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Diseases of the Nose & Sinuses

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1 Diseases of the Nose & Sinuses
Khalid H. Al-Sebeih, MD, FRCSC, ABO Assistant Professor, Department of Surgery Faculty of Medicine, Kuwait University. Department of Otolaryngology, Sabah Hospital

2 Anatomy Nasal cavity: Roof: nasal bones, frontal bone, CFP of ethmoid, fovea ethmoidalis, sphenoid. Septum: PPE, vomer, quadranqular cartilage, memb. septum, columella. Floor: maxillary & palatine bone. Lat wall: maxilla, inf. turbinate, ethmoid bone, lacrimal bone, palatine bone.

3 Anatomy Maxillary sinus Frontal sinus: Largest, 10-20 cc.
Med. = lat nasal wall Sup = orbital floor Floor = alveolar process. Drainage via ostium in lower infundibulum. Frontal sinus: Absent unilat in 12%, bilat 5%. Drainage: into frontal recess posteromedially

4 Anatomy Ethmoid sinuses: 3-18 air cells Ant & post.
Roof = fovea ethmoidalis, Lat = lamina papyracea, post = sphenoid, optic nerve. Ant  mid meatus, post  sup meatus. Medial wall: uncinate process, ethmoid bulla, in between hiatus semilunaris, infundibulum

5 Anatomy

6 Anatomy Sphenoid sinus: Variable pneumatization
Above: pituitary gland & optic nerve Lat: carotid, cavernous sinus, orbital apex structures. Drainage: sphenethmoidal recess

7 29 years old male Nasal obstruction Runny nose Post-nasal drip
Facial fullness

8 Rhinitis Rhinitis Classification Inflammatory Rhinitis
Allergic rhinitis Seasonal allergic rhinitis Perennial allergic rhinitis Perennial nonallergic rhinitis Eosinophilic nasal disease Eosinophilic nonallergic rhinitis (ENR) Nonallergic rhinitis with eosinophilia syndrome (NARES) Associated with aspirin sensitivity Atrophic rhinitis Primary Acquired Infectious rhinitis Granulomatous rhinitis (noninfectious) Irritant dust, chemical, or fume-induced rhinitis Rhinitis induced by cold, dry air Noninflammatory Rhinitis Rhinitis medicamentosa Topical Systemic Hormonal Idiopathic vasomotor rhinitis Structurally Related Rhinitis Septal deviation Neoplasms Cerebrospinal fluid rhinorrhea Miscellaneous

9 Atrophic Rhinitis nasal mucosal atrophy with crusting and an extremely foul odor Cuase : uknown Bacterial: Klebsiella ozaenae, atoxic Corynebacterium diphtheriae, and the Perez-Hofer bacillus Deficiencies in vitamin A and iron Radical surgery Sx & Sn: halitosis, nasal obstruction, epistaxis, and headache. Offensive nasal odor, crusting, and turbinate atrophy.\ Tx: reversing nutritional deficiencies, saline irrigations, vitamin A, & systemic or topical antibiotics. Surgical(faliure of medical therapy): closure of the nostril and nasal vestibuloplasty to narrow the nostrils.

10 Vasomotor Rhinitis Overactive parasympathetic stimulation of the nasal mucosa  vasodilation, edema, and hypersecretion of mucus Sx: nasal obstruction, profuse rhinorrhea, infrequent sneezing, stuffiness, and face pressure and headache. Trigger factors: changes in weather or humidity, the presence of irritating fumes, or air conditioning or stress Tx: Medical: Systemic decongestants, Antihistamines, steroids, topical ipratropium bromide. Surgical: many procedures (inf turbinectomy, submucous resection, Cryotherapy ..etc)

11 Infectious Rhinitis Rhinoscleroma TB, Syphilis, leprosy.
Rhinosporidiosis, histoplasmosis, aspirgellosis.

12 Rhinitis Medicamentosa
Nasal obstruction caused by overuse of topical decongestants or a systemic medications. Rebound vasodilatation after prolonged vasoconstriction with topical agents Tx: discontinuation of the offending medication antihistamine-decongestant combinations topical nasal corticosteroids +/- tapering oral prednisone dosage for 7 to 10 days. gentle submucosal Kenalog-40 injection!!

