Nose and Sinus Disorders


[Nose anatomy] [Allergic and Non-allergic Rhinitis] [Turbinate Hypertrophy] [Deviated Septum]

[Nasal Surgery] [Nose Bleeds] [Polyps] [Sinus anatomy] [Acute Sinusitis] [Chronic Sinusitis] [Sinus surgery]

Nose Anatomy

The nose is an important organ of the face whose function includes passage and humidification of the air that we breath as well as facillitating the sense of smell (olfaction). Additionally, the nose contributes a large degree to the attractiveness of the face, some may argue it is the most important single feature of the face given its prominent location in the middle of it.

The external nose consists of skin that covers a bony framework at the top and cartilage framework towards the tip of the nose. The bone and cartilage of the nose are crucial in supporting its shape and function and trauma or inappropriate surgery can weaken these structures.

Internally the nostrils open to two passageways that are separate by a wall made of cartilage and bone. This wall is called nasal septum. When the nasal septum is deviated (pushed to the right or the left), it can potentially obstruct the flow of air through the nose and cause air to move too fast (turbulent flow) which can dry out the nose and cause crusting and bleeding or too slow which can be perceived as obstruction or blockage of the nose.

Additionally, the nasal passages are occupied by three fleshy bumps internally on each side of the nose. These are called nasal turbinates. The highest one that sits under the brain is called the superior turbinate and contains smell receptors. The middle and lower (inferior) turbinates are much large and they help to humidify the air. In particular the inferior turbinate which is the largest one and sits near the floor of the nose tends to enlarge every 30 minutes and then shrink again. This way, it prevents too much air passing through the nose and drying it out. Many people perceive this as only being able to breathing through one side of the nose. But if this problem alternates about every 30 minutes from right to left and vice versa, this is normal and it is not concerning and should not be treated.

At the back of the nose, the septum ends and the two nasal passages come together in the area just above the back of your throat. This area is called the naso-pharynx. On the sides of the nasopharynx are the openings to the two eustachian tubes that connect to the right and left middle ears. The back wall of the nasopharynx is covered by tonsil-like tissue called “adenoids” (aka pharyngeal tonsils). Adenoids can enlarge in children and cause obstruction of the nose. Additionally, bacteria can accumulate here in children and travel up the eustachian tubes and cause repeat ear infections. Removal of adenoids can treat both of these conditions.

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Rhinitis

Rhinitis, in the simplest terms, means swelling or inflammation of the lining of the inside of the nose. When the inner lining (mucosa) of the nose swells, it means less room for air to flow through (nasal blockage). Inflammed mucosa often also produces too much mucous. So patients with rhinitis also often complain of excessive nasal drainage (rhinorrhea). More commonly in chronic case, flow of mucous is directed towards the back of the throat and patients report this as post-nasal drainage.

Rhinitis can happen acutely, such as when you have a cold and it can happen on a more chronic basis such as with allergies. Patients with allergies produces certain inflammatory chemicals in their nose called “histamine”. Histamine, causes itching, swelling and production of mucous.

 At times, rhinitis is associated with certain non-allergic environmental changes such as sudden drops in temperature. In these cases, symptoms are secondary to rapid changes in size of small blood vessels in the nasal lining (capillaries). This type of rhinitis is also known as vasomotor rhinitis.

A less common type of rhinitis is secondary to effect of overuse of a particular class of topical medications, most commonly: oxymetazoline (Afrin) nasal spray. Although this medication is safe to use over short periods of time (less than 3 days), chronic use can cause changes similar to severe rhinitis. This type of rhinitis is very difficult to treat.

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Enlarged inferior turbinates

Patients with long term rhinitis can develop permanent swelling of soft tissues of the nose which leads to nasal blockage. The most prominent of these soft tissues is the inferior turbinate. Permanent enlargement of the inferior turbinates can cause near total obstruction of the nose. Severe blockage of the nose can prevent delivery of topical medications and saline rinses to the rest of the nose preventing these patients from improving.

Primary treatment for rhinitis and inferior turbinate hypertrophy include use of antihistamine tabs as well as topical antiinflammatory nasal sprays such as steroid sprays (fluticasone etc). Saline irrigations help remove dust and other allergens and help with the overall nasal hygiene.

When above treatments fail, other measures can be considered. Surgical reduction of inferior turbinates can help to rapidly improve nasal breathing while helping with topical drug delivery to the nose and sinuses. However, if the allergies are not treated, surgery alone will not be successful, the the turbinates have a tendency to grow again after surgery and symptoms can recur within 12-18 months.

