NASAL MYIASIS ( Maggots in Nose)

•       Common  in both hot and humid  climate

•       Flies of genus Chrysomyia 

Clinical feature

1. Common in lower socioeconomic pt
2. Predisposing factor:

    Atrophic rhinitis, chronic rhinosinusitis, syphilis, leprosy : provide environment for housefly to lay egg—egg hatch to larvae measuring 1-5 cm which r white in color

Clinical feature

1. First 3-4 days : intense irritation, sneezing, lacrimation
2. Nasal obstruction
3. Foul smelling discharge
4. Thin blood stained discharge , Epistaxsis 
5. Severe pain : in and around nose
6. Cellulitis: redness of skin over nose, face, and eyelid, fistulae  around nose and palate

EXAMINATION:

1. Larvae in nasal cavity
2. s/s of infection

TREATMENT

1. Visible maggots : picked by forceps
2. Liquid paraffin / olive oil or turpentine oil into nasal cavity
3. Antibiotic : if cellulitis/ infection
4. Treatment of cause
5. Isolated with mosquito nets to avoid contact with flies

NASAL CYCLE

1. At given time one side of nose tends to be more blocked than other
2. This alternating pattern is called nasal cycle
3. 4-12 hours
4. Physiological
5. Anxious patient

NASAL OBSTRUCTION

UNILATERAL

1. DNS
2. Unilateral rhinosinusitis
3. AC polyp
4. Foreign body
5. Neoplasm: Angiofibroma, Olfactory neuroblastoma, Nasopharyngeal Ca
6. Choanal Atresia

BILATERAL

1. Acute Rhinosinusitis
2. Allergic rhinosinusitis
3. Adenoid enlargement
4. Vasomotor rhinosinusitis
5. DNS
6. Choanal Atresia

HISTORY

1. Onset
2. Duration
3. Unilateral /Bilateral
4. Complete/Incomplete

SHORT DURATION

•       Acute Rhinosinusitis

•       Foreign body

LONGER DURATION:

1.     DNS

2.     Allergic Rhinosinusitis

3.     Vasomotor Rhinosinusitis

4.     Rhinitis due to environmental factor e.g. pollution, fumes     

5.     Adenoid hyperplasia

LATERALITY:

1.     Unilateral: DNS, FB,  AC polyp

2.     Bilateral: Nasal allergy, Septal hematoma, Ethmoid polyp

LATENCY:

1.     Constant: Nasal mass

2.     Intermittent : Allergic Rhinosinusitis

SEVERITY:

1.     Severe: Noticeable enough to prevent routine work of

2.     patient

PROGRESSIVE:

1.     Polyp or Malignancy

FOREIGN BODY NOSE

Common:

1.  Children 2-6 yrs
2.  Adults especially those with mental retardation or psychiatric illness
3. Children habit of  exploring  new object

Common object :

1.Piece of paper

2.     Sponge

3.     Eraser

4.     Beads

5.     Vegetable seed

Inorganic

1.     Plastic or metal;

2.     beads,

3.     eraser and

4.     small parts from toys.

5.     Often asymptomatic and may be discovered incidentally

Organic

a.     Food, wood and sponge

b.     More irritating to the nasal mucosa and thus may produce earlier symptoms

DANGERS

1. Injury from clumsy attempts at removal by unskilled persons.
2. Local spread of infection- sinusitis or meningitis.
3. Inhalation of foreign bodies leading to lung collapse and infection.
4. All foreign bodies harbor the potential for swallowing or airway obstruction if they are displaced posteriorly. 

CLINICAL FEATURE:

1. Unilateral, usually
2. No symptoms: not uncommon initially
3. Nasal obstruction: if large
4. If children: patient are not aware
5. Long term:

a.     Unilateral foul smelling purulent discharge

b.     Sinusitis

c.     Granulation surrounding FB

If a child presents with unilateral, foul-smelling nasal discharge, foreign body must be excluded

TREATMENT

1. Sort of medical emergency: as chance of going further
2. Most FB removed without anaesthesia by FB hook, forceps
3. GA in uncooperative pt
4. If long term may be associated with rhinosinusitis so antibiotics
5. Vasoconstriction if bleeding

