Diseases of the Nose

Diseases of Diseases of the Nosethe NoseCSA Espina, MD, DPBOCSA Espina, MD, DPBO

Diseases of the NoseDiseases of the Nose

Inflammatory DiseasesInflammatory Diseases– Allergic RhinitisAllergic Rhinitis– Non-Allergic RhinitisNon-Allergic Rhinitis– Nasal PolyposisNasal Polyposis

InfectionsInfections– Acute Bacterial RhinosinusitisAcute Bacterial Rhinosinusitis– Chronic RhinosinusitisChronic Rhinosinusitis

Diseases of the NoseDiseases of the Nose

EpistaxisEpistaxis– MucositisMucositis– Systemic DiseasesSystemic Diseases– Neoplasms Neoplasms – Substance AbuseSubstance Abuse– TraumaTrauma

TraumaTrauma– Nasal Bone FracturesNasal Bone Fractures– Foreign Bodies Foreign Bodies – Substance AbuseSubstance Abuse

INFLAMMATORY INFLAMMATORY DISEASESDISEASES

Allergic RhinitisAllergic Rhinitis

DEFINITION:DEFINITION:– Chronic or recurrent Chronic or recurrent Ig-E mediatedIg-E mediated inflammation inflammation

of the nasal mucosaof the nasal mucosa– With symptoms of rhinorrhea, sneezing, nasal With symptoms of rhinorrhea, sneezing, nasal

itching, nasal congestion, post-nasal drip, and itching, nasal congestion, post-nasal drip, and occasionally, an impaired sense of smell and occasionally, an impaired sense of smell and tastetaste

– Type I Immediate Hypersensitivity ReactionType I Immediate Hypersensitivity Reaction

(of the Gell and Coombs’ Classification)(of the Gell and Coombs’ Classification)


– It can be classified as intermittent or persistent It can be classified as intermittent or persistent (formerly: seasonal and perennial) and mild, (formerly: seasonal and perennial) and mild, moderate, severemoderate, severe

– INTERMITTENT ARINTERMITTENT AR has symptoms occurring has symptoms occurring for for less than 4 days/week or less than 4 weeksless than 4 days/week or less than 4 weeks

– PERSISTENT ARPERSISTENT AR has symptoms occurring has symptoms occurring more than 4 days/week for more than 4 weeksmore than 4 days/week for more than 4 weeks


– Mild ARMild AR normal sleep, normal daily activitiesnormal sleep, normal daily activities

– Moderate ARModerate AR– Severe ARSevere AR

abnormal sleep, impairment of daily activities, abnormal sleep, impairment of daily activities, problems caused at work or school. problems caused at work or school.


PREVALENCE:PREVALENCE:– Prevalent in children and young adultsPrevalent in children and young adults– 10-30% of adults and 40% of children suffer this 10-30% of adults and 40% of children suffer this

conditioncondition


Rhinitis may appear to be a simple disorder, Rhinitis may appear to be a simple disorder, but it can lead to more serious problems if but it can lead to more serious problems if overlooked and left untreated.overlooked and left untreated.

Some of the sequelae of rhinitis:Some of the sequelae of rhinitis: sinusitissinusitis otitis mediaotitis media tonsillopharyngitistonsillopharyngitis laryngitislaryngitis asthmaasthma


Rhinitis and Asthma are common diseases Rhinitis and Asthma are common diseases which frequently co-exist.which frequently co-exist.

This has launched the concept of This has launched the concept of ““Unified Airways”Unified Airways” or or “One airway, One “One airway, One

Disease”,Disease”, suggesting that because of the suggesting that because of the similarities of the mucosa of the whole similarities of the mucosa of the whole airway from nasal cavities to the lungs, the airway from nasal cavities to the lungs, the whole airway may suffer different whole airway may suffer different manifestations of the same disease.manifestations of the same disease.


