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Fulltext When the symptoms remain, the diagnosis may need a change: a missed foreign body

Vengatesh Rao, Irfan Mohamad

Archives of Orofacial Sciences, 2016;11(1):15-17.
MyJurnal

The unilateral nasal symptom should trigger a treating physician to a certain diagnosis. The differential
diagnosis includes foreign body, rhinolith and tumour. The chronicity of symptom helps a lot with the diagnosis.
Foreign body for example, tends to present with positive history of insertion, mainly by children or the acute
symptom of local infection. In the presence of prolonged symptom, rhinolith should be suspected especially when
the patient presents with pathognomonic nasal obstruction with foul smelly discharge. A referral should be made
for a nasoendoscopy evaluation whenever a rhinitis-like symptoms remain after a period of medical treatment for
allergy. We share a case of a missed diagnosis of a rhinolith after six years of symptoms.

Matched MeSH terms: Nasal Obstruction
Fulltext Unilateral foul smelly nasal discharge in an adult

Irfan M, Hasme Zam H, Mohd Khairi M

Malays Fam Physician, 2012;7(1):28-30.
PMID: 25606242 MyJurnal

The incidence of rhinolith is by far very low compared to the nasal foreign bodies, especially in adult. Foreign body (FB) in the nostril will lead to unilateral nasal symptom which can start with nasal obstruction or discomfort. In younger children, they may miss to report the problem to the parents but, later on, the FB will manifest itself with unilateral nasal discharge, which at most of the time fouls smells. We report a case of a healthy adult female who presented with unilateral foul smelly nasal discharge which later was diagnosed as rhinolith, with rubber-tip pencil eraser as the nidus of calcification.

Matched MeSH terms: Nasal Obstruction
Fulltext The hazards of impacted alkaline battery in the nose

Ramasamy V, Nadarajah S

J Family Med Prim Care, 2019 1 2;7(5):1083-1085.
PMID: 30598962 DOI: 10.4103/jfmpc.jfmpc_47_18

A foreign body in the nose is a common referral dealt by the otolaryngologist on daily basis. Here we report a case of a 5-year-old girl who was referred from a primary care center with complaints of left nasal blockage and epistaxis along with foul smelling brownish discharge for 1-day duration. Nasal endoscopic examination of the left side of the nose revealed an impacted button battery at the cartilaginous portion of the nasal septum.

Matched MeSH terms: Nasal Obstruction
The association between the reflux symptoms index and nasal symptoms among patients with non-allergic rhinitis

Hamizan AW, Choo YY, Loh PV, Abd Talib NF, Mohd Ramli MF, Zahedi FD, et al.

J Laryngol Otol, 2021 Feb;135(2):142-146.
PMID: 33494850 DOI: 10.1017/S0022215120002492

BACKGROUND: Laryngopharyngeal reflux symptoms assessed with the reflux symptom index can overlap with non-allergic rhinitis symptoms. This study aims to explore the association between the reflux symptom index and nasal symptoms in non-allergic rhinitis patients.
METHODS: A cross-sectional study was conducted on consecutive adults with non-allergic rhinitis. The reflux symptom index (score of more than 13 = laryngopharyngeal reflux) and nasal symptoms (categorised as mild (total score of 0-3), moderate (4-7) or severe (8-12)) were assessed.
RESULTS: The study included 227 participants (aged 58.64 ± 12.39 years, 59.5 per cent female). The reflux symptom index scores increased with total nasal symptom scores (mild vs moderate vs severe, 8.61 ± 6.27 vs 12.94 ± 7.4 vs 16.40 ± 8.10; p < 0.01). Logistic regression indicated that laryngopharyngeal reflux is more likely in patients with severe nose block (odds ratio 5.47 (95 per cent confidence interval = 2.16-13.87); p < 0.01).
CONCLUSION: Laryngopharyngeal reflux symptoms are associated with nasal symptom severity, and nasal symptoms should be primarily treated. Those with predominant nose block and laryngopharyngeal reflux symptoms are more likely to have laryngopharyngeal reflux.

