Transcript Document

Miscellaneous
Nose Topics
Dr. Vishal Sharma
Contents
1. C.S.F. rhinorrhoea
2. Nasal foreign body
3. Rhinolith
4. Nasal myiasis
5. Choanal atresia
C.S.F. Rhinorrhoea
Introduction
• Leakage of cerebrospinal fluid from nose
• Denotes presence of fistulous communication b/w
sub-arachnoid space & nasal cavity
• Paradoxical CSF rhinorrhoea: leak of CSF from
nose but defect present in mastoid or middle ear
roof. CSF enters nasal cavity via Eustachian tube.
Etiology
Traumatic (96%)
Non-traumatic (4%)
Traumatic
1. Accidental (80%): seen in 2% of head injuries
2. Surgical (20%)
 Endoscopic sinus surgery
 Surgery for meningocele
 Trans sphenoidal hypophysectomy
 Acoustic neuroma surgery
Non-traumatic
1. Normal intracranial pressure (55%)
 Congenital anomaly
 Focal atrophy
 Cough/ strain
 Osteitis / osteomyelitis
 Idiopathic
2. High intracranial pressure (45%)
 Tumor (85%)
 Hydrocephalus (15%)
Pathways for CSF rhinorrhoea
1. From anterior cranial fossa via:
a. Frontal sinus
b. Sphenoid sinus
c. Ethmoid sinus / Cribriform plate
2. From middle cranial fossa via:
a. Sphenoid sinus
b. Mastoid cells / middle ear → Eustachian tube
3. From posterior cranial fossa via:
a. Sphenoid sinus
b. Mastoid cells / middle ear → Eustachian tube
Pathways for CSF rhinorrhoea
Symptoms
1. Unilateral watery nasal discharge:
can’t be sniffed back, sweet taste, increases on
bending down & straining
2. H/o head injury, surgery of nose or skull base
3. Headache
 relieved on reclining or straining: low CSF pressure
 relieved by rhinorrhoea: high CSF pressure
4. Recurrent meningitis: suspect CSF leak
History
Flow
CSF
Rhinorrhoea
Allergic
rhinitis
Head injury, nasal or skull
base surgery, brain tumor
Sneezing, nose block
Intermittent, es on
Continuous, no effect
straining & bending forward, of bending / straining,
can’t be sniffed back
can be sniffed back
Taste
Sweet
Salty
Character
Watery
Watery / mucoid
Sugar
content
> 30 mg/dL
< 10 mg/dL
-2
Transferrin
Present
Absent
Signs
• Reservoir Sign / Tea Pot Sign:
Bending forward produces watery nasal discharge
• Halo Sign / Target Sign / Double Ring Sign:
CSF mixed with blood produces peripheral CSF halo
around central blood on filter paper / pillow cover
• Handkerchief sign: Nasal discharge causes stiffening
of hanky (due to presence of mucin), but not CSF
C.S.F. rhinorrhoea
Teapot sign
Halo sign
Investigations
• Nasal discharge biochemistry
– Glucose levels (> 30 mg % is CSF)
– Beta-2 Transferrin assay positive
• CT / MRI head & brain with contrast
– Localize site of CSF leak
– R/O Tumor
• CT Cisternography with Metrizamide/ Ionohexol
• Intra-thecal Fluorescein dye Injection + DNE under
blue light: fluorescent yellow colored CSF
CT scan showing bony defect
CT scan & D.N.E.
CT scan & D.N.E.
