Just in time for the holidays!
A
patient presents, shows you a picture of what he’s been blowing from his nose. Better yet, he brings a large sample of the actual
stuff. This really makes your day. He’s got clumps of hard material as the picture
shows, colored dark black mixed with a yummy lime-green. He’s thinking it’s an infection, chunks of
his brain or parts of an alien infestation, or a perhaps of all three.
“An alien invaded my brain!” he says. And you’re not sure he’s joking.
Another patient brings in a plastic bag
with numerous small dried substances, some colored light yellow, green or brown. She is convinced these are “bugs” that have
been living and breeding in her nose…for the last 20 years. She’s not joking—she’s serious as hell.
These are true stories, and just one of
the many wonderful experiences that present to an ENT doctor. And these folks aren’t crazy. Well, at least initially.
Coincidentally, both had prior sinus
surgery. What they both brought in to
the unsuspecting doc were different forms of crusted, dried mucous. In the first case, the patient had a more aggressive
sinus surgery, removing much of his nasal turbinates, resulting in a
too-large nasal airspace. Mucous
collected and dried in those generous air spaces, creating large clumps of dried
secretions. The second patient also had
sinus surgery, over 20 years prior, but her crusting would not accumulate and
dislodge itself en masse as the first guy, but in numerous smaller pieces.
In both cases, the crusting forms from a
drying effect from turbulent nasal airflow, which is not unnatural. The inner sanctum of your nose is designed to
create laminar airflow, where air moves in smooth layers through the
nose. The nose is not a simple open
cavity separated by a midline wall or septum, but has outpouching of oval-like
tissue called turbinates. The turbinates
help to create laminar airflow, which in turn allows the nasal tissues to
properly warm and humidify air before it hits the throat and lungs. The turbinates, lined with mucosal, serve to
increase the surface area of that mucosa, increasing mucosal contact with inspired
air. This contact with mucosal surfaces properly
warms and moisturizes the moving column of inspired air.
 |
| Normal nasal airflow |
 |
| The result of over-aggressive turbinate removal |
In cases of altered nasal anatomy, such as
prior sinus surgery or a septal perforation (an uncommon but known
complication after a septoplasty, nasal trauma, or
improper nasal
spray use)
airflow
becomes more turbulent rather than laminar.
This increases mucosal dryness and irritation. Also, mucosal ciliary action (cilia are the
microscopic moving “hairs” on mucosal cells) may be impaired, resulting in
reduced clearance of mucous from the sinus cavities and the nose.
Both patients had of atrophic rhinitis,
also called ozena. Oftentimes the
crusts present with various colors—yellow, green (even fluorescent green),
brown or black, sometimes tinged with blood.
This discoloration is a result of colonized bacteria or fungus or some
of the substances normally found in mucous that present with different colors
upon drying. Bleeding can also occur due
to dryness along with a foul odor if micro-organisms really flourish.
The treatment in most cases is to keep the
nose moist, with a variety of measure including nasal saline (salt solution
similar to in concentration to the body’s natural secretions) in sprays or
rinses, saline gel (which is water based), a humidifier in dry climates, or
with natural oils made for this purpose (Ponaris® is one commonly used
product). The key is restoration of
proper moisture.
Bacterial colonization does not
equate with infection. The bacteria
happen to accumulate in the crust, and are removed when the crusts are
removed. Antibiotics are typically not
needed.
In some patients, regular follow-up
appointments are needed to debride the nose (cleaning it after anesthetizing
and decongesting the nose), every few months or a couple times a year, not
unlike regular dental appointments for teeth cleaning. Occasionally, antibiotics are indicated if
the mucosal tissues appear infected and inflamed once the nose is cleaned. Antibiotic rinses are an effective means to
treat a nasal infection; one of the most common is mupirocin (Bactroban) ointment
mixed into saline; the nose is then rinsed/irrigated with an irrigation bottle. We try avoid oral antibiotics, which requires
the drug to be absorbed into the blood stream and delivered systemically to the
entire body in order to get to the targeted tissue. The rinses are applied directly to the target
with little absorption and less risk for potential side-effects and
complications associated with systemic oral antibiotics.
The first patient was relieved his brain was
not going to pieces, and his prior concern about little green men invading his
head was in jest—sort of. He held a
little serious belief that the alien-thing was possible, telling me how he had
worked around nuclear waste in Nevada, not far from Area 51.
I tried to convince the second patient her
bugs were not “bugs,” even showed them to her under a microscope while
explaining “bugs” have segmented bodies and legs, none of which her many little
crust-critters possessed. I also
stressed she’d have a more horrendous problem if she truly had bugs multiplying
in her nose for so many years.
I thought we cleared the air, but a few months later she presented with the same complaint, and another plastic bag of numerous “bugs.” I thought she was pretty sane, if not misinformed, the first time, but…sanity is in the eye of the beholder, I reckon.
©Randall
S. Fong, M.D.
For more topics on
medicine, health and the weirdness of life in general, check out the rest of
the blog site at randallfong.blogspot.com
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