Matched MeSH terms: Nasal Obstruction/epidemiology
The Nasal Hemangioma

Tan SN, Gendeh HS, Gendeh BS, Ramzisham AR

Indian J Otolaryngol Head Neck Surg, 2019 Nov;71(Suppl 3):1683-1686.
PMID: 31763224 DOI: 10.1007/s12070-015-0918-4

Hemangioma is a disease of head and neck commonly, but its presence in the nasal cavity or sinus is rare. It is a form of benign tumour of vascular origin consisting of predominantly blood vessels. It can be categorized into capillary, cavernous and mixed type in accordance to its histopathology features. Retrospectively, we reviewed five cases of nasal hemangioma presenting at University Kebangsaan Malaysia Medical Center (UKMMC) between September 2007 and May 2015. Information on the patients age, gender, ethnicity, clinical symptoms, imaging findings (if available), treatment modalities were collected retrospectively for analysis. Five patients were analysed. Females were more affected than male with ratio of 4:1. All patients presented with unilateral lobular capillary hemangioma of the nasal cavity with 60 % (3/5) of the lesions on the right side and 40 % (2/5) on the left side. The common symptoms at presentation were epitaxis and nasal obstruction (5/5, 100 %), followed by rhinorrhea (3/5, 60 %) and facial pain (1/5, 20 %). All the patients underwent a surgical excision of the hemangioma. The five patients had no recurrence on subsequent follow ups. Computed tomography of paranasal sinuses can be performed to exclude bony erosions. Endoscopic sinus haemangioma excision provide good visualisation and better outcomes. In conclusion, nasal hemangioma should always be differential diagnosis for nasal lesions and surgical excision is still the preferred first line treatment.

Matched MeSH terms: Nasal Obstruction
Fulltext Swiftlase assisted CO2 laser ablation in the treatment of nasal obstruction due to hypertrophy of the inferior turbinates

Sani A, Primuharsa P

Med J Malaysia, 2001 Jun;56(2):174-9.
PMID: 11771077

Hypertrophy of the inferior turbinates are the major cause of nasal obstruction. CO2 lasers have been used to reduce the size of the inferior turbinates over the last 20 years. However, the many techniques of delivery of the laser show that there is no one standard method reducing the size of the turbinates. We now describe how the laser can be applied directly to the turbinates using a handpiece with a special nasal tip, thus overcoming the disadvantages delivery via arthroscopic devices, microscopes and fibers. This technique is further enhanced by coupling it with Swiftlase which swirls the focused beam in a 3 mm spot thus ablating tissue more quickly. This procedure is done under local anaesthesia. The ablation of the anterior third of the inferior turbinates effectively overcomes nasal obstruction. This new method was compared to the more traditional submucus diathermy. 22 patients were subjected to laser treatment whilst 20 patients were subjected to diathermy. The outcome was evaluated subjectively by the patients themselves at 2 weeks, 3 months and 6 months. At the end of the study, the laser group reported a more significantly improved nasal airway (91% against 75%) and decreased rhinorrhea (72.7% against 35%) when compared to the diathermy group.

Matched MeSH terms: Nasal Obstruction/etiology*; Nasal Obstruction/pathology; Nasal Obstruction/surgery*
Sinonasal hybrid tumour involving the anterior skull base

Mazita A, Gendeh BS, Zainal AI

J Laryngol Otol, 2008 Aug;122(8):861-3.
PMID: 17625030

We report a rare case of sinonasal hybrid tumour within an inverted papilloma.

Matched MeSH terms: Nasal Obstruction/etiology
Fulltext Rhinolith: An important cause of foul-smelling nasal discharge

Yaroko A, Mohamad I, Hashim H

Malays Fam Physician, 2014;9(1):30-2.
PMID: 25606296 MyJurnal

Rhinoliths result from neglected nasal foreign bodies that gradually increase in size. They are usually discovered incidentally during routine ENT examination or due to the associated symptoms such as nasal obstruction or persistent foul-smelling unilateral nasal discharge. A case of a 14-year-old girl was reported with a year history of the symptom. The foul-smelling nasal discharge noted by her mother was not the main concern to them. She was referred by her primary care physician as she complained of impacted ear wax. However, rhinolith was incidentally found upon routine clinical examination in the ENT clinic and was removed uneventfully.

Matched MeSH terms: Nasal Obstruction
Pre-operative identification of the level of obstruction in non-apnoeic snoring

Raman R, Gopalakrishnan G

Trop Doct, 1999 Jul;29(3):160-1.
PMID: 10448240
Matched MeSH terms: Nasal Obstruction/complications; Nasal Obstruction/diagnosis*; Nasal Obstruction/physiopathology; Nasal Obstruction/surgery
Fulltext Papillary variant of nasopharyngeal carcinoma: an unusual variant previously unreported in Malaysia

