1. Introduction What is otolaryngology?
What subdivisions exist within the specialty?
Is otolaryngology a medical or a surgical specialty?
How can you learn otolaryngology well?

2. What is otolaryngology?
The specialty deals with diseases of the head and neck region, the region from eyebrows to the collarbones
The specialty originally included the treatment of eye conditions and was commonly identified as EENT (eyes, ears, nose and throat)

3. What is otolaryngology?
As a result of the explosion of medical knowledge, ophthalmology split from otolaryngology many years ago
The American Academy of Otolaryngology recoginized the expanded breadth and changed the name to otolaryngology-head and neck suegery

4. What subdivisions exist within the specialty?
Initially, otology, laryngology, rhinology, and bronchoesophagology were recognized
With increased medical knowledge, pediatric otolaryngology, otolaryngological allergy, facial plastic and constructive surgery, and head and neck surgery have been identified

5. What subdivisions exist within the specialty?
Otology has been expanded to include otology, neurotology, and skull-base surgery
Otolaryngologists are interested in neurolaryngology, microvascular surgery, chemosensation (taste and smell disorders), audiology, and speech disorders.

6. Is otolaryngology a medical or a surgical specialty?
Actually, it is both. Many conditions are managed medically and require no surgery, whereas others require surgery
In common practice, for every 13 patients needing medical care, only one will require surgery

7. How can you learn otolaryngology well?
The breadth of the field and the complexity of the patients’ conditions make the specialty both challenging and stimulating
To learn it well, you should pay special attention to the disease-associated anatomic and physiological knowledge of the ear, nose and throat, as well as head and neck region

8. Rhinitis
Rhinitis is tissue inflammation and nasal hyperfunction that leads to nasal congestion/obstruction, rhinorrhea, nasal itching, and/or sneezing.

9. Pathophysiology
Nasal congestion arises from engorgement of blood vessels due to the effects of vasoactive mediators and neural stimuli.
The autonomic nervous system mediates both vascular tone and gland secretions. Sympathetic innervation constricts the vessels, decreasing congestion, whereas the parasympathetic innervation dilates the vessels, enhancing congestion.

10. Category
Rhinitis can be divided into allergic and nonallergic types

11. Allergic rhinitis
Allergic rhinitis is the most common of all atopic diseases, it affects up to 20% of the adult population in worldwide
Allergic rhinitis is clinically defined as symptomatic disorder of nose, induced after allergen exposure, by an IgE mediated inflammation of the nasal membranes

12. Common allergens
Pollens
Animal dander
Mold spores
Dust mites

13. Immdiate Hypersensitivity
For unknown reason, some individuals encounter with antigens such as plant pollens, animal dander, mold spores, dust mites, or the certain foods, or if they are exposed to certain drugs such penicillin, the dominent T cell response is the development of TH2 cells

14. allergic response in allergic rhinitis
Histamine
serotonin
Leukotriens
prostaglandins

15. Inflammation mediators
such as histamine, serotonin, leukotrienes, and prostaglandins
Dilating blood vessels, stimulating nerves, and which increase the glands secretion

16. Symptoms of allergic Rhinitis
sneezing, rhinorrhea, and nasal congestion appear promptly

17. Diagnosis of Allergic Rhinitis
Recurrent attacks of sneezing, watery rhinorrhea and nasal congestion, frequently with conjunctival irritation and consequently increased lacrimation, some with itching of soft palate.
The nasal passages contain clear mucoid secretion, and nasal mucous membrane is congested and varies in color from pale to dull red

18. Diagnosis of Allergic Rhinitis
Skin prick test Whealing response
Serum specific IgE

19. Treatment of allergic rhinitis
Avoidance of the antigen exposure
an important step
unfortunately it is often not practical
Pharmacotherapy includes
antihistamines (topical or systemic)
topical corticosteroids,
cromolyn sodium (stabilizes mast cell)
Immunotherapy may beneficial in selected patients.

20. Immunotherapy
The primary indication is symptoms not adequately controlled by avoidance measures and pharmacotherapy
Patients with perennial symptoms may prefer immunotherapy to yearlang daily medication
It begins with low-dose injections of allergen extracts and builds to a maintenance dose.

