Beta-2 transferrin is a protein found in CSF and the aqueous and vitreous
humor of the eye. Nasal fluid is collected and sent for laboratory examination.
Electrophoresis is performed to separate proteins and detect beta-2
transferrin. When present, CSF leak is confirmed; however, a negative
test result does not exclude the diagnosis of CSF leak.
The mucous blanket
o The nasal cavity produces 1 to 2 L of mucus per day.
o Mucus is highly acidic (pH- 6.0) and contains:
– 2-3% glycoproteins
o Mter secretion, mucus forms a bilayer consisting of a thicker, more viscous
gel layer on the surface. This overlies the more serous sol layer.
o Mucus is swept from posterior to cmterior by cilia toward the nasal
Eosinophilic inflammation is an important feature in
the pathogenesis of chronic rhinosinositis (CRS) with
nasal polyps with NP. The eosinophilic accumulation
in the polyp stroma is basically caused by increased
transendothelial migration and increased survival time
in the tissue, where an increased concentration of interleukine
5 (IL-5) plays a major role. The
increased amount of IL-5 is predominantly released
from T-lymphocytes, independently of atopy, and the
highest concentration has been found in polyps from
patients with non-allergic asthma and acetylsalicylic
acid (ASA) intolerance. These are the sub-groups of
patients also known to exhibit the greatest accumulation
In the ASA intolerant patients, a lowered prostaglandin
E2 (PGE2) production has been observed. PGE2
has a significant anti-inflammatory
inhibition of eosinophils. A possible intrinsic defect in
PGE2 production might, therefore, be responsible for a
of eosinophilic accumulation in ASA
Juvenile nasopharyngeal angiofibroma arises in the
confluence of the posterolateral nasal wall and the
lateral nasopharynx and occurs almost exclusively in
males during adolescence. The tumour is sessile
or polypoid and is histologically benign,
but has a tendency to recur and is locally destructive,
causing pressure necrosis of adjacent soft tissue and
bone. It may occasionally extend into paranasal sinuses,
orbit and cranial fossae. It is composed of vascular and
fibrous elements in varying proportions. The vessels in
the superficial portions of the tumour are mainly gaping
capillaries that may become compressed with increasing
stromal fibrosis. Thick-walled vessels without
elastic membranes and with irregular, incomplete or
absent muscle coats and focal intimal thickenings are
usually present in the deeper portions of the tumour.
These vessels resemble those normally seen in the submucosa
of the nasal conchae. The vascular elements are
embedded in fibrous tissue, which varies in cellularity
and collagenisation. Stellate fibroblast-like cells are often
present close to the blood vessels. The fibroblastic
cells of nasopharyngeal angiofibroma are strongly
positive for testosterone receptors. Ultrastructurally,
the nuclei of angiofibroma contain characteristic
dense granules. Occasionally, the fibroblasts may
exhibit cytologic atypia, and some of these cells may
be multinucleated, but mitosis is rare. Mast cells may
be numerous. There may be focal thrombosis, haemorrhage
and chronic inflammatory reaction. With the
advent of preoperative selective embolisation, iatrogenic
emboli are increasingly encountered
in resected specimens.
Myospherulosis is characterised by the presence of cystlike
spaces lined by flattened histiocytes and containing
clusters of brownish spherules resembling fungi.
They lie loosely or within sacs formed by thin
refractile membranes. The brownish spherules do not
stain with PAS or Gomori methanamine silver and their
morphology does not correspond to any known fungus.
They are found within fibrous granulation tissue,
which may show a foreign body reaction. The lesion is
usually found in patients who have had previous operations.
It is now recognised that the spherules are
extravasated red cells that have been altered by interaction
with traumatised fat or petrolatum-based ointments
and gauzes used in surgical procedures.
Mucocele is a cyst filled with mucus that develops within
a sinus cavity as the result of occlusion of the ostium.