13 Allergic Rhinosinusitis
Type I hypersensitivity reaction. Occur 2 to 5 minutes of antigen-antibody reaction. A second (late) phase: result of mediator release from cells (neutrophils, eosinophils) and occurs about 4 to 6 hours after the acute phase.

14 Allergic Rhinosinusitis
Sx: tching, sneezing, rhinorrhea, and postnasal drainage (throat-clearing and cough). Seasonal or perennial, & linkage with known exposure to allergens. Signs: open-mouthed “adenoid facies.”, (“allergic salute”), “allergic shiners”and puffiness around the eyes. high arched palate, prominent pharyngeal lymphoid Dx Nasal smears (Hansel’s stain)  eosinophils (> 25% of the cells).  total IgE Skin test

15 Allergic Rhinosinusitis
Management: Level I: Prevention and Control of Symptoms. Environmental Control First-line Pharmacotherapy: Antihistamines compete with histamine for H1-receptor sites on the target organs during the allergic response Decongestants are sympathomimetic substances that cause vasoconstriction within turbinate stroma, producing shrinkage of congested tissue (Pseudoephedrine & Phenylpropanolamine) Cromolyn nasal spray: stabilizes and protects mast cells from degranulation Level II: Recognition and Management of Complicating Factors  Treat other types of rhinitis: vasomotor, medicamentosa…

16 Allergic Rhinosinusitis
Level III: Corticosteroids for Control of Severe or Chronic Symptoms Level IV: Immunotherapy symptoms are not controlled with pharmacotherapy, allergens that cannot be avoided, symptoms span two or more allergy seasons, willing to cooperate in a program of immunotherapy parenteral administration of antigens  formation of allergen-specific IgG-blocking antibodies  compete with IgE antibodies for target sites on mast cells or basophils.

17 Paranasal Sinusitis 3 factors essential to normal physiology of the paranasal sinuses: patency of the ostia, function of the cilia, & quality of the nasal glandular secretions. Most significant pathophysiology that produces sinusitis: mucosal edema in and around the sinus ostium: Hypooxygenation of the involved sinus. Ciliary function is disturbed  stagnation of the secretion. Local host resistance factors are diminished   darainage & perfect milieu for the growth of bacterial pathogens Inflammation (e.g. allergic rhinitis, URTI..)  increased secretions and edema in the sinonasal mucosa.

18 Obstruction of the sinus ostium

19 Paranasal Sinusitis Classification
Acute: infectious lasting from 1 day up to 4 weeks. Management is medical, and rarely surgical treatment. Subacute: infection lasts from 4 weeks to 3 months. inflammatory process is still reversible  Medical management. Chronic: sinusitis persists longer than 3 months. Results from acute sinusitis that has been either inadequately treated or completely untreated. The process is irreversible  surgical treatment is indicated.

20 Paranasal Sinusitis Acute sinusitis: Bacterial:
Adults: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes groups ABC, and Haemophilus influenzae (gram-negative). Children: S. pneumoniae, Branhamella catarrhalis (formerly known as Neisseria catarrhalis), Haemophilus influenzae, Streptococcus pyogenes groups A and C, and Streptococcus pyogenes a-hemolytic type

21 Management Antibiotics clinical improv. In 2-3 days, Ab should continue for days Penicillin G Amoxicillin Cefaclor Trimethoprim sulfate Erythromycin sulfate Augmentin Analgesics Mucolytics Saline irrigations Topical decongestion  edema around the ostia  oxygenation and facilitate drainage (reverse the hypoxia) Shrinkage and suction with Argyrol: packing the nose  removal of pus & oxygenation Surgical management: presence of mucopurulent material in immunosuppressed pt , pt with acute max. sinusitis, no Improvement or worsening of symptoms.

