Nose / Sinus/ Allergy

A. Epistaxis

Causes:

Nasal causes include trauma, infection and tumor. Systemic causes include blood disorder, hypertension, and drugs that reduce the ability to clot properly.

Investigations offered:

Anterior nose can be examined with speculum and good headlight. Posterior nose and postnasal space would require flexible nasoendoscopy. Blood tests to exclude systemic causes.

Treatments offered:

  • Local pressure on the anterior nose is taught for anterior nose bleed
  • Topical silver nitrate cautery or diathermy to seal the small bleeding capillaries
  • Nasal packing with Merocel, Surgicel, ribbon gauze or balloon for severe bleeds
  • Selective endoscopic arterial ligation/ embolisation

 

B.  Allergic rhinitis, sinusitis, polyposis

Photo House Dust Mite Allergic RhinitisCauses:

Allergies of the nose result in sneezing, itching, runny and block nose. Sometimes there is eye and ear itch. It can be due to inhalant allergens or food allergies, with either acute or more subtle chronic manifestations.

Rhinosinusitis can result from acute or chronic nose passages inflammation, infection, polyps, anatomical nose and sinus structure abnormalities. It is worsened by unmanaged allergies.

Importance:

Allergy and rhinosinusitis causes discomfort and obstruct breathing, disturbing sleep. Rhinosinusitis may require long term medications and antibiotics, and have risks of eye, brain, teeth complications. Frontal and central headaches or eye pain may be due to severe sinusitis. Patients who are immunocompromised have increased risks of complications.

Photo 29 CT Image Guided Functional Endoscopic Sinus SurgeryInvestigations offered:

  • Flexible nasoendoscopy to determine sinonasal anatomy and cause
  • Skin prick testing and blood sampling to identify offending allergens
  • X-ray and CT scans to determine extent, complications and guide surgery

Treatments available:

Avoidance of the offending allergen tested positive reduces the need for over-dependence on medication.

  • Medication (oral antihistamines and nasal steroid sprays)
  • Immunotherapy in oral sublingual drops or injectable forms
  • Functional endoscopic sinus surgery (FESS) guided by image guidance CT scan protocol allows for precise and safer removal of diseased polyps, bone septations and mucopus/ fungal balls

 

C.  Large inferior turbinates, deviated nose bone

Photo 30 Deviated nasal septumCause:

Inferior turbinates can be chronically hypertrophied from inflammation, allergic rhinitis or are structurally predisposed. The nose bone in the centre can be crooked from birth, a normal growth variation, or due to trauma.

Importance:

These block the breathing and also predisposes to rhinosinusitis.

Investigations offered:

Examination under good headlight with nasal speculum. Flexible nasoendoscopy for more detailed and posterior nose examination.

Treatments offered:

  • Allergy avoidance and medications, nasal steroid sprays and decongestants
  • Radiofrequency of inferior turbinates
  • Reduction of the inferior turbinates via partial turbinectomy or turbinoplasty.
  • Septoplasty to correct the crooked nose bone

 

D.  Tumors of the nose/ Nose cancer

Photo 31 AngiofibromaCause:

Tumors can be non-cancerous like polyps, inverted papilloma, angiofibroma. Some tumors are cancerous, located in the nose, sinuses or further back in the nasopharynx. The first presentation of angiofibromas are usually nose bleeds in teenage males.

Importance:

Even non-cancerous tumors can erode important surrounding structures, and affect the eye, teeth and cause bleeding or block breathing. Cancerous tumors benefit from early detection and treatment. Nasopharyngeal carcinoma is the 6th most common cancer in Singapore.

Investigations offered:

  • Examination under good headlight with speculum and flexible nasoendoscopy
  • Blood tests for screening for nose cancer
  • Biopsy of the tumor
  • Radiology examinations to determine extent and spread of tumor

Treatment offered: Depending on the histology, local excision via endoscopic method or open excision may be needed. Nowadays, Image Guided Systems (IGS) for endoscopic surgery offers increased safety and completeness of tumor clearance. For cancerous tumors, chemotherapy and radiotherapy referrals may be additionally needed.