Adenoidal Hypertrophy

Endoscopic view of adenoids

Endoscopic view of the Adenoids at the back of the nose

This is much more common in children where the adenoids obstruct the back of the nose giving rise to a degree of nasal blockage. However, this can also be seen on occasion in adults and the diagnosis is usually made by fibre-optic endoscopy of the nasal passages. In adults, it is often possible to remove adenoid tissue through the nostrils using a suction-cautery technique. It can therefore be done in association with other nasal operative procedures. Large adenoids in children can contribute to obstructive sleep apnoea, and a child who mouth breathes is often the tell tale sign of adenoidal enlargement. It is now commonly believed that adenoidal enlargement and infection are contributory to recerrent middle ear infections and glue ear.

Anterior nosebleeds (Epistaxis)

nose bleed

These are due to bursting of blood vessels in the front of the nose (anterior part). It is by far the most commonly seen in young children. There is an area just inside the nostril along the septum (Little’s area) where there is a confluence of four different blood supplies to the nose forming a plexus of veins which are very near the surface. In addition to this, young children often have a mild infection in the nasal cavity called vestibulitis. Any minimal trauma can therefore set off nosebleeds. This can be made worse by associated conditions such as allergy or a viral infection. Hot weather can also precipitate nose bleeds. In many instances, application of antibiotic ointments such as Bactroban on a twice daily basis for two weeks can resolve nosebleeds in a significant proportion of children

Bipolar Cauterization

Internal views showing a bleeding point before and after cautery

However in those in whom it is persistent, cauterisation of the blood vessels is a successful technique in the outpatient setting using silver nitrate. This is done following application of a local anaesthetic nasal spray. Usually, both sides of the septum are not cauterised at the same time in order to avoid the small risk of septal perforation. It is also often the case that cauterisation needs to occur on at least three separate occasions spaced up by six weeks for the best long term outcome.

Chronic Sinusitis

CT Sinus MaxillaryBy definition, chronic sinusitis means symptoms of sinusitis for more than three months. These include symptoms of nasal blockage, nasal discharge, symptoms of facial pain and headaches, congestion, postnasal drip and altered sense of smell. Probably the most common cause for chronic sinusitis is inadequate resolution from an acute episode, either by lack of treatment or the presence of a very virulent causative bacterium. Risk factors for the development of chronic sinusitis includes allergy, non-allergic chronic rhinitis, immune deficiency disease syndromes, anatomical abnormalities which result in poor sinus drainage, cystic fibrosis, and conditions where there is poor movement of the nasal and sinus mucus.

The sinuses are four groups of cavities, either above, between, below or behind the eye socket (orbit). Although their function is not clear, it is thought that their presence results in the skull being lighter. Each sinus has a lining (mucosa) which contains mucus producing glands. This mucus is wafted towards the natural drainage hole (ostium) and under the microscope, you would see the little tiny hair-like cilia beating the mucus towards the natural drainage point. As a result of one of the above risk factors or after a viral infection, swelling occurs of the lining of the sinuses with increase in mucus production and sometimes occlusion of the natural ostia giving rise to stagnation of mucus. Stagnant mucus invariably gets infected which results in more inflammation and production of thick mucus which fails to drain itself. Eventually, the lining of the sinus swells to such an extent that it occupies the whole of the sinus and gradually due to a build-up of pressure the lining protrudes through the natural ostium and this is the first stage in the development of nasal polyps.

Typical organisms which cause chronic sinusitis include Streptococcus pneumonia, Haemophilus influenzae, Staphylococcus aureus, and Moraxella catarrhalis.

Clinical examination with endoscopy often reveals the presence of deviation of the nasal septum. There is often occlusion of the natural drainage port under the middle turbinate of the nose with the presence of congestion and infected mucus. Sometimes, polyps are seen at advanced stages of sinus disease. The diagnosis is further assisted by imaging studies using CT scan which outlines the various sinuses and a grading system is used to assess the amount of disease present.

Currently, the majority of patients with chronic sinusitis can be managed successfully with medical treatment which consists of a combination of antibiotics, nasal decongestants, nasal steroids, oral steroids and management of associated allergies.

Failure of resolution following appropriate medical therapy for up to one to  three months may necessitate surgical intervention. The goal of surgery is to correct any anatomical deformities, improve the sinus drainage, remove the nasal polyps thereby improving natural drainage of mucus and improving access for future medical treatment. Currently, the techniques used involved Functional Endoscopic Sinus Surgery (FESS). This is a procedure done under general anaesthetic and is usually carried out as a day-care procedure. There are risks with the FESS surgery which include postoperative bleeding, infection, adhesion formation, trauma to the neighbouring structures such as the orbit and the base of the skull. This can result in leakage of cerebrospinal fluid which bathes the brain and can therefore result in further complications such as meningitis or brain abscess. In some patients, despite adequate drainage of the sinuses, the lining of the nose and sinuses are unable to resume normality due to the presence of chronic infection. Recent theories have included the development of biofilms which attach to the nasal lining teaming with bacteria preventing antibiotics to be effective.

