Rhinology

• The olfactory epithelium is made up of four cell types:

1.       Olfactory receptor

2.       Sustenticular

3.       Microvillar

4.       Basal cells

• Taste refers to the sensations (sweet, sour, salty, bitter) arising from the taste receptors. Smell refers to the sensations arising from the olfactory receptors. There are many different smell qualities for which no satisfactory classification exists. Flavor is the combined sensation of taste, smell, temperature, texture, and pungency. Of these, smell has the largest input. It is estimated that about 80% of flavor comes from smell.

·         MEATUS --STRUCTURES OPENING

(1)    SPHENO-ETHMOIDAL RECESS=Opening of SPHENOID sinus

(2)    SUPERIOR MEATUS=POST.ETHMOIDAL air sinuses

(3)    MIDDLE MEATUS

·         =(a) BULLA ETHMOIDALIS

·         =(b) HIATUS SEMILUNARIS

·         =(c) INFUNDIBULUM

·         =(d) Opening of FRONTAL air sinuses

·         =(e) Opening of MAXILLARY air sinuses

·         =(f) Opening of ANTERIOR ETHMOIDAL air sinuses

·         =(g) Opening of MIDDLE ETHMOIDAL air sinuses

(4)    INFERIOR MEATUS=Opening of NASOLACRIMAL DUCT ( gauded by Hasner's valve/lacrimal fold)

·         "EPISTAXIS---most common site--AnteroInferior Part of the Nasl Septum ,this is also called as ' LITTLE'S AREA ' ,in Ederly pt.--commonest cause-HTN.,Rx give NTG to decrease B.P., Recurrent epistaxis in a 15 yrs.female--most common cause-Hematopoietic disorder, Epistaxis in a 5 yrs. old Boy is due to Bleeding Disorder, Recurrent Epistaxis=causes--DNS, Atrophic Rhinitis, Maxillary Ca.,"

·         "MIDDLE MEATUS OF NOSE---Frontal air cells,Ant. Ethmoide, Maxillary sinus opens in it, BULLA-ETHMOIDALIS, HIATUS SEMILUNARIS are seen, "

·         "NASAL POLYP---ANTROCHOANAL P.---& POLYPECTOMY-intranasal & ext.approach--arises from maxillary sinus, single & unilateral,"

·         "ATROPHIC RHINITIS---Sx young operation done., ozaena is seen, anosmia, alkaline douche sol'n=NaCl, Na-borate, NaHCo3"

·         "LITTLE'S AREA--- arterial supply= Ant.Ethmoidal art., Septal branch of facial art., Nasal branch of Sphenopalatine art., it is the commonest Bleeding site of nose / EPISTAXIS, or KIESSELBACH'S PLEXUS---Bleeding Area of nose is situated in the AnteroInferior surface of septum/medial wall of nasal cavity ,” ----------------((6))

·         "NASAL CAVITY---Function--Warming, Moistening, Filtration, NASAL SEPTUM---is formed by Vomer bone, Perpendicular bone of Ethmoid, Rostrum of Sphenoid, APPLE-JELLY NODULES on nasal septum--is due to Lupus Vulgaris, NASAL CARTILAGE-- 3 Paired & 1 Unpaired cartilages, NASAL MUCOSA---supplied by mainly Ext.Carotid artery,"-----------((5))

·         "RHINOSPORODIOSIS---russel bodies seen, Rx- Dapson, fungal infec.,max.in Tamil nadu, Rx excision with cautery at base,"-----------((5))

·         "DNS / DEVIATED NASAL SEPTUM ---sharp DNS--Epitaxis, SPUR, recurrent sinusitis, Newborn with DNS= 20%, inf.tubinate hypertrophy, COTTEL'S TEST--patency of nares in DNS,"------------((5))

·         "FRONTAL SINUS--F.S. develops from ant. Ethmoidal cells, PNEUMATOCELE--fracture of F.S., not present at birth, FRONTAL MUCOCELE--"-----------((5))

·         "SEPTAL PERFORATION---of Cartilagenous nasal septum--septal abscess,leprosy ( ant. Septal perf.), Bony septal perforation--syphilis, Mucosa; inv. With nasal septum perforation in jaws-is-known as GANGOSA, "--------((4))

·         "MAXILLARY SINUSITIS---commonest / chronic sinusitis in children,"---------((4))

·         "RHINOSCLEROSIS / RHINOSCLEROMA--- bacilli infec., Mickulitz & Russel bodies seen,"-------------((3))

·         "ETHMOIDAL SINUS--First sinus to appear after Birth, ETH.S. Adenocarcinoma--seen in WOOD workers & Nickel workers,"--------((3))

·         "MAXILLARY SINUS---maxillary antrum commonest malignancy=sq.cell ca., secondary deposits from M.S.-->submandibular L.N.'S,this is present at birth,"----------((3))

·         "SINUSITIS---bloood stainded rhinorrhoea, nasal blockage, facial edema, complication=orbital cellulitis, Sx-proof puncture,"---------((3))

·         Choanal atresia is a component of the CHARGE association:

Coloboma

Heart anomalies

Atresia of the choanae

Retarded growth (may also have renal anomalies)

Genital hypoplasia for males

Ear anomalies and/or hearing loss

• Anterior epistaxis is often associated with Kiesselbach's plexus, whereas the posterior variety is often thought to be linked to the sphenopalatine artery (Woodruff's plexus).