Most commonly it is due to infection, but may also result
from trauma or be congenital. Retained secretions
cause expansion of the sinus and bone erosion. The
most common sites of occurrence are the frontal and the
sphenoidal sinuses. The cyst is lined by respiratory epithelium
that shows prominent goblet-cell hyperplasia.
Expansion of the cyst may cause atrophy and
metaplasia of the epithelium.
Any neoplasm with a predilection for the upper respiratory tract
can involve all or part of the septum. These include squamous
cell carcinoma, minor salivary gland neoplasms, or olfactory
neuroblastomas. Metastatic disease from a large number of
sources may also involve the nose, affecting the nasal septum. In
a 25-year review of cases from the Armed Forces Institute of Pathology,
Thompson et al. found that 17% of 115 melanomas of
the sinonasal tract involved the nasal septum alone. However,
these are exceedingly rare and constitute approximately
0.5% of all sinonasal neoplasms. Other rare tumors include
paragangliomas, chordomas, chondromas, glomus tumors,
Sinonasal papillomas are divided into three distinct histologies:
exophytic (fungiform), inverted, and cylindrical (oncocytic).
It should be noted that the sinonasal membrane and papillomas
that occur therein are often named for J.V. Schneider, an
early pioneer of the histology of this region. Thus, the alternative
terms of Schneiderian membrane and Schneiderian papilloma
are occasionally utilized.
Inverted papillomas have a predilection for the lateral nasal
wall and are characterized by squamous cell architecture with
classic papilloma-like features extending into the underlying
stroma. Mucinous cysts or cells can be identified either grossly
or by special stains. Hyams found a 46% recurrence rate and
a 13% malignancy rate in this papilloma subtype. Malignant
transformation has also been reported in cylindrical papilloma,
but because of its rarity, it is difficult to quantify its malignant
potential. Exophytic or fungiform papilloma
is the entity with the highest predisposition for the nasal septum,
and the septum is only rarely the site of origin of the other
papilloma subtypes. Presenting signs include nasal mass, nasal
obstruction, or bleeding. Exophytic papilloma is histologically
similar to papilloma found elsewhere on the body, such as the
common cutaneous wart. In contrast to the inverting and cylindrical
forms, exophytic papilloma does not have any malignant
potential. Complete excision is usually curative.
Systemic lupus erythematosus (SLE) is a chronic, multifaceted
inflammatory disease that can affect every organ system of the
body. SLE is variable in its manifestations and follows a remitting
and relapsing course. This disease involves multisystem microvascular
inflammation caused by autoantibodies. Nasal septal
pathology is an uncommon feature of SLE, with perforation
as the most common septal manifestation, and generally
occurs during exacerbations and in a context of systemic vasculitis.
There are reports of septal perforation being the presenting
symptom of SLE. Lesions are typically asymptomatic
and patients are many times not aware of their nasal problem.
A theory of the pathogenesis of perforation is that the defect
begins with ischemia, causing a nasal mucosal ulceration with
subsequent chondrolysis. Another theory of vasculitis is as
an important etiologic feature in perforation. However, no histological
evidence of vasculitis has been documented in the nasal
mucosa of SLE patients with nasal septum perforation.
Prior to any therapy for the septal pathology, the underlying
rheumatologic process needs to be treated.
Rheumatoid arthritis (RA) is a chronic systemic inflammatory
disease. The disease primarily affects the peripheral joints symmetrically.
The etiology of RA is unknown. Other common
manifestations include fatigue, malaise, and morning stiffness.
Extra-articular involvement of organs such as the skin, heart,
lungs, and eyes can be significant. Nasal septal nodules and perforation
have been reported as rare manifestations of this disease
Nasal septal perforations have been attributed
to the destructive potential of the vasculitic component of the
condition. Raynaud’s phenomenon has been described in a
subset of these patients and speculation that local vasospasm
following inspiration of cold air leading to ischemia in the nose
with the similar effect of fingertip ulcers. Treatment of the
rhinologic component relies upon control of the underlying pathology.