DIAGNOSIS:DIAGNOSIS:– Should be strongly considered in the presence Should be strongly considered in the presence

of the following in the medical history:of the following in the medical history: Nasal itchinessNasal itchiness SneezingSneezing RhinorrheaRhinorrhea Nasal congestion/obstructionNasal congestion/obstruction Associated itching and watering or reddening of eyesAssociated itching and watering or reddening of eyes Triggered by exposure to particulate antigensTriggered by exposure to particulate antigens


DIAGNOSIS:DIAGNOSIS:– Gold standard is the ALLERGY SKIN TESTGold standard is the ALLERGY SKIN TEST


PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:– Allergic SaluteAllergic Salute– Facial GrimacingFacial Grimacing– Allergic Facies:Allergic Facies:

Allergic CreaseAllergic Crease Allergic ShinersAllergic Shiners

ALLERGIC SHINERS ALLERGIC SALUTE


PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:– Anterior rhinoscopy findings include pale, Anterior rhinoscopy findings include pale,

blue/grey, dull red boggy turbinates, watery or blue/grey, dull red boggy turbinates, watery or mucoid minimal to profuse nasal discharge and mucoid minimal to profuse nasal discharge and mucus threadsmucus threads

– Anterior rhinoscopy also excludes other Anterior rhinoscopy also excludes other conditions, like nasal polyposis, infection, and conditions, like nasal polyposis, infection, and anatomic abnormalities like septal deviationanatomic abnormalities like septal deviation

– Nasal endoscopy may also be performedNasal endoscopy may also be performed

Reddish, congested

nasal mucosa

White, non-purulent, stringy mucus

NORMAL NASAL MUCOSA


TREATMENT:TREATMENT:– AvoidanceAvoidance– PharmacotherapyPharmacotherapy– ImmunotherapyImmunotherapy


PHARMACOLOGIC TREATMENT:PHARMACOLOGIC TREATMENT:– Symptomatic treatment Symptomatic treatment

Oral and topical antihistaminesOral and topical antihistamines Oral and topical decongestantsOral and topical decongestants Anticholinergics (Ipratropium Bromide)Anticholinergics (Ipratropium Bromide)

– ControllersControllers Oral and topical steroidsOral and topical steroids AntileukotrienesAntileukotrienes Mast Cell Stabilizers (Cromolyn Sodium)Mast Cell Stabilizers (Cromolyn Sodium)

– Adjunctive MedicationAdjunctive Medication Nasal saline doucheNasal saline douche AntibioticsAntibiotics


INDICATIONS FOR IMMUNOTHERAPY:INDICATIONS FOR IMMUNOTHERAPY:– Poor control with simple drugsPoor control with simple drugs– Symptoms spanning more than one seasonSymptoms spanning more than one season– Severe symptoms that interfere with the Severe symptoms that interfere with the

patient’s work and lifestylepatient’s work and lifestyle– Allergens not readily avoidableAllergens not readily avoidable


PRINCIPLES OF IMMUNOTHERAPY:PRINCIPLES OF IMMUNOTHERAPY:– Administration of increasing doses of antigen by Administration of increasing doses of antigen by

injectioninjection– Result is the eventual lowering of allergen-Result is the eventual lowering of allergen-

specific IgEspecific IgE

Non-Allergic RhinitisNon-Allergic Rhinitis

DEFINITION:DEFINITION:– Symptoms similar to allergic rhinitis, except that Symptoms similar to allergic rhinitis, except that

there is there is no triggering allergenno triggering allergen – Allergy skin tests are Allergy skin tests are not positivenot positive– Not immunoglobulin E mediatedNot immunoglobulin E mediated– There are a number of various etiologiesThere are a number of various etiologies


VARIOUS CAUSES:VARIOUS CAUSES:– Certain medications:Certain medications:

Nasal decongestant spraysNasal decongestant sprays AntihypertensivesAntihypertensives CocaineCocaine Birth control pillsBirth control pills


OTHER EXAMPLES OF VARIOUS CAUSES:OTHER EXAMPLES OF VARIOUS CAUSES:– HormonesHormones– HypothyroidismHypothyroidism– EmotionsEmotions– Temperature ChangesTemperature Changes– Inhaled irritants such as gases, fumes, chemicals and Inhaled irritants such as gases, fumes, chemicals and

aerosolsaerosols– Gustatory stimuli such as hot or spicy foods/drinksGustatory stimuli such as hot or spicy foods/drinks


TREATMENT:TREATMENT:– Sleeping with head elevatedSleeping with head elevated– Regular exerciseRegular exercise– Avoidance of inhaled irritantsAvoidance of inhaled irritants– Oral decongestantsOral decongestants– Steroid nasal spraysSteroid nasal sprays– Anticholinergic spraysAnticholinergic sprays– Surgical management of anatomic causesSurgical management of anatomic causes

Nasal PolyposisNasal Polyposis

DEFINITION:DEFINITION:– Benign inflammatory disorder of the nasal and Benign inflammatory disorder of the nasal and

sinus mucosasinus mucosa– Most common mass lesion of the nasal cavityMost common mass lesion of the nasal cavity– Outpouching of the mucosa covering the Outpouching of the mucosa covering the

ethmoid or maxillary sinusesethmoid or maxillary sinuses– Commonly associated with allergyCommonly associated with allergy