Sphenoid sinus meningocoele
MRI showing CSF leak
Intra-thecal Fluorescin
Plain DNE
Blue light Endoscopy
CT Cisternography
Conservative management
Indications:
1. Immediate post-traumatic leak (within 48 hours)
2. Small post-operative leaks
3. Poor risk patients for surgery
Conservative Treatment
• Bed rest in head up position (300)
• Avoid coughing, sneezing, nose blowing, straining
• Anti-tussive: for dry persistent cough
• Laxative: for constipation
• Medications: Acetazolamide, Furosemide
• Repeated removal of CSF via repeat lumbar taps
or indwelling lumbar sub-arachnoid drain
• Prophylactic antibiotics to prevent meningitis
Indications for Surgical Rx
1. Non-traumatic CSF rhinorrhoea
2. Failed conservative management for 2 weeks
3. Delayed post-traumatic CSF leak (> 48 hours after trauma)
4. Massive post-operative leaks & recurrent leaks
5. Associated facial fractures
6. Indication for intra cranial exploration: a. Large skull base
defect with brain herniation. b. Foreign body penetrating brain
7. Meningitis / pneumocele refractory to conservative Rx by 1 wk
Surgical Approaches
1. Extracranial (endoscopic)
 Precisely located leak
 Single, small leak (< 1 cm)
2. Intracranial (preferably intradural)
 Non-identifiable leaks
 Large leak (> 1cm)
 Multiple leaks
4-layer endoscopic repair
1. Bone graft: put intra-cranially
as underlay
2. Temporalis fascia /
perichondrium: as onlay
3. Fat: over fascia /
perichondrium
4. Gel foam / Merocel: over fat
Bone graft & perichondrium
Turbinate flap repair
Foreign body nose
(Children, mentally challenged adults)
Types of nasal foreign body
Inanimate
• Vegetable:
Pea, maize, gram, bean, nut
• Non vegetable:
Paper, cotton wool, pencil, eraser, chalk
• Mineral:
Part of metal / plastic toy, washer, pebble, nail,
metal screw, button, sponge, disc battery
Animate
Maggot, leech, insect
Etiology
• Self insertion
– Into anterior nares
• Accidental insertion
– Into posterior nares by vomiting, coughing
– Penetrating wounds
– Nasal surgery: gauze pack left behind
– Palatal perforation
Pathophysiology
Neglected FB nose will lead to:
– Stasis of secretions & infection
– Pressure effects, mucosal damage
– Ulceration & granulation formation
– Calcification of inspissated mucosa
– Rhinolith formation
– Leaking disc battery may cause necrosis &
septal perforation within hours
Symptoms
Inanimate FB
Animate FB
• Nasal obstruction
• Sero-sanguinous / foul
• Purulent or blood-
smelling discharge
stained nasal
• Formication
discharge
• Marked swelling of
• Epistaxis
• Hyposmia
nose, cheek, face
• Fever
Diagnostic nasal endoscopy
Metallic ring
Live leech
Metallic screw
Diagnosis
• U/L nasal obstruction with blood-stained or foul
smelling discharge in children = foreign body
until proven otherwise
• Foreign body may be seen on anterior rhinoscopy
• Foreign body may be hidden behind granulations:
felt on probing
• X-ray PNS lateral view: show radio-opaque FB
• Nasal endoscopy: show radiolucent FB
Treatment
• Curved FB hook or Eustachian catheter passed
beyond foreign body & FB gently pulled forward
• General anesthesia needed for uncooperative pt,
impacted or deep foreign body, troublesome bleeding
• Leech removed after putting pinch of salt or hypertonic
saline or few drops of oxalic acid on their body.
• Maggots removed (after putting turpentine oil soaked
ribbon gauze pack in nasal cavity) with Tilley forceps
Tilley’s nasal dressing forceps
Eustachian tube catheter
FB removal with Fogarty catheter
Rhinolith
Etiology
• Neglected foreign body nose buried in granulations or
inspissated nasal secretions or blood clot → forms
nucleus (nidus) around which coating of Ca & Mg salts
(PO4 + CO3) occurs → rhinolith formation
• Gradually it grows into large, irregular mass filling
nasal cavity → pressure necrosis of septum & or
lateral nasal wall
Clinical Features
• More common in adults
• U/L nose block & foul-smelling, blood-stained
nasal discharge
• Epistaxis & neuralgia due to mucosal ulceration
• O/E brown or greyish irregular mass, feels stony
hard on probing, brittle & may break off while
probing, may be surrounded by granulations
D.N.E. & X-ray P.N.S.
