............................................................................................................................................... 10
Anterior nasal packing ........................................................................................................................ 12
Nasal obstruction ................................................................................................................................ 14
Nasal discharge ................................................................................................................................... 15
Foreign body in nose .................................................................................................................... 16
Nasal septum ............................................................................................................................... 18
DNS...................................................................................................................................................... 18
Septal abscess ..................................................................................................................................... 19
Septal Hematoma ............................................................................................................................... 21
Septal perforation ............................................................................................................................... 22
Nasal polyp .................................................................................................................................. 23
Ethmoidal polyp .................................................................................................................................. 23
Antrochoanal polyp............................................................................................................................. 24
Rhinitis ........................................................................................................................................ 28
Atrophic rhinitis .................................................................................................................................. 28
Allergic rhinitis .................................................................................................................................... 30
Para nasal sinus............................................................................................................................ 33
Acute sinusitis ..................................................................................................................................... 33
Chronic sinusitis .................................................................................................................................. 34
Maxillary growth .......................................................................................................................... 38
Rhinosporidiosis ........................................................................................................................... 39
Nasal tumor ................................................................................................................................. 40
Operative surgery of nose ............................................................................................................ 41
Surgery of DNS .................................................................................................................................... 41
Antral washout .................................................................................................................................... 43

1
 FESS ..................................................................................................................................................... 44
Rhinoplasty ......................................................................................................................................... 46

2
Nose
Anatomy
Nasal septum
Q. Draw and label nasal septum

Ans:

1 → quadrilateral cartilage
2→ perpendicular plant of
ethmoid
3→ vomer
4→nasal crest of maxilla
5→ nasal crest of palatine
6→ nasal bone
7→ nasal spine of frontal
bone
8→rostrum of sphenoid

Q. Enumerate blood supply of nasal septum

Ans:

3
Arterial supply of nasal septum: shown in figure

2 plexus in septum:

4
1, 3, 4, 5 form a plexus in antero-inferior part pf the septum: called Little’s area/Kiesselbach’s plexus

Branches of sphenopalatine → form another plexus in posterior part of nasal septum → Woodruff’s
plexus

Venous drainage of nasal septum:

➢ Sphenopalatine vein → pterygoid plexus

➢ Facial vein
➢ Ophthalmic vein

Q. Short note: Little’s area/Function and importance of little’s area (use the above pic)

Ans:

1, 3, 4, 5 form a plexus in antero-inferior part pf the septum: called Little’s area/Kiesselbach’s plexus

➢ Little’s area
o Also called Kieselbach’s plexus
o Location
▪ situated in anterior inferior part of nasal septum
▪ 5 mm behind the muco-cutaneous junction
o Function
▪ Anastomosis between branches of both ext. and int. carotid artery
o Participating vessels:
▪ Int carotid: ant ethmoidal
▪ Ext carotid: sphenopalatine, greater palatine, superior labial branch of facial artery
o Clinical importance
▪ It is the commonest site of epistaxis
▪ In children and young adults
▪ Usually due to finger nail trauma, following picking of nose
▪ Also, a common site of angioma

Extra:

Lateral wall of the nose: structures opening into the meatuses

5
6
 Blood supply of the lateral wall of nose:

7
Physiology of the nose
Q. Mention the functions of the nose

Ans:

➢ Respiration
➢ Air condition
o Filtration
o Purification
o Humidification
o Temperature control
➢ Protective function
o Muco-ciliary clearance
o Secretion of enzymes: lysozyme
o Secretion of immunoglobulin (IgA and IgE)

8
 o Interferon
o Sneezing
o pH maintenance at 7 (all the above protective factors best work at this pH)
➢ Vocal resonance
➢ Nasal reflex function
o Sneezing reflex (protective)
o Smell → reflex salivation → initiate gastric juice secretion
o Naso-bornchial reflex
o Naso-pulmonary reflex
➢ Olfaction
➢ Drainage function
o Drainage of tears
o Drainage of sinuses

Misc
Q. Name some indication of anterior nasal packing.

Ans:

➢ Epistaxis
➢ Septal hematoma
➢ Removal of foreign body
➢ Any nasal surgery such as
o Septoplasty
o Sub mucosal resection
o Caldwell-luc operation
o Fracture repair of nasal bone polypectomy
➢ DCR (dacro-cysto-rhinostomy operation)

**structures seen by posterior rhinoscopy

➢ Posterior border of the nasal spetum

➢ Posterior end of mid and inf turbinate
➢ Post turbinate
➢ Superior posterior wall of NP
➢ Soft palate
➢ Eustachian tube
➢ Fossa of rosenmuler – depression beside the end of eustachian tube – nasopharyngeal
carcinoma/malignancy – commonly take place here
**instruments used for posterior rhinoscopy: tongue depressor, head light, Posterior nasal space mirror

9
Symptoms of nasal diseases
Epistaxis
Q. Define epistaxis

Ans: Bleeding from inside the nose is called epistaxis

Q. Mention the causes of epistaxis

Ans:

Local cause:

➢ Traumatic
o Nasal fracture
o Operative trauma
o Digital trauma: pricking with skin, itching (children)
➢ Foreign body
➢ Infection/inflammation
o Acute
▪ Non specific
• Viral rhinitis
• Acute Rhino-sinusitis
▪ Specific
• Nasal diphtheria
o Chronic (all crust forming condition)
▪ Non specific
• Atrophic rhinitis
▪ Specific
• TB
• Syphilis
• Rhinosporidiosis (fungal)
➢ Neoplastic
o Benign
▪ Hemangioma, papilloma
▪ Angiofibroma
o Malignant
▪ Naso-pharyngeal Carcinoma
➢ Others
o DNS
o Septal perforation
o Maggots in nose

