Presentation on

Causes of Nasal
Obstruction &
Management
Prepared by; of DNS
Muhammad Muzammil
Sangani
Muhammad Ali Yousuf
Sajjad Hussain Bhatti
Student of Final Year MBBS
 Anatomy and
Physiology of
nose
By: Muhammad Muzammil
Sangani
ANATOMY OF NOSE:
Nose is primarily for breathing and
Olfaction , design of it’s cavity results warming
and moisturing the inspired air & cleaning it
also.
Ext.nose.
 Nose broadly divided into
Nasal cavity
Right half
 Nasal cavity subdivided into
Left half
[By nasal septum]
 EXTERNAL NOSE

It projects forwards and

Downwards from the face.
Shape: Pyramidal shape.

PARTS:
 ROOT: Projects forwards from the upper
end which continues with forehead.
 BASE: Lower part consisting two
nostrils.
 DORSUM: Sides of nose meet anteriorly
to form it.
Upper part- bridge
Dorsum
Lower part-tip

 ALA: It is lower flaccid part of side of nose.

SUPPORTING FRAMEWORK:
Supporting framework of the nose is cartilages
And bones.

Cartilages [hyaline]

Bones [nasal pair bones]

 BONES:
1. NASAL BONES
-Upper part of external nose supported by
it.
-It articulating posteriorly with maxilla &
Above with frontal bone & inferiorly
Overlap with lateral cartilages.
2. FRONTAL PROCESS OF MAXILLAE
 CARTILAGES

1. Lateral cartilages Major

2. Alar cartilage
Minor
3. Septal cartilage.
SKIN OF EXTERNAL NOSE
Thinnest at upper part.
Thickest at lower part containing abundant of
sebaceous glands.

MUSCLES OF EXTERNAL NOSE

1. Procerus.
2. Depressor septii.
3. Nasalis.
FACIAL EXPRESSIONS
Procerus-frowning,
Depressor septii-anger
Nasalis-sadness.
 BLOOD SUPPLY

1. Dorsal nasal artery- branch of ophthalmic artery.

2. External nasal-branch of anterior ethmoidal.
3. Lateral nasal
4. Superior labial artery -branches of facial artery.
NERVE SUPPLY
1. External nasal nerve-branch of anterior ethmiodal.
2. Infratrochlear branch of nasociliary nerve.
3. Nasal branch of infra orbital nerve.
NASAL CAVITY
Broader below & narrowed at top.
Shape: Pyriform shape.
EXTENSION
Extends anteriorly anterior naris[nostrils] &
posteriorly posterior nasal aperture [choana]
CHOANA
-Which lies between vomer &
Medial pterygoid plate of sphenoid
COMMUNICATION
-Anteriorly communicates with environment.
-Posteriorly communicates with nasopharynx.
DIVISION
Nasal cavity subdivided into right & left half by
nasal septum.
Each half has
 Roof.
 Floor.
 Medial wall- septum.
 Lateral wall.
ROOF
Length-7 cm, Width-2cm.
-It slopes downwards both in front & behind.
-Anterior slope formed by nasal part of frontal
Bone & nasal bone.

-Posterior slope formed by body of sphenoid.

-Middle horizontal slope formed by cribriform
Plate of ethmoid.
FLOOR
Length-5cm, Width-1.5cm.
-Which forms the roof of oral cavity & floor
of
nasal cavity.
-Which is formed by horizontal plate of
palatine
bone & palatine process of maxilla.
-It concaves from side to side.
MEDIAL WALL OR NASAL SEPTUM
It is divided into three parts.
Bone
Cartilage
Cuticular part.

It articulates above with sphenoidal body

BONY PART

1. Vomer.
Forms posterior border of septum

2. Perpendicular plate of ethmoid bone.

It articulates with vomer superiorly.
 CARTILAGE

a) Septal cartilage
Unossified part of ethmoid perpendicular plate forms
the anterosuperior part of septum

b) Septal process of inferior nasal cartilage.

