1.1a Nose & Paranasal Sinuses

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CHOANAL ATRESIA

Embryonic failure of the bucconasal membrane to rupture prior to birth Persistence of a bony plate or membrane

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IMAGING STUDIES

Plain Films Cheap, inaccurate, overlapping structures CT Scan More expensive, more accurate and detailed, no overlapping of structures MRI Most expensive, accurate especially to extent of soft tissue and fluid, poor in bone delineation

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Infectious diseases Endocrine changes or diseases Hemorrhagic diathesis Coagulopathies 

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Platelet Disorders Thrombocytopenia 

hypertension Influenza, measles, typhus Pheochromocytoma, pregnancy, diabetes mellitus Congenital: e.g. hemophilia A and B, Willebrand diseas Acquired: e.g. anticoagulant therapy, hepatocellular insufficiency Idiopathic thrombocytopenic purpura, platelet proliferation disorders, platelet distribution disorders

DISEASES OF THE NOSE & PARANASAL SINUSES MANAGEMENT

Surgical Excision Sclerosing agents Propanolol Vascular endothelial growth factor

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EPISTAXIS KISSELBACH’S PLEXUS in the Little’s Area –  90% of Epistaxis

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Posteroinferior bleeding – Sphenopalatine vessels Roof of the nose – from anterior and posterior ethmoid arteries

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LOCAL CAUSES OF EPISTAXIS CLASSIFICATION EXAMPLES

Change in the nasal septum Mucosal or vascular injury

Neoplasma

Perforation traumatic, iatrogenic inflammatory: spurs or ridges Foreign bodies, rhinoliths, trauma (including nose picking), allergy, acute rhinitis, traumatic aneurysm of the internal carotid artery (very rare) Benign and malignant neoplasms of the nose, paranasal sinuses and nasopharynx

RHINOLITH MANAGEMENT OF RHINOLITH  

VESTIBULITIS    

Idiopathic

Infection of the sebaceous glands Staphylococcus aureus Warm compress I&D antibiotics RHINOSINOGENIC COMPLICATIONS COMPLICATIONS

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SYSTEMIC CAUSES OF EPISTAXIS CLASSIFICATION EXAMPLES

Vascular and circulatory diseases

Endoscopic guided removal Lateral Rhinotomy

ORBITAL - Orbital cellulitis - Cavernous sinus thrombosis

Atherosclerosis, arterial BEI SAMONTE

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INTRACRANIAL - Epidural, subdural and intracerebral abscesses - Clinical manifestations are nonspecific 

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“ALLOS” – other

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“ERGON” – reaction

 

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OSTEOMYELITIS / SUBPERIOSTEAL - Abscess 

CAVERNOUS SINUS THROMBOSIS Complications: - Loss of vision – 10% - Ischemia of other organs - Intracranial complications (meningitis, brain abcess) Prognosis - 30% mortality

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Very quick reaction of the immune system to harmless foreign substance, 5-15 minutes, i.e. hay fever, astma, food and drug allergy

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DELAYED HYPERSENSITIVITY

Atrophy of nasal mucosa Loss of cilia Etiology : Unknown Symptoms: Crusting, viscid secretions, fetid nasal odor Endoscopy: Broad nasal cavity lines with dry, crusted mucosa Management: - Nasal douche - Medical (steroids, antibiotics) - Surgical (submucous implantation of cartilage)

Much slower reaction of the immune system, two or more days, i.e. contact dermatitis

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SYMPTOMS

Rhinorrhea Stuffiness / Nasal obstruction Nasal itching Sneezing

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 ALLERGENS

RHINITIS MEDICAMENTOSA  

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Rebound vasodilation Prolonged used of sympathomimetic decongestant nose drops & nasal spray (oxymetazoline) Initial vasoconstriction -> Vasodilation -> Nasal obstruction & excessive mucous secretion Discontinue medication & substitute topical steroids (mometasone, flucasone, ciclesonide) for allergy VASOMOTOR RHINITIS Exact cause is unknown Triggers: - Dry atmosphere - Air pollution - Alcohol - Spicy foods - Strong emotions Primary treatment: Avoiding triggers - Decongestants - Antihistamines - Corticosteroid nasal sprays

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"ALLOS" - Other than "ERGON" - reaction Immediate hypersensitivity - very quick reaction of the immune system to harmless foreign, substance, 5-15 minutes Ex. Hay fever, asthma, food & drug allergy Delayed hypersensitivity - Much slower reaction of the immune system, 2 or more days. Ex. Contact dermatitis2

TREATMENT    

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Allergy

Antihistamines Steroids SCIT (Subcutaneous immunotherapy) SLIT (Sublingual immunotherapy) SUBCUTANEOUS IMMUNOTHERAPY

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 ALLERGIC RHINITIS

House dust mites - tiny insects that live in dust Proteins in Danders - Dry skin of human / pets Molds & Milder Cockroach Pollens - grass, flowers & trees Food - milk, wheat, soy, eggs, nuts, seafoods

CLASSIFICATION OF ALLERGIC RHINITIS (ARIA - ALLERGIC RHINITIS AND ITS IMPACT ON ASTHMA) INTERMITTENT SYMPTOMS PERSISTENT < 4 days per week 4 weeks  And >4 weeks MILD MODERATE - SEVERE Normal sleep  Abnormal sleep No impairment of daily activities, Impairment of daily activities, sport, sport, leisure leisure No impairment at work and school Impaired work and school No troublesome symptoms Troublesome symptoms

