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Miscellaneous Nose Topics

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

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Miscellaneous Nose Topics

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  1. Miscellaneous Nose Topics Dr. Vishal Sharma

  2. Contents 1. C.S.F. rhinorrhoea 2. Nasal foreign body 3. Rhinolith 4. Nasal myiasis 5. Choanal atresia

  3. C.S.F. Rhinorrhoea

  4. 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.

  5. Etiology Traumatic (96%)Non-traumatic (4%)

  6. 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

  7. 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%)

  8. 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

  9. Pathways for CSF rhinorrhoea

  10. 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

  11. 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

  12. C.S.F. rhinorrhoea

  13. Teapot sign

  14. Halo sign

  15. 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

  16. CT scan showing bony defect

  17. CT scan & D.N.E.

  18. CT scan & D.N.E.

  19. Sphenoid sinus meningocoele

  20. MRI showing CSF leak

  21. Intra-thecal Fluorescin Plain DNE Blue light Endoscopy

  22. CT Cisternography

  23. Conservative management Indications: 1. Immediate post-traumatic leak (within 48 hours) 2. Small post-operative leaks 3. Poor risk patients for surgery

  24. 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

  25. 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

  26. Surgical Approaches Extracranial (endoscopic) Precisely located leak Single, small leak (< 1 cm) Intracranial (preferably intradural) Non-identifiable leaks Large leak (> 1cm) Multiple leaks

  27. 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

  28. Bone graft & perichondrium

  29. Turbinate flap repair

  30. Foreign body nose(Children, mentally challenged adults)

  31. 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

  32. Etiology • Self insertion • Into anterior nares • Accidental insertion • Into posterior nares by vomiting, coughing • Penetrating wounds • Nasal surgery: gauze pack left behind • Palatal perforation

  33. 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

  34. Symptoms Inanimate FB Nasal obstruction Purulent or blood-stained nasal discharge Epistaxis Hyposmia Animate FB Sero-sanguinous / foul smelling discharge Formication Marked swelling of nose, cheek, face Fever

  35. Diagnostic nasal endoscopy

  36. Metallic ring

  37. Live leech

  38. Metallic screw

  39. 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

  40. 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

  41. Tilley’s nasal dressing forceps

  42. Eustachian tube catheter

  43. FB removal with Fogarty catheter

  44. Rhinolith

  45. 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

  46. 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

  47. D.N.E. & X-ray P.N.S.

  48. CT scan & removed specimen

  49. 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

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