Anatomy and physiology of the nose
The nose is divided by the piriform aperture into an anterior (facial) component and a posterior nasal cavity. Both components are subdivided into right and left by the nasal septum. The nasal septum is predominantly bony in the posterior cavity and cartilaginous anteriorly. The external nose is covered by skin, subcutaneous tissue and a musculoaponeurotic layer. The upper 40% of the external nose consists of paired nasal bones, which articulate with each other and with the frontal processes of the maxillae and the maxillary processes of the frontal bones. The lower 60% of the external nose is cartilaginous consisting of the paired upper lateral cartilages and lower lateral cartilages.
Posteriorly, the right and left nasal cavities are separated by the nasal septum, which forms their medial
Table 18.5 A simplified classification of rhinitis
Allergic seasonal and perennial Infectious acute and chronic Other idiopathic occupational medicamentosa hormonal vasomotor
Table 18,4 Functions of the nose
Heat exchange (warming inspired air) Olfaction
The treatment of rhinitis depends on the cause. The common cold is usually self-limiting and responds to the short-term use of topically applied decongestants (ephedrine or xylometazoline), which most patients self prescribe. Most other forms of chronic rhinitis respond to potent topical steroids such as beclomethasone or mometasone, but these drugs should not be used without medical supervision. Persistent nasal obstruction, rhinor-rhoea and nasal congestion, especially if unilateral, should be seen as a reason for referral to a specialist.
The quadrilateral cartilage of the septum may be fractured, resulting in a septal deviation that can give rise to nasal obstruction. Characteristically, this produces unilateral nasal obstruction and examination reveals a convexity of the septum touching the lateral nasal wall. The unilateral nature of the symptoms helps distinguish this from rhinitis. Treatment consists of the operation of septoplasty, which resects and straightens the quadrilateral cartilage, perpendicular plate of ethmoid and vomer, and thus recentralises the septum. Fig- 18.6 The paranasal sinuses.
Nasal polyps are inflammatory masses that originate predominantly from the lining of the ethmoid sinuses. Polyps are more common in patients with asthma and, in a proportion of patients, there is an association with aspirin allergy. Symptoms are similar to severe rhinitis, with total nasal obstruction, hyponasal speech, hyposmia and nasal discharge. Diagnosis is usually easy on nasal examination. Polyps should be referred for specialist assessment to exclude tumour. Topical or systemic corticosteroid medication can shrink polyps but surgical removal is often required, followed by topical medication to prevent recurrence.
Children often put foreign bodies into their nose. The classic presentation is of unilateral, foul-smelling rhinor-rhoea (oezena). Common foreign bodies include pieces of foam rubber mattress or pillow, organic matter such as peas, and parts of toys, beads, etc. Often, by the time of presentation there is a secondary vestibular infection, 156 which makes the nose very tender to touch and makes instrumental removal difficult. A suspected foreign body is a reason for specialist referral and children will occasionally require general anaesthesia for its removal.
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