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Diseases of nose by Dr. Kavitha Ashok Kumar MSU MAlaysia

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Diseases of nose by Dr. Kavitha Ashok Kumar MSU MAlaysia

  1. 1. Dr KavithaAshok kumar
  2. 2. Dr. Kavitha Ashok Kumar 7/25/2014 2
  3. 3. Dr. Kavitha Ashok Kumar 7/25/2014 3
  4. 4. Diseases of external nose Conditions affecting the nasal septum Infections/inflammation of the nose Tumoursof the nose and nasopharynx Dr. Kavitha Ashok Kumar 7/25/2014 4
  5. 5. Congenital: Cleft lip/ palate, meningocoele, dermoid, hemangioma, etc. Inflammatory Non-specific: Furuncle,cellulitis Specific: Rhinoscleroma, TB, syphilis, leprosy, lupus, etc. Trauma: Facial trauma, surgical trauma Neoplastic Benign: Papilloma, rhinophyma Malignant: Basal cell ca, squamouscell ca. Dr. Kavitha Ashok Kumar 7/25/2014 5
  6. 6. Dr. Kavitha Ashok Kumar 7/25/2014 6
  7. 7. External nasal skeleton is made of various bones and cartilages Differential growth rate of these components can give rise to deformed nose Influenced by Fetal position in utero Birth trauma Dr. Kavitha Ashok Kumar 7/25/2014 7
  8. 8. Bony/ cartilaginous/ both Hump Depressed dorsum-Saddle nose Lateral deformities Crooked nose-C/ S/ V shaped Deviated nose Tip deformities Alardeformities ‘Frog face’ deformity Dr. Kavitha Ashok Kumar 7/25/2014 8
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  10. 10. Dr. Kavitha Ashok Kumar 7/25/2014 10
  11. 11. Dr. Kavitha Ashok Kumar 7/25/2014 11
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  13. 13. Dr. Kavitha Ashok Kumar 7/25/2014 13
  14. 14. Investigations Radiological: rule out secondary sinusitis Nasal endoscopy Preoperative photography Treatment Treat associated or secondary rhinitis/ sinusitis Treat the cause Surgical treatment: Rhinoplasty/ septorhinoplasty Dr. Kavitha Ashok Kumar 7/25/2014 14
  15. 15. Acute staphylococcal infection of the hair follicle commonly seen in the nasal vestibule Etiology of recurrent furuncle: Nose picking Diabetes Immuno-compromised states Dr. Kavitha Ashok Kumar 7/25/2014 15
  16. 16. Pain on touching the nose especially the tip/ ala Pus pointing or swelling over the nose or in the vestibule Purulent discharge if it ruptures Tenderness of the nasal tip/ ala Dr. Kavitha Ashok Kumar 7/25/2014 16
  17. 17. Not to squeeze the lesion Dangerous area of the face—infection can spread along the angular and ophthalmic veins to cavernous sinus Systemic antibiotics and analgesics I&D if it becomes an abscess Management of underlying diabetes, if present. Dr. Kavitha Ashok Kumar 7/25/2014 17
  18. 18. Facial cellulitis Abscess of the upper lip Septal abscess Cavernous venous thrombophlebitis Vestibular stenosis-in recurrent forms Dr. Kavitha Ashok Kumar 7/25/2014 18
  19. 19. Diffuse dermatitis of the nasal vestibule caused by staphlococcusaureus Etiology:frequentpicking of the nose Clinical features: red ,painful nose.crustsand scales,fissures Treatment:cleanthe crusts,ointment. Dr. Kavitha Ashok Kumar 7/25/2014 19
  20. 20. Thickening and heaped raised lesions of the tip of the nose due to hypertrophy of the sebaceous glands Typically afflicts white males between 40 and 60 years of age (M:F::12:1) End result of acne rosaceawhich is actually more common in females Dr. Kavitha Ashok Kumar 7/25/2014 20