21. The causes of nonallergic rhinitis
Pharmacology (rhinitis medicamentosa)
Infection (commen cold)
Structural abnormalities
Irritation (formaldehyde)
Hormonal factors (Pregnency)
Atrophy

22. The causes of nonallergic rhinitis
Substance abuse ( cocaine, alcohol, nicotine)
Foreign bodies
Trauma
Temperature
Exercise
Recumbency
Emotions

23. The causes of nonallergic rhinitis
Decreased nasal airflow states
after laryngectomy or tracheostomy
Systemic diseases
Wegener's granulomatosis
Idiopathic disease
vasomotor rhinitis
eosinophilic or basophilic nonallergic rhinitis

24. Clinic picture of nonallergic rhinitis
Main complain is nasal obstruction
Troublesome symptom is excessive rhinorrhonea
Post-nasal drip is sometimes a complaint
On clinical examination the predominant finding the inferior turbinate are usually enlarged

25. Diagnosis and management
Diagnosis of nonallergic rhinitis is not difficult
Nasal allergy must be excluded in all cases by a careful history, skin sensitivity testing or serum specific IgE determination
Treatment depends on associated factors

26. Rhinitis medicamentosa
Drug-induced rhinitis
It is caused by rebound nasal congestion
It is often associated with prolonged use of topical decongestants. With time, the strong vasoconstrictive effect of topical decongestants leads to the metabolic accumulation of vasodilators that are responsible for the rebound vasodilation.

27. Structural abnormalities that can cause rhinitis
Deviated nasal septum
Turbinate hypertrophy
Nasal valve collapse
Intranasal and extranasal deformities
Polyps
Neoplasms (e.g., papilloma, angiofibroma, malignancy)

28. Atrophic rhinitis
or ozena, is associated with atrophy of the nasal mucosa and turbinates in association with excessive crusting and mucopurulent discharge.
This condition is marked by an extremely foul odor that can be easily detected by others.
Patients often complain of epistaxis, nasal obstruction, headaches

29. Atrophic rhinitis
Although the cause is unknown, hereditary, infectious, developmental, nutritional, and endocrine factors have been implicated.
Atrophic rhinitis may also be iatrogenic because it may be associated with excessive turbinate resection.

30. Atrophic rhinitis Although no cure exists, treatment revolves around
Frequent saline irrigation and topical antibiotics
Surgical options have been aimed at narrowing the nasal cavity and nostril

31. Treatment of nonallergic rhinitis
Should be directed toward the specific cause
correction of structural problems
treatment of infection
Symptomatic treatment includes the use of
steroids
sympathomimetic agents
anticholinergics

32. Surgery used in treating rhinitis
directed toward mechanical-obstructive issues
Surgeries include
septoplasty
polypectomies
out-fracture of the inferior turbinates
resection of hypertrophic mucosa

33. Sinusitis (Rhinosinusitis)
Sinusitis is extremely prevalent disorder that has a significant impact on the quality of life of affected individuals

34. Categories of sinusitis
Clinical categories of rhinosinusitis are largely based on the duration of symptoms and include the following:
acute up to 4 weeks
chronic > 12 weeks
This classification is symptom based and should serve only as a general guideline.

35. Pathophysiology of sinusitis
Mucosal edema of the paranasal sinuses is the basic event leading to both acute and chronic disease.
Edema may lead to obstruction of the drainage routes of the sinuses, causing stasis of secretions.
These local changes lead to impaired mucociliary clearance, alteration in local immune defenses, and ultimately bacterial overgrowth.

36. Ciliary epithelium

37. Symptoms of acute bacterial sinusitis
Nasal drainage
Nasal congestion
Facial pain/pressure
Postnasaldrip
Hyposmia/anosmia
Fever, Cough
Fatigue
Maxillary dental pain
Ear fullness/pressure

38. Symptoms of acute bacterial sinusitis
The early symptoms may be difficult to distinguished from the common cold or allergic rhinitis
Headache or facial pain, nasal obstruction, mucopurulent nasal discharge (if ostia patent)

39. Symptoms of acute bacterial sinusitis
The location of pain is related to the sinus involved
Ethmoid—medial nose or retro-orbital pain
Sphenoid—occipital, vertex,
or parietal headaches
Maxillary—suborbital tenderness, dental pain
Frontal—frontal headaches and tenderness

40. Diagnosis of acute bacterial sinusitis
in adults or children with a viral upper respiratory infection does not dissipate within 10 days (or worsens after 5-7 days) and is accompanied by some or all of those above symptoms.

41. Common organisms Most common pathogens associated
Streptococcus pneumoniae (20-40%)
Haemophilus influenzae (20-35%)
and Moraxella catarrhalis (2-10%)
Less common pathogens include
Staphylococcus aureus (0-9%)
anaerobes (0-9%)
and streptococcal species (3-9%).

42. Complications of sinusitis
Complications include
disease extension into the orbit or
intracranial structures
facial cellulites
cavernous sinus thrombosis
osteomyelitis
visual changes
mucocele formation.

43. Complications of sinusitis
Orbital complications
preseptal or orbital cellulitis
owing to easy extension of infection along the thin sinus bone surrounding the orbit on three sides.