 CUTICULAR PART
Formed by fibro fatty tissue covered by skin
Lower margin of septum is called the columella
It has four borders
Superior
Inferior
Anterior
Posterior
It has two surfaces right and left
Nasal Septal Blood Supply
 LATERAL WALL
It is mainly formed by maxilla
It separates the nose
From orbit above (Intervening with ethmoidal air
sinuses)
From maxillary sinus below
From lacrimal groove and naso lacrimal canal infront
PARTS
It has three parts:-
Vestibule
Atrium of middle meatus
Chonchae-Space seperating chonchae called meatus
VESTIBULE
Small depresed area in anterior part
It is lined by modified skin containing short,
stiff, curved hairs called VIBRISSAE
ATRIUM
Atrium bounded above and anteriorly by a ridge
called agger nasi (contains few ethmoidal cells)
Lateral wall of nose is made up of bone cartilage
and soft tissue
Choncae or Turbinates
Inferior Turbinate:
 An inferior infolding of
the lateral nasal wall.

60 mm in anterior to
posterior direction.
 Forms an important
component of the
nasal valve.
Middle Turbinate
 Lies medial to the
anterior ethmoid air
cells, the maxillary
sinus ostium, the
nasofrontal duct, and
the uncinate process.

Length of 40 mm and
mean height of 14.5
mm anteriorly and 7
mm posteriorly.
Superior Turbinate
 Meatus drains the
posterior ethmoid air
cells.
 Histology
Three layers of
Turbinates

Medial thin mucosa

Bone
 Lateral thick mucosa

From:   Berger: Laryngoscope,

Volume 111(12).December
2000.2100-2105
 Histology
Mucosa

Pseudostratified columnar ciliated respiratory
epithelium
 Goblet cells produce salts, glycoproteins,
polysaccharides, lysozymes.

Complex array of arteries, veins, and venous
sinusoids.
 Lamina Propria contains the above tissue.
 Meatus
Inferior Meatus:

It runs along the whole length of the lateral wall

Nasolacrimal duct opens in its anterior part
 Middle Meatus:

It runs posterior half of lateral wall.

In the middle meatus is a rounded bulge called bulla ethmoidalis
which is due to middle ethmoidal air cell which opens on or above
it.
Below and in front of the bulla is a gap called hiatus semilunaris
Which leads into a funnel shape space called ethmoidal
infundibulum
Frontal and Anterior ethmoidal sinuses open into the infundibulum.
Maxillary sinus open into the posterior part of infundibulum
Superior Meatus:

It is limited to posterior third of lateral wall

Posterior ethmoidal sinuses open into it

Sphenoethmoidal recess
It lies above the superior turbinate and receives
the opening of the sphenoid sinus
Nerve Supply of nose
Physiology of
Nose
Function of the Nose
The only externally visible part of the respiratory
system that functions by:
Providing an airway for respiration
Moistening and warming the entering air
Filtering inspired air and cleaning it of foreign
matter
Serving as a resonating chamber for speech
Housing the olfactory receptors
Respiratory mucosa
Lines the balance of the nasal cavity
Glands secrete mucus containing lysozyme and
defensins to help destroy bacteria
Inspired air is:
Humidified by the high water content in the nasal
cavity
Warmed by rich plexuses of capillaries
Ciliated mucosal cells remove contaminated mucus
Superior, medial, and inferior conchae:
Protrude medially from the lateral walls
Increase mucosal area
Enhance air turbulence and help filter air
Sensitive mucosa triggers sneezing when stimulated
by irritating particles
During inhalation the conchae and nasal
mucosa:
Filter, heat, and moisten air
During exhalation these structures:
Reclaim heat and moisture
Minimize heat and moisture loss
Sinuses in bones that surround the nasal
cavity
Sinuses lighten the skull and help to warm and
moisten the air
Olfactory Function of nose
REASONS FOR OLFACTION
SAFETY
 ASSESS QUALITY
OF AIR
AVOID DANGEROUS
ENVIROMENTS
AVOID DANGEROUS
FOODS

PLEASURE

DETERMINES
FLAVOUR OF FOOD
AND BEVERAGES
 OTHER AESTHETICS
 INTRANASAL
CHEMOSENSATION
CN I (OLFACTORY)
 Mediates “smell”—provides flavour
 Aggregate of 40 nerve bundles that
course from olfactory epithelium
through cribiform plate to brain
 Large number of receptor cells
CN V (TRIGEMINAL)

Dispersed throughout nasal mucosa
 Mediate:
chemical and non chemical
stimuli
Somatosensory sensations
(irritation, burning, cooling,
tickling)
 Induces reflexes (e.g. mucous
secretion, inhalation cessation) to
prevent /minimize injury to
nose/lungs
THE OLFACTORY NERVE