  21. 21. Dr. Kavitha Ashok Kumar 7/25/2014 21
  22. 22. Medical treatment Treatment of secondary infection and inflammation with antibiotics and steroids Surgical: Full thickness excision followed by application of split thickness skin grafts Partial thickness "decortication" using cryosurgical techniques, chemical peels, dermabrasion, or Argon/CO2 lasers Dr. Kavitha Ashok Kumar 7/25/2014 22
  23. 23. Most common malignancy of the skin commonly affecting the nose long-term exposure to sunlight and frequently occur on sun exposed skin, such as the face, scalp, ears, etc. > White adult population > Outdoor workers, sailors and the very fair skinned. >50 years and above Dr. Kavitha Ashok Kumar 7/25/2014 23
  24. 24. Locally slow growing and mutilating lesion Lymphatic and distant metastasis-uncommon Early diagnosis-prevents disfigurement of face Treatment: Excision and reconstruction Prognosis-very good on complete removal Dr. Kavitha Ashok Kumar 7/25/2014 24
  25. 25. Dr. Kavitha Ashok Kumar 7/25/2014 25
  26. 26. Deviated Nasal Septum Dr. Kavitha Ashok Kumar 7/25/2014 26
  27. 27. Dr. Kavitha Ashok Kumar 7/25/2014 27
  28. 28. C –SHAPED S SHAPED Dr. Kavitha Ashok Kumar 7/25/2014 28
  29. 29. •Duplication •SPUR •DISLOCATION 7/25/2014 Dr. Kavitha Ashok Kumar 29
  30. 30. •TRAUMA •DEVELOPMENT ERROR •HEREDITARY Dr. Kavitha Ashok Kumar 7/25/2014 30
  31. 31. SIGNS External examination Anterior rhinoscopy Cottle’sTest SYMPTOMS Nasal obstruction Headache Sinusitis Epistaxis Anosmia External deformity Middle ear diseases Anterior ethmoidalnerve syndrome. Dr. Kavitha Ashok Kumar 7/25/2014 31
  32. 32. COTTLE’S TEST 7/25/2014 Dr. Kavitha Ashok Kumar 32
  33. 33. HEMATOLOGICAL -Hb -WBC -OTHERS RADIOLOGY -X Ray -PNS DIAGNOSTIC ENDOSCOPY Dr. Kavitha Ashok Kumar 7/25/2014 33
  34. 34. MEDICAL -EXERCISES -DECONGESTANTS SURGICAL -SEPTOPLASTY -SUBMUCOSAL RESECTION OF SEPTUM(SMR) Dr. Kavitha Ashok Kumar 7/25/2014 34
  35. 35. Symptomatic DNS Grafting material-cartilage/bone Septalperforation closure. Surgical access Dr. Kavitha Ashok Kumar 7/25/2014 35
  36. 36. Steps INCISION ELEVATION OF FLAPS CORRECTION OF DEFORMITY CLOSURE ANTERIOR NASAL PACKING Dr. Kavitha Ashok Kumar 7/25/2014 36
  37. 37. COTTLE’S LINE Dr. Kavitha Ashok Kumar 7/25/2014 37
  38. 38. INCISION FREER’S KILLIAN’S Dr. Kavitha Ashok Kumar 7/25/2014 38
  39. 39. ELEVATION OF FLAPS Anterior Tunnel Inferior Tunnel 7/25/2014 Dr. Kavitha Ashok Kumar 39
  40. 40. BEFORE AFTER Dr. Kavitha Ashok Kumar 7/25/2014 40
  41. 41. SMR KILLIAN’S INCISION FLAP ELEVATED BOTH SIDES CARTI+ BONY REMOVED SUPRATIP DEFORMITY COLLUMELLAR RETRACTION DORSAL COLLAPSE SEPTAL PERFORATION FLAPPING SEPTUM SEPTOPLASTY FREER’S INCISION FLAP ELAVATED ON ONE SIDE ONLY CORRECTION OF DNS COMPLICATIONS LESS RESIDUAL DNS Dr. Kavitha Ashok Kumar 7/25/2014 41
  42. 42. EARLY ANAESTHETIC COMPLICATIONS SEPTAL HEMATOMA / ABCESS PERFORATION LATE SUPRATIP DEFORMITY COLUMELLAR RETRACTION SEPTAL PERFORATION RESIDUAL DEVIATION ATROPHIC RHINITIS Dr. Kavitha Ashok Kumar 7/25/2014 42
  43. 43. SEPTAL HEMATOMA SEPTAL ABCESS Dr. Kavitha Ashok Kumar 7/25/2014 43