Systemic causes:

➢ CVS:

10
 o Hypertension
o Mitral stenosis
➢ Hematologic
o Aplastic anemia
o Leukemia
o ITP
o TTP
o Hemophilia
o Nutritional
▪ Scurvy
▪ Vitamin K deficiency
➢ Liver disease: CLD/cirrhosis
➢ Renal disease: Chronic nephritis
➢ Drugs: NSAID, anticoagulants
➢ General infection
o Dengue
o Whooping cough
o Influenza, measles
➢ Mediastinal tumor: raised venous pressure

Q. Mention 5 common causes of epistaxis in children

Ans:

➢ Trauma from pricking

➢ Injury
➢ Foreign body in nose
➢ Viral rhinitis
➢ Acute rhino-sinusitis
➢ Nasal diphtheria

Q. Treatment of epistaxis from the anterior part of the nose

Ans:

➢ Assess the patient for shock

o If shock present:
▪ Start IV fluid
▪ Send blood for grouping, cross matching, coagulation profile
▪ Start blood transfusion early
▪ Stabilize the patient
o If shock not present, take detailed history about cause and nature + proceed
➢ Measures to stop bleeding
o Digital pressure/pinching the nose

11
 o Ice cube packing/sucking on ice cubes
o Local cauterization of the visible bleeding point
o Anterior nasal packing: kept 48-72 hours
o If not controlled: posterior nasal packing
o If not controlled by cautery or packing, surgical control of bleeding needed
▪ Ligation of arteries
• Anterior ethmoidal artery
• Maxillary artery
• External carotid artery
▪ Endoscopic cauterization
▪ Embolization
▪ Septoplasty/SMR operation

➢ General measures
o Patient should be in sitting position
o Reassurance + mild sedation
o Antibiotic (if pack >24 hours)
o Monitor vital signs (pulse, BP, respiratory rate, temperature)
➢ After bleeding is controlled, do detailed evaluation and investigation to find out the underlying
cause

➢ Treatment of the underlying cause

**common causes of epistaxis in elderly patient: hypertension, CLD, Kidney disease, hematological
disease, nasopharyngeal carcinoma ….

Q. How will you treat epistaxis in an elderly patient: (due to hypertension): same as the above answe

Q. Short note: epistaxis: define, common cause, treatment outline

Anterior nasal packing

Q. Indications of anterior nasal packing

Ans:

➢ Epistaxis
➢ Septal hematoma
➢ Removal of foreign body
➢ Any nasal surgery such as
o Septoplasty
o Sub mucosal resection
o Caldwell-luc operation
o Fracture repair of nasal bone polypectomy
o After excision of naso-pharyngeal angiofibroma
➢ DCR (dacro-cysto-rhinostomy operation)

Q. Procedure of anterior nasal packing:

Ans:

12
Instruments needed:

➢ Ribbon gauze/cotton
➢ Xylocaine + adrenaline solution (for epistaxis)
➢ Antibiotic ointment (to prevent infection)
➢ Vaseline (for easy removal)
➢ Tilley’s nasal dressing forceps
➢ Killian’s nasal speculum
➢ Head light

Procedure:

➢ Soak ribbon gauze with Xylocaine + adrenaline

o May apply antibiotic ointment + Vaseline
➢ 1 meter ribbon gauze needed for each nasal cavity
➢ 1st few centimeter: folded upon itself → placed along the floor of nasal cavity
➢ Then the whole cavity is packed, layer by layer, by layering the gauze from floor to roof
➢ Keep the anterior end of the pack outside the nasal cavity

Duration:

➢ Can be removed after 24 hours

➢ Can be kept upto 48-72 hours with antibiotics

Removal

➢ Gentle removal needed

➢ Soaking with normal saline/lubrication with Vaseline is done to prevent tearing of mucosa

Q. What are the complications of anterior nasal packing?

➢ Synechia (adhesion)
➢ Infection
o Sinusitis
o ASOM
➢ OME (due to blockage)
➢ Toxic shock syndrome

13
Nasal obstruction
Causes – unilateral, bilateral, both

Q. Common causes of unilateral nasal obstruction

Ans:

➢ Foreign body in nose

➢ DNS
➢ Unilateral hypertrophy of inferior turbinate
➢ Antro-choanal polyp (unilateral)
➢ Angiofibroma
➢ Maxillary antral growth
➢ Rhinosporidiosis

Q. Common causes of bilateral nasal obstruction?

Ans:

➢ Septal hematoma
➢ Septal abscess
➢ DNS + HIT (hypertrophied inferior turbinate)
➢ Ethmoidal polyp
➢ Adenoid
➢ Rhinitis
o Allergic rhinitis
o Vasomotor rhinitis
➢ Rhinosporidiosis
➢ NPC

Q. How will you manage case of nasal obstruction?

Ans: (write later….)