CT scan & removed specimen
Treatment
• Majority removed endoscopically with local
anesthesia
• Removed under general anesthesia if painful
• May be necessary to break & then remove
piecemeal
• Large rhinolith may require lateral rhinotomy
Nasal myiasis
(Scholeiasis)
• Maggots = larval form of blue bottle fly (Chrysomyia)
• Attracted by foul smelling nasal discharge in:
atrophic rhinitis, nasal syphilis & leprosy; purulent
sinusitis; post radiotherapy Ca maxilla
• Fly eggs hatch into 200 larvae within 24 hours
• Larvae cause destruction of nose, nasopharynx,
paranasal sinus, soft tissue of face, palate, eyeball
• Cases seen mostly b/w August & October
Life cycle of Chrysomyia
Chrysomyia fly & maggot
Clinical Features
• Intense nasal irritation, sneezing, lacrimation,
headache for first 3 days after infestation
• Nasal obstruction & foul smelling, blood-stained
nasal discharge
• Facial pain & puffy eyelids & lips
• Crawling sensation in nose (formication) &
maggots coming out from nose (after 3 - 4 days)
• Fistulae on nose / palate
• Death may occur from meningitis
Treatment
• Endoscopic removal of maggots with forceps
• Nasal irrigation with dilute chloroform or turpentine oil
• Nasal douching with normal saline QID to remove
slough, crusts, dead maggots.
• Nasal instillation of liquid paraffin for lubrication
• Isolation with mosquito net to avoid contact with flies
• Antibiotics to control secondary infection
• Maintenance of nasal hygiene
Choanal Atresia
Pierre Roederer described choanal atresia in 1755
Embryology
1. Persistence of bucco-nasal (oronasal) membrane
2. Failure of rupture of bucco-pharyngeal membrane
3. Medial outgrowth of palatine processes
4. Abnormal mesodermal adhesion in choanal area
5. Prenatal use of antithyroid medication (carbimazole)
6. Proliferation of epithelial cells within nasal cavities
6 - week embryo
7- week embryo
9 - week embryo
Pathology
• Unilateral : bilateral = 3 : 2
• Pure bony (30%); bony + membranous (60%);
membranous (10%)
• CHARGE association:
Coloboma (iris, choroid)
Heart defects (ASD)
Atresia of choana
Retarded growth
Genitourinary anomaly
Ear defect
Clinical Features
• Unilateral: usually present at 18 months, with
feeding difficulty, U/L nasal block & discharge
• Bilateral  presents at birth with:
• Asphyxia when mouth is closed (neonates are
obligate nasal breathers)
• Paradoxical cyanosis: cyanosis disappears while
crying (when baby opens mouth)
• Feeding difficulty, fatigue, frequent URTI
Examination
• Mucoid nasal discharge without air bubbles
• Failure to pass 8F rubber catheter through nasal
cavity for > 5.5 cm from alar rim
• Absence of fogging in cold spatula test
• Lack of movement of thin wisp of cotton placed
under nostrils (with mouth closed)
• Cyanosis resolves on putting an oral airway
Investigations
• D.N.E. with 2.7 mm scope: atretic plate seen
• Flexible nasopharyngoscopy: atretic plate seen
• Rhinogram (choanogram): dye instilled in nasal
cavity collects at choanal level
& does not pass into pharynx
• CT scan: detects type & thickness of atretic plate
Nasal Endoscopy
B/L choanal atresia
Nasopharyngoscopy
Normal posterior choanae
B/L atretic plates
Rhinogram
CT scan
U/L bony atresia
B/L membranous atresia
Treatment
Emergency:
– Endotracheal intubation / tracheostomy
– Mc Govern’s feeding nipple (with large hole)
put orally or oropharyngeal airway prevent
intubation / tracheostomy
Definitive: perforation of atretic plate
• Trans-nasal: for membranous & thin bony atresia
• Trans-palatal: for thick bony atresia
Trans-nasal approach
Drilling of atretic plate
Trans-palatal approach
Preparation of nasal tube
Passing catheters via nasal tubes
Tying of posterior knot
Tying of anterior knot
• Membranous plate perforated using Antrum
puncture trocar or female urethral dilator.
• Bony plate perforated with 5 mm diamond burr
directed parallel to nasal floor. Shaft of drill
covered with rubber to avoid damage to alar skin.
• 12F Foley’s catheter / Endotracheal tube inserted
B/L through new choana to prevent re-stenosis.
• Prolene passed through nasal tubes (with smaller
catheter) & tied in front to prevent displacement.
Acknowledgement
• Dr. Binaya Basyal
• Dr. Bhishma Barakoti
• Dr. Karishma Gupta
• Dr. Rachit Chawla
Thank You