  44. 44. Trauma Submucosal blood vessel Chondrocytes die Infected abscess Dr. Kavitha Ashok Kumar 7/25/2014 44
  45. 45. Traumatic •Surgery / Cautery/ Nose picking Malignant •Tumours/ Granuloma Chronic inflammation •Wegeners/syphilis/tuberculosis/candida/lupus erythematosus/rheumatoid arthritis. Poisons •Industrial/cocaine addicts/topical corticosteroids/topical decongestants Idiopathic Dr. Kavitha Ashok Kumar 7/25/2014 45
  46. 46. SEPTAL PERFORATION Anterior Rhinoscopy Size: Small: upto 1 cm Medium: 1-2 cm Large: >2cm Dr. Kavitha Ashok Kumar 7/25/2014 46
  47. 47. REPAIR SEPTAL BUTTONS Dr. Kavitha Ashok Kumar 7/25/2014 47
  48. 48. REPAIR SURGERY Dr. Kavitha Ashok Kumar 7/25/2014 48
  49. 49. Aetiology: viral--influenza ,coxsackie, reovirus,ECHOvirus and rhinovirus Pathology: transient vasoconstriction followed by vasodilatation,oedemaand increased secretions Clinical features: Irritation—burning sensation---watery nasal discharge 2-3days later—fever,nasalobstruction mucopurulantdischarge 5-10 days-------recovery Dr. Kavitha Ashok Kumar 7/25/2014 49
  50. 50. Nonspecific: Chronic hypertrophic rhinitis Atrophic rhinitis Rhinitis caseosa(nasal cholesteatoma) Rhinitis sicca Allergic rhinitis Vasomotor rhinitis Dr. Kavitha Ashok Kumar 7/25/2014 50
  51. 51. Specific: Lupus vulgarisof the nose Tuberculosis Syphilitic rhinitis Leprosy Rhinosporidiosis Rhinoscleroma Dr. Kavitha Ashok Kumar 7/25/2014 51
  52. 52. Clemens Von Pirquet, ViennessePaediatriciancoined the term allergyin 1906 denoting an altered state of reactivity to an organic substance i.e‘allergen’ Dr. Kavitha Ashok Kumar 7/25/2014 52
  53. 53. Is a protein with a size of 2 to 50 micrometer in diameter & molecular weight of 1000 to 40,000 Daltons Dr. Kavitha Ashok Kumar 7/25/2014 53
  54. 54. Definition: It is an IgEmediated immunological response of the mucosa of nose charecterizedby bouts of sneezing watery nasal discharge, itching and a sense of nasal obstruction Dr. Kavitha Ashok Kumar 7/25/2014 54
  55. 55. Seasonal allergic rhinitis March to May(Hay fever) orJuly to September Prevalence of pollens of grasses, flowers, trees/shrubs Dr. Kavitha Ashok Kumar 7/25/2014 55
  56. 56. 1. Pollens Weed pollen Grass Pollen Timothy Grass (Phleumpratense) Cocksfoot (Dactylisglomerata) Birch, hazel, Plane tree ash and pine Tree pollens NETTLE, DOCK & MUGWORT FLOWER Dr. Kavitha Ashok Kumar 7/25/2014 56
  57. 57. Perennial allergic rhinitisThroughout the yearExogenous allergens like house dust, soaps, creams, perfumes, egg, odoursof fish coffee Commonest is house dust which contains faecesof mites-DermatophagoidesPteronyssinus Dr. Kavitha Ashok Kumar 7/25/2014 57
  58. 58. Dr. Kavitha Ashok Kumar 7/25/2014 58
  59. 59. Seasonal Paroxysmal sneezing Watery Nasal discharge Nasal obstruction Itching Perennial Frequent colds persistently stuffy nose Loss of smell Postnasal drip Chronic cough Hearing impairment Dr. Kavitha Ashok Kumar 7/25/2014 59
  60. 60. Nose transverse crease on nose pale, oedematous nasal mucosa turbinates are swollen thin, watery/ mucoid discharge Ears retracted T M Serous otitis media 7/25/2014 Dr. Kavitha Ashok Kumar 60
  61. 61. Investigations 1.Blood -TC, DC, AEC 2.Nasal smear for eosinophils 3.Nasal provocation tests 4.Skin test (Prick/ Scratch/ Intradermaltests) 5.Radioallergosorbenttest Antigen (radioactive) + Pt’s serum (Contains IgE) Radioactive IgEcomplex (Measured) 7/25/2014 Dr. Kavitha Ashok Kumar 61