Madhusudhan Krishnamoorthy, Zaleha Kamaludin, Hasnan Jaafar, Norhafiza Mat Lazim

Malaysian Journal of Medicine and Health Sciences, 2020;16(2):339-341.
MyJurnal

Nasopharyngeal carcinoma is a commonly encountered malignancy in endemic regions of the world namely South
East Asia, China and Hong Kong. In Malaysia, the ethnic Chinese population is particularly at risk due to genetic
susceptibilities and environmental exposure to carcinogenic agents. We herein report a case of nasopharyngeal carcinoma in a middle-aged man of Malay ethnicity who presented with nasal blockage and neck nodes. The biopsy of
the nasopharyngeal mass came back as papillary variant of nasopharyngeal carcinoma. The commonly reported histopathological types are the keratinizing and non-keratinizing types, and rarely the basaloid type. In this case report,
we aim to highlight one of the rare variants of the non-keratinizing nasopharyngeal carcinoma. When diagnosing the
non-keratinizing type, appreciation of the different morphological variants is crucial not only to help aid in procuring
an acurrate histopathologic diagnosis, but also to help in subsequent treatment plan.

Matched MeSH terms: Nasal Obstruction
Fulltext Orbital rhabdomyosarcoma: a case series

Chen, C.Y., Nor Hidayah, A.B., Adil, H.

Malaysian Journal of Medicine and Health Sciences, 2013;9(2):69-72.
MyJurnal

In this paper, we report three cases of orbital rhabdomyosarcoma in different age groups with different histopathologic types. Case 1 is a 10-year old Malay boy who presented with painless proptosis of the left eye. Magnetic resonance imaging (MRI) showed soft tissue mass arising from the lateral rectus muscle. Tissue biopsy revealed rhabdomyosarcoma of embryonal type. Case 2 is a 32-year old Malay man who presented with a progressive left eye proptosis associated with pain and redness. Computed Tomography (CT) scan showed a retrobulbar mass extending medially in the left orbit. Meanwhile, biopsy showed rhabdomyosarcoma of pleomorphic type. Case 3 is a 67-year old Malay woman who presented with proptosis and fungating growth of left orbital region, epistaxis and nasal blockage. CT scan revealed an ill-defined mass filling up the left orbital cavity. Biopsy showed rhabdomyosarcoma of alveolar type. Rhabdomyosarcoma is the most common in childhood but it should be considered as a differential diagnosis of orbital tumours irrespective of age.

Matched MeSH terms: Nasal Obstruction
Objective assessment of nasal resistance in patients with nasal disease

Suzina AH, Hamzah M, Samsudin AR

J Laryngol Otol, 2003 Aug;117(8):609-13.
PMID: 12956914

Nasal obstruction is a subjective complaint in patients with nasal disease. The ability to quantitate the nasal ventilation dysfunction would be useful for making the appropriate choice of nasal disease management. This cross-sectional study comprised of 200 adult subjects. They underwent assessment of relevant symptoms, nasal examination and investigations before undergoing active anterior rhinomanometry (AAR) assessment. A group of 88 normal subjects and 112 patients with nasal disease were included. The mean total nasal air resistance (NAR) was significantly higher in patients with nasal disease (0.33 Pa/cm(3)/s) as compared to normal subjects (0.24 Pa/cm(3)/s). There was no significant difference in total NAR between patients with symptoms of nasal obstruction and those without the symptoms (p = 0.42). It is concluded that AAR is a sensitive but not a specific tool for the detection of abnormalities in NAR and it failed to relate to the symptom of nasal obstruction.

Matched MeSH terms: Nasal Obstruction/diagnosis; Nasal Obstruction/physiopathology
Nasopharyngeal undifferentiated carcinoma with sarcomatoid features: Pitfalls in the immunohistochemistry

Lee M, Son HJ, Kim NY, Kim SJ, Yu IK

Malays J Pathol, 2019 Aug;41(2):201-206.
PMID: 31427557

We present a case of an undifferentiated subtype of non-keratinizing squamous cell carcinoma (NK-SCC) with sarcomatoid features in the nasopharynx in a 69-year-old man who was difficult to diagnose due to spindle-shaped malignant cells. He was admitted because of a right nasal obstruction and right headache, and imaging revealed a heterogeneously enhanced irregularly shaped mass at the nasopharynx. Histopathologically, the tumour was partially organised, and the tumour cells were epithelioid or spindle-shaped. Initially, we erroneously diagnosed the tumour as an angiosarcoma owing to its false-negative immunoreaction for cytokeratins and a mistaken interpretation for CD31. After in situ hybridization for Epstein-Barr virus was positive, a consultation and additional immunostaining (including re-staining for cytokeratin with varying dilutions) were performed, and the diagnosis was revised to NK-SCC with sarcomatoid features. We believe that sarcomatoid features may be observed in nasopharyngeal carcinoma and in this case, immunostaining using various epithelial markers is necessary and careful attention should be paid to the interpretation of immunostaining.