44. Complications of sinusitis
Meningitis is usually regarded as the most common intracranial complication of sinusitis and can arise from the sphenoid or ethmoid sinuses
Epidural and subdural abscesses are most commonly associated with frontal sinusitis
A brain abscess may also occur in the setting of sinusitis and carries a high mortality rate (20-30%). It is most often associated with frontal or ethmoid disease.

45. management of acute bacterial sinusitis
In addition to antibiotics, the medical management should include adjunctive treatments directed at reducing mucosal inflammation. These commonly include
nasal steroids
topical decongestants (for the ostia patent)
mucolytics (for mucocillary cleaning)
nasal saline irrigation.

46. Symptoms of chronic sinusitis
Nasal drainage
Nasal congestion
Facial pain/pressure
Postnasaldrip
Hyposmia/anosmia
Ear fullness/pressure
Nasal polyps

47. Nasal polyps and sinusitis
Apear as soft, smooth masses, varying in color, translucent, white, yellowish, pink, or fleshy
Can arise from any part of the nasal and/or sinus mucosa, often bilateral, tend to be multiple, coexist with chronic sinusitis

48. Nasal polyps and sinusitis
Most commonly they are seen in the middle meatus, but they occur also on the medial surface of the middle turbinate

49. Nasal polyps and sinusitis

50. Nasal polyps and sinusitis

51. Nasal polyps and sinusitis

52. Nasal polyps and sinusitis

53. Often involved sinus
In the majority of cases, the maxillary sinus and anterior ethmoid sinuses are involved.
This can be predicted by the anatomy of the middle meatus or infundibulum, the location for drainage of the "anterior sinuses" (maxillary, anterior ethmoid, frontal sinuses)

54. Opening of anterior sinuses

55. Opening of anterior sinuses

56. Treatment of chronic sinusitis
The importance of bacterial infection in CRS still remains debated
Treatment options include
prolonged intranasal steroids
the use of systemic steroids
leukotriene receptor antagonists
Immunotherapy/antibiotics for select patients
Surgery for select patients

57. Surgical intervention
For chronic or recurrent sinusitis, the role of surgery is to facilitate the natural drainage of the sinuses, when possible, through correction of identifiable anatomic aberrations.

58. Surgical intervention
Generally speaking, surgery is not a cure for CRS but an adjunctive treatment option for select patients.
Medical management remains the primary option for sinusitis and is effective in the majority of patients.

59. Surgical intervention
For complicated acute sinusitis, such as subperiosteal or epidural abscesses, the role of surgery is acute decompression of the affected sinuses as well as the area of abscess.
For chronic sinusitis with polyps, surgery is indicated

60. Functional Endoscopic Sinus Surgery (FESS)
Endoscopic sinus surgery has become the preferred technique for the surgical management of most forms of sinusitis.
FESS describes a series of techniques that use nasal endoscopes for access to the paranasal sinuses rather than external approaches.

61. Functional Endoscopic Sinus Surgery (FESS)
The concept of functional surgery implies using techniques that facilitate the natural drainage patterns of the sinuses through the osteomeatal complex.

62. Functional Endoscopic Sinus Surgery (FESS)
The key concept is atraumatic surgical technique, mucosal preservation, and restoration of normal sinus physiology.
FESS may be considered an option in patients with persistent symptoms of sinusitis combined with objective evidence of disease on endoscopy and/or CT despite maximal medical therapy.

63. Fungal sinusitis
Some form of sinusitis are caused by fungal microorganisms within the sinonasal tract. The fungal infection can be either invasive or noninvasive.

64. The categories of fungal sinusitis
Acute fulminant invasive fungal sinusitis
Chronic invasive fungal sinusitis
Granulomatous invasive fungal sinusitis
Fungus balls, or mycetomas
Allergic fungal sinusitis
Eosinophilic fungal rhinosinusitis

65. Fungus balls or mycetoma
usually present as a unilateral opacification of either the maxillary or sphenoid sinus.
Patients are classically immunocompetent without evidence of atopy

66. CSF Leaks
Cerebrospinal Fluid occur due to dural tears or areas of dural weakness
Otorrhea due to temporal bone fractures
Rhinorrhea due to anterior or central skull base dural defects

67. Important Questions Recent trauma History of recurrent meningitis
Recent sinus surgery, endoscopic surgery, or neurosurgery
History of hydrocephalus, or increased intracranial pressure

68. Diognosis and management
Nasal endoscopy
Beta-2-transferrin, or beta trace protein
Imaging to localize defect. HRCT for bony defects, MRI for herniations
Endoscopic surgical repair provides 90% 1st time success

69. Diognosis and management

70. Thanks !