Acute Sinusitis (Acute Rhinosinusitis): Classification, Clinical Manifestations, Diagnosis, and Treatment
A detailed review of rhinosinusitis, including classification, symptoms, diagnostic approaches, and current treatment strategies.
Post-Traumatic Nasal Disorders: Classification, Etiology, Diagnosis, and Management
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This article covers pathological conditions that arise from disruption of the anatomical integrity of the nasal structures due to various mechanical impacts.
Classification and Anatomy of Post-Traumatic Nasal Disorders
Nasal Synechiae
Nasal synechiae, also called nasal adhesions, are fibrous bands that form between the nasal septum and the lateral wall structures (turbinates). These adhesions disrupt normal airflow and nasal function.
Acquired Choanal Atresia
Acquired choanal atresiais characterized by a connective tissue or cartilaginous membrane forming at the level of the choanae, which obstructs airflow from the nasal cavity to the nasopharynx.
It can involve one side (unilateral) or both sides (bilateral) and may be partial, allowing limited airflow, or complete. Partial and unilateral forms are most frequently observed.
Post-Traumatic External Nasal Deformity
Post-traumatic deformities of the external nose involve disruption of the normal anatomy of the nasal skeleton, including the nasal dorsum, tip, or septum, in the cartilaginous and/or bony regions. These changes usually develop when timely and proper surgical treatment, such as bone repositioning, is not carried out.
Over time, the nose can assume various shapes depending on the type of deformity. In cases of saddle-nose deformity, the nasal dorsum is depressed inward. When the deformity is arch-shaped (scoliotic), the straight axis of the dorsum becomes disrupted. Alternatively, in angular deviations, the nasal bridge is displaced laterally, while its overall axis remains preserved.
Etiology
Several common factors contribute to the development of post-traumatic nasal disorders:
- Trauma: The most common cause of these disorders is mechanical trauma. This includes falls, blunt injuries, and motor vehicle accidents. Such trauma may result in immediate structural damage, as well as delayed post-traumatic changes.
- Surgical interventions (iatrogenic causes):
- Although rare, previous nasal surgeries such as septoplasty, polypectomy, or surgical reduction of blood supply to the hypertrophied inferior turbinate mucosa can lead to post-traumatic nasal changes.
- Improper postoperative care may result in delayed healing, persistent edema, or secondary bacterial infection, all of which can exacerbate tissue disruption and impair normal nasal function.
- Poorly performed anterior nasal packing can cause significant damage to the nasal mucosa, potentially resulting in adhesions or other long-term complications.
- Chronic conditions: Persistent or slowly progressing infections, as well as autoimmune disorders affecting the nasal cavity, can contribute to the development of these pathologies, especially when patients delay seeking medical attention.
Etiology of Nasal Synechiae
Nasal synechiae most often develop due to:
- Complications following surgery,
- Trauma to the nasal mucosa,
- Autoimmune diseases.
Etiology of Acquired Choanal Atresia
The most common causes of acquired choanal atresia include:
- Severe facial bone injuries,
- Burns affecting the upper airways,
- Prolonged use of a nasogastric tube,
- Autoimmune processes.
Etiology of Post-Traumatic External Nasal Deformities
Post-traumatic deformities of the external nose occur when mechanical forces, such as blows or falls, impact the facial skeleton with varying intensity and direction.
Permanent changes in nasal shape may develop if the nasal bones are not promptly repositioned following trauma. This may happen for various reasons, including delayed diagnosis, patient refusal, or contraindications to early intervention.
Clinical manifestations
Nasal synechiae are usually associated with:
- Difficulty breathing through the nose and reduced sense of smell,
- Dryness and crust formation,
- Recurrent sinus infections,
- Snoring.
In cases of acquired choanal atresia, patients often experience:
- Nasal obstruction ranging from mild to severe,
- Thick mucus discharge or clot formation,
- Reduced sense of smell,
- Nasal speech (hyponasality).
Post-traumatic external nasal deformities commonly lead to:
- Concerns about the appearance of the nose,
- Difficulties breathing through the nose.
