Nose and Nasopharynx Disorders

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Acquired structural deformity of the nose is almost invariably the result of trauma

The skin of the nose is susceptible to a large number of dermatological disorders

The nose is heir to many skin disorders that are associated with exposure to sunlight; thus, basal cell carcinoma and solar keratoses are common. 

Common inflammatory diseases include rosacea and discoid lupus erythematosus .
Rosacea affecting the nose may lead to the bulbous disfigurement called rhinophyma,
particularly in elderly men. 

Pale, firm nodules in the skin of the nose are a frequent presenting symptom. The most common causes are:

Nodular sebaceous hyperplasia or sebaceous adenoma - the nose is very rich in sebaceous glands.
Basal cell carcinoma - these enlarge and eventually develop central ulceration.
Trichoepithelioma - a benign tumour of hair follicles.

The only certain way to distinguish a basal cell carcinoma from the other, less aggressive,
lesions is to use excision biopsy.

The most common nasal symptom seen in family practice is rhinitis

Rhinitis (a runny, blocked and perhaps sore nose) is usually due either to infection or to allergy.

Infective rhinitis is usually viral in origin, e.g. common cold, influenza. Viral necrosis of surface epithelial cells is followed by exudation of fluid and mucus from the damaged surface (runny nose). Later sub-mucosal oedema produces swelling, which may lead to partial blockage of the narrow nasal airways.

In allergic rhinitis a Type 1 hypersensitivity reaction to inhaled materials such as grass and flower pollens produces a mixed serous-mucous exudate, and sub-mucosal oedema leads to nasal blockage. In allergic rhinitis, where the antigenic stimulus may persist for many weeks, the sub-mucosal oedema may persist and worsen. An irregular, swollen, polypoid mucosa can develop, in which one or more nasal polyps may develop , usually bilaterally.

Typical nasal polyps are smooth-surfaced, creamy, semi-translucent, ovoid masses. They are histologically characterized by immense oedema and a scattered infiltrate of chronic inflammatory cells (including plasma cells); eosinophils are often very numerous in allergic polyps.

In acute rhinitis, there is usually associated inflammation of the sinus linings

Acute maxillary sinusitis is the most important type of sinus inflammation, ethmoidal and frontal sinusitis being less significant. Swelling of the mucosa around the drainage foramen of the maxillary sinus may prevent drainage of maxillary sinus secretions into the nasal cavity, causing stasis. Stasis of maxillary secretions predisposes to secondary bacterial infection, with alteration of the retained maxillary fluid from seromucous to frankly purulent. In severe cases the infection may spread into the ethmoids and frontal sinuses, with the risk of spread of infection to the meninges.

Chronic maxillary sinusitis may follow acute sinusitis, chronic inhalational insult, or nasal obstruction

Failure of an acutely inflamed sinus to drain, even after the resolution of the acute rhinitis that initiated it, leads to chronic maxillary sinusitis, with a chronically thickened and inflamed mucosa, and persistent fluid accumulation. Chronic inhalation of irritant material is sometimes the result of industrial exposure, but most commonly involves cigarette smoke. Chronic rhinitis and maxillary sinusitis develop, initially as a toxic allergic reaction, but such cases are always liable to secondary bacterial infection, or exacerbation during a viral infection.

Obstruction to maxillary sinus drainage may result from a severely deviated nasal septum, or from the presence of nasal polyps.

Nosebleeds (epistaxis) and loss of smell sense (anosmia) are common complaining symptoms

The nasal sub-mucosa is highly vascular, and bleeding from the nose (epistaxis) is common. In most cases the cause is readily apparent, e.g. trauma, especially a blow to the nose or vigorous nose-picking, or acute rhinitis. The most common site for bleeding is a small patch on the anterior septum. This area is particularly prone, being the site of numerous sub-mucosal anastomoses (Little's area). However, persistent nosebleeds may be an indication of significant underlying disease. 

Granulomatous inflammation in the nose is an important disorder worldwide; most cases are due to leprosy, TB or fungal infections, being largely confined to the Third World. However, sarcoidosis may involve the nose (see sarcoidosis), and a specific form of granulomatous vasculitis, Wegener's granulomatosis, frequently presents with nasal lesions.

The most frequent malignant tumours of the nose and sinuses are squamous and transitional cell carcinomas

The most common site for malignant tumour in the nasal cavity is in the anterior region near the nostrils; the tumour is usually squamous carcinoma. Further back in the nose there is an increasing proportion of transitional cell carcinomas. Malignant tumours of the sinuses are most common in the maxillary sinus, but some originate in the ethmoid sinus.

The major effects of tumours in the nose and nasal sinuses result from local invasion, often with destruction of the cheek, palate and, most dangerously, the orbit.

Malignant melanoma can also occur, mostly affecting the middle-aged and elderly; in the nose they are often highly pigmented.

True benign tumours of the nose and paranasal sinuses are uncommon

The lesion most commonly mistaken for a benign tumour clinically is most often seen in the nasal vestibule, just inside the nostril, arising from the squamous epithelium of the vestibule. Although it is clinically labelled a 'squamous papilloma', histological examination shows that the vast majority of these lesions are viral warts identical to those seen on the skin.
Among the most frequently occurring benign tumours are haemangiomas (so-called 'bleeding polyps'). Usually located on the septum, they are responsible for repeated nosebleeds. Some are vascular chronic inflammatory lesions, resembling the pyogenic granulomas seen on the skin.

Juvenile angiofibroma is a rare tumour that occurs in male children and juveniles. It is mainly located in the nasopharynx rather than the nose. During puberty these lesions can grow quickly, mimicking a malignant tumour in their rapid growth and tendency to erode bone. They frequently ulcerate, and present with bleeding.

Transitional cell papilloma and inverted papilloma occur in adults. Although benign, they tend to recur or to be difficult to eradicate. Malignant change can supervene, but is rare.

The nasopharynx is an important site of malignant tumours

The nasopharynx is that part of the pharynx lying immediately behind the nasal cavities. It is lined by respiratory-type columnar epithelium, and there is a considerable amount of lymphoid tissue in the sub-mucosa, which is part of the mucosa-associated lymphoid tissue (MALT). Squamous metaplasia is frequent in adults, so much of the lining epithelium eventually becomes squamous lined. Carcinoma of the nasopharynx is particularly common in China, and is usually a squamous carcinoma or an undifferentiated carcinoma. Because the nasopharynx is an inaccessible site, these tumours may remain small and undetected until after the tumour has spread to the lymph nodes in the neck. The vast majority of patients with nasopharyngeal carcinoma have lymph node metastases when they first present. One of the histological characteristics of both squamous and anaplastic carcinomas is the presence of abundant lymphoid tissue in the stroma.

Malignant lymphoma also occurs in the nasopharynx, presumably arising from the sub-mucosal lymphoid tissue forming part of Waldeyer's ring.
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Revised: 02-11-2014.