RISK FACTORS:RISK FACTORS:

a. Chronic infectiona. Chronic infection

b. Allergiesb. Allergies

c. Trauma c. Trauma

d. Metabolic diseased. Metabolic disease

e. Aspirin intolerancee. Aspirin intolerance


DEFINITION:DEFINITION:– Usually round, soft, moist, grape-like, gelatinous or Usually round, soft, moist, grape-like, gelatinous or

fleshy, pedicled massesfleshy, pedicled masses– Amber-colored or have a peeled-grape appearance but Amber-colored or have a peeled-grape appearance but

may become reddened or hemorrhagic from local may become reddened or hemorrhagic from local irritation or secondary infectionirritation or secondary infection

– Sizes may range from small outpouchings to massive Sizes may range from small outpouchings to massive polyps filling the nasal cavity, sinuses and extending polyps filling the nasal cavity, sinuses and extending into the oropharynx throught the choanaeinto the oropharynx throught the choanae

How do you distinguish How do you distinguish between a nasal turbinate between a nasal turbinate

and a nasal polyp?and a nasal polyp?


SIGNS AND SYMPTOMS:SIGNS AND SYMPTOMS:– May present as unilateral or bilateral nasal May present as unilateral or bilateral nasal

obstructionobstruction– Mouth-breathingMouth-breathing– HalitosisHalitosis– AnosmiaAnosmia– Chronic RhinosinusitisChronic Rhinosinusitis– Widening of the nasal dorsum areaWidening of the nasal dorsum area

Round, soft, moist, grape-like, Round, soft, moist, grape-like, gelatinous or fleshy, pedicled gelatinous or fleshy, pedicled massesmasses


MANAGEMENT:MANAGEMENT:– Nasal steroidsNasal steroids should now be given as first- should now be given as first-

line therapy to most patients with nasal polyp line therapy to most patients with nasal polyp for 4-6 weeks (Naclerio and Mackay, 1997)for 4-6 weeks (Naclerio and Mackay, 1997)

– A combination of topical and short-term A combination of topical and short-term systemic steroid therapy can help improve systemic steroid therapy can help improve symptoms thereby avoiding surgerysymptoms thereby avoiding surgery


MANAGEMENT:MANAGEMENT:– Antibiotic, mucolytic, decongestants may be Antibiotic, mucolytic, decongestants may be

given adjunctively when there is evidence of given adjunctively when there is evidence of sinusitis.sinusitis.

– Endoscopic sinus surgery is performed if signs Endoscopic sinus surgery is performed if signs and symptoms of sinusitis do not improve after and symptoms of sinusitis do not improve after adequate medical management.adequate medical management.

INFECTIONSINFECTIONS

Acute Bacterial RhinosinusitisAcute Bacterial Rhinosinusitis

DEFINITION:DEFINITION:– Rhinosinusitis is a group of disorders generally Rhinosinusitis is a group of disorders generally

characterized by inflammation of the mucosa of characterized by inflammation of the mucosa of the nose and PNSthe nose and PNS

– Sinusitis is preceded by rhinitis and rarely Sinusitis is preceded by rhinitis and rarely occurs without itoccurs without it

– Hence the term, Hence the term, rhinosinusitisrhinosinusitis


DEFINITION:DEFINITION:– Acute Rhinosinusitis is an inflammatory Acute Rhinosinusitis is an inflammatory

condition involving the lining of the nasal cavity condition involving the lining of the nasal cavity and PNS which lasts up to and PNS which lasts up to 4 weeks or 28 days4 weeks or 28 days


DIAGNOSIS:DIAGNOSIS:– When there are symptoms of a viral upper When there are symptoms of a viral upper

respiratory tract infection (URTI) that respiratory tract infection (URTI) that have not have not improved after 10 days or worsen after 5 to 7 improved after 10 days or worsen after 5 to 7 daysdays


SIGNS AND SYMPTOMS: (some or all)SIGNS AND SYMPTOMS: (some or all)– Nasal drainage or dischargeNasal drainage or discharge– Nasal congestion or obstructionNasal congestion or obstruction– Facial pressure/painFacial pressure/pain– Postnasal dripPostnasal drip– Hyposmia/anosmiaHyposmia/anosmia– FeverFever– CoughCough– FatigueFatigue– Maxillary dental painMaxillary dental pain– Ear pressure/fullnessEar pressure/fullness


