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Nasal obstruction

Nasal obstruction. Blocked nose. Causes. Congenital - choanal atresia - repaired cleft palate - tumours. Causes. Acquired - trauma (without discharge) - polyps - neoplasms - PNS masses. Causes. Acquired - mucosal inflammation (with discharge) - viral

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Nasal obstruction

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  1. Nasal obstruction Blocked nose

  2. Causes • Congenital - choanal atresia - repaired cleft palate - tumours

  3. Causes • Acquired - trauma (without discharge) - polyps - neoplasms - PNS masses

  4. Causes • Acquired - mucosal inflammation (with discharge) - viral - bacterial - chemical - allergy - foreign body (unilateral, foul-smelling)

  5. Causes • Congenital - choanal atresia (uni- or bilateral, soft-tissue or bony) ~ presents at birth ~ bilateral is problem as neonate is obligate nose breather ~ airway must be provided as emergency

  6. Causes • Congenital - repaired cleft palate ~ before repair - “common” airway ~ after repair maxillary crest may occlude nose ~ provide oral airway ~ surgical correction

  7. Causes • Congenital - tumours ~ meningo-encephalocoele !! biopsies in nose !! ~ nasal glioma NB radiological imaging

  8. Causes • Acquired - trauma (without discharge)

  9. Nasal trauma • May be part of more extensive injury to face, skull, skull-base, neck, chest ……. REMEMBER TO CONSIDER THE AIRWAY AND EXCLUDE CERVICAL SPINE INJURIES

  10. Remember that low velocity trauma usually results in isolated nasal injury, while high-velocity trauma often has accompanying facial fractures and cervical spine injury must be considered

  11. N.B. • Document all injuries, symptoms and signs • Supplement notes with drawings, diagrams and photographs These injuries often require reports for legal purposes and good, clear documentation is vital

  12. Causes • Acquired - trauma (without discharge)~ deviated septum - unilateral

  13. Deviated septum • Developmental as well as • Traumatic The convexity of the septum is usually to the obstructed side while the concave side often has enlarged (compensatory) inferior and middle turbinates.

  14. Septal deviations • A truly straight septum is rare - deviations, deflections and spurs occur and, if severe, can cause obstruction. • Perceptions of “abnormality” are subjective as some patients with minimal loss of airflow complain bitterly while complete obstruction is often an incidental finding in others.

  15. Septal deviation

  16. Symptoms • Usually unilateral • Obstruction - convex side - septum itself - concave side - turbinate • Facial pain / - enlarged turbinate sinusitis • Chronic otitis media - E.Tube dysfunction

  17. Clinical appearance • External appearance of the nose gives idea of symmetry. • Inspection (anterior & posterior rhinoscopy) - deflection(s) - caudal dislocation - spur(s) - compensatory turbinate enlargement

  18. External deformity

  19. Treatment • Depends on degree of symptoms / discomfort • Is surgery is indicated, choice is between septoplasty and submucosal resection • Aim is to straighten or remove the deviated section and reposition it in the midline, while retaining adequate support of the nasal dorsum • Turbinates may be trimmed or realigned

  20. Causes • Acquired - trauma (without discharge) ~ septal haematoma - bilateral Surgical correction – haematoma as emergency

  21. Septal haematoma

  22. Management • Septal haematoma (collection of blood beneath mucoperichondrium causing bilateral complete obstruction) - aspirate if small - usually incise and drain with a “quilt” suture to prevent re-collection - appropriate antibiotic cover

  23. Management • If septal haematoma is missed or not treated adequately, septal abscess may follow and result in cartilage necrosis and “saddle” deformity

  24. Saddle deformity

  25. Causes • Acquired - polyps (without discharge)~ “grapes” ~ non-tender ~ clinical diagnosis ~ NOT inferior turbinate Surgical removal + steroids (topical, systemic short term)

  26. Causes • Acquired - neoplasms (without discharge) - inverted papilloma - juvenile angiofibroma - malignancies Surgical excision

  27. Causes • Acquired - Post Nasal Space masses (without discharge) ~ adenoids (commonest in children) ~ carcinoma / lymphoma ~ angiofibroma Surgical removal

  28. Causes • Acquired - mucosal inflammation (with discharge) - viral ~ clear rhinorrhoea ~ chills, fever - bacterial ~ purulent rhinorrhoea Symptomatic + antibiotics if indicated

  29. Symptomatic treatment • Decongestants - systemic - pseudo-ephedrine - antihistamine - topical • Antipyretics • Antibiotics - 2º bacterial infection ? always in children from lower socio-economic groups • Steam inhalations

  30. Causes • Acquired - mucosal inflammation (with discharge) - chemical ~ nose drops (rhinitis medicamentosa) - inflamed mucosa - clear rhinorrhoea

  31. Causes • Acquired - mucosal inflammation (with discharge) - allergy ~ atopy history ~ seasonal or perennial ~ obstruction, rhinorrhoea, itch Allergen avoidance ± antihistamines ± topical nasal steroids

  32. Causes • Acquired - mucosal inflammation (with discharge) - foreign body ~ unilateral, foul-smelling rhinorrhoea in a child is a foreign body until disproven. Visualise and remove ± local anaesthetic

  33. Conclusion – common sense • Identify cause • Remove cause • Treat any underlying / residual problems • Reassurance

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