22 Complications Mucocele
chronic, cystic lesion of the paranasal sinuses. Expand slowly and concentrically  bony erosion & extrasinus expansion. Most common in the frontal sinus. Sx: frontal headache and proptosis, displacement of the globe in a downward and outward direction and diplopia but no nasal obstruction and rhinorrhea Tx: surgery

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24 Complications classification (Chandler):
Inflammatory edema — lid edema; no limitation of extraocular movement with normal acuity Orbital cellulitis — diffuse edema of orbital contents; no discrete abscess formation Subperiosteal abscess —purulent collection beneath periosteum of lamina papyracea; displacement of globe downward and laterally Orbital abscess—purulent collection within orbit; proptosis and chemosis with ophthalmoplegia and decreased vision Cavernous sinus thrombosis—bilateral eye findings; prostration; meningismus

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34 Complications Intra-cranial complications
direct extension through a defect in the posterior wall of the frontal sinus Retrograde thrombophlebitis of the valveless ophthalmic vessels The subdural space abscess cerebral abscess, seizures, and neurologic deficits. Meningitis (rare). Septic thrombosis of major dural sinuses Tx: High-dose antibiotic therapy management of increased intracranial pressure, and prevention of seizures. Surgical drainage

35 Fungal Rhinosinusitis
Classification: Acute invasive fungal sinusitis Life threatining Mucor mycosis, immunocompromised host Tx: radical resection, correct underlying medical problem, systemic antifungal. Chronic invasive fungal sinusitis Similar to ch. Sinusitis, caused by aspergillus Endemic in hot dry climates e.g. Sudan Mycetoma (fungus ball): concentric hyphae of aspegillus Tx: simple excision. Allergic fungal sinusitis Most common, Demitaceous groub Nasal polyps, +ve skin test, Charcot-Layden crystals Tx: surgery & steroids Saprophytic infection: fungal contamination

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38 Epistaxis Local Systemic 10% of cases  unknown
Trauma (facial fractures, Vascular digital trauma) Blood dyscrasia Inflammatory reactions Drugs Anatomical or structural Systemic toxic (heavy metals) deformities Infectious Foreign bodies Cardiovascular Toxic chemical Surgery Intranasal tumors (benign, malignant) 10% of cases  unknown

39 Epistaxis Osler-Rendu-Weber’s disease (hereditary hemorrhagic telangiectasia autosomal dominant disease Lack of contractile elements in the vessel walls  arteriovenous fistulae are formed. Precipitating factors include mucosal fragility and trauma. Blood dyscrasias Identified early in life Most common Factor VIII (80% of cases). Von Willebrand’s: prolonged bleeding time, deficiency in antihemophilic Factor VIII, and impaired platelet adhesiveness. Drugs (acetylsalicylic acid, anticoagulants), Systemic toxic agents (phosphorous, mercury), infectious diseases (scarlet fever, smallpox).

40 Management ABC, IV fluid, cross matching. Silver Nitrate Cauterization
Electrical Cauterization Cryotherapy Nasal Packing Anterior Nasal Packing Posterior Nasal Packing Greater Palatine Foramen Block Embolization

41 Surgery Septoplasty/Submucous Resection
Internal Maxillary Artery Ligation Transantral Sphenopalatine Artery Ligation Anterior and Posterior Ethmoidal Artery Ligation External Carotid Artery Ligation Laser Photocauterization (HHT) Septodermoplasty (HHT) Cutaneous/Myocutaneous Flaps - Microvascular Free Flaps (HHT)

42 Epistaxis

43 Epistaxis

44 Epistaxis

45 CSF Leak traumatic 95% (Accidental trauma 80%, iatrogenic 15%)
nontraumatic 5% (tumors, hydrocephalus, congenital anomalies or osteomyelitis Violation of arachnoid, dura, bone, and mucosa