MOST COMMON BACTERIAL MOST COMMON BACTERIAL PATHOGENS INVOLVED:PATHOGENS INVOLVED:– Streptococcus pneumoniaeStreptococcus pneumoniae– Haemophilus influenzaeHaemophilus influenzae– Moraxella catarrhalisMoraxella catarrhalis

OTHERS:OTHERS:– AnaerobesAnaerobes– Staphylococcus aureusStaphylococcus aureus


PREDISPOSING FACTORS:PREDISPOSING FACTORS:– Viral URTIViral URTI– Allergic rhinitisAllergic rhinitis– Non-allergic rhinitisNon-allergic rhinitis– Nasal polypsNasal polyps– Vasomotor rhinitisVasomotor rhinitis– TraumaTrauma– Dental infectionsDental infections– Immunocompromised stateImmunocompromised state


PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:– InspectionInspection– Palpation of maxillary and frontal/ethmoid Palpation of maxillary and frontal/ethmoid

sinusessinuses– Anterior and posterior rhinoscopyAnterior and posterior rhinoscopy– Nasal endoscopyNasal endoscopy


PHYSICAL EXAMINATION:PHYSICAL EXAMINATION:– Inpection: Inpection: certain facial features may reveal certain facial features may reveal

signs of underlying allergic rhinitis or sinusitissigns of underlying allergic rhinitis or sinusitis– Palpation of maxillary and frontal/ethmoid Palpation of maxillary and frontal/ethmoid

sinuses: sinuses: tendernesstenderness– Anterior and posterior rhinoscopy: Anterior and posterior rhinoscopy: congested congested

turbinates, purulent discharge, post-nasal dripturbinates, purulent discharge, post-nasal drip– Nasal endoscopy:Nasal endoscopy: predisposing nasal polyps, predisposing nasal polyps,

post-nasal drippost-nasal drip

Purulent, yellowish-green mucoid foul-smelling nasal discharge

Orbital cellulitis can be a complication of

ethmoiditis!


TREATMENT:TREATMENT:– AntibioticsAntibiotics– Intranasal steroids (particularly when there is Intranasal steroids (particularly when there is

concomitant allergic rhinitis)concomitant allergic rhinitis)– Oral and topical decongestantsOral and topical decongestants– Adjunctive treatment with nasal saline spray, Adjunctive treatment with nasal saline spray,

and mist humidificationand mist humidification– Supportive treatment with mucolyticsSupportive treatment with mucolytics

Chronic RhinosinusitisChronic Rhinosinusitis

Most common predisposing factor is an Most common predisposing factor is an untreated or a poorly treated acute untreated or a poorly treated acute sinusitis sinusitis usually of more than 3 months usually of more than 3 months duration. duration.

Other predisposing factors include Other predisposing factors include trauma, structural deformities of the trauma, structural deformities of the nose, allergy, and presence of nasal nose, allergy, and presence of nasal polyps or other nasal masses.polyps or other nasal masses.


Patients present with chronic nasal obstruction, Patients present with chronic nasal obstruction, chronic purulent foul smelling nasal & post-chronic purulent foul smelling nasal & post-nasal discharge. nasal discharge.

Symptoms are Symptoms are usually less severeusually less severe than that of than that of acute sinusitis.acute sinusitis.

Word of caution: the symptoms of chronic Word of caution: the symptoms of chronic sinusitis may be the presenting symptoms of a sinusitis may be the presenting symptoms of a more serious underlying disorder, like a more serious underlying disorder, like a neoplasm.neoplasm.


MOST COMMON BACTERIAL MOST COMMON BACTERIAL PATHOGENS INVOLVED:PATHOGENS INVOLVED:– Coagulase negative Coagulase negative Staphylococcus Staphylococcus sp. (51%)sp. (51%)– Staphylococcus aureusStaphylococcus aureus (20%) (20%)– Streptococcus pneumoniaeStreptococcus pneumoniae (4%) (4%) – Anaerobes (3%)Anaerobes (3%)

** On the average, ** On the average, multiple organismsmultiple organisms are found are found in 16% of cultures.in 16% of cultures.


MANAGEMENT:MANAGEMENT:– Medical therapy consists of appropriate Medical therapy consists of appropriate

antibiotics (3-4 weeks) antibiotics (3-4 weeks)

– Decongestants or mucolytics, if warranted. Decongestants or mucolytics, if warranted.

– Saline nasal douche may be beneficial. Saline nasal douche may be beneficial.