RHINOLITH

1. Rare
2. Resemble stone in nasal cavity
3. Small FB , mucous , blood clot—nucleus for concretion & those get coated with calcium & magnesium phosphate--- rhinolith
4. White/ brown or grey in color
5. Irregular surface , hard
6. Brittle and portion may break off while manipulating
7. Radio-opaque
8. May fill up entire nasal cavity: obstruction
9. Unilateral nasal obstruction & foul smelling

    discharge commonly blood stained  

Treatment

1. Removal under GA

Nasal Polyps

Definition:

Polyps – Greek word – Polypous – many footed

  - Oedematous, hypertrophied, Pedunculated mucosa of Nose + Paranasal sinuses

Sites

1. Ethmoidal:

1.  Poor Blood Supply of Ethmoid Sinus
2.  Complex anatomy of Ethmoid Labyrinth

2. Maxillary

     Rare – Sphenoidal and Frontal

    Site of origin – Middle meatus (All the sinus ostium opens)

Types of Nasal Polyps

1.     Antrochoanal Polyps (Killian’s Polyps)

2.     Ethmoidal Polyps (Nasal Polyps)

3.     Sphenoidal Polyps (Rare)

Etiological Factors

1. Infection:-

Recurrent Infection of PNS 

2. Allergy:-

1. Associated with asthama
2. Allergic symptoms like Sneezing, rhinorrhea  and itching
3. aspirin Hypersensitivity

Age & Sex

1. Any age group above 2 yrs
2. Cystic fibrosis develops earlier (Befroe 10 yrs)
3. Below 2 yrs – Meningocoele and Encephalocoele
4. Sex : Equal – In our context (Male:female = 2:1)

Symptoms

1. Nasal obstruction :

    Unilateral / Bilateral, Mild / Severe

2. Rhinorrhea and sneezing

3. Decrease sense of smell / complete loss

              Decrease sense of taste

4. Pain – Normally Painless

    Over bridge of Nose, forehead and cheek

5. Post Nasal Drip :

    White / Yellow (Severe Eosinophillia)

6. Epistaxis :

    Uncommon, Inverted Papilloma, Malignancy

7. Hypo Nasal Voice

8. Mouth Breathing

Signs

1. Anterior Rhinoscopy

1.  Translucent white bags of polyp
2.  Pinkish – Repeated Trauma, Infection
3.  Polyps may protrude out through the vestibule

Polyp may

•       Flaring of Alae of nose

•        Polyps Hanging in oral cavity

Investigation

1. X-ray
2. PNS OM view – Mucosal Thickening / Opaque antrum – fluid level
3. CT Scan – Nose and Para Nasal Sinuses
4.      - Both coronal and axial section (Osteomeatal complex)

TREATMENT

1. Medical Treatment –

    Minimal Polyps, Extesive polyps – to reduce the size

    “Medical Ethmoidectomy”

Tab. Prednisolone  -  1mg /kg body wt.

Betamethasone Nose Drop – 2 drops bid for 2 weeks

Steroid spray – for 3 months

2. Surgical treatment

A.FESS

B. External Approach

       Ethmoid – External ethmoidectomy (Lynch Howarth)

                      Intra Nasal Ethmoidectomy

                      Horgans Approach

        AC polyp – Caldwel Luc Surgery

                          Intra Nasal Polypectomy

Complications of surgery

Bleeding

- Intra Operative

- Post Operative

-        Damage to Lamina Papyracea

- Black Eye / Subcutanious oedema in infra orbital area.

- Occ. CSF Rhinorrhea

- Late Complication – Synechiae formation

Differentiation between AC polyp and Ethmoidal Polyp

AC	Ethmoidal
Origin- Lateral Wall+ floor of Maxillary Antrum	Ethmoid Lybrinth
Single	Multiple
Goes posteriorly	Comes anteriorly
Etiology: Infection	Allergy
Recurrence: Uncommon	Common
Caldwel Luc Surgery	Ethmoidectomy

SINUSITIS    

Inflammation of the paranasal sinuses.

Aetiology

1. Allergy

 2. Infection

             Acute-Bact.- Strept., Staph., H. influenzae, N. 

                 sp., anaerobes.

                 Viral-Rhinovirus, Inf. Virus,parainfl.

             Chronic – Specific-Fungal-Aspergillus

                  -  Non-specific

3. Structural e.g.. OMC-DNS, HIT

                

Contributing factors

1. Anatomical varience -DNS, Concha bullosa, 

     enlarged ethmoidal  bulla, everted uncinate 

     process,  paradoxical MT.