Allergy testing can identify specific allergies (dust, mold, tree pollen etc). Once we know what the patient is allergic to, patient is advised to try to avoid exposure to the allergen. This can be manageable at times (getting rid of pets or using dust mite covers for pillows and mattresses). At other times, it is impossible to completely avoid an allergen (ie tree or grass pollen). In those cases, a treatment regiment consisting of “shot therapy” otherwise known as desensitization or immunotherapy can be proposed. This treatment involves weekly injections with miniscule amounts of an allergen for 2 or more years. Over time, immunotherapy can help overcome allergies. However, because of the length of treatment, patients must adjust to delayed gratification and the long term cost of the treatment.

Newer treatments for rhinitis include a new class of topical antihistamine sprays that help to effectively control allergies without the associated side effects of antihistamine tabs (drowsiness etc). Newer procedures are being developed to address non-allergic rhinitis such as identifying and cutting the nerve the induces mucous production (vidian nerve section) thus stemming the problem at the source. In-office procedures using plasma technology can help melt away excessive bulk of the inferior turbinates under local anesthesia without need for a trip to the operating room.

Many of us take breathing through the nose for granted, but for those that have suffered for years, the promise of new therapies to help improve their condition is…well… a breath of fresh air.

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Septal Deviation

Septum is a wall inside the nose that divides the right and left nostrils. This wall is made of cartilage in the front and bone in the back and it is covered by nasal lining (mucosa). The septum is very important and functions as a tent-pole like structure in holding the tip of the nose in place. If the septum is destroyed by disease, severe nasal deformity can result.

When the septum is not situated at an exact midline position within the nose, it can “deviate” to the right or the left, thereby narrowing the nostril on the right or left side. When the narrowing is significant enough, it can cause obstruction. Septal deviation can be developmental and some people are just born with this condition. In many cases, however, a history of trauma to the nose or a broken nose in the past exists.

Surgery to correct the deviated septum and reposition in to achieve open nostrils on both sides is called septoplasty. This procedure is performed outpatient and involves a small incision inside the nostril to gain access to the bone and cartilage of the septum. Deviated portions of bone and cartilage are removed and the incision is then closed with resorbable suture. Newer endoscopic septoplasty techniques allow access to the depths of nasal passages to better visualize and correct deformities for a more ideal result.

Patients may or may not need nasal packing in the nose after surgery which may cause some discomfort for up to one week before they are removed. Improved breathing is anticipated within 3-4 weeks after surgery once the swelling subsides. Risks of surgery include bleeding and risk of poor healing of the septum resulting in an hole (aka septal perforation). With careful technique and normal tissue healing, this surgery is generally completed with excellent outcomes.

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Surgical Treatment of the Nose

Septoplasty

When nasal sprays and treatment of allergies fail, physicians should consider other causes of nasal blockage. May of these causes can be treated with surgery. When septum is deviated, a surgical procedure called septoplasty is used to correct that help open the nose for improved breathing through both sides. Septoplasty involves addressing the deviated (crooked) bones and cartilage of the septum of the nose to create a straight, midline septum. This procedure is done oftern under general anesthesia, and it is outpatient (no hospital stay) with a recovery time of approximately 1 week. In recent years, endoscopic septoplasty has become popularized. This technique allows magnified visualization of the deepest portions of the nasal septum with the endoscope which in turn helps to ensure the most optimal outcome for the patients.

Turbinate Reduction Surgery

When inferior turbinates have grown to block one or both nasal passages after years of full blown allergies, even adequate allergy treatment may not be enough to reduce their size. Instead turbinate reduction surgery is proposed. In this treatment bone and soft tissue from inside of the turbinate is removed while leaving the delicate out side lining alone. The outside lining has the important function of helping to humidify air as it enters the nose. In the distant past, surgeons would remove part or all of the turbinates without regard to this important function. Modern turbinate surgery technique typically use plasma field technology or cold microdebriding machines to gently reduce the size of the turbinates while preserving their vital functions. Often this procedure is done simultaenously with a septoplasty.

Rhinoplasty

Obstruction of nasal passages can sometimes result from weakness of the cartilages of the nasal side wall. In these cases, patients experience collapsed nasal passages that can not be corrected with septoplasty alone. In these cases, an overhaul of the external structure of the nose is warranted. Functional rhinoplasty utilizes cartilage grafts and other plastic surgery techniques to improve nasal breathing when septoplasty and inferior turbinate reduction alone are not sufficient.

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Nose Bleed (Epistaxis)

Nose bleed is a very common problem in both children and adults. There are many causes for it. Some straight forward (ie dry air, nose picking, trauma to the nose) and others are more complicated (large artery bleed, tumors, use of blood thinning medications, liver and kidney disease).

Depending on the cause and severity of the nose bleed, various modalities can be used to treat it. Slow bleeding from the front of the nose (septum) can often be treated by an Ear nose and throat doctor with cauterization. Cauterization is most commonly done with silver nitrate which is a chemical that coagulates blood and burns skin to help form a thick scar to cover the blood vessel and prevent future bleeds.

