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ENT — The Nose: Comprehensive Notes

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1. ANATOMY

External Nose

• Inspected from frontal, profile, and base views for deformity or asymmetry
• Assess: nasal tip projection, dorsal width, alar base width, skin quality and thickness
• Nasolabial angle and height-to-length ratio change with age (tip droops due to weakening of lower lateral cartilage and caudal septum)

Nasal Cavity

Ostiomeatal Complex (OMC)

• Key drainage pathway for the frontal, maxillary, and anterior + middle ethmoid sinuses — all drain via the semilunar hiatus under the middle turbinate
• Posterior ethmoids + sphenoid drain through the sphenoethmoidal recess (under superior turbinate)
• A small lesion at the OMC can obstruct multiple sinuses simultaneously — critical concept for sinusitis pathogenesis

Blood Supply — Kiesselbach's Plexus (Little's Area)

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2. EXAMINATION OF THE NOSE

Anterior Rhinoscopy

• Uses headlamp + nasal speculum (directed laterally — never touch septum with metal edges)
• Assess: septum, inferior turbinate, drainage, polyps, foreign bodies, clots
• Mucosal appearance:
  • Boggy, pale, edematous → allergic rhinitis
  • Erythematous, edematous → sinusitis/infection

Nasal Endoscopy

• Rigid endoscope (0°) passed along nasal floor → visualises septum, inferior turbinate, eustachian tube orifice
• Reintroduced above inferior turbinate → middle turbinate, ostiomeatal complex, nasopharynx
• Accessory maxillary ostia may be visible (often mistaken for true ostium, which lies behind the uncinate process)
• Flexible fiberoptic scope = safer in children/uncooperative patients

Nasopharynx

• Extends from skull base → soft palate
• Inspect: adenoids, eustachian tube orifice, torus tubarius, fossae of Rosenmüller
• Adults should have minimal adenoid tissue; its presence suggests lymphoma or HIV
• All patients with unilateral otitis media → inspect nasopharynx for mass

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3. PARANASAL SINUSES

Anatomy Summary

Anatomic Variants (Clinical Significance)

• Haller cells (infraorbital ethmoid air cells) — can narrow the infundibulum
• Concha bullosa — pneumatized middle turbinate; can obstruct OMC
• Paradoxical middle turbinate — curves medially rather than laterally
• Deviated septum — very common; significant if causing obstruction or OMC narrowing

Imaging

• CT (non-contrast) is the gold standard for sinuses
  • Screening: 5-mm axial slices
  • Pre-operative (FESS): thin-slice coronal + axial + sagittal reconstructions
  • Normal mucosa: not visible on CT
  • Mucosal thickening → chronic sinusitis, polyps, retention cysts
  • Air-fluid level → acute sinusitis, trauma
• MRI: superior for soft tissue characterisation, distinguishing tumour from mucus (different viscosity signals)

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4. NASAL OBSTRUCTION

Causes (Nasal Level)

Nasal Valve

• Internal nasal valve (angle between upper lateral cartilage and septum, ~10–15°) = the narrowest segment of the airway
• Collapse → most common cause of nasal obstruction post-rhinoplasty

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5. EPISTAXIS (NOSEBLEED)

Epidemiology

• Bimodal distribution: peaks in childhood and in elderly
• Higher incidence in winter (dry air desiccates mucosa, cold impairs coagulation)
• Anterior epistaxis: 90% of cases — Kiesselbach's plexus
• Posterior epistaxis: ~10% — more severe, older patients with comorbidities; sphenopalatine artery is most often identified

Risk Factors / Causes

Note: Hypertension is NOT causal, but persistent hypertension is associated with difficulty controlling bleeding.

Assessment

1. Airway, perfusion, haemodynamics first
2. History: timing, frequency, severity, medications (anticoagulants), comorbidities
3. Examine: instruct patient to blow nose → compress cartilaginous nose for 10–15 minutes with 2 sprays of 0.05% oxymetazoline before pressure
4. Floor of nose should be parallel to the room floor for examination
5. Identify source → enables cautery (reduces recurrence)

Management — Step Ladder

Prophylactic antibiotics after nasal packing: common practice for TSS prevention (Staph. aureus), though evidence is limited.

