NOSE

Causes of Nasal block?

• Deviated nasal septum with inferior turbinate bone hypertrophy (most common cause)
• Polyps
• Adenoid hypertrophy ,etc

What is nasal septum?

The septum is a structure that separates the nasal cavity into two halves. The nasal septum is composed of bone, cartilage, and membranes

What is deviated nasal septum?

It is displacement of nasal septum to one side presenting with nose block. It has to be corrected by surgery

Surgeries to correct deviated septum include

• Submucous resection(SMR)
• Septoplasty

We tailor make every nasal  surgery is to correct most deviated part of nasal septum ie cartilaginous or bony deviation, leaving behind sufficient structures to support nose. Every patient will have a unique septal framework and distortion, we take utmost care to correct this to near normal framework.

What are inferior turbinates?

The turbinates are structures on the side wall of the inside of the nose. They project into the nasal passages as ridges of tissue. The turbinates help warm and moisturize air as it flows through the nose. Patients come with nasal block when they have enlarged inferior turbinates

Surgeries for enlarged inferior turbinates

• Inferior turbinectomy- removal of inferior turbinates
• Partial inferior turbinectomy – removal of inferior turbinates partially
• Microdebrider assisted submucous resection
• Coblation assisted reduction

We remove part of inferior turbinate using a special instrument called microdebrider. This is done under endoscopic visualization so that inferior turbinate bone is evenly cut and taking pains not to remove excessively. Post reduction of turbinate its posterior end which has bleeders will be cauterized with valley lab spray cautery device. This technique is used in adults as results are mostly permanent.

Above: before surgery image with deviated nasal septum to left and turbinate hypertrophy

Above : post operative images with adequate bilateral nasal airway

Second technique we use is coblation assisted turbinate shrinkage. This is mostly opted for paediatric age group. As the shrinked turbinate can increase its size after months or years. As it’s a non aggressive surgery its opted in children.

Pain after surgery?

Pain will be present but very much bearable as analgesic tablets will be give in post operative period

Nose packing?

Post surgery there will be sponge (merocel) packs kept in nose. They will be removed in 24-48 hours. During this period patient may feel-dryness of throat, excessive watering of eyes, ear blocked sensation or some headache. All symptoms will subside ones packs are removed.

Post-Operative Instructions

1. You may have medicated gauze or sponge (merocel) packs in your nose for 24-48 hours following surgery; this will make breathing through your nose difficult
2. Do not pull at the packing material or the thin suture holding them in place.
3. Some oozing of blood and mucus is expected for 2-3 days after surgery.
4. Do not excessively blow your nose until cleared to do so.
5. Avoid straining with bowel movements.
6. Take all of your routine medications as prescribed, unless told otherwise by your surgeon; any medications which thin the blood should be avoided. These include aspirin and aspirin-like products (Advil, Motrin, Excedrin, Alleve, Celebrex, Naproxyn).
7. There are no diet restrictions, but alcohol consumption is not recommended and tobacco use is prohibited as Nicotine decreases blood flow to the healing nasal tissues and can actually compromise wound healing. Please make sure that you have eaten something the morning of pack removal; low blood sugar may make you feel faint when the packs are removed.
8. No heavy lifting , no bending or stooping to lift, and no vigorous exercise until cleared by surgeon
9. You can expect to have a stuffy nose for about 3-5 days after surgery, with some intermittent congestion for up to 2 weeks depending on a personal history of allergies or other factors. Sense of smell will be diminished during this time,. There may be some tenderness or numbness in your upper teeth. You may express old clot and discolored mucus from your nose for up to 3-4 weeks after surgery, depending on how frequently and how effectively you irrigate your nose with the saltwater spray.
10. Patients can go to office approximately 7 days of rest after surgery. Nasal crest cleaning is performed at post-op weekly visits
11. Post op review visits will be scheduled by your surgeon.
12. Patients should follow post op nasal douching, nasal sprays for duration suggested by your surgeon for quicker clearance of symptoms.

Sinusitis

Sinusitis (sinus infection) is inflammation of the sinuses. Patients will have facial pain, nose block, thick nasal discharge, fever, loss of sense of smell, cough and sore throat. It can be caused by either bacteria or fungus. Bacteria causing rhinosinusitis include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis commonly.

Fungal sinusitis

Fungal sinusitis is the inflammation of the lining mucosa of the paranasal sinuses due to fungal infection. It occurs in people with reduced immunity (ex-diabetes mellitus) The maxillary sinus is the most commonly involved .Fungi responsible for fungal sinusitis are Aspergillus fumigatus (90%), Aspergillus flavus, and Aspergillus niger. Mucormycosis is another type of fugal sinusitis where the disease spreads into blood and other surrounding tissues including eye and brain.

What are nasal polyps?

