Nose / Sinus/ Allergy

A. Epistaxis

Causes

Nasal causes are usually picking of the nose, especially with allergic rhinitis. It can be due to foreign body, polyp, tumor, nose bone deviation or trauma. Systemic causes include blood disorders and certain drugs.(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 pediatric sized nasoendoscopy after local anaesthetic nose spray. Blood tests to exclude systemic causes.

Treatment offered:

  • Proper local pressure on the anterior nose is taught
  • Topical silver nitrate cautery or diathermy to seal the small bleeding capillaries
  • Nasal packing with Merocel, ribbon gauze or nasal balloon for severe bleeds
  • Selective endoscopic arterial ligation/ embolisation of supplying blood vessels
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, ear and throat itch, skin eczema or asthma. It can be due to inhalant airborne allergens, or food allergies. Food allergy is more common than airborne allergy in those below 3 to 4 years of age. (Read More: More Than a Tickle); (Read More: Beyond A Snort and Sniffle); (Read More: Is This A Cold, Flu, Allergy Or Sinusitis)

Rhinosinusitis can result from acute or chronic nose passages inflammation, infection, polyps, anatomical nose and sinus structure abnormalities. It is worsened by unmanaged allergies. Less frequently, polyps of the nose are possible even in children, with increased risk in cystic fibrosis or immune-compromised cases. Untreated allergies increase the risk of sinusitis, chronic cough and asthma. Rhinosinusitis can also be aggravated by immune problems, poor general health, lack of important vitamins or minerals.

Photo 28 SinusitisImportance:

Allergy and rhinosinusitis cause discomfort and obstruct breathing, disturbing sleep. Rhinosinusitis may require long term medications and antibiotics, with complication risks to eye, brain and teeth, especially in immunocompromised patients. A child with eye swelling associated with rhinosinusitis needs to be examined emergently, to exclude orbital abscesses from the sinusitis.

Investigations offered:

Flexible nasoendoscopy tailored to age of patient to determine sinonasal anatomy and cause. Skin prick testing or RAST blood sampling to identify offending allergens. Food diary to better guide allergy testing. X-ray and CT scans to determine extent of disease and anatomy. Blood tests to identify systemic disorders or mineral deficiencies. Biopsy to exclude cancer or tumor in polyps

Photo 29 CT Image Guided Functional Endoscopic Sinus SurgeryTreatment available:

  • Avoidance of the offending allergen tested positive reduces the need for over-dependence on medication. Over avoidance of suspected food allergens without testing may impair dietary planning and proper nutrition for growing children.
  • Medication (oral antihistamines, nasal steroid sprays) is usually needed initially and can be tailed down to maintenance or as needed doses longer term.
  • Sublingual drops or oral tablet immunotherapy- 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 in older children.
C. Large inferior turbinates, deviated nose bone

Photo 30 Deviated nasal septumCause:

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

Importance:

These block the breathing, increase snoring and obstructive sleep apnea, and predisposes one to rhinosinusitis.

Investigations offered:

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

Treatment offered:

  • Allergy avoidance and medications, nasal steroid sprays and decongestants
  • Radiofrequency or coblation reduction or partial turbinoplasty of inferior turbinates
  • Septoplasty to correct the crooked nose bone in teenage children
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. Even young children can have tumors like aggressive rhabdomyosarcomas, and 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, but less common in children compared to our adults.

Investigations offered:

  • Examination under good headlight with speculum and flexible nasoendoscopy.
  • Biopsy of the tumor for histopathology in the clinic or under sedation.
  • 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 needed.

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