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6. RHINOSINUSITIS

Definition

Classification

Symptoms

• Facial pain/pressure, nasal congestion, mucopurulent nasal discharge, postnasal drip
• Fever (more common in acute bacterial)
• Patients with CRS often relatively asymptomatic — mainly congestion and discharge
• Cough/bronchospasm from postnasal drainage (pulmonary presentation)

Bacteriology

Treatment

• Analgesics, nasal saline, topical intranasal corticosteroids

• Watchful waiting (mild) OR amoxicillin ± clavulanate 5–10 days (first-line)
• Penicillin allergy: doxycycline, levofloxacin, or moxifloxacin

• Observation 72 hours if non-severe
• Amoxicillin ± clavulanate ≥10 days for severe/worsening/failing
• Penicillin allergy (non-severe): cefdinir, cefuroxime, or cefpodoxime

• Longer-duration antibiotics, nasal saline irrigation, intranasal steroids
• Polymicrobial biofilms → may need surgery (FESS) + antibiotic irrigations
• Do NOT use topical or systemic antifungals routinely in CRS without invasive fungal infection

Complications of Sinusitis

• Orbital complications (from ethmoid sinusitis): preseptal cellulitis → orbital cellulitis → subperiosteal abscess → orbital abscess
• Cavernous sinus thrombosis (from sphenoid/ethmoid sinusitis): high morbidity
• Intracranial extension: meningitis, epidural/subdural/brain abscess

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7. NASAL POLYPS

Characteristics

• Benign pedunculated outgrowths of nasal mucosa
• Pale, translucent, insensate (distinguish from turbinates which are pink and tender)
• More common with advancing age; associated with CRS, asthma, aspirin sensitivity (Samter's triad), cystic fibrosis, allergic rhinitis

Special Type: Antrochoanal Polyp

• Originates from maxillary sinus mucosa, prolapse through ostium into nasal cavity → choana → nasopharynx
• Usually unilateral; commoner in children/young adults
• Treatment: complete surgical excision (FESS)

Differential of Nasal Mass

• Nasal polyp (benign)
• Inverting papilloma (benign but locally aggressive; risk of malignant transformation)
• Angiofibroma (adolescent males — highly vascular)
• Esthesioneuroblastoma (olfactory neuroblastoma)
• SCC, adenocarcinoma, adenoid cystic carcinoma
• Lymphoma
• Meningoencephalocele (pulsatile, compressible — do NOT biopsy)

Imaging for Nasal Masses

• Coronal CECT or coronal/sagittal MRI to assess extent within nasal cavity, adjacent sinuses, orbits, cribriform plate
• "Cascading polyps" appearance on contrast CT
• MRI distinguishes tumour from different viscosity mucus — key for staging

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8. DEVIATED NASAL SEPTUM

Anatomy

• Septum = quadrangular cartilage (anterior) + perpendicular plate of ethmoid (superior bony) + vomer (inferior bony)
• Caudal deviation: detected by palpation with gloved fingers anteriorly; most symptomatic type
• Bony spurs: at junction of cartilaginous and bony septum

Clinical Features

• Unilateral or bilateral nasal obstruction
• Predisposes to recurrent sinusitis (OMC narrowing), snoring, sleep-disordered breathing

Treatment

• Septoplasty: surgical correction of the septal cartilage/bone; often combined with turbinate reduction
• Combined with rhinoplasty = septorhinoplasty

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9. OLFACTORY DYSFUNCTION

Physiology

• Olfactory neurons in the olfactory epithelium (roof of nasal cavity, cribriform plate) → CN I fibres → olfactory bulb
• Smell typically peaks in 3rd–4th decade, declines from 5th decade
• Higher rates of decline in men than women

Causes of Anosmia/Hyposmia

Clinical pearl: Olfactory dysfunction can be a screening marker for early Parkinson's disease — often present years before motor signs.

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10. AGING NOSE

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11. SINONASAL MALIGNANCIES

Warning Signs of Nasal Malignancy

• Unilateral nasal obstruction (progressive)
• Blood-stained unilateral discharge
• Facial swelling or pain
• Proptosis (orbital invasion)
• Loosening of teeth, trismus (palate/pterygoid invasion)
• Cervical lymphadenopathy

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12. QUICK CLINICAL PEARLS

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1. Anatomy — external nose, nasal cavity, turbinates, ostiomeatal complex, blood supply (Kiesselbach's plexus with diagram)
2. Examination — anterior rhinoscopy, nasal endoscopy, nasopharyngoscopy
3. Paranasal Sinuses — anatomy, drainage pathways, anatomic variants (Haller cells, concha bullosa), CT/MRI imaging
4. Nasal Obstruction — causes at each anatomical level
5. Epistaxis — epidemiology, Kiesselbach's vs sphenopalatine, causes, step-ladder management (pressure → cautery → packing → tranexamic acid → balloon/Foley → embolisation/ligation)
6. Rhinosinusitis — classification, bacteriology by type, treatment guidelines (AAP + adult), complications
7. Nasal Polyps — features, antrochoanal polyp, differential of nasal mass
8. Deviated Septum — anatomy, clinical features, septoplasty
9. Olfactory Dysfunction — causes, Parkinson's connection
10. Aging Nose — structural and functional changes
11. Sinonasal Malignancies — tumour types, warning signs
12. Quick Clinical Pearls table — high-yield exam facts