Nasal polyps are soft, painless, noncancerous growths arising from the lining of your nasal cavity or sinuses. They hang down like teardrops or grapes. They result from chronic inflammation due to asthma, recurring infection, allergies, drug sensitivity or certain immune disorders. Patients usually come with nasal block or loss of sense of smell.

Endoscopic sinus surgery

Functional endoscopic sinus surgery (FESS) is a minimally invasive surgical treatment which uses nasal endoscopy guidance  to enlarge the nasal drainage pathways of the paranasal sinuses to improve sinus ventilation. This procedure is generally used to treat inflammatory and infectious sinus diseases, including chronic rhinosinusitis that doesn’t respond to drugs, nasal polyps, some cancers, etc.

Widening of Sinus ostium, polyps removal are done using  various specialized blades of microdebrider  which are custom made for each sinus. We use xomed microsdebrider  system with m4 hand piece which is one of the best devices in the world. Our endoscopy guidance is via storz spice HD which is currently the latest and best endoscopy system available in ENT.

polyps seen in left side nasal cavity.

Using debrider blade to cut polyps

Post clearence of polyps we can see wide sinus openings for easy drainage and  nasal airway block clearence

Removed polyps from sinus cavity

Above videos are sinus surgery

Sinus Surgery Post-Operative Instructions

1. You may have medicated gauze or sponge packs in your nose for 2-3 days following surgery; this will make breathing through your nose difficult
2. Do not pull at the packing material or the thin suture holding them in place.
3. Some oozing of blood and mucus is expected for 2-3 days after surgery.
4. In case of profuse nasal bleeding, apply ice to the bridge of the nose and pinch the nose just above the tip and hold for 10 minutes; if bleeding continues, contact your surgeon.
5. Do not excessively blow your nose until cleared to do so.
6. Avoid straining with bowel movements.
7. Take all of your routine medications as prescribed, unless told otherwise by your surgeon; any medications which thin the blood should be avoided. These include aspirin and aspirin-like products (Advil, Motrin, Excedrin, Alleve, Celebrex, Naproxyn).
8. There are no diet restrictions, but alcohol consumption is not recommended and tobacco use is prohibited as Nicotine decreases blood flow to the healing nasal tissues and can actually compromise wound healing. Please make sure that you have eaten something the morning of pack removal; low blood sugar may make you feel faint when the packs are removed.
9. No heavy lifting , no bending or stooping to lift, and no vigorous exercise until cleared by surgeon
10. No airplane travel for 2 weeks following sinus surgery; the cabin pressure changes can cause pain and swelling within the sinuses. You may fly sooner after nasal septal surgery alone.
11. You can expect to have a stuffy nose for about 3-5 days after surgery, with some intermittent congestion for up to 2 weeks depending on a personal history of allergies or other factors. Sense of smell will be diminished during this time,. There may be some tenderness or numbness in your upper teeth. You may express old clot and discolored mucus from your nose for up to 3-4 weeks after surgery, depending on how frequently and how effectively you irrigate your nose with the saltwater spray.
12. Signs of a post-operative infection, which may occur within the 6 weeks after surgery, include fever, foul odor in the nose, discolored nasal secretions, facial pain and pressure, and a cough. If any of these signs develop, contact your doctor to discuss treatment.
13. Patients can go to office approximately 7 days of rest after surgery. Sinus cleaning is performed at post-op weekly visits and small tampons or spacers may be removed from the sinus cavities.
14. Post op review visits will be scheduled by your surgeon.
15. Patients should follow post op nasal douching, nasal sprays, antifungal medication for duration suggested by your surgeon to avoid recurrence of disease.

What gives the nose its shape?

The shape of the nose on the outside is due to the shape of bone and cartilage and the overlying skin. The top of the nose is made of bone shaped like a roof, which is hard. The middle and tip of the nose are made of cartilage which is softer. The skin varies in thickness from person to person, and also affects the shape.

Reasons for surgery

Improving the features of the nose and face by cosmetic surgery can also involve improving its function and help with breathing. There is a great deal of variety in human appearance. Nasal shape depends on the bony contours, dimensions of the face, skin colour, thickness and race. Most people have reconciled themselves with their appearance but some are unhappy with it and seek surgery. The most common features people are concerned with are deviations of the nose to one side, a nasal hump, a nasal depression, too wide or too narrow a nose, over or under projection of the soft nasal tip. There is no perfect shape to the nose and any alteration has to fit and suit the rest of the face. It is important that expectations about the effects of surgery are not unrealistic. People who believe that their lives will change if they have cosmetic surgery are often disappointed.

What is rhinoplasty?

Rhinoplasty is an operation to change the shape of the nose. The type of rhinoplasty depends on which particular area of the nose needs correction. The nose can be straightened, made smaller or bigger and bumps may be removed. The shape of the tip of the nose can be changed. Pieces of cartilage or bone may be removed from or added to the nose to change its shape. Sometimes the wall that separates the nose into right and left (nasal septum) is twisted. We may need to correct it at the same time. The combined operation is called septorhinoplasty.

