Nasal obstruction

Dr. Ramesh Parajuli,MSChitwan medical college teaching hospital, bharatpur-10,chitwan Nepal

Differential Dx of nasal obstruction&

Neoplasms of Nose and PNS

Differential diagnosis of nasal obstruction

1.Structural: DNS, inf.turbinate

hypertrophy,concha bullosa

2.Infection: Unilateral sinusitis

3.Polyp: Antrochoanal polyp

4.FB

5.Neoplasms

6.Congenital:choanal atresia

7.Trauma

8.Granulomatous Dx:Rhinoscleroma

1.Infection:-Acute rhinitis

-CRS, Atrophic rhinitis

2.Allergy:Allergic rhinitis

3.Non allergic,non infective:

Vasomotor rhinitis

4.Adenoid hypertrophy

5.Structural: DNS

6.Trauma:Septal hematoma

7. Ethmoidal polyposis

8.Neoplasms

9.Rhinitis medicamentosa

Causes of unilateral nasal obstruction Causes of Bilateral Nasal obstruction

Neoplasms of Nose and PNS

Benign

1. Papilloma

2. Ossifying Fibroma

3. Osteoma

4. Haemangioma

5. Neurofibroma

Intermediate

Inverted papilloma

Malignant

1. Squamous cell carcinoma

2. Adenocarcinoma

3. Anaplastic carcinoma

4. Transitional cell carcinoma

5. Malignant melanoma

6. Salivary gland tumours

7. Rhabdomyosarcoma

Classification

Frontal sinus osteoma

Normal medullary bone is replaced by abnormal proliferation

of fibrous tissue, resulting in distortion & expansion of bone

C.T. scan: ground - glass appearance

Treatment: complete surgical excision

Fibrous dysplasia

•Locally aggressive sino-nasal tumour

•Synonyms: Ringertz or Schneiderian papilloma

•Common in males between 50-70 years

•It arises from the lateral wall of nose

•Presents as unilateral, friable, pink mass

•Diagnosis made by punch biopsy

Inverted papilloma

Treatment:

•Medial maxillectomy (& ethmoidectomy)by lateral rhinotomy approach

•Tendency to recur after surgical removal

•Squamous cell ca is present in 10 15% cases

•Radiotherapy is avoided

Lateral rhinotomy

Epidemiology

•Maxillary sinus>ethmoid>frontal>sphenoid

•>80% are squamous cell carcinoma

•Male : female = 2:1

•Commonly seen in 45-60 years

Sinonasal malignancy

1. Hardwood dust (adenocarcinoma)

2. Softwood dust (squamous carcinoma)

3. Nickel refining; chromium workers

4. Boot, shoe and textile workers

5. Mustard gas exposure

6. Human papilloma virus

Risk factors

Carcinoma Maxillary Sinus(Maxilla)

Early symptoms

•Mimic maxillary sinusitis

•Nasal blockage

•Blood-stained nasal discharge

•Facial paraesthesia or pain

•Epiphora

Spread

Medial spread:

Unilateral nasal obstruction

Unilateral purulent nasal

discharge

Epistaxis

Unilateral, friable, nasal mass

Anterior spread:

Cheek swelling

Invasion of facial skin

Late Clinical features

Inferior spread:

Expansion of alveolus with dental

pain

Loosening of teeth, poor fitting of

dentures

Swelling in hard palate or alveolus

Superior spread:

Proptosis

Diplopia

Ocular pain

Posterior spread:

Pterygoid muscle involvement trismus

Intracranial spread via:

Ethmoids, cribriform plate or foramen lacerum

Lymphatic spread:

Neck node metastases in late stages

Systemic spread: Lungs, bone

Initial presentation 7 months 11 months

Diagnostic nasal endoscopy

C.T. Scan Nose & Paranasal sinus: expansion & destruction of bony wall

Biopsy

Diagnosis

C.T. Scan

Ohngren’s Classification

Lederman’s Classification

TNM Staging

T1 = Tumor confined to antral mucosa

T2 = Bone destruction of hard palate / middle meatus

T3 = Involvement of skin of cheek, floor or medial

wall of orbit, ethmoid sinus, posterior antral wall,

pterygoid plates, infratemporal fossa

T4 = Involvement of orbital contents, cribriform plate,

frontal or sphenoid sinus, skull base, nasopharynx

Treatment

• T1 & T2 = Surgery or Radiotherapy

• T3 = Surgery + Radiotherapy

• T4 = Surgery + Radiotherapy + Chemotherapy

• Surgery post-operative Radiotherapy after 4-6 weeks

Surgical Options

1.Total maxillectomy:

Weber Fergusson incision

Malignancy limited to maxilla

2.Radical maxillectomy (with orbital exenteration):

Involvement of orbital fat

3. Anterior Cranio-Facial Resection:

Involvement of cribriform plate, frontal sinus

Weber Fergusson incision

Osteotomy cuts

Total maxillectomy done & incision closed

Palatal defect & prosthesis

Orbital exenteration indications

• Involvement of orbital apex

• Involvement of extra-ocular muscles

• Involvement of bulbar conjunctiva or sclera

• Lid involvement beyond a reasonable hope for

reconstruction

• Non-resectable full thickness invasion through

periorbita into retrobulbar fat

Orbital exenteration

Post-operative defect & prosthesis

Cranio-facial resection