When bleeding is severe, cauterization with silver nitrate is not effective and it often requires packing the nose with synthetic foams, or balloon packs. These packing material generally expand inside the nose and apply pressure to the area of bleeding. They are often quiet effective in controlling bleeding and very comonly used in ERs and urgent care centers. However, the pressure can often be very uncomfortable and the packing will have to stay in for a period of around 5 days to allow the nose to heal before it is removed.

When packing fails there are other options: having an Ear, Nose and Throat doctor to assess the packing and make adjustments is one option. Another option is to place a double pack or so called posterior pack which involves both a balloon in the back of the nose and some form of packing in the front. This generally helps control majority of bleeds, even ones that are coming from the back portion of the nose and are otherwise very difficult to stop.

Another option is to place coagulating agents inside the nose. This option is usually only effective in bleeding that is slow and due to liver or kidney disease or blood thinners. If all other options fail, a trip to the operating room to cauterize or ligate the major blood vessels of the nose with endoscopy under anesthesia is a last resort. Dr. Oliaei has expertise in controlling difficult cases of nose bleed by ligating the major blood vessel in the back of the nose (sphenopalatine artery) using endoscopic techniques.

Nasal Polyps

Polyps are swellings of the nasal and sinus mucous membrane that occur in response to inflammation and can be the cause of symptoms of nasal blockage and sinusitis. Polyp formation is often related to allergies.

Common symptoms in patients with nasal and sinus polyps include nasal obstruction, decreased sense of smell, repeated sinus infections, facial pressure, and a lot of drainage from the nose. It is common, as in sinusitis, to feel as if you have a constant cold or sinus infection. Voice quality is also often affected due to blockage of the nose and sinuses. Occasionally, patients have polyps, asthma, and aspirin sensitivity together, a situation known as Samter’s triad or aspirin-exacerbated respiratory disease (AERD).

The presence of polyps can be easily confirmed by an in-office endoscopy under local (topical spray) anesthesia, which utilizes a small telescope that is placed inside of the nostril to examine the nose and sinuses. CAT scan of the sinuses may help to show the exact location of polyps within these cavities and the extent of involvement.

Initial treatment of polyps typically includes anti-inflammatory medical treatments (ie prednisone tabs) to shrink the polyps. In many cases, this treatment alone can be quite effective with improvement in symptoms. In severe cases, sinus surgery may be necessary to remove the polyps.

One benefit of surgery in this regard is removing diseased tissue and creating space for delivery of medications. Following surgery, it is therefore very important to continue the medication regimen (ie steroid nose sprays), in some cases on a long-term basis, in order to prevent polyps from re-growing. The nose and sinus cavities should be watched closely on a regular basis. If early swellings in the mucous membrane are found, they may be treated medically before causing symptoms or requiring another surgery.

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Sinus Anatomy

Sinuses are bony air chambers that surround the nose and reside under the eyes, between the eyes, behind the eyes and above the eyes. Their exact function is unclear but it is thought that they serve as airbags for important structures in the head namely the eyes and the brain. Studies have showed that in cases of severe facial trauma, sinuses fracture first thereby cushioning the blow so that skullbase and orbital fractures would be less likely.

There are typically four paired (right and left) sinuses: frontal sinuses (located above the eyes). maxillary sinuses (located over the cheeks and under the eyes), ethmoid sinuses (series of small sinuses located between the eyes and under the base of the skull).

The external nose consists of skin that covers a bony framework at the top and cartilage framework towards the tip of the nose. The bone and cartilage of the nose are crucial in supporting its shape and function and trauma or inappropriate surgery can weaken these structures.

Internally the nostrils open to two passageways that are separate by a wall made of cartilage and bone. This wall is called nasal septum. When the nasal septum is deviated (pushed to the right or the left), it can potentially obstruct the flow of air through the nose and cause air to move too fast (turbulent flow) which can dry out the nose and cause crusting and bleeding or too slow which can be perceived as obstruction or blockage of the nose.

Additionally, the nasal passages are occupied by three fleshy bumps internally on each side of the nose. These are called nasal turbinates. The highest one that sits under the brain is called the superior turbinate and contains smell receptors. The middle and lower (inferior) turbinates are much large and they help to humidify the air. In particular the inferior turbinate which is the largest one and sits near the floor of the nose tends to enlarge every 30 minutes and then shrink again. This way, it prevents too much air passing through the nose and drying it out. Many people perceive this as only being able to breathing through one side of the nose. But if this problem alternates about every 30 minutes from right to left and vice versa, this is normal and it is not concerning and should not be treated.