Anterior epistaxis consists of approximately 80% of total cases. Anterior epistaxis generally occurs in children and young adults and is frequently caused by trauma (nose picking!) and drying.

Posterior epistaxis takes up the remaining 20% of total cases. Posterior bleeds occur much more frequently in adults older than 50 years of age. There is a male predominance in adults younger than age 49, and some attribute this to the protective effects of estrogen in females.

·         Five percent to 15% of posterior bleeds eventually progress to surgical intervention. The current literature favors endoscopic sphenopalatine artery ligation (ESPAL). This procedure uses 0° and 30° rigid telescopes. The surrounding mucosa is injected with 1% lidocaine with 1:100,000 epinephrine. The middle turbinate is gently pushed medially; a vertical incision is made in the lateral mucosa over the palatine bone behind the posterior fontanel. The mucosal flap is reflected posteriorly, and the terminal branches of the sphenopalatine artery are coagulated using monopolar diathermy.

·         Anterior ethmoid artery ligation can be combined with ESPAL if it is thought that the bleed is more anterior. Posterior ethmoid artery ligation, if indicated by an uncontrolled high posterior bleeder, must be performed carefully due to the proximity of this artery to the optic nerve.

• Osler-Weber-Rendu disease, or hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant disorder that occurs in all races with a frequency of 1-2/100,000. The incidence in Vermont is one in 16,500, likely due to a founder effect.

A number of patients with HHT present with no family history of the disease due to "skipped generations," a phenomenon termed ATAVISM.

The nasal mucosa is the most common site for the telangiectasia, followed by the tongue, palate, lips, buccal area, gum, pharynx, and conjunctivae. Epistaxis occurs in 93% of patients, with a mean onset age of 12 years and a mean frequency of 18 bleeding episodes/month.

Treatment consists of embolization, laser photocoagulation, septodermoplasty, microvascular free flap, regional facial cutaneous flap, and a modified Young's procedure (surgical closure of nostrils).

• Concha bullosa refers to the pneumatization of the middle turbinate. Approximately 30% of persons have concha bullosa.

• Agger nasi cells are the most anterior of the anterior ethmoid cells. These cells are located at the agger ridge, just anterior to the anterosuperior attachment of the middle turbinate. They are in close proximity to the frontal recess. The surgeon often opens the agger nasi cells during endoscopic sinus surgery to get a better view of the nasofrontal duct. They also can occasionally obstruct outflow from the frontal sinus.

• Haller cells are ethmoid cells that have extended into the maxillary sinus and are adherent to the roof of the maxillary sinus in the region of the maxillary sinus ostium. Haller cells occur in 10% of the population. They can be asymptomatic or can have a negative influence on maxillary sinus ventilation and drainage, leading to recurrent or chronic sinusitis.

• Onodi cells are posterior ethmoid cells that extend posteriorly, either laterally or superiorly, along the sphenoid sinus. The optic nerve can lie within an Onodi cell. These cells should be recognized prior to endoscopic sinus surgery to avoid injury to the optic nerve on posterior dissection of the ethmoids.

• The muscle with the longest name is the levator labii superioris alaeque nasi, which attaches to the nose. It provides minimal depressor activity to the lateral nasal lobule, along with elevator motor action to the lateral corner of the mouth.

• The vomeronasal organ (VNO), or organ of Jacobson, is an accessory concentration of olfactory tissue. In animals, the VNO primarily functions in mating behavior. Thought to be vestigial in humans, its existence in adults has been described recently. Located in a 1- to 3-mm tubule with an oval orifice, this structure is approximately 1 cm posterior from the caudal septum and 2-4 mm off the floor of the nose. Its pale yellowish mucosa distinguishes it from the surrounding pinkish respiratory mucosa. An electrovomerogram has recently been recorded from the vomeronasal region in response to specific odorants.

• Rhinometry, a measurement of nasal airflow, would seemingly provide an inverse measurement of obstruction.

• Bernhard Rudolf Konrad Von Langenbeck (1810-1887) is generally regarded as the "Father of Septal Surgery" because he described a method of shaving down acute spurs and angulations of the nasal septum. Most of these early procedures exchanged a septal deflection for a septal perforation, however.

• Polychondritis is characterized by inflammation of cartilage and its subsequent destruction. It is often associated with Hashimoto's thyroiditis, Sjögren's syndrome, scleroderma, and collagen III antibodies. Otolaryngologic manifestations are common, with 70-80% of cases exhibiting septal involvement. It commonly presents as rhinitis and epistaxis with progression to saddle-nose deformity. For diagnosis, patients must meet three of the following six criteria:

1.       Bilateral, recurrent ear chondritis

2.       Noneroding polyarthritis

3.       Nasal chondritis

4.       Ocular inflammation

5.       Laryngotracheal chondritis

6.       Cochlear or vestibular lesions

·         Rhinitis medicamentosa is the medical name for "hooked-on-Afrin nose." It is a cycle of dependence on over-the-counter nasal decongestant sprays such as Afrin (oxymetazoline).

·         Ohngren's line is an imaginary line extending from the medial canthus of the eye to the angle of the mandible (Figure 34-1). Tumors above the line have a poorer prognosis because of their tendency to metastasize superiorly and posteriorly. Tumors below the line are more easily resected and carry a better prognosis.