New techniques include three-dimensional image-guidance. This is particularly useful when operating near the skull base and orbit. In revision cases, there is often much scarring and the normal anatomic landmarks are often lost. The 3D image-guidance can therefore be very helpful in avoiding complications.

Another new technique is that of balloon sinuplasty. This is particularly helpful in management of frontal sinus disease. The frontal sinuses are the most difficult of the sinuses to access and the narrow passageway leading up to the frontal sinus can be difficult to find and normal surgical techniques run the risk of traumatising the skull base, giving rise to CSF leakage and also the use of standard techniques can result in long term scar tissue formation closing the nearly created drainage hole. With balloon sinuplasty, a wire is gently guided into the sinus and a balloon is railroaded over the wire. A balloon is then gently inflated which creates a new wider drainage hole with the minimum of trauma and thus the risk of scar tissue formation is much less. Current studies have reported long term success rates in excess of 95%. The risks associated with balloon sinuplasty have also been very minimal indeed due to the very minimally invasive nature of this technique.

Common cold

By far the commonest cause for nasal blockage is the common cold. The infection usually due to one of the many respiratory viruses which spread by contact or airbourne droplets when an infected person sneezes. Symptoms include congestion, nasal discharge, sneezing, loss of sense of smell, together with general malaise and occasionally associated with fever. Treatment is symptomatic with decongestants such as topical oxymetazoline nasal drops, paracetamol and plenty of fluid intake. Only when symptoms persist or associated with clear signs of infection are antibiotics indicated.

Deviated Nose/Septum

septum

Basal view showing deviatd septum

septum

Septum after surgical correction

The septum is the thin piece of cartilage and bone in the nose which separates the 2 nostrils. The septum may be deviated and cause blockage on one or both sides. Septal deviation can also result in external deformity of the nose. Although septal deviation can result from injury, in the majority of patients it is due to the way the septum has grown relative to the rest of the nose. Similarly the nasal bones too can be deviated and this is usually evident from just looking at the nose. In some patients the cause of nasal blockage is due to collapse of what are called the nasal valves. There are thin strips of cartilage in the fleshy part of the nose whose purpose it is to prevent inward collapse of the nostrils during inspiration. These cartilages can weaken with age or be deficient after excessive surgery and result in what is called “Alar Collapse”.

In all of these scenarios, there are structural factors which need correcting with a surgical procedure. A septoplasty is a relatively simple operation done through an incision within the nostrils. When the nasal bones need to be re-set in the midline or other changes need to be made, the operation is called Septo-Rhinoplasty.

Foreign Body

This is most common in children who may put something up their nose. This is often associated with a history of minor trauma. Some objects can be difficult to remove and requires a short anaesthetic to remove. The importance of removing foreign objects is the theoretical risk of inhaling the object into the windpipe/lungs. In humans the left main bronchus is more vertical so foreign objects tend to lodge on the left side. A common situation is the inhaled peanut. This can be difficult to manage as the oils within the peanut  cause a brisk inflammatory reaction making it difficult to visualize the object and the peanut begins to disintegrate.

The presence of foreign bodies in the lungs can present with long term symptoms such as asthma and cough.  Chest X ray will show collapse on the affected side.

Foreign bodies in the bronchus can be removed using special endoscopic equipment and a basket wire retriever (see picture below)

CXR Peantu Left Bronchus

Note the “white out” on the left due to collapse of the lung

 

peanut in left bronchus

Notice the inflammation around the peanut

 

Basker Retreiver

 

Foreign bodies can also lodge at the top of the gullet . A typical case would be a coin (see picture below).

lung

Coin stuck at the top of the gullet

Nasal Allergy

This can cause both acute and long term nasal blockage symptoms. Allergy causes swelling of the lining (mucosa) of the nose and after a long period of allergen exposure, the lining can become permanently enlarged. The mucosal swelling can result in secondary drainage problems of the sinuses which in turn can result in infection. In some patients it may contribute to the development of nasal polyps which further obstructs the nasal airway.

Nasal Allergy

Patients with severe allergies may develop acute nasal blockage symptoms together with sneezing, itchy feeling in the nose, watery nasal discharge, and associated eye and throat irritation. Common allergies include those to grass pollens, house dust mites, and animal dander. Diagnosis can be made on the history but skin prick testing with RAST blood testing usually confirms the nature and extent of allergies. Treatment involves allergen avoidance, oral anthistamines, topical steroid sprays and more recently consideration of immunotherapy options.

Nasal Discharge

This can be either from both sides or one side. Many conditions can give rise to nasal discharge including infections, allergy, acute or chronic sinusitis, adenoidal hypertrophy, and the presence of nasal polyps. Most of these conditions have been dealt with previously. The most important scenario is the presence of unilateral one-sided nasal discharge. In a child, this invariably is due to a foreign body until proven otherwise. Usually, part of a toy or a household object is inadvertently pushed into the nasal cavity and can often be forgotten about by the child. The presenting symptom is a smelly nasal discharge from one side.