2. Mucociliary abnormalities

1. Primary-primary ciliary dyskinesia, cystic fibrosis, Young’s syndrome
2. Secondary-allergy, Bacterial infection

3. Immune deficiency .- primary-IgA def.,C4 def.,

                    -Secondary- HIV, Immunocompromised 

                     drugs.

3.     Allergy

Clinical Features

Acute sinusitis

Symptoms

1. Acute  Maxillary sinusitis: Pain over the cheek® frontal  region, teeth, in the morning increased by straining & bending forward

2.  Acute Frontoethmoidal:  Pain about the eye & frontal

3. Acute . Sphenoid: Rare,

                     Pain over retro-orbital® vertex, temple or occiput.

SIGNS

1. Hyperamic nasal mucosa, mucopus in Middle Meatus ,

2. Tenderness over paranasal sinus

3. Post Nasal drip

4. Redness, swelling of cheek® eyelids

CHRONIC SINUSITIS-

Symptoms

1.   Nasal obstruction
2.   Persistent mucopurulent discharge
3.   Coughing, irritaiton in throat
4.   Facial pain
5.   Hyposmia, cachosmia

Investigations

1. Nasal endoscopy
2. Swabs and antral lavage
3. Radiology- Plain x-rays   * Ct scan
4. Sinoscopy
5. Blood tests- TC,DC, ESR, Immunoglobulins

Treatment

1. Acute

   I. Medical

       a. Antibiotic

a.     Amoxycillin 500mg tds *7-10 days

b.     Azithromycin 500mg *Qid*5-7

c.     Cephalexin 500mg*OD

d.     Erythromycin  500mg qid  *7-10 dys

e.     Cotrimaxazole 960mg bd * 7-10days

f.      Doxycline 100mg bd * 7-10days

g.     Ampicillin 500mg qid * 7-10 days

h.     Cefixime 200-400mg bd *7-10dys

                                               i.     <50kg  8mg/kg

i.      Cefaclor 250-500mg tda (max 4mg/day)

ii>1month 20mg/kg/days*tds

      b. Analgesic

1.     Pcm 500mg qid or

2.     Ibruprofen 600mg tds or

3.     Nimesulide 100mg *BD

      c. Decongestant-systemic/topical

      D. Antihistamine

Antihistaminics

i.            Cetrizone 10mg to 20 mg BD

1.           Child 2-6yrs 2.5mg BD or 5mg OD

2.           >6yrs 10mg OD

ii.           Chlorpherarmine 4mg tds

1.           1-2 yrs  1mg BD

2.           2-5yrs  1mg tds (max=6mg/day)

3.           6-12yrs 2mg tds (max=12mg/day)

iii.          Fexofenadine  60mg BID

1.           >2yrs 0.23mg/kg/day (4-6)hrs

2.           2-6yrs 1mg

3.           6-12yrs 2mg

4.           >12yrs 4mg of 4-6 hrs

   II. Supportive

         Steam inhalation

2. Chronic- same

              - Steroids- topical spray

SURGICAL TREATMENT OF SINUSISTIS

•       Maxillary sinusitis: Antral lavage

                                  Caldwell-luc operation

•       Frontal sinusitis:   Trephining-Acute sinusistis

                        

•       Ethmoid sinusitis:  Intranasal/external/transantral       

                                     ethmoidectomy

  

•     Functional Endoscopic Sinus Surgery

Complications

1. Acute

Local:

•       1.Orbital-preseptal cellulitis, orbital cellulitis

       without  abscess, orbital cellulitis with 

       extraperiosteal abscess,  orbital cellulitis with

       intraperiosteal abscess,  cav. sinus thrombosis

   2. Intracranial              

   3. Bony- osteitis/osteomyelitis    4. Dental

Distant:

      Toxic shock syndrome

2. Chronic- Mucocoele/pyocoele

                   Ottitis media, adenotonsillitis, bronchitis,             

               

Allergic rhinitis

Definition

1. IgE mediated immunological response of nasal mucosa to air borne allergen
2. Characterized by sneezing, itching, watery nasal discharge, nasal obstruction

Aetiopathogenesis

1. IgE mediated hypersensitivity reaction to specific allergen
2. Allergens
1. pollen, grass, weeds- seasonal allergic rhinitis
2. House dust mite, animal hair, dander, perfumes, feathers, smoke, dust, atmospheric pollutant- perennial allergic rhinitis

Types

1. Seasonal allergic rhinitis (Hay Fever)
1. Inhaled allergen- pollen grain
2. Certain season –spring, autumn
2. Perennial allergic rhinitis
1. Occur throughout year
2. Caused by house dust mite etc