  62. 62. a. Avoid possibly known allergen b. Drugs 1. Antihistamines 2. Sympathomimetic drugs 3. Corticosteroids Oral/Local/Injection 4. Mast cell stabilizer (2% Sodium chromoglycate nasal spray) c. Immunotherapy Dr. Kavitha Ashok Kumar 7/25/2014 62
  63. 63. Vasomotor rhinitis Rhinitis medicamentosa Endocrinal rhinitis a. Thyroid dysfunction b. pregnancy c. Honeymoon Rhinitis Drug induced rhinitis a.Contraceptive pills b. Antihypertensives c. Neostigmine Dr. Kavitha Ashok Kumar 7/25/2014 63
  64. 64. Definition It is a clinical condition due to imbalance of autonomic nervous system Epidemiology Common in emotionally unstable persons( Women of 20 to 40 years) Dr. Kavitha Ashok Kumar 7/25/2014 64
  65. 65. Nasal Obstruction, Rhinorrhoea Postnasal drip, Head ache, fatigue Signs Enlargement of turbinates Mucosa is dusky red in color (Mulberry like appearance) Dr. Kavitha Ashok Kumar 7/25/2014 65
  66. 66. Physical exercise Tranquillizers Decongestants Surgical treatment Cauterization of turbinates submucosaldiathermy Cryosurgery Surgical resection of turbinates VidianNeurectomy( Malcomson1959) in intractable rhinorrhoea Dr. Kavitha Ashok Kumar 7/25/2014 66
  67. 67. Atrophy of nasal mucosa & turbinate bones. • Excessive drying, crusting and infection Klebsiellacolonization Types: Primary:Causeis not known Theories proposed : Hereditary,Endocrinal,Racial,Nutritionaldef,Infective, Autoimmune. Secondary:in Syphilis,TuberculosisLeprosy,Lupus. Dr. Kavitha Ashok Kumar 7/25/2014 67
  68. 68. Metaplasiafrom ciliated columnar to squamous Type 1;Endarteritis & periarteritisdue to chronic inflammation Type 2;Vasodilatation of capillaries Dr. Kavitha Ashok Kumar 7/25/2014 68
  69. 69. Nasal block, epistaxis (Merciful) anosmia Choking when detached crusts slips from the nasopharynxto oropharynx Atrophic pharyngitis& laryngitis O/E Greenish/grayish black crusts, Roomy nasal cavity Shrivelledturbinates. Dr. Kavitha Ashok Kumar 7/25/2014 69
  70. 70. Nasal douche 3-4 times per day for 2-3 months,then1-2 times per day indefinitely 280ml of water + 28.4gm(1tsp)Sodium bicarbonate +1tsp sodium diborate+ 56.7gm(2tsp) sodium chloride Drops of 25% glucose in glycerin locally Local antibiotics Oestradiolspray Placental extract Rifampicin600mg daily / Streptomycin Oral KI Dr. Kavitha Ashok Kumar 7/25/2014 70
  71. 71. Narrowing: Young’s operation; Modified young’s Lautenslager’soperation, Submucousinjof Teflon,Cancellousbone graft. Transplant:Witmack’sprocedure, Nerve destructive:Ganglion nerve blocks, Dr. Kavitha Ashok Kumar 7/25/2014 71
  72. 72. Crust formation seen in patients who work in hot dry surroundings Confined to anterior1/ 3rd Nose Treatment Correction of occupational surroundings, Local application of ointment, Nasal douche. Dr. Kavitha Ashok Kumar 7/25/2014 72
  73. 73. Mostly affects males Nose filled with offensive,cheesymaterial Secondary to chronic sinus infection Treatment-Removal of debris, drainage of sinus. Dr. Kavitha Ashok Kumar 7/25/2014 73
  74. 74. 7/25/2014 Dr. Kavitha Ashok Kumar 74
  75. 75. Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.