Techniques Rhinoplasty

surgery employs reduction, augmentation or refinement of the patient’s nose to give a balanced and proportioned nose. Reduction rhinoplasty commonly involves the removal of a nasal hump along with re-breaking the nose to reduce the width. The tip of the nose may be asymmetrical, depressed or the nose itself may need building up. Augmentation can be achieved using tissue moved from another part of the patient’s body such as skin or cartilage from the ear or rib. Alternatively synthetic material can be used (gortex, silastic) but there is a greater risk of rejection or infection. Approaches for the surgery can be either through the nostrils (intranasal) or by the use of a small incision on the underside of the nose (external).

How successful is the operation?

Everybody’s nose and face is different, so it may not be possible to make your nose look exactly like your perfect nose. The thickness of the skin is important in how much better the nose will look after rhinoplasty and in what can be done. If the skin is thin, it makes bumps or hollows in the nose difficult to hide. If it is thick not all changes that can be made on the inside will show up on the outside. Your surgeon will aim to produce a nose that looks natural. However, your surgeon may not be able to say exactly how your nose will look after your operation. It is important that you discuss your expectations with your surgeon. 80 % of patients are happy with the results of their operation but some people request more surgery. You may change your mind about the operation at any time, and signing a consent form does not mean that you have to have the operation. If you would like to have a second opinion about the treatment, you can ask your specialist. He or she will not mind arranging this for you. You may wish to ask your own GP to arrange a second opinion with another specialist.

How is the operation done?

Rhinoplasty and septorhinoplasty are usually performed with you asleep. Cuts are made inside your nose. Occasionally a small cut on the skin between the nostrils or at the base of the nostrils may be necessary. The skin of your nose is gently lifted off the bone and cartilage underneath. A hairline fracture may be made in the nasal bones to allow the surgeon to change the shape of the nose. Pieces of bone and cartilage can be removed from or added to the nose to smooth out any bumps or dips.

Packs and splints

We may need to put a dressing in each side of your nose to keep things in place and prevent bleeding. The dressings are called ‘packs’, and they will block your nose up so that you have to breathe through your mouth. We may take them out the morning after your operation. You may get a little bit of bleeding when the packs come out – this will settle quickly. Sometimes we put small pieces of plastic in your nose to prevent scar tissue from forming. These are called ‘splints’ and we will take them out after a week. You will have a temporary splint on the outside of the nose for a week. This should be kept dry.

After the operation

The front of your nose can be a bit tender for a few weeks. Do not blow your nose for about a week, or it might start bleeding. If you are going to sneeze, sneeze with your mouth open to protect your nose. You may get some blood-coloured watery fluid from your nose for the first two weeks or so – this is normal. Your nose will be blocked both sides like a heavy cold for 10-14 days after the operation. We may give you some drops or spray to help this. It may take up to three months for your nose to settle down and for your breathing to be clear again. Try to stay away from dusty or smoky places. There will be some stitches inside your nose – these will dissolve and fall out by themselves. You may have some bruising and swelling around your nose and eyes for one to two weeks. Sleeping upright with extra pillows for a few days helps. Most of the swelling has subsided after two weeks but it may be longer before the skin and soft tissues over the bone and cartilage settle. Fine swelling may take up to a year to settle at which time the final results of surgery may be judged. Following rhinoplasty or septorhinoplasty, the skin of the nose is very sensitive to the sun. It is important to wear strong sunscreen and a hat for at least six months. The nose may feel a little stiff and numb for up to three months, particularly around the tip.

How long will I be off work?

You can expect to go home the day after your operation. Sometimes it is possible to go home the same day. You should rest at home for at least a week. Most people need one to two weeks off work, especially if their work involves heavy lifting or strenuous activity. You should not play sports where there is a risk of your nose being knocked for six weeks. Ask your nurse if you need a sick note for your time in hospital.

What can go wrong?

Sometimes your nose can bleed after the operation, and we may have to put packs into your nose to stop it. This can happen within the first 6 – 8 hours after surgery or up to 5 – 10 days after surgery. Very occasionally patients need to have another general anaesthetic and return to the operating theatre to stop the bleeding. Infection in your nose is rare after this operation but if it happens it can be serious, so you should see a doctor if your nose is getting more and more blocked and sore. Very rarely, you can have some numbness of your teeth, which usually settles with time. Up to 10% of people may have some reservations about the end results and about 5-10% of patients need further operations in the future to further adjust the shape of the nose.

Tear duct or nasolacrimal duct block

Tear glands and tear ducts

When you have a blocked tear duct (Nasolacrimal duct block) , your tears can’t drain normally, leaving you with a watery, irritated eye. The condition is caused by a partial or complete obstruction in the tear drainage system.