Clinical features

1. B/L nasal obstruction
2. Rhinorrhoea
3. Paroxysms of sneezing
4. Hyposmia
5. Post nasal drip
6. Itchiness of nose, eyes, palate
7. Associated  other allergy

Signs

1. Boggy, bluish edematous turbinates
2. Excessive nasal secretions

Sequelae

1.     Regression

2.     Progression to bronchial asthma, ethmoidal polyp

3.     Recurrent sinusitis

4.     Serous ottitis media

Investigations

1. Nasal smear microscopy- eosinophilia
2. Skin prick test- 10-30% asymptomatic- positive test
3. RAST (radioallerosorbent test)
4. Serum IgE
5. Nasal provocation test
6. Scratch test

Treatment

1. Avoidance of allergens
2. Medication
1. Antihistaminics-

                                                               i.      Cetrizine  10-20mg BD

                                                             ii.       Fexofenadine 120-180mg daily

                                                            iii.       loratadine

2. Topical corticosteroids spray-

                                                               i.      fluticasone,

                                                             ii.      momentasone,

                                                            iii.      budesonide,

                                                            iv.       beclomethasone 200mcgbd or 100mcg 3-4times

3. Mast cell stabilizers- sodium chromoglycate
4. Nasal decongestant-

                                                               i.      oxymetazoline,

                                                             ii.      xylometazoline

5. Oral steriod : for severe symptoms
2. Desensitization
1. Blocking IgG antibody that prevent antigen binding to IgE
2. Effective for seasonal allergy
3. Drawbacks

                                                               i.      Multiple allergy

                                                             ii.      Difficult to identify exact allergen

                                                            iii.      Series of injections

                                                            iv.      Anaphylaxis

                                                             v.      Recurrence

Rhinitis sicca
Crust forming disease in hot,

dry dusty climate
Confined to ant 1/3 of nose
Similar to early mild anterior

AR
C/f discomfort, irritation,

epistaxis & crusting
O/e: dry, whitish glazed mucous

membrane
Septal perforation
T/t: douching, Fe & vit supp,

Atrophic Rhinitis (Ozaena)

1. Chronic nasal disease
2. Progressive atrophy of mucosa and underlying bone of turbinates
3. Presence of viscid secretion → foul odour crust

Aetiology

a.     Primary (unknown cause)

                                               i.     Infection

1.     Klebsiella ozaena

2.     Bacillus mucosus

3.     Coccobacillus foetidus ozaena

4.     Diphtheria bacilli

                                             ii.     Endocrine imbalance 

1.     Female

2.     Puberty

                                           iii.     Heredity

                                            iv.     Racial influence

                                             v.     Nutritional

1.     Iron deficiency

                                            vi.     Autoimmune disease

b.       Secondary

                                                               i.      Chronic sinusitis

                                                             ii.      Excessive surgical destruction

                                                            iii.      Chronic granulomatus disease

1.       Syphilis

2.       Lupus

3.       Leprosy

4.       TB

5.       Rhinoscleroma

                                                            iv.      Radiotherapy

Pathology

1.     Metaplasia – columnar ciliated to squamous epithelium

2.     ↓ in no. & size of alveolar glands .

3.     + endarteritis and periarteritis of terminal arterioles.

4.     Active absorption of bone

•       C/F :

–       Symptoms

1.       Nasal obstruction

2.       Epistaxis

3.       Anosmia (merciful anosmia)

–       Signs

1.       Fetor

2.       Crusts- green, yellow, black

-           detached –bleeding

1.       Roomy cavity

2.       Atrophic laryngopharngitis

Treatment

1.     Conservative

a.     Nasal douching x 2

                                                        i.     280ml –warm water

                                                      ii.     28.4 g sod. bicarbonate

                                                    iii.     28.4 g sod diborate

                                                     iv.     56.7 g sod chloride

b.     25% glucose in glycerin

                                                        i.     Inhibits proteolytic organism

c.     Oestradiol in arachis oil

d.     Kemicetine antiozaena solution

                                                        i.     Chlormphenicol , estradiol, vit D2

e.     Potassium iodide

f.      Autogenous vaccines

g.     Human placental extracts

h.     Rifampicin

2.Surgical

1.Young’s operation

2.     Modified Young’s operation

3.     Submucosal inj of teflon paste

4.     Insertion of fat/ cartilage bone or teflon

5.     Medial displacement of lateral wall.