In adults, the presence of a unilateral discharge can be due to the presence of a serious medical condition such as a tumour and therefore needs to be urgently referred for assessment. See red flag symptoms.

Nasal Polyps

Nasal polyps occur when the lining of the sinuses swell and thereafter protrude through the natural ostia. This then results in prolapsing of swollen mucosal tissue into the nasal cavity which has the appearance of a bunch of grapes. A number of conditions are associated with the development of nasal polyps. One example is Samter’s triad, which is a condition associated with nasal polyps, Aspirin sensitivity and asthma. Many patients with nasal polyps also have underlying allergies and as a result, it is not uncommon for nasal polyps to recur after surgery, making medical management a more useful option in the long term.

In vast majority of cases, nasal polyp is a bilateral condition affecting both sides of the nose. Any patient presenting with a polyp on one side only will invariably require a biopsy of the polyp to ensure that it is entirely benign. Any patients who have nasal polyps with bleeding or offensive discharge should also be seen as a matter of urgency to rule out a malignant diagnosis.

Nasal Polyps

Left nasal polyps filling the nose on the left almost completely

Nasal Tumours

Fortunately nasal tumours are relatively uncommon. The vast majority are benign and presents with symptoms of nasal blockage or bleeding from the nose. Obstruction of the nasal passage can also result in stagnant mucus and secondary infection. Probably, the commonest nasal tumour is called an inverted papilloma. This arises from the lining of the maxillary sinus usually and presents with unilateral flat fleshy polyp. A small percentage of these tumours can progress to malignant transformation and for this reason the condition was usually treated in the form of a lateral rhinotomy where incision was made between the inner aspect of the eye down the side of the nose between the cheek and along the nostril of the nose, thereby allowing access to the sinus through the front of the face. The middle part of the maxillary sinus was then removed and the tumour scooped out in its entirety. However, recent advances in endoscopic techniques can now allow this to be carried out endoscopically in the majority of cases. This condition requires long term surveillance and any recurrences need to be proactively removed and assessed for malignant change.

Malignant tumours can occur in the ethmoid sinuses. A classic one was seen in those who worked in the woodworking industry. It is thought that some of the resins found particularly in hardwoods such as mahogany can give rise to malignant changes in the ethmoid sinuses. Such conditions when diagnosed can require extensive cranio facial operations to ensure complete removal of the disease but involvement of the surrounding tissues, such as the eye and brain, are not uncommon making this condition quite difficult to manage.

Posterior Epistaxis

This occurs in elderly patients due to the presence of often age-related problems such as brittle blood vessels. Many patients of that age group are also on anticoagulant therapy such as Aspirin or Warfarin which exacerbates the problem. In this group of patients, the nosebleeds can be from a small artery but this can result in quite profound haemorrhage. This type of nosebleed requires nasal packing in the first instance if the bleeding cannot be isolated. If nosebleeds persist despite a period of nasal packing, then the feeding blood vessel can be clipped (sphenopalatine artery ligation).

In these patients, it is often necessary to stop anticoagulant therapy until the nosebleed problem has been resolved.

Septal haematoma

This is when a collection of blood occurs in the septum itself and presents as a swollen septum blocking the nasal passages in a patient with a history of nasal trauma.

When pressed with a cotton bud it feels boggy and is on both sides of the septum. It needs urgent medical attention as failure to drain it may result in loss of septal cartilage with consequent saddle deformity of the nose and worst still the development of a septal abscess which can lead to brain infection.

septa lhaematoma

Following injury there is swelling of the septum on both sides due to collection of blood.

Septal/ Nasal Deformity

The majority of patients with deviated nose/septum have no history of injury. However, those who play contact sports, or have a road traffic accident, may have injured the nose and the bones/cartilages may have healed in a displaced manner. This can result in nasal airway blockage with possible related sinus problems. Another consequence is an aesthetic deformity. Occasionally the irregularities can result in pain across the nasal bridge and resting spectacles or sun glasses on the nasal bridge can be uncomfortable.

When the injury is within 3 weeks of occurring, it is sometimes possible to reposition the nasal bones. This is called Manipulation under Anaesthesia (MUA) of fractured nose. Although it should be done within 3 weeks of the injury, if it is later than this, sometimes the recently set bones can be carefully re-broken using a specialised chisel like instrument (osteotome).

On some occasions the post traumatic nasal deformity requires a formal Septo-Rhinoplasty procedure to correct the deformity. This is done under general anaesthetic.

Nasal trauma can also lead to septal deviation giving rise to nasal blockage symptoms in the future. Most septal deviations can be managed by a procedure called Septoplasty. Here an incision is made just inside the nostril and the septal cartilage is repositioned into the midline. In severely deviated cartilage is repositioned into the midline. In severely deviated cartilages, an open procedure is necessary.

Please visit www.londonrhinoplasty.com which is another site with details of Mr Patel’s work on nasal surgery.

septum

Patient with very deviated septum seen from below.

septum
Following surgery the septum is now straight and breathing is much improved.