1. Lecture’s Objectives Chronic Sinusitis Mucocele
Tumors of the nose and paranasal sinuses
Disorders of Smell

2. Chronic Maxillary Sinusitis
Definition..
Predisposing factors:
1) Nasal:
* Obstruction of the drainage ostia
*Recurrent acute infection
*Chronic irritation from environmental gases.
2) Dental:
The upper 2nd premolar and the 1st and 2nd molar

4. Diagnosis:/ History Major symptoms Nasal discharge Nasal obstruction
Headache and facial pain
Anosmia( because air not reach the olfactory region) and cacosmia (i.e. unpleasant smell, due to chronic odiferous sepsis).
b) Minor symptoms
Fever
Halitosis (bad mouth odor )

5. chronic irritation in side the nose may produce
vestibulitis
nose bleeds
otitis media
granular pharyngitis
chronic laryngitis

6. Examination /often unhelpful
Normal
Generalized inflammation of the mucosa
Purulent secretion or crusts.
Otitis media and granular pharyngitis

7. Investigation
Radiography;

10. 2) CT scan Coronal CT scan provide most information about the osteo-meatal complex

12. 3) Endoscopic assessment:
Important features are;
The presence of pus in the middle meatus.
The cause of osteal obstruction .
Sometimes biopsy is taken to confirm the diagnosis.

13. Treatment:
The principle of treatment is to restore the normal mucosa to the sinus lining.
At the stage of chronic changes medical treatment has been tried and is of no value.

14. Surgical treatment of the chronic maxillary sinusitis include;
FESS (functional endoscopic sinus surgery ) to remove only the diseased areas in order to relieve the obstruction and so restore natural sinus drainage, ventilation and physiology.

15. . 2. Antral lavage. 3. Intranasal antrostomy.
4. Caldwell-Luc procedure .

16. Complication of chronic sinusitis; Mucoceles :
Definition; A mucocele is a mucous-containing cyst completely filling a sinus and capable of expansion
They arises in order of frequency in the
frontal Frontoethmoidal
ethmoidal
maxillary
sphenoidal sinuses

17. Aetiology
1) Polyps.
2) Trauma (Surgical or Non-Surgical).
3) Tumours.

18. Frontoethmoidal mucocele
Clinical presentation;
Starts asymptomatic
dull ache
swelling (supramedial aspect of the orbit).
The swelling is tender and feels rubbery
Increase in size thins the bone more and pressure may damage the optic nerve or vasculature causing blindness.
Infection pyocoele / dangerous
Increase enlargement proptosis.

20. Radiography of the sinus;
Thinning of the bone.
Displacement of the medial frontal sinus floor downwards .
Loss of scalloping .
The intersinus septum may be displaced or eroded.

21. Treatment; Is by evacuation of the contents of the sinus by ;
Endoscopic technique.
Radical frontal sinus operation.
Osteoplastic flap operation

22. Radical frontal sinus operation.

23. Osteoplastic flap operation

24. Tumors of the nose and paranasal sinuses
Benign ; e.g. Squamous papilloma (in the vestibule) , osteoma (in frontal ,ethmoidal and maxillary sinus) and inverted papilloma .
Malignant tumours ( uncommon);
Squamous carcinoma (is the most common) followed by adenocarcinoma, malignant melanoma…etc

25. Squamous papilloma

26. Osteoma

27. About malignant tumours:
The maxillary sinus is the most common site
Do not usually occur in heavy smoking or heavy drinking population.
…..(e.g. adenocarcinoma in woodworkers)
The chief symptoms of nasal malignancy are unilateral obstruction with haemorrhage
Men > woman , average age at presentation is 60

28. Inverted papilloma (Transitional cell papilloma or Schneiderian papilloma);
This lesion represents about 4% of all nasal neoplasms.
It is the most common benign neoplasm of the nose and sinuses.

29. Aetiology; unknown.
Sex; Male-female ratio 5-1.
Age; most commonly in the 5th decade.
Site of origin; lateral wall of the nose (occasionally from the septum) with extension to the ethmoid and maxillary sinus.

30. Clinical presentation;
Unilateral nasal polyp.
The tumour is soft and friable and may become detached or bleed with hard nose blowing.
CT scan

31. Histopathological examination ;
The surface of the tumour is covered by
transitional type of epithelium.
The lesion is characterized by;
Locally aggressive
Tendency to undergo malignant change
There may be coincidental URT malignancy.
It has high propensity for recurrence after removal.