Matched MeSH terms: Nasal Obstruction
Nasal vestibule schwannoma: report of a rare case

Fadzilah I, Salina H, Khairuzzana B, Rahmat O, Primuharsa Putra SH

Ear Nose Throat J, 2014 Jun;93(6):E33-5.
PMID: 24932827

Schwannomas of the nasal cavity and paranasal sinuses are quite rare, especially in the nasal vestibule. We report the case of a 61-year-old woman who presented with a 2-month history of progressively worsening right-sided epistaxis and nasal blockage. Rigid nasoendoscopy showed a mobile, smooth, globular mass occupying the right nasal vestibule. The mass arose from the lateral nasal wall and impinged on the anterior part of the middle turbinate posteriorly. Computed tomography of the paranasal sinuses showed a 3.8 × 1.7-cm enhancing mass in the right nostril. The mass obliterated the nasal cavity and caused mild deviation of the septum. The preoperative histopathologic examination showed positivity for vimentin and S-100 protein, suggesting a diagnosis of schwannoma. The patient underwent an intranasal laser-assisted excision biopsy. The histopathologic examination confirmed the diagnosis of schwannoma. Postoperative recovery was uneventful, and no recurrence was seen in the follow-up period.

Matched MeSH terms: Nasal Obstruction/etiology
Fulltext Nasal Septal Angiofibroma in a Post-Menopausal Woman: A Rare Entity

Ewe S, Dayana F, Fadzilah FM, Gendeh BS

J Clin Diagn Res, 2015 Dec;9(12):MD03-5.
PMID: 26816925 DOI: 10.7860/JCDR/2015/14921.6947

Juvenile angiofibromas (JAs) are well-characterised in literature, arising typically in the posterolateral wall of the nasal cavity of young males. Numerous theories have been proposed to explain the occurrence of this unique and rare tumour. Angiofibromas originating in other sites within the head and neck have been described but this is exceedingly rare, constituting less than 2% of all diagnosed cases. Extranasopharyngeal angiofibroma is a rare lesion, and more importantly, controversial. It is not known whether it is actually a relative of the well-known JA that is seen exclusively in adolescent males. We present the case of a post-menopausal woman with unilateral nasal obstruction who was unexpectedly diagnosed as nasal septal angiofibroma.

Matched MeSH terms: Nasal Obstruction
Nasal Peak Inspiratory Flow in Healthy and Obstructed Patients: Systematic Review and Meta-Analysis

Mo S, Gupta SS, Stroud A, Strazdins E, Hamizan AW, Rimmer J, et al.

Laryngoscope, 2021 02;131(2):260-267.
PMID: 32386248 DOI: 10.1002/lary.28682

OBJECTIVES: Nasal peak inspiratory flow (NPIF) is a practical and affordable tool that measures maximum inspiratory flow rate through both nostrils. Although NPIF values for healthy controls and patients appear to differ considerably, a generally expected value for populations with and without nasal obstruction has yet to be established. The aim of this systematic review and meta-analysis was to determine the mean NPIF value in populations with and without nasal obstruction.
METHODS: Medline (1946-) and Embase (1947-) were searched until July 1, 2017. A search strategy was used to identify studies that reported NPIF values for defined healthy or disease states. All studies providing original data were included. The study population was defined as having either normal nasal breathing or nasal obstruction. A meta-analysis of the mean data was presented in forest plots, and data were presented as mean (95% confidence interval [CI]).
RESULTS: The search yielded 1,526 studies, of which 29 were included. The included studies involved 1,634 subjects with normal nasal breathing and 817 subjects with nasal obstruction. The mean NPIF value for populations with normal nasal breathing was 138.4 (95% CI: 127.9-148.8) L/min. The mean value for populations with nasal obstruction was 97.5 (95% CI: 86.1-108.8) L/min.
CONCLUSIONS: Current evidence confirms a difference between mean NPIF values of populations with and without nasal obstruction. The mean value of subjects with no nasal obstruction is 138.4 L/min, and the mean value of nasally obstructed populations is 97.5 L/min. Prospective studies adopting a standardized procedure are required to further assess normative NPIF values. Laryngoscope, 131:260-267, 2021.