– No response to adequate medical therapy No response to adequate medical therapy warrants radiographic evaluation.warrants radiographic evaluation.

– Endoscopic sinus surgery if indicatedEndoscopic sinus surgery if indicated

EPISTAXISEPISTAXIS

EpistaxisEpistaxis The nasal cavity is richly supplied with The nasal cavity is richly supplied with

vasculature because of its functions: vasculature because of its functions: warming, filtering and humidifying inhaled airwarming, filtering and humidifying inhaled air

Blood supply comes from Blood supply comes from bothboth the internal the internal and external carotid arteries and external carotid arteries

ANATOMYANATOMY

Little’s Area – where Kiesselbach’s plexus is found

ANTERIOR EPISTAXISANTERIOR EPISTAXIS

POSTERIOR EPISTAXISPOSTERIOR EPISTAXIS

LOCAL CAUSESLOCAL CAUSES

Mechanical and Traumatic CausesMechanical and Traumatic Causes Septal DeformitySeptal Deformity Inflammatory DiseaseInflammatory Disease TumorsTumors AneurysmsAneurysms

Mechanical and Traumatic CausesMechanical and Traumatic Causes

habitual nose-picking or blowing and rubbing habitual nose-picking or blowing and rubbing intranasal mucosal lacerations intranasal mucosal lacerations dry aerosol topical nasal spraysdry aerosol topical nasal sprays chronic cocaine abusechronic cocaine abuse septorhinoplasty, endoscopic sinus surgery, septorhinoplasty, endoscopic sinus surgery,

turbinate resectionturbinate resection nasal intubationnasal intubation

Septal DeformitySeptal Deformity

septal deflections and spurs septal deflections and spurs septal perforationsseptal perforations

Inflammatory DiseaseInflammatory Disease

mucositismucositis viral respiratory infections viral respiratory infections allergic rhinitisallergic rhinitis bacterial rhinosinusitis bacterial rhinosinusitis

MucositisMucositis

Engorged blood vessels of the septal mucosaEngorged blood vessels of the septal mucosa

NeoplasmsNeoplasms

benign and malignant neoplasms benign and malignant neoplasms recurrent bouts of epistaxis or severe recurrent bouts of epistaxis or severe

episodes of bleeding should prompt episodes of bleeding should prompt fiberoptic/radiologic examinationfiberoptic/radiologic examination

examples: juvenile nasopharyngeal examples: juvenile nasopharyngeal angiofibroma, sinonasal carcinomaangiofibroma, sinonasal carcinoma

watch out for other signs like: bulging of the watch out for other signs like: bulging of the maxilla, proptosis, firm and enlarged neck maxilla, proptosis, firm and enlarged neck nodesnodes

Inverting PapillomaInverting Papilloma

Fleshy Nasal MassFleshy Nasal Mass

Malignant-Looking NeoplasmMalignant-Looking Neoplasm

CT Axial View of a CT Axial View of a

Nasopharyngeal MassNasopharyngeal Mass

CT Coronal View of a CT Coronal View of a

Nasopharyngeal MassNasopharyngeal Mass

Magnetic Resonance Imaging Magnetic Resonance Imaging Axial View of a Juvenile Axial View of a Juvenile

Nasopharyngeal AngiofibromaNasopharyngeal Angiofibroma

Note the intensely-enhancing mass

Systemic CausesSystemic Causes

Coagulation DeficitsCoagulation Deficits Arteriosclerotic Vascular DiseaseArteriosclerotic Vascular Disease Hereditary Hemorrhagic TelangiectasiaHereditary Hemorrhagic Telangiectasia

Coagulation DeficitsCoagulation Deficits

congenital or acquiredcongenital or acquired underlying clotting disorder should be underlying clotting disorder should be

correctedcorrected suspected in: a positive family history, easy suspected in: a positive family history, easy

bruisability, prolonged bleeding from minor bruisability, prolonged bleeding from minor lacerations, dental extractions and other lacerations, dental extractions and other minor traumaminor trauma

examples: von Willebrand’s disease, examples: von Willebrand’s disease, drug/disease-induced thrombocytopeniadrug/disease-induced thrombocytopenia