14
Nasal discharge
Q. What are the causes of unilateral nasal discharge?

Ans:

➢ Congenital: unilateral choanal atresia

➢ Foreign body in the nose
➢ Rhinolith
➢ Antrochoanal polyp
➢ Unilateral sinusitis
➢ Unilateral nasal tumor
➢ Rhinosporidiosis

Q. Causes of foul smelling nasal discharge

Ans:

➢ Atrophic rhinitis
➢ Old foreign body impaction
➢ Purulent sinusitis
➢ Infected nasal polyp
➢ Nasal malignancy
➢ Rhinitis caseosa

15
Foreign body in nose

**scenario: unilateral foul smelling nasal discharge and obstruction, usually in a child, for few days (if
longer hx: rhinolith/long impacted foreign body)

Q. What are the foreign bodies seen in the nose?

Ans:

➢ Living: maggot, insects

➢ Non living
o Organic: seed, cotton, wool, nut,pea
o Inorganic: metal, glass, plastic, paper

Q. Write the signs and symptoms of foreign body in the nose

Ans:

Sympotms:

➢ History of foreign body impaction (may be absent)

➢ Nasal discharge
o Unilateral
o Foul smelling
o If infection: purulent
➢ Unilateral nasal obstruction
➢ Epistaxis
➢ Pain

Signs:

➢ Anterior rhinoscopy
o Early: between septum and inferior turbinate
o Late: b/n middle turbinate and septum
o Discharge maybe seen in late cases
➢ Nasal probing

Q. Investigation and treatment of foreign body in nose

Ans:

Investigation:

➢ X ray of nose lateral view: only for radio-opaque material

➢ X ray paranasal sinus OM view

Treatment: Removal of the foreign body

Anesthesia:

➢ In cooperative children + adult: L/A

16
 ➢ In non-cooperative/psychiatric patient: G/A

Instruments used:

➢ Foreign body hook (if round)

➢ Tilley’s forceps (if flat)
➢ Jobson horne probe

Patient placed in: rose position

Q. complications of FB (long term) (not DU)

Ans:

➢ Aspiration of FB
➢ Ingestion
➢ Epistaxis
➢ Infection
➢ Sinusitis
➢ Rhinolith/nasal calculus

**rhinolith: stone formation in nasal cavity, more in adult; around the nucleus of small exogenous
foreing body, by deposition of calcium and mg salt. Over time it grows and fills the cavity. Obstruction,
foul discharge, epistaxis,.

17
Nasal septum
DNS
Q. What are the types of DNS? (deviated nasal septum)

Ans:

➢ Anterior deviation
➢ C shaped deviation
➢ S shaped deviation
➢ Septal spur
➢ Septal thickening
➢ Septal shelf/groove

Q. mention the clinical features of DNS

Ans:

Symptoms

➢ Nasal obstruction
o Initially unilateral
o Later, bilateral if HIT develops
➢ Epistaxis
➢ Snoring/obstructive sleep apnea
➢ Secondarily due to DNS
o Post nasal drip, nasal discharge: rhinitis, sinusitis
o Headache: sinusitis
o Sore throat: tonsillitis
o OME/ASOM (conductive deafness)
o Hoarseness (laryngitis)

Signs:

➢ External deformity of the nose

➢ Anterior rhinoscopy
o Septum is deviated to one side
o The opposite nasal cavity is roomy

18
 o Inferior turbinate of opposite side: compensatory hypertrophy
o Discharge maybe seen
o Nasal mucosa maybe congested

Q. How will you investigate a case of deviated nasal septum?

Ans:

➢ X ray PNS OM view

o See septal deviation
o See associated sinusitis
➢ Routine investigation for G/A fitness

Septal abscess
**scenario: young boy, bilateral nasal obstruction. Fever, pain in nose; bilateral symmetrical swelling in
the anterior part of nasal septum, purplish in color

Q. Define septal abscess

Ans:

➢ Collection of pus
➢ Underneath the muco-periosteum
➢ Or muco-perichondrium
➢ Or both
➢ Of the nasal septum is called septal abscess

Q. Clinical features (not DU)

Ans:

Symptom

➢ Bilateral nasal obstruction

➢ Throbbing pain
➢ Fever with chills
➢ Headache
➢ There may be history of: nasal surgery, digital manipulation, furunculosis

Sign:

➢ General: fever, tachycardia

➢ Swollen and widened septum
➢ Tender septum
➢ Doughy soft swelling on both sides of the septum
➢ Consistency: cystic, fluctuant
➢ Aspiration → pus
➢ Enlarged + tender draining LN

19
Q. Investigations of septal abscess

Ans:

➢ X ray PNS OM view

➢ Aspiration of pus for c/s

Q. Treatment of septal abscess

Ans:

➢ Incision and drainage of abscess

➢ Removal of pus + devitalized tissue
➢ Systemic antibiotics
➢ Analgesic

Q. What are the complications of septal abscess?

Ans:

➢ Septal perforation (necrosis of cartilage)

➢ Saddle nose deformity (necrosis of cartilage)
➢ Spread of infection to CNS
o Meningitis
o Cavernous sinus thrombosis

20
Septal Hematoma
Q. Management of a case of septal hematoma

Ans:

Symptom:

➢ Bilateral nasal obstruction

➢ Pain in nose

Examination

➢ widened septum
➢ non-Tender septum
➢ swelling on anterior part of septum
o bilateral
o purplish
o soft
o fluctuating
o painless

Investigation: X ray PNS, OM view

Treatment:

➢ if small: aspiration of hematoma

➢ if larger: incision and drainage of hematoma
➢ nose packed on both sides to prevent re-accumulation
➢ antibiotics (to prevent septal abscess)

Q. Cause of septal hematoma (not DU)

Ans:

➢ trauma
➢ RTA
➢ Post-operative (after SMR, septoplasty)
➢ Blood dyscrasia

Q. complications of septal hematoma

Ans:

➢ Septal abscess
➢ Septal perforation
➢ Septal thickening
➢ Saddle nose (necrosis of cartilages)

21
 ➢ Cavernous sinus thrombosis

Septal perforation
Q. Name some causes of septal perforation

Ans:

➢ Traumatic
o Accidental trauma
o Chemical injury
o Cosmetic piercing
o Surgical complication: SMR, septoplasty
➢ Pathological
o Septal hematoma
o Septal abscess
o Long impacted FB: pressure necrosis
o Chronic granulomatous inflammation: TB, lepsory, syphilis
o Neoplastic conditions
➢ Drugs
o Prolonged use of steroid spray in nasal allergy
o Cocaine addict
➢ Idiopathic

22
Nasal polyp
Q. Define nasal polyp

Ans: They are defined as

➢ Non neoplastic pedunculated masses of

➢ Hypertrophied Edematous mucosa
➢ Prolapsed from the nose or the paranasal sinuses

Q. Classify nasal polyp

Ans:

➢ Antro-choanal polyp
➢ Ethmoidal polyp

Q. Mention the etiology of nasal polyps

Ans:

➢ Majority: idiopathic
➢ Infection/inflammation (chronic rhino-sinusitis)
➢ Allergy
➢ Combined infection + allergy
➢ Aspirin hypersensitivity
➢ Cystic fibrosis
➢ Celiac disease

Ethmoidal polyp
**multiple, bilateral, like bunch of grapes, common in adult; direction: comes out of ethmoidal sinus
forwards, thru external nasal opening

Q. Clinical features of ethmoidal polyps

Ans:

Age: usually adult/middle age

Symptoms:

➢ Nasal obstruction
➢ Nasal stuffiness
➢ Loss of smell (partial/total)
➢ Headache + facial pain (sinusitis)
➢ Watery nasal discharge
➢ Sneezing
➢ Post nasal drip

23
Sign:

Anterior rhinoscopy:

➢ Polyps seen
o Multiple, bilateral
o smooth, grapelike cluster
o Pale color
o Insensitive
o Do not bleed to touch
➢ Purulent discharge in nasal cavity (associated sinusitis)

Posterior rhinoscopy: only post nasal drip seen, no polyp

Q. Management of ethmoidal polyp

Ans: Clinical feature: from above

Investigation:

➢ Radiology:
o X ray PNS OM view (associated sinusitis + opacity in ethmoid sinus)
o CT scan of PNS (to see if there is bony erosion – to exclude neoplasia + to plan for
surgery)
➢ Test for allergy
o Skin prick test
o IgE levels measurement

Treatment:

➢ Medical
o Steroid (short course, <4 weeks)
▪ Nasal drop/nasal spray (beclomethasone)
▪ Oral
o Antihistamine (fexofenadine)
➢ Surgical
o Functional Endoscopic sinus surgery (FESS)
o Polypectomy
o Radical surgery: ethmoidectomy
▪ Intranasal approach
▪ Extra nasal
▪ Trans nasal

Antrochoanal polyp
**scenario: polyp seen in nasopharynx on posterior rhinoscopy…

Q. What are the D/D of Nasal polyp?

24
Ans:

➢ Hypertrophied inferior turbinate

➢ Meningocele
➢ Encephalocele
➢ Nasopharyngeal angiofibroma
➢ Rhinosporidiosis
➢ Tumor arising from nose and para nasal sinuses

*usually unilateral, single, occurs in children, dumbbell shaped, has got 3 constrictions and 3 dilatations.
3 parts: antral, choanal, nasal.

Q. Management of antro-choanal polyp

Ans:

Symptoms:

➢ Unilateral nasal obstruction (in advanced case: bilateral)

➢ Nasal discharge
➢ Headache/facial pain (sinusitis)
➢ Voice change (loss of nasal resonance)
➢ Change of smell
➢ Hearing defect (OME)

Sign:

Anterior rhinoscopy: (Killian’s forceps)

➢ Polyp usually not seen

➢ If polyp seen: large, smooth, grey mass
➢ Discharge seen: associated inflammation

25
Posterior rhinoscopy: (PNS mirror)

➢ Polyp seen
➢ Greyish, globular mass
➢ On probing
o Insensitive
o Doesn’t bleed to touch
o Mobile

Investigation:

➢ X ray PNS OM vieew: opacity in maxillary sinus and antrum

➢ X ray nasopharynx, lateral view: opacity seen (mass), air column is posterior to the mass (in
adenoid, air column in anterior to the mass)
➢ CT scan of PNS: extent of polyp, to exclude other d/d

Treatment: surgery in the treatment of choice

➢ Method of choice: Functional endoscopic sinus surgery

➢ Other methods
o Polypectomy (intra-nasal) (age <16)
o Destructive operation: Caldwell-Luc operation (age >16 and recurrent polyps)

Q. Mention the difference between antro-choanal polyp + ethmoidal polyp

Ans:

Ethmoidal Antrochoanal
Age Elderly Children
Arises from Ethmoidal sinus Maxillary antrum
Comes out usually By anterior nasal opening By posterior nasal
opening/choana
Number Multiple Single
Distribution Bilateral Unilateral
Single major cause Allergy Infection
Anterior rhinoscopy Polyps seen (multiple grape like Not well seen
cluster)
Instrument used in Thudicum nasal speculum Killian’s foceps
anterior rhinoscopy for a
good view
Posterior rhinoscopy Nothing seen except post nasal nasal Polyp is seen
Extension into No Yes
nasopharynx
Recurrence rate High Low
Name of radical surgery Ethmoidectomy Caldwell-Luc operation

26
 X ray Bilateral opacity in ethmoidal sinus Unilateral opacity in maxillary
antrum

Q. How will you differentiate between Nasal polyp and hypertrophied inferior turbinate?

Ans:

Nasal polyp Hypertrophied inferior

turbinate
Cause Infection/allergy DNS
Rhinitis
Sinusitis
Appearance Pink/greyish, shiny, polypoidal Dark colored swelling
mass
Probe test:
Sensitivity Insensitive Sensitive
Mobility Mobile Fixed
Treatment FESS SMD (sub mucosal diathermy)
Ethmoidectomy (ethmoidal Turbinectomy
polyp)
Caldwell-Luc operation (antro-
choanal polyp)

27
Rhinitis
Atrophic rhinitis
**scenario: young girl, bilateral nasal obstruction, crusting, foul smelling

Q. Define atrophic rhinitis

Ans:

➢ It is a chronic inflammation of the nose

➢ Characterized by atrophy of
➢ Nasal mucosa
➢ And Turbinate bones
➢ With presence of viscid secretion
➢ Which dry rapidly
➢ To form crust
➢ And produce characteristic foul smell

Q. Mention the Etiology of this condition

Ans:

➢ Primary atrophic rhinitis (HERNIA)

o Hereditary
o Endocrine disturbance (more in female, in reproductive age, no disease after
menopause)
o Racial factor (some races are more susceptible)
o Nutritional deficiency (deficiency of vitamin A, D, Iron)
o Infection (Klebsiella ozaenae, Diphtheroids)
o Auto-immune cause
➢ Secondary atrophic rhinitis
o Trauma
▪ Surgery
▪ Radiation
o DNS
o Chronic infection/inflammation in nose
▪ Syphilis
▪ TB
▪ Sarcoidosis
▪ Granulomatous condition in nose

Q. Mention the Clinical feature of atrophic rhinitis

Ans:

Clinical feature

➢ Foul smelling nasal discharge (felt by other person)

➢ Crusting

28
 ➢ Anosmia (merciful anosmia)
➢ Bilateral Nasal obstruction
➢ Epistaxis
o Spontaneous
o When crusts are removed
➢ Roomy nasal cavity
➢ Atrophied turbinate
➢ Unhealthy nasal mucosa (pale appearance)
➢ Posterior wall of nasopharynx can be seen
➢ Saddle deformity of nose

Q. How will you treat a case of atrophic rhinitis?

Ans:

Counselling:

➢ There is no definite rx
➢ Treatment mainly symptomatic
➢ Don’t stop treatment upon cessation of symptoms

Treatment:

➢ Medical treatment
o Nasal irrigation
▪ With normal saline
▪ With alkaline solution douching
o Application of 25% glucose in glycerin drop (3-4 drops, 3-4 times daily)
o Local antibiotic drops (to prevent secondary infection)
o Nutritional supplement: vitamin A, D, Iron
o Oral potassium iodide (to increase + liquefy nasal secretion)
o Estradiol spray (increase vascularity + regeneration of nasal mucosa)
o Systemic Streptomycin (effective against klebsiella, to reduce odor and crusting)
➢ Surgical treatment
o Young’s operation (anterior nares closed)
o Modified young’s operation (anterior nares closed with small hole in the middle – so
that pt can breath
o Parotid gland duct placed inside the maxillary antrum (to make the nasal cavity wet)
o Narrowing of the nasal cavities by
▪ Insertion of Teflon
▪ Insertion of bone/cartilage/fat etc under mucoperiosteum
➢ Treatment of the underlying cause: in case of secondary atrophic rhinitis

Q. Management of atrophic rhinitis

Ans: clinical feature + investigation + rx

Investigation:

29
 ➢ X ray PNS OM view
o Atrophies nasal turbinate
o Roomy nasal cavity
➢ C/S of nasal swab
➢ Blood examination
o CBC
o VDRL
o Serum Iron
➢ MT test, Genexpert test

Q. Short note: write in brief; definition + management

Allergic rhinitis
Q. Clinical feature of atrophic rhinitis

Ans:

Symptoms

➢ Runny nose/watery nasal discharge

➢ Sneezing
➢ Nasal obstruction
➢ Nasal itching/irritation
➢ Irritation/itching in eyes (watery, red eyes)
➢ Itching in pharynx
➢ Anosmia
➢ Post nasal drip
➢ Chronic cough
➢ Hearing impairment
➢ There may be family history of asthma

Sign: (all the signs maynot be present)

➢ Nasal sign:
o Transverse nasal crease (black line across middle of dorsum of nose – due to constant
upward rubbing of nose – nasal/allergic salute)
o Edematous nasal mucosa
o Swollen turbinate
o Discharge present
o Hypertrophied inferior turbinate (may be seen)
o Polyps (may be seen)
o Post nasal drip (seen in posterior rhinoscopy)
➢ Ocular sign
o Lid edema
o Conjunctival congestion
o Dark circle under eyes
➢ Otologic sign

30
 o Retracted TM
➢ Pharyngeal sign
o Granular pharyngitis
➢ Laryngeal sign
o Edema of vocal cord

Q. How will you manage a case of allergic rhinitis?

Ans:

**clinical feature: from above

Investigation:

➢ CBC
o Eosinophilia
➢ Nasal smear
o Eosinophilia
➢ Skin test
o Skin prick test
➢ IgE level measurement by
o PRIST
o RAST
➢ Nasal provocation test (inhale suspected allergen and see response)
➢ X ray PNS
o haziness in sinus
o polypoidal change

Treatment:

➢ avoidance of allergen
➢ drug treatment
o anti-histamine: fexofenadine
o nasal decongestant: xylometazoline, oxymetazoline
o corticosteroid
▪ local: in form of nasal spray
▪ oral: only in acute/severe cases
o mast cell stabilizer: Na-cromoglycate
o Montelukast (Leukotriene receptor blocker)
o Anti-IgE: omalizumab
➢ Immunotherapy: allergen is given gradually in increasing doses
➢ Surgical treatment (when medical treatment fails)
o In case of hypertrophied inferior turbinate:
▪ Sub mucosal diathermy
▪ Electro-cautery of inferior turbinate
▪ Partial inferior turbinectomy
o Polypectomy

31
 o Cryosurgery

Q. What complications will occur in absence of treatment of allergic rhinitis?

Ans:

➢ Recurrent sinusitis
➢ Nasal polyp
➢ Serous OM (OME)
➢ Secondary bacterial infection
➢ Risk of developing bronchial asthma
➢ Problems associated with mouth breathing

Q. Short note: allergic rhinitis

Ans: Add the above + below points:

➢ Type 1 hypersensitivity mediated

➢ 2 types
o Seasonal allergic rhinitis
o Perennial rhinitis

32
Para nasal sinus
Acute sinusitis
Q. What are the clinical features of acute maxillary sinusitis

Ans:

➢ Constitutional symptom
o Fever
o Malaise
o Body ache
➢ Headache
➢ Pain (gum, upper jaw, worsened by coughing chewing stooping))
➢ Tenderness (over the area of maxillary sinus)
➢ Redness and edema od cheek
➢ Nasal discharge (muco-purulent discharge in front of middle meatus)
➢ Postnasal drip (seen in posterior rhinoscopy)
➢ Nasal obstruction
➢ Loss of smell
➢ Change in voice

Examination:

➢ Anterior rhinoscopy:
o Red, edematous nasal mucosa
o Thick pus in middle meatus
o Hypertrophied inferior turbinate (on the same side)
➢ Posterior rhinoscopy: post nasal drip
➢ Transillumination test
o Opacity of maxillary sinus
o Loss of infra-orbital crescent of light
o Loss of pupillary glow

**investigation: X ray PNS: opacity and fluid level in maxillary sinus; CT scan; others: CBC, c/s of the
discharge for c/s

Q. Treatment of acute maxillary sinusitis

Ans:

➢ Medical
o Antimicrobial drugs: amoxicillin + clavulanic acid (10-14 days, upto 21 days)
o Nasal decongestant: oxymetazoline/xylometazoline nasal drop
o Steam inhalation: Steam + menthol
o Hot fomentation: soothing effect

33
 o Analgesics
o Antipyretics
➢ Surgical
o Antral wash out/lavage (only if no response to medical treatment within 24-48 hours)
o FESS

Q. What are the complications of acute maxillary sinusitis?

Ans:

➢ Local
o Progression to subacute/chronic sinusitis
o Frontal sinusitis
o Osteomyelitis of maxilla
o Orbital cellulitis
o Orbital abscess
➢ Distant
o CSOM
o Dental infection
o Pharyngitis
o Laryngitis
o Intracranial
▪ Meningitis
▪ Encephalitis
▪ Brain abscess
▪ Cavernous sinus thrombosis

Chronic sinusitis
**scenario: sign and symptom for >3 weeks

Q. Mention the etiology/cause of chronic sinusitis

Ans:

Etiological/causative factors:

➢ Local
o Recurrent acute sinusitis
o Pre-existing rhinitis
o DNS
o Nasal polyp
o Nasal FB
o Nasal tumor
o Tonsillitis
o Hypertrophied adenoids
o Teeth infection

34
 ➢ General (that cause lowered host defense)
o Diabetes
o Steroid therapy
o Chemotherapy
o Immune-suppressed condition
o AIDS
o Immotile cilia syndrome
o Cystic fibrosis (impaired muco-ciliary clearance)
o Smoke, dust, fume, burn (damage the cilia)

Causative organism:

➢ Staphylococcus aureus
➢ Pseudomonas aeruginosa
➢ Klebsiella pneumonia
➢ Escherichia coli
➢ Anerobic organism

Q. Mention the Clinical features of chronic maxillary sinusitis

Ans:

Symptoms:

(symptoms such as headache should persist for more than 3 weeks)

➢ Local (nasal)
o Nasal obstruction
o Nasal discharge
o Post nasal drip
o Reduced sensation of smell
o Facial discomfort
➢ Pharyngeal symptom
o Sore throat
o Dysphagia
o Odynophagia (tonsillitis)
o ET block: loss of hearing
➢ Laryngeal symptom
o Hoarseness of voice
➢ Headache (periodicity present)
➢ Low grade fever

Examination:

➢ Anterior rhinoscopy
o Red, edematousu nasal mucosa
o Pus in middle meatus
o Pus appears when pt puts head under the knee

35
 ➢ Post turbinate
o Upper surface of palate full of pus
o Post nasal drip

Q. Investigations for chronic sinusitis

Ans:

➢ X ray of Para nasal sinus OM view

o Opacification of involved sinus
o Mucosal thickening
o Polypoid changes
o Other associated pathology
➢ CT scan of PNS
o Detailed anatomy of sinus + associated pathology can be seen
➢ Examination of the pus
o Culture and sensitivity
➢ CBC: eosinophilia

Q. Treatment of chronic maxillary sinusitis

Ans:

➢ Medical treatment
o Antibiotic (minimum 14 days up to 21 days)
o Nasal decongestant
o Anti-histamine
o Steroids: local and systemic
o Steam inhalation: with menthol: soothing effect
➢ Surgical treatment
o Antral washout
o FESS (functional endoscopic sinus surgery)
o Surgery for removal of underlying cause (E.g DNS correction by SMR/Septoplasty)
➢ Treatment of underlying cause