Matched MeSH terms: Nasal Obstruction/diagnosis*; Nasal Obstruction/physiopathology
Nasal Angiomyolipoma (AML) Mimicking Juvenile Nasopharyngeal Angiofibroma

Ameen SA, Salina H, Zahedi FD, Primuharsa-Putra SH, Masir N

Iran J Otorhinolaryngol, 2019 May;31(104):191-195.
PMID: 31223601

Introduction: Angiomyolipoma (AML), a benign mesenchymal tumor that commonly arises from the kidney, may be associated with tuberous sclerosis complex and perivascular epithelioid cell tumors (PEComas). Nasal angiomyolipoma is very rare and usually occurs in elderly individuals with epistaxis and nasal obstruction.
Case Report: We report a rare case of nasal angiomyolipoma in a young male. To the best of our knowledge, this is the first documented case of angiomyolipoma originating from the posterior end of the inferior turbinate, clinically mimicking juvenile nasopharyngeal angiofibroma (JNA). The tumor was removed completely via coblator-assisted endoscopic sinus surgery. The patient was asymptomatic at a 2-year follow-up.
Conclusion: Nasal AML located in the posterior nasal cavity in a male patient can mimic the presentation of JNA. A computed tomography scan of the paranasal sinuses played an important role in differentiating nasal AML from JNA. The coblator-assisted endoscopic technique is useful in controlling intraoperative hemostasis in the removal of a suspicious vascular tumor.

Matched MeSH terms: Nasal Obstruction
Fulltext Multifocal nodal and extranodal Rosai-Dorfman disease initially diagnosed as histiocytic lymphoma

Shiran MS, Tan GC, Kenali MS, Sabariah AR, Pathmanathan R

Malays J Pathol, 2008 Jun;30(1):63-5.
PMID: 19108414 MyJurnal

Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a systemic disease involving nodal and extranodal tissues. We report a 48-year-old female with recurrent nasal obstruction due to polypoidal masses involving the nasal sinuses, turbinates and septum bilaterally, and lumps in the right infra-orbital region and region of the right lacrimal sac. A 4 cm right upper neck mass was also noted, which was initially diagnosed as histiocytic lymphoma. Histopathology of the nasal and infraorbital lesions revealed fibro-inflammatory masses containing histiocytic cells with large vesicular nuclei and abundant foamy cytoplasm exhibiting emperipolesis and lymphophagocytosis, admixed with scattered plasma cells and lymphocytes. These histiocytes revealed immunohistochemical positivity for S-100 protein and CD68, but were negative for CDla. The findings supported a diagnosis of RDD. This report serves to remind pathologists and clinicians of the extranodal manifestations of RDD and its potential confusion with lymphomas.

Matched MeSH terms: Nasal Obstruction/etiology*
Fulltext Mucoepidermoid carcinoma of the nasal septum (case report)

Alazzawi S, Sivalingam S, Raman R, Mun KS

Ann Saudi Med, 2015 10 29;35(5):400-2.
PMID: 26506975 DOI: 10.5144/0256-4947.2015.400

We report an extremely rare case of mucoepidermoid carcinoma of the nasal septum. A patient with a history of right-sided nasal obstruction presented to our clinic. Clinical examination revealed a mass in the right nasal cavity originating from the nasal septum. Biopsy revealed a high-grade mucoepidermoid carcinoma. The patient was treated with surgical resection only. Surgery alone might be suitable for small tumors when direct inspection of the surgical site is feasible to detect early recurrence.

Matched MeSH terms: Nasal Obstruction/etiology; Nasal Obstruction/pathology
Fulltext Management of congenital choanal atresia (CCA) after multiple failures: A Case Report

Abdullah A, Abdul Rahman R, Aziz S, Abu Bakar S, AbAziz AA

Med J Malaysia, 2013;68(1):76-8.
PMID: 23466775 MyJurnal

Nasal obstruction in neonates is a potentially fatal condition because neonates are obligatory nasal breathers. Bilateral choanal atresia is therefore a neonatal emergency. Several approaches for corrections of choanal atresia are available including the helium laser: YAG. A 5-year-old Chinese girl born with bilateral choanal atresia, had birth asphyxia that required intubation. She underwent multiple surgeries for correction of choanal atresia at other hospitals but failed to improve. She was referred to Universiti Kebangsaan Malaysia Medical Center (UKMMC) after presenting with intermittent respiratory distress and cyanosis following an upper respiratory tract infection. A repeat computed tomography (CT) scan done preoperatively showed complete bony stenosis over the left choana and finding was confirmed by examination under general anesthesia. She underwent endoscopic transnasal removal of left bony atretic plate. There was no intra or postoperative complications. During follow up 10 years later, the airway on both sides remains patent.

Matched MeSH terms: Nasal Obstruction*

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