Diagnosis of Post-Traumatic Nasal Disorders
A thorough medical history, focusing on previous trauma or surgery, along with a standard nasal examination (rhinoscopy), is usually sufficient to make the diagnosis.
Nasal endoscopy and CT scans may be used when further assessment of adhesions, obstruction, or skeletal deformities is needed.
Treatment of Post-Traumatic Nasal Disorders
Management of Nasal Synechiae
Synechiae are surgically removed using techniques such as laser, ultrasound, radiofrequency, scalpel, or scissors, depending on the surgeon’s preference and available equipment.
Postoperatively, it is essential to prevent recurrence. Silicone splints are usually placed along the nasal septum to keep the healing surfaces separated, and hemostatic sponges may be used to control bleeding.
Postoperative care is also critical and typically involves gentle removal of crusts and the application of ointment-soaked tampons to support proper healing.
Management of Acquired Choanal Atresia
Treatment is performed under endoscopic guidance. The obstructing tissue is carefully excised, and normal anatomy is restored as fully as possible. To prevent re-scarring, silicone tubes matching the size of the choanae are left in place until full healing occurs, usually 3–4 weeks.
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Management of Post-Traumatic External Nasal Deformities
Surgical technique depends on the severity and location of the deformity and may include rhinoplasty or septorhinoplasty to restore both function and appearance.
FAQ
1. What are the main types of post-traumatic nasal disorders?
There are three main types of post-traumatic nasal disorders, each with distinct features. Synechiae are formed when scar tissue creates bands between the nasal septum and the turbinates, often leading to obstruction. Acquired choanal atresia occurs when the posterior nasal passages become partially or completely blocked by connective or cartilaginous tissue. Finally, post-traumatic external nasal deformities involve lasting changes to the structure of the nasal skeleton, whether bony or cartilaginous, and may result in noticeable deformities such as a saddle nose or a deviated nasal dorsum.
2. What usually causes these conditions?
The most frequent cause of post-traumatic nasal disorders is mechanical trauma, such as blows, falls, or motor vehicle accidents. The effects of such injuries may appear immediately or develop gradually over time. The second most frequent cause is iatrogenic, meaning complications following nasal surgery. Less commonly, chronic inflammatory or autoimmune conditions, such as ANCA-associated vasculitis, may also lead to these disorders.
3. How do the symptoms differ between these conditions?
Symptoms vary depending on the specific condition. Synechiae often cause unilateral nasal obstruction, dryness, crusting, and recurrent sinus infections. In choanal atresia, patients experience nasal blockage along with a nasal-sounding speech (hyponasality) and accumulation of thick mucus. Post-traumatic external nasal deformities can result in both cosmetic concerns and difficulty breathing through the nose.
4. How is the diagnosis usually confirmed?
The diagnosis is based on a detailed medical history, with attention to previous trauma or surgery, and a standard ENT examination, such as rhinoscopy. When necessary, nasal endoscopy and CT scans of the facial bones are used to assess the extent of scar tissue, airway obstruction, or skeletal deformities, and to plan any corrective procedures.
5. How are these conditions treated?
Surgery is the mainstay of treatment for all post-traumatic nasal disorders. Synechiae are removed using laser, radiofrequency devices, or conventional surgical instruments. Endoscopic surgery is performed to remove the scar tissue causing choanal atresia. Post-traumatic external nasal deformities are treated with rhinoplasty or septorhinoplasty to restore the shape and function of the nose.
6. How can the recurrence of nasal synechiae be prevented after surgery?
Preventing recurrence is an essential part of management. After the adhesions are removed, silicone splints are placed in the nasal cavity to keep the healing surfaces separated until healing is complete. Careful and regular postoperative nasal care, including gentle cleaning and moisturizing, is crucial to support proper healing and reduce the risk of new adhesions forming.
References
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Berbom, Kh., Kashke, O., Navka, T., & Svift, E. (2016). Bolezni ukha, gorla i nosa [Diseases of the ear, throat, and nose] (2nd ed., transl. from English). MEDpress-Inform. ISBN 978-5-00030-322-1.
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