Acquired Disorders of the Nose

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Chapter 369 Acquired Disorders of the Nose

Joseph Haddad, Jr.

Tumors, septal perforations, and other acquired abnormalities of the nose and paranasal sinuses can manifest with epistaxis. Midface trauma with a nasal or facial fracture may be accompanied by epistaxis. Trauma to the nose can cause a septal hematoma; if treatment is delayed, this can lead to necrosis of septal cartilage and a resultant saddle-nose deformity. Other abnormalities that can cause a change in the shape of the nose and paranasal bones, with obstruction but few other symptoms, include fibro-osseus lesions (ossifying fibroma, fibrous dysplasia, cementifying fibroma) and mucoceles of the paranasal sinuses. These conditions may be suspected on physical examination and confirmed by CT scan and biopsy. Although these are considered benign lesions, they can all greatly change the anatomy of surrounding bony structures and often require surgical intervention for management.

369.1 Foreign Body

Joseph Haddad, Jr.

Etiology

Foreign bodies (food, beads, crayons, small toys, erasers, paper wads, buttons, batteries, beans, stones, pieces of sponge, and other small objects) are often placed in the nose by small children and developmentally delayed children and constitute ≤1% of pediatric emergency department visits. Initial symptoms are unilateral obstruction, sneezing, relatively mild discomfort, and rarely pain. Presenting clinical symptoms include history of insertion of foreign bodies (86%), mucopurulent nasal discharge (24%), foul nasal odor (9%), epistaxis (6%), nasal obstruction (3%), and mouth breathing (2%). Irritation results in mucosal swelling because some foreign bodies are hygroscopic and increase in size as water is absorbed; signs of local obstruction and discomfort can increase with time. The patient might also present with a generalized body odor known as bromhidrosis.

Diagnosis

Unilateral nasal discharge and obstruction should suggest the presence of a foreign body, which can often be seen on examination with a nasal speculum or wide otoscope placed in the nose. Purulent secretions may need to be cleared so that the foreign object can actually be seen; a headlight, suction, and topical decongestants are often needed. The object is usually situated anteriorly, but unskilled attempts at removal can force the object deeper into the nose. A long-standing foreign body can become embedded in granulation tissue or mucosa and appear as a nasal mass. A lateral skull radiograph assists in diagnosis if the foreign body is metallic or radiopaque.

Treatment

A quick examination of the nose is made to determine if a foreign body is present, and whether it needs to be removed emergently. Planning is then made for office or operating room extrication of the foreign body. Prompt removal minimizes the danger of aspiration and local tissue necrosis. This can usually be performed with topical anesthesia, using either forceps or nasal suction. If there is marked swelling, bleeding, or tissue overgrowth, general anesthesia may be needed to remove the object. Infection usually clears promptly after the removal of the object and, generally, no further therapy is necessary.

Complications

Infection often follows and gives rise to a purulent, malodorous, or bloody discharge. Local tissue damage from long-standing foreign body, or alkaline injury from a disk battery, can lead to local tissue loss and cartilage destruction. A synechia or scar band can then form, causing nasal obstruction. Loss of septal mucosa and cartilage can cause a septal perforation. Disk batteries are dangerous when placed in the nose; they leach base, which causes pain and local tissue destruction in a matter of hours.

Tetanus is a rare complication of long-standing nasal foreign bodies in nonimmunized children (Chapter 203). Toxic shock syndrome is also rare, and most commonly occurs from nasal surgical packing (Chapter 174.2); oral antibiotics should be administered when nasal surgical packing is placed.

Prevention

Tempting objects such as round, shiny beads should only be used under adult supervision. Disk batteries should be stored away from the reach of small children.

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