Arteriosclerotic Vascular Arteriosclerotic Vascular DiseaseDisease

seen in the elderly, hypertensive population seen in the elderly, hypertensive population actual increase in frequency or severity of actual increase in frequency or severity of

epistaxis has not been demonstratedepistaxis has not been demonstrated

Hereditary Hemorrhagic Hereditary Hemorrhagic TelangiectasiaTelangiectasia

autosomal dominant autosomal dominant Osler-Weber-Rendu Osler-Weber-Rendu disease disease

diffuse mucocutaneous telangiectasias and diffuse mucocutaneous telangiectasias and arteriovenous malformations (occurs in 93% arteriovenous malformations (occurs in 93% of patients with this disease)of patients with this disease)

involves both skin and mucous membranesinvolves both skin and mucous membranes very difficult to managevery difficult to manage

Substance AbuseSubstance Abuse

Substance AbuseSubstance Abuse

Septal Perforation with Septal Perforation with

overlying infection overlying infection

secondary to Cocaine Abusesecondary to Cocaine Abuse

MANAGEMENT OF EPISTAXISMANAGEMENT OF EPISTAXIS

General MeasuresGeneral Measures Treatment of Anterior EpistaxisTreatment of Anterior Epistaxis Treatment of Posterior EpistaxisTreatment of Posterior Epistaxis

General MeasuresGeneral Measures

good history and physical examinationgood history and physical examination ask about:ask about:

– locationlocation– lateralitylaterality– severity severity – durationduration– frequencyfrequency– response to control measuresresponse to control measures

General MeasuresGeneral Measures

Digital pressure and head elevation should be Digital pressure and head elevation should be triedtried

Anterior rhinoscopy before and after topical Anterior rhinoscopy before and after topical anesthesia and/or vasoconstriction anesthesia and/or vasoconstriction

Flexible or rigid endoscopy Flexible or rigid endoscopy Laboratory evaluation for assessment:Laboratory evaluation for assessment:

– blood lossblood loss– fluid statusfluid status– coagulopathycoagulopathy– underlying systemic diseasesunderlying systemic diseases

Treatment of Anterior EpistaxisTreatment of Anterior Epistaxis

Digital PressureDigital Pressure PackingPacking Chemical or Electrical CauteryChemical or Electrical Cautery

Treatment of Posterior EpistaxisTreatment of Posterior Epistaxis

less common and is associated with less common and is associated with hypertension and atherosclerotic disease; hypertension and atherosclerotic disease; occurs mostly posterior to the middle occurs mostly posterior to the middle turbinateturbinate

blood pressure stabilizationblood pressure stabilization

Treatment of Posterior EpistaxisTreatment of Posterior Epistaxis

Posterior Nasal PackingPosterior Nasal Packing Arterial EmbolizationArterial Embolization

TRAUMATRAUMA

Foreign BodiesForeign Bodies

A unilateral foul-smelling purulent nasal discharge in an otherwise healthy child is a nasal foreign body unless proven

otherwise!

Foreign BodiesForeign Bodies

Sometimes, foreign bodies may have to be extracted from children under general anesthesia.

Nasal Bone FracturesNasal Bone Fractures


The nasal bones are the most commonly

fractured bones in the face!


REMEMBER:REMEMBER:

It is important to assess the other facial bones It is important to assess the other facial bones when suspecting a nasal bone fracture…the when suspecting a nasal bone fracture…the

nasal bones may not be the only/isolated nasal bones may not be the only/isolated fractures in the patient!fractures in the patient!

REFERENCESREFERENCES Cummings, C., Frederickson, J. et al. Cummings, C., Frederickson, J. et al.

OTOLARYNGOLOGY HEAD & NECK SURGERY OTOLARYNGOLOGY HEAD & NECK SURGERY 33rdrd Edition, Volume 2. Edition, Volume 2.

CLINICAL PRACTICE GUIDELINES, Philippine CLINICAL PRACTICE GUIDELINES, Philippine Society of Otorhinolaryngology, 2006.Society of Otorhinolaryngology, 2006.

Allergic Rhinitis and its Impact on Asthma Protocol, 2001Allergic Rhinitis and its Impact on Asthma Protocol, 2001 Lectures of Dr. J.G. Hernandez, UP-PGH Dept. of Lectures of Dr. J.G. Hernandez, UP-PGH Dept. of

Otorhinolaryngology-Head and Neck SurgeryOtorhinolaryngology-Head and Neck Surgery Frank Netter – Atlas.Frank Netter – Atlas. Ruckenstein, M.J. COMPREHENSIVE REVIEW OF Ruckenstein, M.J. COMPREHENSIVE REVIEW OF

OTOLARYNGOLOGY Copyright 2004.OTOLARYNGOLOGY Copyright 2004.

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Diseases of the Nose

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