Q. What are the complications of chronic maxillary sinusitis?

Ans:

➢ Nasal
o Nasal polyp
o Atrophic rhinitis
➢ Orbital
o Orbital cellulitis
o Orbital abscess
➢ Pharyngeal
o Pharyngitis
o Tonsillitis

36
 ➢ Ear
o Heaviness of ear
o Middle ear effusion
o OM
➢ Intra-cranial
o Meningitis
o Encephalitis
o Brain abscess
o Cavernous sinus thrombosis
➢ Bony
o Osteomyelitis of facial bones
➢ Miscellaneous
o Mucocele
o Oro-antral fistula

37
Maxillary growth
Q. 48-year-old male: right cheek mass, right nasal obstruction, right sided upper teeth loosening. Dx,
clinical feature, investigation, management

Ans:

➢ Dx: Maxillary tumor/growth//antral carcinoma

➢ What are the clinical examinations you will do?
o General examination
▪ Redness and pain over maxilla
o Lymph node examination: there may be enlarged and hard cervical LN (metastasis)
o ENT examination
▪ Anterior rhinoscopy
• Unilateral nasal obstruction
• Nasal discharge
• Epistaxis
▪ Oral cavity examination
• Loosening of teeth
• Ulceration of palate
o Eye examination
▪ Proptosis
▪ Epiphora
➢ What investigations will you do?
o X ray Para nasal sinus OM view
o CT scan PNS
o Biopsy and histopathology
➢ Treatment: depends on stage of disease. Modalities are:
o Surgery
o Chemotherapy
o Radiotherapy
o Palliative care

38
Rhinosporidiosis
Q. Short note: Rhinosporidiosis

Ans:

➢ Definition
o Chronic granulomatous fungal infection
➢ Site
o Mucous membrane of nose
o Nasopharynx
o Lio
o Palate
o Uvula
o Epiglottis
o Larynx
o Conjunctiva
➢ Causative organism
o Rhinosporidium seeberi
➢ Risk group
o Farmers
o Rural people
➢ Transmission
o Cow/horse dung ➔ spore ➔ inhalation
o Dung in pond ➔ swimming/bathing in that water ➔ inhalation
➢ Clinical feature
o Symptom
▪ Nasal obstruction
▪ Nasal discharge
▪ Itching
▪ Headache
o Sign
▪ Mass in nasal cavity
▪ Red color
▪ With white stud/spot (strawberry)
▪ Sensitive to touch
▪ Bleeds to touch
➢ Investigation
o Nasal smear with 10% KOH
o Gram staining
o CBC, ESR
o X Ray PNS OM view: radio-opaque lesion seen
o X ray nose lateral view
o CT scan PNS
o Biopsy and histopathology of the lesion
➢ Management

39
 o Wide excision ➔ cauterization of the base
o Medication after excision
▪ Dapsone
▪ Amphotericin B
▪ Sodium stibo-gluconate

Nasal tumor
Short note: Ringertz tumor/inverted papilloma

Ans:

➢ Description
o Benign neoplasm of nasal cavity
o Grows towards underlying stroma
o Rather than towards the surface
➢ Presentation
o Arises in lateral wall of nose
o Red/grey mass
o Edematous
o Appears like a polyp
➢ Investigation
o X ray PNS OM view
o X ray nose lateral view
o Biopsy and histopathology
➢ Treatment
o Wide local excision
o Ethmoidectomy

40
Operative surgery of nose
Surgery of DNS
Q. What are the surgical options available for DNS?

Ans:

➢ To correct the deviation

o Sub mucosal resection (SMR) (now obsolete)
o Septoplasty
➢ Management of hypertrophied inferior turbinate:
o Submucosal diathermy (SMD)
o Cautery of the inferior turbinate (CIT)

**SMR: elevation of muco-periosteum + muco-perichondrium on both sides → removal of the affected

part of septum (bone/cartilage) → keep a small part of septum at the very front → close the elevated
flaps → nasal packing and regular dressing done

Q. complications of SMR operation

Ans:

➢ Epistaxis
➢ Septal hematoma
➢ Septal abscess
➢ Septal perforation
➢ Synechia/adhesion of nasal cavity
➢ Nasal deformity (saddle nose)
➢ Persistent/recurrent DNS
➢ Toxic shock syndrome (due to packing)
➢ CSF leak

Q. What do you mean by septoplasty operation?

Ans:

➢ It is a conservative approach to septal surgery

➢ Much of the septal framework is preserved
➢ Flap of muco-perichondrium and muco-periosteum is elevated only on one side

Q. What are the indications of septoplasty?

Ans:

➢ DNS with symptoms (e.g nasal obstruction)

o Children <16 years: septoplasty is mandatory: SMR cannot be performed on them
o Recurrent epistaxis (from the spur)
o Sinusitis
o DNS, in contact with lateral wall, causing headache
o sleep apnea

41
 ➢ as a part of other procedures
o As a part of cosmetic surgery: septo-rhinoplasty
o To approach middle meatus in FESS
o As a part of endoscopic DCR operation
o Trans-septal trans-sphenoidal hypophysectomy

Q. What are the complications of septoplasty operation?

Ans: same as SMR, but less and less common

➢ Epistaxis
➢ Septal hematoma
➢ Septal abscess
➢ Septal perforation
➢ Synechia
➢ Saddle nose
➢ CSF leak
➢ Toxic shock syndrome