A blocked tear duct is common in newborns. The condition usually gets better without any treatment during the first year of life. In adults a blocked tear duct may be due to an injury, an infection or a tumor.

A blocked tear duct is almost always correctable. Treatment depends on the cause of the blockage and the age of the affected person.

Symptoms

Signs and symptoms of a blocked tear duct include:

• Excessive tearing
• Redness of the white part of the eye
• Recurrent eye infection or inflammation (pink eye)
• Painful swelling near the inside corner of the eye
• Crusting of the eyelids
• Mucus or pus discharge from the lids and surface of the eye
• Blurred vision

When to see a doctor

See your doctor if you tear constantly for several days or if your eye is repeatedly or continually infected. A blocked tear duct may be caused by a tumor pressing on the tear drainage system.

Causes: Blocked tear ducts can happen at any age. common Causes include:

• Age-related changes.As you age, the tiny openings that drain tears (puncta) may get narrower, causing blockage.
• Infection or inflammation.Chronic infection or inflammation of your eyes, tear drainage system or nose can cause your tear ducts to become blocked.
• Injury or trauma.An injury to your face can cause bone damage or scarring near the drainage system, disrupting the normal flow of tears through the ducts. Even small particles of dirt or loose skin cells lodged in the duct can cause blockage.

Procedure for correction is Endoscopic dacryocystorhinostomy

Endoscopic dacryocystorhinostomy (DCR) is used to treat patients diagnosed with lacrimal sac or nasolacrimal duct obstruction.

under endoscopy guidance  nasal mucous membrane is incised and removed, to allow for the creation of a window on the lacrimal sac and upper nasolacrimal duct there by clearing block and dirct drainage of nasal secretions into nose.  we may also take help of microdebrider during surgery .Silicone tubes can be inserted to assist long-term patency.

Endoscopic image of peroperative  DCR surgery. white arrow indicates opening made on sac and part of duct so that tears can easily drain into nasal cavity

post operative period care

1. sponge packs (merocel) packs kept during surgery are removed after 2-3 days.
2. weekly visits with us once a week for 2-3 weeks.patient has to be under oral medication and eye drops for this duration.
3. saline nasal douching twice a day till surgeon suggests
4. avoid dust exposure for 2 weeks post surgery.
5. If silicon tubes are interested they will be removed after 15-30 days.

Cerebrospinal Fluid (CSF) Leak

What is a CSF leak?

Cerebro spinal fluid leak results when the fluid around the brain (called cerebro spinal fluid) leaks through a hole through the skull bone. This fluid can either drain from the ear or the nose, depending on where the skull bone is damaged.

What are the symptoms of CSF leak?

Patients typically complain of clear, watery drainage usually from only one side of the nose. Drainage can increase with tilting the head forward or straining. Other symptoms can include headache, vision changes.

CSF leaks can be separated into two groups. Spontaneous leaks occur without any known cause. Traumatic leaks are most commonly related to a history of head injury, surgery, or tumors.

How are CSF leaks diagnosed?

Your doctor will perform a history and physical exam. Often, the doctor will examine the nose with an endoscope. Your physician may also ask you to lean forward for several minutes to see if this increases drainage. If the drainage can be collected, it is often sent for laboratory testing to confirm that it is cerebral spinal fluid. Imaging studies such as CT scans or MRI cisternography may be ordered to evaluate for skull bone defects.

What is the treatment for a CSF leak?

Treatment can be either medical or surgical.

Conservative treatment is usually recommended first in cases of spontaneous CSF leak. This includes 1-2 weeks of bed rest. Patients are encouraged to avoid coughing, sneezing, and heavy lifting. Straining is avoided by taking stool softeners.

Surgical treatment of CSF leaks is used when conservative treatment fails. The approach can be either through endoscopy guidance. During surgery site of leak is identified. It is then freshened and then packed with patients fat and fascia obtained from lateral aspect of thigh most of times. This layer is further supported by surgical glue. After thorough checking of further leakage wound site is supported by surgical sponge(merocel) which will be removed at a later date.

Postoperative care

1. regular hospital visits till suggested by surgeon and regular nasal toileting
2. 1-2 weeks of bed rest. Avoid dust exposure.
3. Patients are encouraged to avoid coughing, sneezing, and heavy lifting.
4. Straining is avoided by taking stool softeners if necessary

Pituitary surgeries

Pituitary tumors can be reached endoscopically from nasal cavity through sphenoid. Pituitary tumors like adenoma, prolactinoma, craniopharyngioma can be removed endoscopically. Advantages with endoscopic removal are complications are less.

Nasal tumour \JNA surgeries

We take help of coblation and microdebrider for clearance of nasal tumours. We do maxillectomy surgeries also for nasal cancers.