32. Treatment
Is by adequate local excision usually through lateral rhinotomy approach.

33. Disorders of smell
The olfactory cleft occupies the upper third of the nasal cavity in the area between the superior turbinate, cribriform plate and corresponding area of the septum and is lined by specialized olfactory epithelium (this is a specialized pseudostratified neuroepithelium containing the primary olfactory receptors and has a golden yellow color ).

34. Terminology; Anosmia; Inability to detect odors.
Hyposmia; Decreased ability to detect odors.
Parosmia; Altered perception of smell in the presence of an odor.
Phantosmia; Smelling of nonexistent odor .
( Both parosmia and phantosmia are associated with epilepsy and olfactory hallucination of schizophrenia ).
Cacosmia ; Unpleasant smell, due to chronic odiferous sepsis.

35. Classification of olfactory dysfunction:
Conductive anosmia; Is due to impaired transport of airborne odorants to the olfactory cleft.
Neuronal anosmia; Is due to impairment of olfactory epithelial function or disrupted neuronal pathway.

36. Causes of olfactory dysfunction;
Obstructive nasal disease (23%) :
Postviral anosmia (19%):
Head trauma (15%):
Toxins, drugs ( 3% ):e.g. Aminoglycosides, formaldehyde, alcohol, nicotine, …
Miscellaneous (21% ): Aging, neoplastic, psychologic, nutritional deficiencies (e.g. vitamin A , thiamine ) and other causes.
Idiopathic ( 21% ).

37. A patient presented external swelling of the upper two third of the nose following car accident 24 hours ago. Treatment requires:
A. Immediate rhinoplasty.
B. Immediate packing and external splint.
C. no more than antibiotic and pain killer.
D. reassessment after edema subside

38. Unilateral foul smelling nasal discharge in a 4 years old child is pathognomonic of ;
a. Rhinolith.
b. Foreign body.
c. Allergic Rhinitis.
d. Antrochoanal polyp.

39. Disorders of nasal septum
1. Septal haematoma
2. Septal Abscess
3. Septal deviation

40. 4. Ulceration and perforation of the septum
Causes:
Trauma; surgical, repeated cautery, digital trauma (nose picking)
Malignant disease.
Chronic inflammation; TB, syphilis
Poisons; industrial, cocaine addicts, topical corticosteroid, topical decongestants.
Idiopathic.

41. Cerebrospinal fluid (CSF) Rhinorrhoea
Nasal trauma+Clear rhinorrhoea
=CSF leak.
Aetiology
1) Trauma: fracture of the base of the skull e.g. the cribriform plate and the posterior wall of the frontal sinus
2) Spontaneous: Destructive lesion involving the floor of the anterior cranial fossa

42. Diagnosis; Clinical Picture
1) Watery fluid drips from the nose which increase in bending forward.
2) Meningitis.
Examination
Handkerchief test:
Nasal endoscope to see the site of the lesion.
Investigations
1) Identification of glucose in the secretion.
2) Injection of radioactive material into CSF via lumber puncture.
3) CT. scan of the base of the skull.

44. Treatment; Medical (Conservative); Bed rest in the head up position.
Avoidance of coughing ,sneezing, nose blowing and straining.
Reduction of CSF production rate by drugs
( acetazolamide , frusemide ) or by repeated lumber puncture.
Prophylactic antibiotics to prevent development of meningitis.
Surgical treatment;
If no response after days--- craniotomy with repair of dura with fascia lata.

45. Oroantral fistula
Definition; a fistula that communicates the oral cavity with the maxillary sinus.
Aetiology
1) Dental extraction , particularly of the 1st upper molar teeth.
2) Malignant tumours of the antrum.
3) Penetrating wound.
4) Fistula following Caldwell-Luc operation.

46. Choanal Atresia
Congenital atresia of the posterior nares due to persistence of the bucconasal membrane.
The obstruction either composed of bone (most commonly) or membrane.
F>M
Unilateral 60%( usually Rt.) noticed after years.
Bilateral (neonatal emergency) associated with other congenital anomaly.

47. Examination 1. mirror test and cotton test.
2. Plastic catheter or probe.
3. Fibroptic endoscopy

48. Investigations
Contrast radiography by instillation of radioopaque substance in the affected side.
CT scan to see the thickness of a bony atresia.

49. Treatment Bilateral  oral airway  surgical intervention.
Unilataral  elective perforation of the occlusion usually prior starting of school.

50. Thank You