Q. Advantage, disadvantage of septoplasty.

Ans:

Advantage:

➢ It is a conservative operation
➢ Can be done in all ages, also in children
➢ Complications are less than SMR
➢ Revision surgery can be undertaken if recurrent DNS

Disadvantage

➢ Residual deviation may persis

➢ (write the complications)

42
Q. Difference between septoplasty and SMR (not DU)

Ans:

SMR Septoplasty
Type Destructive operation Conservative operation
Flap elevated on Both sides One side
Age >16 years Any age
Principle Excision of the bony and Other methods: scoring, ross
cartilaginous parts of the hatching, wedge escision
septum
Chance of complication More Less
Re-operation Not easy Easier
Persistence of DNS Less common More common

Q. What are the different surgical options for HIT.

Ans:

➢ Partial/total turbinectomy
➢ Submucosal resection of turbinate bone

Antral washout
Q. Short note: Antral washout:

Ans:

➢ It is a surgical procedure to get temporary access to the maxillary sinus thru the inferior meatus
➢ Indication
o Chronic maxillary sinusitis
o Acute maxillary sinusitis not responding to medical treatment
o Frontal and ethmoidal sinusitis
o For taking cytology in suspected malignancy
➢ Anesthesia
o Local anesthesia preferred
o g/a needed for uncooperative pt + children
➢ instrument required
o thudicum nasal speculum
o killian’s speculum
o antral washing trochar and cannula
o gulley pot
o warm normal saline
o 50 cc syringe
➢ Procedure
o Patient is counselled
o Local anesthesia is applied
o Position: supine/sitting

43
 o Trochar and cannula along roof of inferior meatus in the medial wall of nasal cavity
o Puncture of the medial wall is done
o Sudden release of pressure, presence of pus/fluid
o Trochar is removed, cannula is left inside
o Cannula is connected with syringe containing warm normal saline
o Syringing/washout done until clear fluid comes out
o After syringing, cannula taken out
➢ Complication
o Vaso-vagal shock
o Bleeding
o Failure to puncture
o Puncture at wrong site – injury to surrounding structure
o Air embolism
o Injury to orbital floor → proptosis

FESS
Q. What is FESS/functional endoscopic sinus surgery?

Ans:

➢ It is a minimally invasive technique in which ostium and air cells of a para nasal sinus are opened
➢ Under the guidance of a fiberoptic endoscope and CT scan
➢ Then, anatomy and disease process in the sinus is assessed
➢ And operation is done in order to restore normal function pf sinus + air flow

Q. What are the indications of FESS?

Ans:

➢ Sinusitis
o Chronic bacterial sinusitis – no response to medical treatment
o Recurrent acute bacterial sinusitis
o Fungal sinusitis (with fungal ball)
➢ Nasal polyp
o Antro-choanal polyp
o Ethmoidal polyp
o Associated with fungal sinusitis
o Polypoid rhino-sinusitis (multiple, diffuse polyp in nose)
➢ Mucocele of sinus
➢ Removal of benign tumor
o Inverted papilloma
o Angiofibroma
➢ Epistaxis control
➢ Removal of foreign body
➢ Endoscopic septoplasty
➢ Endoscopic DCR
➢ Orbital abscess

44
 ➢ Orbital cellulitis
➢ Endoscopic orbital decompression (in case of-)
o Optic neuropathy
o Exophthalmos
➢ Repair of CSF leak
➢ Pituitary surgery
➢ Diagnostic
o To take biopsy material (chronic sinus disease/tumor)

Q. What are the complications of FESS?

Ans:

➢ Per-operative
o Hemorrhage
o Lamina papyracea injury
o Nasolacrimal duct injury
o Optic nerve injury
o Direct brain trauma
o Complication related to anesthesia
➢ Post-operative
o Immediate
▪ Hemorrhage
▪ Orbital hematoma
▪ Epistaxis
▪ Intra-cranial hemorrhage
▪ Diplopia
▪ Blindness
o Early
▪ CSF leak (CSF rhinorrhea)
▪ Meningitis
▪ Brain abscess
o Late
▪ Synechia (adhesion between medial and lateral wall of nasal cavity)
▪ Recurrence of the disease/persistence of the disease

Q. Short note: FESS (combine the above points and below, briefly)

Steps:

➢ General anesthesia
➢ Patient lies flat, head resting on a head rest
➢ 2 techniques (choice depends upon indication)
o Anterior to posterior
o Posterior to anterior

45
 ➢ Steps
o If maxillary sinus disease
▪ Uncinectomy
▪ Identify + enlarge maxillary ostium
▪ Bullectomy
o If ethmoidal sinus disease
▪ Penetration of basal lamella
▪ Removal of posterior ethmoid cells
o If frontal sinus disease
▪ Clearance of frontal recess
▪ Frontal sinusotomy
o If sphenoidal sinus disease
▪ Sphenoidotomy
o Nasal packing
➢ Post-operative care
o Removal of nasal pack
o Antibiotics
o Antihistamine
o Analgesic
o Steroid nasal spray
o Nasal irrigation
o Endoscopic nasal toileting

**Caldwell-luc operation (not DU) (also called anterior antrostomy)

➢ Indication
o Sinusitis: when other measures failed
o Polyp: antro-choanal polyp
o Antral carcinoma: to take biopsy
o Removal of foreign body
o Management of orbital fracture
➢ Complication
o Bleeding
o Anesthesia of cheek
o Anesthesia of teeth
o Nasolacrimal duct injury
o Osteomyelitis

Rhinoplasty
Short note

46