Common Nose Conditions

 

Nasal Polyps

Nasal polyps are growths found in the nose as a result of inflammation of mucous membranes of the nose and sinuses. They cause nasal obstruction, hyposmia (decrease sense of smell) and discharge. Other non-specific symptoms include facial ache, pressure around the eye, frontal headache and postnasal drip.

The cause of nasal polyps is multifactorial. Some studies have suggested that nasal polyps are related to allergy. This may include inhalant allergy such as house dust mite and food allergy. Allergy causes swelling of the lining of the nasal cavity and sinuses. Chronic infection of the sinuses also results in mucosal swelling and polyp formation.

sinusitis | nasal cavities as grape-like swellings

Nasal polyps generally present in both nasal cavities as grape-like swellings (figure 1). If the polyp is unilateral (one-sided), it should be biopsied to exclude inverted papilloma which is a benign growth with malignant potential.

sinus CT scan

The approach to the management of nasal polyps always starts with medical therapy. A course of steroids, antibiotics, nasal steroid spray and topical decongestants is prescribed to ascertain if the polyps will clinically shrink. This is followed by a CT scan of the sinuses to determine the extent of disease (figure 2). Unless the polyps are very small, endoscopic sinus surgery is usually advocated to relieve the symptoms and arrest progression of the disease.

Acute Sinusitis

The condition is defined as an infection of the sinuses caused by bacteria. This is usually preceded by a viral upper respiratory tract infection or allergy.

sinus | middle turbinate

Patients present with a history of nasal obstruction, foul-smelling purulent nasal discharge, facial pain and toothache. This may be associated with sorethroat, cough, hoarseness, fever, general lethargy and loss of appetite. On examination, the nasal cavity is congested with mucopus and the turbinates are swollen. A nasopharyngoscopy may reveal mucopus tracking from under the middle turbinate (figure 3) into the oropharynx. The face may be tender on palpation.

acute sinusitis X-rays

The diagnosis of acute sinusitis can be made on the history and examination. Sometimes, ENT doctors perform sinus x-rays (Figure 4) to confirm their diagnosis although the value of such x-rays is not clear.

Treatment of acute sinusitis is aimed at relieving any swelling, overcoming infection and managing any predisposing factors such as allergy.

  1. Simple measures – Steam inhalations with menthol crystals help soften crusts. Staying well-hydrated and avoiding smoky environments help prevent further irritation.
  2. Decongestants – the rationale for decongestants is to reduce swelling and allow drainage of infection. I find topical decongestant drops more useful than oral decongestants.
  3. Antibiotics – although the initial cause for inflammation of the sinuses is viral, oral antibiotics that cover upper respiratory tract pathogens are usually prescribed to prevent superinfection by bacteria.
  4. Allergy management – if the patient has symptoms of nasal allergy, topical nasal steroid sprays and antihistamines can be prescribed.
  5. Antral (Sinus) Washout – Studies have shown the benefit of antral washouts in patients with acute sinusitis (see under Commonly Performed Clinic Procedures). This is especially so if the symptoms persists despite maximal medical therapy. This procedure is performed under local anaesthesia in the clinic.
  6. Nasal irrigation – studies have shown nasal irrigation has beneficial effect on acute sinusitis. Commonly used irrigation systems include Sinusflo and ENTsol. This involves flushing the nasal cavity with isotonic/hypertonic solution through a delivery pump.

Related links – http://en.wikipedia.org/wiki/Sinusitis

Chronic Sinusitis

Symptoms of acute sinus infections last less than 4 weeks. If the symptoms last more than 12 weeks without resolution, chronic sinusitis has developed. The symptoms are similar to acute sinusitis but because of its chronic nature, affects the patient’s quality of life more significantly.

Patients experience persistent nasal discharge, obstruction, Cacosmia (bad smell), Halitosis (bad breath), headaches, cough and sorethroat. This affects the ability to sleep, causes lethargy and can affect ability to concentrate.

The diagnosis is made on clinical history and confirmed on CT scan of the sinuses (fig 5) after adequate antibiotic treatment.

sinuses CT scan

Figure 5 shows that white arrow is normal, black arrow indicates infection

The aim of treatment is to completely eradicate the symptoms once and for all. Treatment options include:

  1. Prolonged course of antibiotics – your doctor may prescribe a four to six week course of antibiotics
  2. Corticosteroids – the anti-inflammatory effect of steroids reduce swelling, promote drainage and healing
  3. Douching and steam inhalation – this helps loosen and flush mucopus stuck in the sinuses
  4. Functional endoscopic sinus surgery (fess) – when all conservative measures fail to eradicate the disease, surgery may be required to physically widen the sinus openings to restore function to the sinuses. A new technique called balloon sinuplasty may be applicable in limited sinus disease (figure 6). Unlike standard fess, balloon sinuplasty involves dilating and widening the sinus openings with a non-complaint balloon guided by a wire into the sinus.

sinus | balloon sinuplasty

Chronic sinusitis tends to recur without proper follow-up and control of predisposing factors. This includes allergy management with nasal steroid sprays, early treatment of viral upper respiratory tract infections, regular douching and endoscopic examination by your ent doctor.

Related links –
http://emedicine.medscape.com/article/232791-overview

Nasopharyngeal Carcinoma (Nose cancer)

Nasopharyngeal Carcinoma (NPC) is cancer of the nasopharynx (back of nasal cavity) which is commonly seen in the Chinese. The causes for this condition are genetic, viral and environmental.

ENT | neck lump

The most common presenting symptom is a neck lump (figure 7). Fifty to seventy percent of patients present with a neck lump. One third of these have lumps over both sides of the neck. Nasal symptoms such as bleeding, nasal obstruction and blood-stained sputum are second most common. Patients can also present with ear blockage from fluid in the middle ear (see otitis media with effusion under common ear conditions), diplopia (double-vision), headache.

Routine screening is recommended for two groups of patients;

a. patients in whom the Epstein-Barr Virus (EBV) serology is positive (usually found on routine medical health screening) and

b. patients with a positive family history of nose cancer (family history refers to a first-degree relative eg. Parents or siblings). Patients in these two groups require examination of the postnasal space.

sinusitis | nasal disease

The best way to examine the postnasal space (nasopharynx) is using endoscopy. A flexible fibreoptic endoscope is passed through the nasal cavity and the postnasal space is examined. If a mass is seen (figure 8), it can be biopsied under local anaesthesia as a clinic procedure. Neck lumps are subjected to fine needle aspiration cytology (FNAC). This generally yields the diagnosis if the disease is present in 95% to 98% of the time.

The treatment for NPC depends on the stage of disease. If it is detected early, radiotherapy is the main modality of treatment. If the disease is advanced, combined chemotherapy and radiotherapy is advocated. Surgery only has a role in persistent or recurrent disease.

Related Links –
http://www.gpnotebook.co.uk/simplepage.cfm?ID=1872363526
http://www.cancer.gov/cancertopics/pdq/treatment/nasopharyngeal/patient

Dr Gerard Chee

MBBS (S'pore), FRCS (Edin), FRCS (Glasg) Fellow, Otology / Neurotology (Can)

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ENT-Specialist-nose_StaffJinnahHosp
Visit to Jinnah Hospital, Karachi PAkistan Jan 2004