  76. 76. Anatomical considerations:
  77. 77. Osteo-meatal complex
  78. 78. Depending on the site Unilateral/ bilateral Pansinusitis Multisinusitis Maxillary/ frontal/ ethmoidal/ sphenoidal Depending on whether the sinus is draining or not Open type Closed type Depending on the pathology Suppurative Non-suppurative
  79. 79. Rhinogenic-Commonest (85%) Usually after viral rhinitis (Flu) Any form of rhinitis Dental (Maxillary) Root abscess, dental procedure, etc. Trauma RTA, Swimming and diving, FB, barotrauma, etc. Iatrogenic-nasal packing, septal surgery Hematogenous-Rare
  80. 80. Mucosal odema of MM Any form of rhinitis: Viral, bacterial, Irritant, allergic, VMR, atrophic, etc. (environmental factors play role) Mechanical (anatomical) obstruction of nose/ MM DNS, spur, polyp, hypertrophic turbinate, any mass, FB, nasal packing, etc. Pathological mucous Thick mucous (mucoviscidosis, cystic fibrosis) Primary mucociliary dysfunction Others: Poor general health, immunodeficiency states, DM, nutritional def., etc,
  81. 81. Str.Pneumoniae B-hemolytic streptococcus H.influenzae Stap. Aureus Klebsiella pneumoniae Others
  82. 82. Obstruction to sinus ostium/ meatus Stasis of secretions (serous-mucinous): Non-suppurative Secondary bacterial invasion: Suppurative Severity and resolution depends on Open/ closed. May drain creating accessory opening. Organism virulence Host resistance Treatment received
  83. 83. Acute inflammatory changes: Hyperemia, odema, acute infl. infliterate. Increased activity of the mucous glands Severe suppuration Mucosal destruction Empyema Bony destruction Complications
  84. 84. Constitutional symptoms: Fever, malaise, lethargy Headache/ facial pain: Dull ache, postural/diurnal. Max: Facial, forehead Frontal: Forehead, “Office headache” Ethmoid: Between the eyes, may > with eye movement Sphenoid: Vertex, occipital Nasal discharge mucous/ mucopurulent/ purulent/ blood stained Anterior/ postnasal Nasal obstruction Cheek/ lid congestion, swelling
  85. 85. Fever Tenderness Cheek swelling Lid edema: in ethmoid and frontal Inflamed nasal mucosa especially the meatus Discharge in MM/ SM as on anterior/posterior rhinoscopy Signs of complications
  86. 86. Endoscopicappearance of acute infective sinusitis, with pus exuding from under the right middle turbinate and down into the middlemeatus.
  87. 87. Clinical diagnosis Diagnostic nasal endoscopy (DNE) Radiological X-ray PNS Water’s view (Occipetomental) Caldwel view (Occipetofrontal) Lateral view Base skull view (Submento-vertical) CT scan: indicated in impending complications C/S: rarely done
  88. 88. Postural test Transilluminationtest X-Rays PNS CT Scan Pus swab 7/25/2014 Dr. Kavitha Ashok Kumar 89
  89. 89. CT –Coronal views centered on OMC Investigations (cont…) Dr. Kavitha Ashok Kumar 7/25/2014 90
  90. 90. 7/25/2014 Dr. Kavitha Ashok Kumar 91
  91. 91. CT Coronal CT shows the inflammatory changes in the right frontal recess and anterior middle meatus(star). 7/25/2014 Dr. Kavitha Ashok Kumar 92
  92. 92. 7/25/2014 Dr. Kavitha Ashok Kumar 93
  93. 93. •Acute Sinusitis
  94. 94. Antibiotics Nasal decongestants (Topical/systemic) Anti-inflammatory analgesics Medicated steam inhalation Mucolytics Hot fomentation
  95. 95. If not responding to medical treatment Impending or manifest complications Depends on the sinus involved
  96. 96. Acute maxillary: Antral washout/ endoscopic MMA Acute frontal: Frontal trephination/ endoscopic frontal recess clearance Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy
  97. 97. Chronic sinusitis Acute sinusitis or acute exacerbations of chronic sinusitis may give rise to following complications: Orbital Intracranial Osteomyelitis Septic focus for other infections
  98. 98. Spiking fever Lid odema, facial/orbital swelling Proptosis, reduced vision, reduced extraoccular movt. Severe headache and hyperirritable Projectile vomiting Meningeal signs Hypothermia Altered sensorium
  99. 99. Common in acute ethmoiditis or frontal sinusitis Direct spread/ ostitis/ thrombophlebitic Odema of the lids Subperiosteal abscess Orbitial cellulitis Orbital abscess Superior orbital fissure syndrome: Deep orbital pain, frontal headache, progressive paralysis of extraoccular movements Blindness
  100. 100. A patient with acute ethmoiditis threatening vision.