Neuroepithelium is located on the cribiform plate, superior

septum and superior and middle turbinates
 THE OLFACTORY NERVE
Neuroepithelium:
•Pseudostratified columnar

epithelium
•Comprised of 6 different cell types

including the receptor cell (Bipolar

Cell)
First cell (Bipolar cell):
•Bipolar receptor cell

•Projects from nasal cavity into brain

without an intervening synapse

•Cilia have transmembrane receptors

that interact with odorant ligands

•Provides major rout of viral, fungal

and bacterial invasion into CNS

http://www.leffingwell.com/olf2.gif
•1000 types of receptors are present

within the epithelium

•Synapses with dendrites of second

order neurons within a glomerulus

Glomerulus
Decreased number with age
Location of synapse between
bipolar cells and second order
neurons (mitral and tufted cells)
Olfactory bulb Olfactory tract
olfactory cortex (primary and
secondary)
 OLFACTORY CORTEX—JUST
REMEMBER THAT IT’S COMPLEX

http://www.nature.com/nature/journal/v444/n7117/images/nature05405-f2.2.jpg
 OLFACTION
Definition:

Sense of smell
Other terminology:
 Anosmia: loss of sense of smell

Hyposmia: reduced sense of smell
 Dysosmia: olfactory distortion
 Presbyosmia: olfactory loss, sensorineural in
nature, related to aging
 CAUSES OF OLFACTORY
LOSS
CONDUCTIVE
 Airflow to olfactory
receptor cells is blocked
 Usually treatable
SENSORINEURAL
 Damage to olfactory
receptors or to central
neural structures
 Usually untreatable
MIXED
 Combination of
conductive and
http://upload.wikimedia.org/wikipedia/commons/3/3a/Head_olfactory_n sensorineural
erve.jpg
Thanks for today….now answer this question!!s
Causes of Nasal
Obstruction
By:
Muhammad Ali Yousuf
 Nasal Obstruction
Definition: Obstruction to the nasal airway. It
may be:

Bilateral, unilateral, or position-

dependent.
Partial or complete.
Continuous or intermittent.
Acute, chronic or recurrent
Nasal obstruction may be:

1. Structural : due to an obstructing lesion ,e.g.,

adenoids or deviated nasal septum.
2. Mucosal: due to mucosal swelling and
congestion, e.g. acute rhinitis and allergy.
3. Mixed: due to a mucosal disease that caused
an obstructive lesion, e.g., rhinitis
complicated by polyps or hypertrophied
turbinates.
 Causes:
Almost all nasal diseases may cause nasal
obstruction.
Common cold is the commonest cause of
nasal obstruction.
Allergy is the second common cause of nasal
obstruction in general, and the commonest
cause of chronic or recurrent nasal obstruction.
Common causes of chronic nasal
obstruction in children are : allergy
,rhinosinusitis, and adenoids.
Causes (Cont’d):

I. Causes in Nose.
II. Causes in the Sinuses.
III. Causes in the Nasopharynx.
Causes (Cont’d):
A- Causes in the Nose:

1. Congenital choanal atresia.

2. Trauma, e.g. septal hematoma, foreign bodies, irritant

fumes.

3.Rhinitis:

i. Acute, e.g. common cold (commonest cause)

ii. Chronic:
a. Non-specific: hypertrophic, atrophic (primary or
secondary).
b. Specific (granulomata), e.g. scleroma
Causes (Cont’d):
5. Nasal Polyps.
6. Deviated nasal septum.
7. Nasal allergy and vasomotor rhinitis.

8. Tumors: e.g. inverted papilloma or carcinoma.

B. Causes in the Sinuses:

1. Acute rhinosinusitis.
2. Chronic rhinosinusitis.
3. Tumors
Causes (Cont’d):
C- Causes in the Nasopharynx:

1. Adenoids (Children).
2. Nasopharyngeal angiofibroma (young adult males).

3. Nasopharyngeal carcinoma (old males).

 Causes of chronic nasal obstruction:
1. Adenoids (in children).
2. Allergic and vasomotor rhinitis.
3. Chronic rhinitis.
4. Chronic rhinosinusitis.
5. Hypertrophied inferior turbinate.
6. Deviated septum.
7. Nasal Polyps.
8. Tumors.
Causes of Unilateral Nasal Obstruction:
1. Unilateral congenital choanal atresia.
2. Trauma, e.g. foreign bodies and fractures.
3. Deviated septum.
4. Antrochoanal polyp.
5. Dental maxillary sinusitis.
6. Tumors.
 Causes