At the back of the nose, the septum ends and the two nasal passages come together in the area just above the back of your throat. This area is called the naso-pharynx. On the sides of the nasopharynx are the openings to the two eustachian tubes that connect to the right and left middle ears. The back wall of the nasopharynx is covered by tonsil-like tissue called “adenoids” (aka pharyngeal tonsils). Adenoids can enlarge in children and cause obstruction of the nose. Additionally, bacteria can accumulate here in children and travel up the eustachian tubes and cause repeat ear infections. Removal of adenoids can treat both of these conditions.

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Acute Sinusitis

Sinuses produce mucous which is then moved out of openings of each sinus into the nose where it is cleared out towards the back of the nose. When openings of sinuses are narrowed because of anatomic blockage or swelling from chronic inflammation, mucous can accumulate and cause pressure symptoms. When this occurs, the lining of the sinuses can thicken and produce more mucous which further exacerbates the condition. Stagnant, non-moving mucous invites bacteria to invade and cause infection. Sinus infection or sinusitis can result.

Acute sinusitis are symptoms are sinusitis lasting less than 4 weeks. These symptoms include facial pain and pressure, nasal congestion, discolored nasal drainage, loss of sense of smell and/or taste, upper tooth pain, post nasal drip. It can be caused (most commonly) by viruses and (less commonly) by bacteria. Viral sinusitis is usually less severe and best treated with supportive measures (saline rinses, nasal decongestants, anthistamines, and nasal or oral steroids such as Flonase or prednisone). Bacterial infections typically are more severe, last longer and require oral antibiotics to resolve. Some patients suffer from recurrent acute sinusitis bouts (several sinusitis episodes yearly). Contribution of certain immune system deficiencies, anatomic abnormalities,

Some symptoms of sinusitis:
Bad breath or loss of smell
Fatigue and general feeling of being ill
Fever
Headache — pressure-like pain, pain behind the eyes, toothache, or tenderness of the face
Nasal stuffiness and discharge
Sore throat and postnasal drip
Cold or respiratory illness that has been getting better and then begins to get worse
High fever, along with a darkened nasal discharge, that lasts for at least 3 days
Nasal discharge, with or without a cough

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Chronic Sinusitis

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Endoscopic Sinus Surgery

There are two forms of sinus infection that may require Endoscopic Sinus Surgery:

1. Recurrent Acute Sinusitis
When a sinus infection lasts less than 4 weeks, it is considered acute sinusitis. This is usually treated with antibiotics or steroids and other medications. When frequent acute sinus infections occur they can lead to significant time off from work, school and loss of productivity. Sinus surgery can help to expand narrow openings of the sinuses so that they are less prone to recurrent infections.

2. Chronic sinusitis
Sinusitis lasting several months is considered a chronic condition. Although endoscopic sinus surgery does not cure this condition, it helps relieve obstructions and open sinuses so that nasal sprays and irrigations can effectively be delivered into the sinuses to help maintain healthy sinuses at relieve chronic symptoms.

3. Sinus masses/cysts/fungus balls
In rare cases, there are non-infectious causes for endoscopic sinus surgery. Endoscopic techniques allow biopsies of suspicious masses and removal of symptomatic cysts.

 

How is endoscopic sinus surgery performed?

This surgery is done under general anesthesia using video endoscopes which allow operation through narrow openings of the nostrils without making any open incisions on the face. Fine microinstruments and various other tools are used during surgery to remove unwanted tissue and stop any bleeding that may arise while keeping vital structures that surround the sinuses safe. The surgery can take anywhere from 30 minutes to several hours depending on the extent of surgery needed and the number of sinuses involved.

 

What are the risks of surgery?

Bleeding is the most important risk of surgery and significant bleeding can occur occasionally up to 2 weeks after surgery. Small amount of bleeding is expected the night after surgery but if significant bleeding occurs, it is important to call your doctor to discuss management. Most bleeding can be managed with some simple measure at home or in the ER but occasionally bleeding needs to be controlled at the operating room.
Nasal sinuses are close to the brain and the eyes. Injury to the eyes, including double vision, blindness, brain injury, leakage of brain fluid or bleeding into the brain are rare possibilities. Risk of infection and unwanted scarring after surgery can complicated results and may require re-operation. Risks of anesthesia common to all surgery should also be considered.

 

What to expect after surgery?

Discharge: Most patients go home the same day. Occasionally different types of packing or stents are placed in the nose during surgery and will need to stay in place for one or more weeks after surgery.
Pain: Facial pain and pressure similar to a sinus infection or worse is expected after surgery. Generally symptoms begin to improve after 4-5 days or when the nasal packings are removed in the office at one week.
Bleeding: Small amounts of bleeding usually resolves on its own. For severe bleeding, vomiting of blood and clots, immediate return to the hospital.
Follow-up: You will see your surgeon after surgery to remove any packings and to remove crusting and suction mucous and clots. This is exceedingly important in determining the outcome of surgery. Use of prescribed irrigations/sprays and other

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May 9th, 2017 by Sepehr Oliaei, MD