  101. 101. Anterior cranial fossa and cavernous sinus closely related Meningitis Extradural abscess Subdural abscess Frontal lobe abscess Cavernous sinus thrombophlebitis, etc
  102. 102. •BRAIN, ABSCESS,SINUSITIS
  103. 103. “Acute sinusitis especially in a child should be treated adequately to prevent consequent chronic sinusitis or other more severe complications which may be even fatal”.
  104. 104. DR KAVITHA ASHOKKUMAR
  105. 105. HISTOLOGICALLY BENIGN, LOCALLY AGGRESSIVE NONENCAPSULATED VASOFORMATIVE NEOPLASM SEEN EXCLUSIVELY IN MALE ADOLESCENTS.
  106. 106. Dr. Kavitha Ashok Kumar 7/25/2014 108
  107. 107. MACROSCOPY WELL CIRCUMSCRIBED .LOBULATED PURPLE RED MASS COVERED WITH INTACT MUCOSA APPEAR DECEPTIVELY AVASCULAR Dr. Kavitha Ashok Kumar 7/25/2014 109
  108. 108. TWO MAIN CELLULAR COMPONENTS FIBROUS STROMA BLOOD VESSEL CHANNELS --RICH DISTINCT LACK --SMOOTH MUSCLES ELASTIC FIBRES Dr. Kavitha Ashok Kumar 7/25/2014 110
  109. 109. JUVENILE --OCCURS 10 TO 25 YR NASAL BLOCK --UNILATERAL EPISTAXIS --80 PERCENT FACIAL SWELLING PROPTOSIS OCULAR SYMPTOMS Dr. Kavitha Ashok Kumar 7/25/2014 111
  110. 110. WELL DEFINED ROUTES
  111. 111. PLAIN X-RAY --ANT.BOWING OF THE POSTERIOR WALL OF MAXILLARY SINUS(HOLMAN-MILLER’S SIGN) CT-SCAN --BONY INVOLVEMENT MRI --SOFT TISSUE—INTRA CRANIAL SPREAD ANGIOGRAPHY --FEEDING VESSEL Dr. Kavitha Ashok Kumar 7/25/2014 113
  112. 112. 1.ENDOSCOPIC INTRANASAL 2.OPEN ACCESS # TRANSPALATAL # MIDFACIAL DEGLOVING # LATERAL RHINOTOMY INTRACRANIAL APPR. --SURGERY --RADIATION EMBOLISATION RECURRANCE-30-40% Dr. Kavitha Ashok Kumar 7/25/2014 114
  113. 113. Most common in southern states of China Taiwan and Indonesia Etiology Genetic Abnormality in chromosome 1 to6, 9,11,13,14,16,17,22, and X Viral -Epstein Barr virus Environmental –smoking, airpollution Dietary –Nitrosamines from dry salted fish Dr. Kavitha Ashok Kumar 7/25/2014 115
  114. 114. Pathology Squamouscell carcinoma ( 85%) Graded in to well, moderately, poorly differentiated Lymphoma (10%) Rhabdomyosarcoma, Malignant salivary tumour, malignant chordoma(5%) Clinical features Age –4thto 5thdecades of life Male : female -3:1 Symptoms Neck mass, hearing loss, Nasal obstruction, epistaxis, cranial nerve palsies, weight loss Dr. Kavitha Ashok Kumar 7/25/2014 116
  115. 115. Signs – proliferative/ulcerative/ infiltrative Unilateral serous otitismedia Rhinolaliaclausa Squint and diplopia(CN -VI) Opthalmoplegia(CN –III, IV, VI) Facial pain and reduced cornialreflex (CN –V) Blindness (CN –II) Jugular Foramen Syndrome (CN -IX, X, XI) Collet–Sicardsyndrome (CN –IX, X, XI, XII) Horner’s syndrome (cervical sympathetic chain) Trotter’s triad Cervical Neck Nodes Distant metastasis Dr. Kavitha Ashok Kumar 7/25/2014 117
  116. 116. Investigations Endoscopy and biopsy FNAC MRI Scan CT Scan Serology for Epstein Barr virus Positron emission tomography (for residual or recurrent disease after treatment) Treatment Irradiation Systemicchemotherapy Radicalneck dissection Overallsurvival is 50 to 80% Dr. Kavitha Ashok Kumar 7/25/2014 118
  117. 117. Dr. Kavitha Ashok Kumar 7/25/2014 119

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