46 Cerebrospinal Fluid Leak

47 History

48 History Trauma Surgery Sinonasal disease: sinusitis, Rhinitis, allergy
Symptoms Symptoms No. of patients Rhinorrhea 8 Headache 5 Sinus congestion 3 Anosmia 1 Meningitis

49 History Examination

50 Cerebrospinal Fluid Leak
Physical examination: Valsalva maneuver Endonasal scope: 00,300 Collecting CSF

51 History Examination Confirm CSF

52 Confirm CSF Leak Lab. Tests: Glucose (> 30mg/100ml) -2 transferrin

53 History Examination Confirm CSF Conservative Tx

54 Medical Management Effective for traumatic leak
Strict bed rest, no straining Head elevation 300 10 – 14 days Prophylactic antibiotic (controversial) L.P Carbonic-anhydrase inhibitors (acetazolamide) ??

55 History Examination Confirm CSF Conservative TX Failure Localization

56 Cerebrospinal Fluid Leak
Radiology: Radionuclide Cisternography: High Resolution CT Scan MRI (+/- FLAIR)

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60 Water-Soluble Contrast CT Cisternography
MRI after intrathecal injection of diluted Gadolinium (Gd) ( Gd MRI Cisternography)

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62 History Examination Confirm CSF Localization Surgical repair
Conservative TX Failure Localization Surgical repair

63 Surgical management Spontaneous CSF Leak
Unlikely stops with conservative therapy 2 patients responded to medical management Our experience consistent with Mayo Clinic experience Surgical intervention Combined team: Otolaryngology & neurosurgery

64 Surgical management Intracranial Advantage: Disadvantage:
ability to achieve a fluid-tight dural closure repair multiple areas of leakage. Treat associated problems e.g. tumors Disadvantage:  morbidity,  mortality prolonged hospitalization period Loss of olfaction

65 Surgical management Extracranial (Extranasal & Intranasal) Advantage:
minimal morbidity and mortality while still achieving excellent visualization of the dural defect Disadvantage: precise, preoperative localization of the leakage site

66 Surgical management Graft selection: Connective tissue grafts:
Fascia lata, temporalis fascia, nasal septal cartilage Mucosal grafts: Contralateral inf. turbinate Other grafts: Lyophilized dura, synthetic dura, glass-ionomer bone cement

67 Cerebrum Dura Graft Orbit

68 Cerebrum Dura Cartilage Graft Orbit

69 Olfactory Disorders Olfactory bulb lies on top of the cribriform plate at the base of the brain Olfactory epithelium: upper septum & lat nasal cavity Epithelium: olfactory receptor (bipolar neuron) microvillar cell (another type of olfactory receptor cell) supporting, or sustentacular, cells basal cells (stem cells to replace the dying olfactory receptors)

70 Olfactory Disorders Causes Obstructive Nasal and Sinus Disease
Olfactory Loss Following Upper Respiratory Infection damage to olfactory neurons at the level of the epithelium, the bulb, or the central olfactory tracts 1/3 of patients will regain olfactory ability in 3 to 6 months Head Trauma 5% to 10% of adults who have sustained both major and minor head trauma shearing of the delicate fila olfactoria nerves as they pass through the cribriform plate 8% to 39% of the patients  recovery of olfactory function usually within 3 months

71 Olfactory Disorders Toxins Aging Congenital
Formalduhyde, benzene, smoking Permenant Aging olfactory loss in old people can occur from dementia-related diseases two dementia-related diseases: Alzheimer’s disease and Parkinson’s disease Congenital hypogonadotrophic hypogonadism (Kallmann’s syndrome

72 Midline Nasal Masses Congenital masses of neuroectodermal origin
Lesion Dural connection Transillumination Furstenberg’s test Meningitis Histology Glioma None No Negative No Solid mass of glial tissue with a fibrous stalk Encephalocele Always Yes Positive Yes Ependymal-lined space that communicates with the ventricles Dermoid Rare Rarely Negative Rare Fluctuating cyst with sinus tract leading to skin

73 Midline Nasal Masses


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