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 ALLERGY

Symptoms - Rhinorrhea - Nasal obstruction - Nasal itching - Sneezing Reversible spontaneous or with treatment Localized to nose; affects both sides Watery and clear nasal discharge Boggy and pale turbinates IMMEDIATE HYPERSENSITIVITY

 ATROPHIC RHINITIS 

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Provides symptomatic relief Modifies allergic disease by targeting the underlying immunological mechanism Efficacy and safety established Treatment of - Asthma - Allergic rhinitis / rhinoconjunctivitis BEI SAMONTE

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- Hypersensitivity Numerous controlled clinical trials

RHINOSINUSITIS 

A group of disorders generally characterized by inflammation of mucosa of the nose and para-nasal sinuses

SUBLINGUAL IMMUNOTHERAPY     

Small doses of allergen sublingually Boost tolerance allergen 2009 World Allergy Organization (WAO) Widely accepted in Europe, South America, and Asia Safety nor the efficacy yet to be considered by the US FDA

 ACUTE RHINOSINUSITIS 

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SLIT VS SCIT 

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SLIT Cochrane meta-analysis demonstrated efficacy in control of rhinitis symptoms in patients older than 12 years Safety profile: Much safer than subcutaneous IT SCIT: Scandanavian study compared the effectiveness and safety of injection therapy with SLIT using birch pollen antigens No difference between subcutaneous and sublingual in terms of efficacy  ACUTE RHINITIS

 

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Viral - Transient signs and symptoms - Self limiting - Both sides, watery and clear discharge, congested turbinates - Rhinovirus and Coronavirus Bacterial - Follows viral i nfection - Pneumococcus, Staphylococcus Streptococcus - Thick, yellow-green discharge - May be one side, congested turbinates and mucosa - Antibiotics are warranted CHRONIC RHINITIS FUNGAL

     

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CHRONIC SINUSITUS 

 

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Aspergillosis Mucormycosis Rhinoscoridosis BACTERIAL

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An inflammatory condition involving the paransal sinuses, as well as the lining of the nasal passages, which last up to 4 weeks (28 days) Most common pathogens - Streptococcus pneumoniae - Haemophilus influenzae - Moraxella catarrharalis - Staphylococcus aureus - Anaerobic bacteria Inflammation and edema formation causes increased secretion which are retained in the sinuses Symptoms: Severe nasal discharge Rhinoscopy: Greenish or purulent foul smelling nasal discharge over congested turbinates X-ray: Air fluid level, mucosal thickening, mucosal opacification

Inflammation of the nasal cavity and paranasal sinuses and/or the underlying bone that has been present for at least 12 weeks Symptoms: - Nasal congestive/obstructive or blockage - Facial pain or pressure - Discolored discharge (Anterior or Post-nasal drip) - Hyposia or anosmia Fungal - Aspergillosis - Mucormycosis - Rhinoscoridosis Bacterial - Tuberculosis - Leprosy - Rhinoscleroma - Sarcoidosis - Syphilis - Actinomycosis

Follows bacterial infection Pneumococcus, Staph, Strep Thick, yellow-green discharge May be one side, congested turbinates and mucosa Antibiotics are warranted VASOMOTOR RHINITIS Exact cause is unknown Triggers - Dry atmosphere - Air pollution - Alcohol - Spicy foods - Strong emotions Primary treatment: Avoiding triggers Decongestants Antihistamines Corticosteroid Nasal Sprays

TUMORS OF NOSE & PARANASAL SINUSES NASAL POLYPOSIS 

Presence of bilateral, smooth, semitranslucent pearly white to pinkish, pedunculated masses arising from the muscosa surrounding the ostiomeatal complex

BEI SAMONTE

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CLASSIFICATION OF NASAL POLYPS (MACKAY) GRADE CLINICAL FINDINGS 0 Absence polyps 1 Polyps do not prolapse beyond the most anterior part of the middle turbinate (requires nasal endoscopy) 2 Polyps extend below the middle turbinate and are visible with nasal speculum 3 Polyps are massive and occlude the entire nasal cavity

 

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- Neck mass Neurological - Facial Pain MANAGEMENT

     

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Radiotherapy Chemotherapy Combination SCCA MANAGEMENT

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Surgery is still the mainstay

INVERTING PAPILLOMA  

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Benign Locally invasive May resemble nasal polyp but may contain areas of carcinoma Inverts into the surface epithelium Treatment: Surgical excision  ANGIOFIBROMA

 

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Benign Young male Originates in the nasal chamber near nasopalatine foramen Symptom: Severe epistaxis, and nasal obstruction

PRINCIPLES FOR THE STAGING OF SINONASAL TUMORS REGIONS SUBREGIONS

Nasal cavity Upper Level Midlevel Tumor Stage T1 T2

T3 T4

Nasal floor and roof Maxilloethmoid angle, ethmoid cells, sphenoid sinus, frontal sinus Inferior, superior and medial portions of maxillary sinus Tumor Extent Example: maxillary sinus carcinoma 1 subregion Floor of maxillary sinus > 1 subregion or 1 Floor and medial region portion of maxillary sinus Invasion of Invasion of nasal cavity adjacent region Tumor crosses Skull base, cranial organ boundaries nerves, orbit, sphenoid sinus, frontal sinus, skin

NASOPHARYNGEAL CA SYMPTOMS OF NPCA  

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Nasal - Obstruction - Sanguineous discharge Ear - Deafness - Pain Eye - Preptosis - Diplopia Neck BEI SAMONTE

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