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.(Read More: First Aid for Nose Bleeds)

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:

  • Proper local pressure on the anterior nose is taught
  • Topical silver nitrate cautery or electrical diathermy is used to seal the small bleeding capillaries
  • Nasal packing with Merocel, Surgicel, ribbon gauze or balloon for severe bleeds
  • Selective endoscopic arterial ligation/ embolization for recurrent and severe bleeds
B.  Allergic rhinitis, sinusitis, polyposis

Photo House Dust Mite Allergic RhinitisCauses:

Allergies of the noseresult in sneezing, itching, runny and block nose. Sometimes there is eye, ear and throat itch. It can be due to inhalant airborne allergens or food allergies. Many adults may develop new allergies even if they were not afflicted previously. Untreated allergies increase the risk of sinusitis, chronic coughand asthma. Rhinosinusitis can result from acute or chronic nose passages inflammation, infection, polyps, anatomical nose and sinus structure abnormalities like deviated nasal septum and narrow sinus passages. Rhinosinusitis can also be aggravated by immune problems, poor general health, lack of important vitamins or minerals. Pregnancy may increase swelling in the nose and sinuses.(Read More: More Than a Tickle); (Read More: Beyond A Snort and Sniffle); (Read More: Is This A Cold, Flu, Allergy Or Sinusitis)

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 RAST sampling to identify offending allergens for airbone and food allergens
  • Blood tests to identify systemic disorders or mineral deficiencies
  • Biopsy to exclude cancer or tumor in polyps
  • X-ray, CT and MRI scans to determine extent, complications and guide surgery

Treatments available:

  • Medication (nasal rinses, topical/ oral antihistamines and decongestants, nasal steroid sprays, antibiotics)
  • Avoidance of the offending allergen tested positive reduces the need for over-dependence on medication.
  • Immunotherapy in new oral tablet, or the usual sublingual drops or injectable forms. This offers a chance for long term cure, desensitizing the body to the allergens, instead of just treating the symptoms arising from the allergen attacking the body.
  • Functional Endoscopic Sinus Surgery (FESS) guided by special image-guidance system (IGS) CT scan protocol, precisely angled microdebriders and endoscopic micro-instruments allows for precise removal of diseased polyps, bone septations. Inflamed mucosa and mucopus/ fungal balls. This can be done without any external incisions, going through the nose. This real-time tracking of the anatomy and precision of instruments reduce risk to the eyes, base of skull, vessels and allow a more complete removal of disease.
  • Balloon Sinuplasty helps in cases where there is very limited sinus disease, and may be of some help to identify sinus openings in complex cases.
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 predisposes to snoring, obstructive sleep apnea (OSA) and 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 or coblation reduction of inferior turbinates
  • Reduction of the inferior turbinates via partial turbinectomy or turbinoplasty.
  • Septoplasty to correct the crooked nose bone
  • Open septorhinoplasty to correct both external and internal crooked nose bone. This allows cosmetic correction of the external appearance of the crooked nose together with functional correction of the internal crooked nose bone. I work together with specialists in plastic nose reconstruction for this.
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, and common in South China and South East Asia. It usually presents with blocked ears, blood stain of the mucus and neck lymph nodes enlargement.

Investigations offered:

  • Examination under good headlight with speculum and flexible nasoendoscopy
  • Blood tests for screening for nose cancer
  • Biopsy of the suspected tumors
  • Radiology CT scan and MRI 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.

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