Congenital - choanal atresia

- repaired cleft palate

- tumours
 Causes

Acquired - trauma
(without discharge) - polyps
- neoplasms
 Causes
Acquired - mucosal inflammation
(with discharge) - viral
- bacterial
- chemical
- allergy
- foreign body
(unilateral, foul-smelling)
 Causes

Congenital - choanal atresia

(uni- or bilateral, soft-tissue or bony)

~ presents at birth
~ bilateral is problem as
neonate is obligate nose breather
~ airway must be provided
as emergency
 Causes

Congenital - repaired cleft palate

~ before repair - “common” airway
~ after repaired maxillary crest may
occlude nose
~ provide oral airway

~ surgical correction
 Causes

Congenital - tumours

~ meningo-encephalocoele
!! biopsies in nose !!
~ nasal glioma
 Causes

Acquired - trauma
(without discharge)
 Nasal trauma

May be part of more extensive injury to

face,
skull, skull-base, neck and chest.
 Causes

Acquired - trauma
(without discharge) ~ deviated septum
- unilateral
 Deviated septum
Developmental as well as
Traumatic

The convexity of the septum is usually to

the obstructed side while the concave side
often has enlarged (compensatory) inferior
and middle turbinates.
 Septal deviations
A truly straight septum is rare -
deviations, deflections and spurs occur
and, if severe, can cause obstruction.

Perceptions of “abnormality” are

subjective as some patients with
minimal loss of airflow complain while
complete obstruction is often an
incidental finding in others.
Septal deviation
 Symptoms
Usually unilateral

Obstruction - convex side - septum

itself
- concave side - turbinate

Facial pain / - enlarged turbinate

sinusitis
 Clinical appearance
External appearance of the nose gives
idea of symmetry.

Inspection (anterior & posterior

rhinoscopy)
- deflection(s)
- caudal dislocation
- spur(s)
- compensatory turbinate
enlargement
External deformity
 Treatment
Depends on degree of symptoms / discomfort

Is surgery is indicated, choice is between

septoplasty and submucosal resection

Aim is to straighten or remove the deviated

section and reposition it in the midline, while
retaining adequate support of the nasal dorsum

Turbinates may be trimmed or realigned

 Causes

Acquired - trauma
(without discharge)
~ septal haematoma
- bilateral

Surgical correction – haematoma as emergency

Septal haematoma
 Management
Septal haematoma
(collection of blood beneath
mucoperichondrium causing
bilateral complete obstruction)

- aspirate if small
- usually incise and drain with a “quilt”
suture to prevent re-collection
- appropriate antibiotic cover
 Management

If septal haematoma is missed or not

treated adequately, septal abscess may
follow and result in cartilage necrosis and
“saddle” deformity
Saddle deformity
 Causes

Acquired - nasal polyps

(without discharge)  represent edematous
glistening masses in
the nasal and
paranasal cavities

mostly originating from
the mucosal linings of
the sinuses and
prolapsing into the
nasal cavities.
 Causes

Acquired - neoplasms
(without discharge)

- inverted papilloma
- juvenile angiofibroma
- malignancies

Surgical excision
 Causes

Acquired - Post Nasal Space

masses
(without discharge)
~ adenoids (commonest in children)
~ carcinoma / lymphoma
~ angiofibroma

Surgical removal
 Causes
Acquired - mucosal inflammation
(with discharge) - viral
~ clear rhinorrhoea
~ chills, fever
- bacterial
~ purulent rhinorrhoea

Symptomatic + antibiotics if indicated

 Symptomatic treatment
Decongestants - systemic - pseudo-ephedrine

- antihistamine
- topical
Antipyretics
Antibiotics - 2º bacterial infection
? always in children from lower socio-economic groups
Steam inhalations
 Causes

Acquired - mucosal
inflammation
(with discharge) - chemical
~ nose drops
(rhinitis medicamentosa)
- inflamed mucosa
- clear rhinorrhoea
 Causes

Acquired - mucosal inflammation

(with discharge) - allergy
~ atopy history
~ seasonal or perennial
~ obstruction, rhinorrhoea, itching

Allergen avoidance ± antihistamines ± topical nasal

steroids
 Causes

Acquired - mucosal inflammation

(with discharge)
- foreign body
~ unilateral, foul-smelling
rhinorrhoea in a child is a
foreign body until disproven.

Visualise and remove ± local anaesthetic

Conclusion – common sense
Identify cause

Remove cause

Treat any underlying / residual problems

Reassurance
Thank you