Nasal and sinus disease

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Nasal and sinus disease

• Babak saedi M.D
• Assistant professor of Tehran university

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Anatomy
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Bony Structure
Ethmoid Maxilla Palatine Lacrimal Pterygoid plate
of Sphenoid Nasal Inferior Turbinate
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Nose and Para nasal sinuses
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Arterial Supply
External Carotid Maxillary A.
Sphenopalatine Internal Carotid Ophthalmic A.
Ant. Ethmoid Post. Ethmoid
Supraorbital Supratrochlear
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The Nose

• Vascular Supply
• - Anterior - branches of internal carotid
• - Posterior - distal branches of external carotid

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Neurovascular Supply
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Facial Analysis

• Analysis of nose is very important

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Facial Analysis

• Face General
• Divided in 1/3s
• trichion to NFA
• NFA to subnasale
• subnasale to menton

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Function of Nose Paranasal Sinuses

• Humidifying and warming inspired air
• Regulation of intranasal pressure
• Increasing surface area for olfaction
• Lightening the skull
• Resonance
• Absorbing shock
• Contribute to facial growth

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Sinus Anatomy Overview
7 bones 4 paired sinuses 4 turbinates 3
meati Drainage system Nervous supply Vascular
supply Related structures
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Sinus

• Maxillary
• Frontal
• Ethmoid
• Sphenoid

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Fontanelles
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Nasolacrimal Duct
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Ethmoid Bulla Uncinate Process Hiatus
Semilunaris
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EpistaxisAnterior

• 90 (Littles Area) Kisselbachs plexus - usually
  children, young adults
• Etiologies
• Trauma, epistaxis digitorum
• Winter Syndrome, Allergies
• Irritants - cocaine, sprays
• Pregnancy

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EpistaxisPosterior

• 10 of all epistaxis - usually in the elderly
• Etiologies
• Coagulopathy
• Atherosclerosis
• Neoplasm
• Hypertension (debatable)

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EpistaxisManagement

• Pain meds, lower BP, calm patient
• Prepare ! (gown, mask, suction, speculum, meds
  and packing ready)
• Evacuate clots
• Topical vasoconstrictor and anesthetic
• Identify source

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EpistaxisManagement

• Anterior Sites
• - Pressure /- cautery and/or tamponade
• - all packs require antibiotic prophylaxis

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Packing - anterior

• BIPP impregnated gauze in layers

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EpistaxisPosterior Packing

• Need analgesia and sedation
• require admission and 02 saturation monitoring

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Packing - posterior

• Inflatable balloons

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EpistaxisComplications

• severe bleeding
• hypoxia, hypercarbia
• sinusitis, otitis media
• necrosis of the columella or nasal ala

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Osler-Weber-Rendu
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Scope of Sinusitis

• Affects 30-35 million persons/year
• 25 million office visits/year
• Direct annual cost 2.4 billion and increasing
• Added surgical costs 1 billion
• Third most common diagnosis for which antibiotics
  are prescribed

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Sinusitis
Infectious or noninfectious inflammation of 1 or
more sinuses

• 4 paranasal sinuses, each lined with
  pseudostratified ciliated columnar epithelium
  and goblet cells
• Frontal
• Maxillary
• Ethmoid
• Sphenoid

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Ostiomeatal Complex

• Ostiomeatal complex is that area under the middle
  meatus (airspace) into which the anterior
  ethmoid, frontal and maxillary sinuses drain
• Posterior ethmoids drain into the upper meatus
• Ostiomeatal complex is the functional
  relationship between the space and the ostia that
  drain into it

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Viral Rhinosinusitis

• Most upper respiratory infections are viral
• Short lived, last less than 10 days
• Sinus mucosa as well as nasal mucosa is involved
• Most will clear without antibiotics
• Treatment decongestants, nasal lavage, rest,
  fluids

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Classification of Bacterial Sinusitis

• Acute bacterial sinusitis- infection lasting 4
  weeks, symptoms resolve completely (children 30
  days)
• Subacute bacterial sinusitis- infection lasting
  between 4 to 12 weeks, yet resolves completely
  (children 30-90 days)
• Chronic sinusitis- symptoms lasting more than 12
  weeks (children gt90 days)
• Some guidelines add treatment failure a
  positive imaging study

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Differentiating Sinusitis from Rhinitis

• Sinusitis
• Nasal congestion
• Purulent rhinorrhea
• Postnasal drip
• Headache
• Facial pain
• Anosmia
• Cough, fever

• Rhinitis
• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

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Pathogenesis of Nasal Obstruction

• Viral upper respiratory infections
• Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
• Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
• Deviated septum, concha bullosa, polyps

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Treatment of Acute Sinusitis

• Antihistamines recommended if allergy present
• Oral or topical
• Decongestants
• Oral or topical
• Antibiotic when indicated (bacteria)
• Nasal irrigation
• Guaifenesin 200-400 mg q4-6 hrs
• Hydration

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Antibiotics for Acute Bacterial Sinusitis

• Amoxicillin 500 mg tid for 10-14 days
• First line choice in most areas
• Local differences in antibiotic resistance occur
• Where beta-lactamase resistance is an issue
• Amoxicillin/clavulanate
• Cefuroxime
• Cefexim
• Cefprozil

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Additional Antibiotics for Acute Bacterial
Sinusitis

• Amoxicillin should be considered because of its
  efficacy, low cost, side-effect profile, and
  narrow spectrum (45-90 mg/kg/d in children 500
  mg tid or qid in adults for 10 to 14 days)
• If penicillin-allergic clarithromycin or
  azithromycin
• Erythromycin does not provide adequate coverage
• Trimethoprim/suflamethoxazole and
  erythro/sulfisoxazole have significant
  pneumococcal resistance

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Rhinoscopy Aids in Diagnosing

• Nasal polyps
• Septal deviation
• Concha bullosa
• Eustachian tube dysfunction
• Causes of hoarseness
• Adenoid hyperplasia
• Tumors

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Chronic Sinusitis

• Symptoms present longer than 8 weeks or 4/year in
  adults or 12 weeks or 6 episodes/year in children
• Eosinophilic inflammation or chronic infection
• Associated with positive CT scans
• Poor (if any) response to antibiotics

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Sx of Chronic Sinusitis

• Nasal discharge
• Nasal congestion
• Headache
• Facial pain or pressure
• Olfactory disturbance
• Fever and halitosis
• Cough (worse when lying down)

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Bacteria Involved in Chronic Sinusitis Role of
Viruses is Unknown

• Streptococcus pneumoniae
• Haemophilus influenza
• Moraxella catarrhalis
• Staph aureus
• Coagulase negative staphylococcus
• Anerobic bacteria

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CT Scan Maxillary and Ethmoid Sinuses
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Sinusitis
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Treatment of Chronic Sinusitis

• Nasal steroid spray
• Guafenesin
• Decongestants
• Steam inhalation
• Nasal irrigation
• Antibiotics with exacerbations

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FESS
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Sinus endoscopy
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Complications of Sinusitis

• Orbital
• Diplopia, proptosis
• Periorbital erythema, swelling
• Bone
• Periosteal abscesses
• Brain
• Intracranial abscesses causing neurologic
  symptoms

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Nasal obstruction

• Infection
• Allergy
• Adenoid hypertrophy
• Nasoseptal deformity
• Chronic sinusitis
• Septal hematoma (abscess)
• Foreign body
• Neoplasm
• Choanal atresia

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Looking at the turbinates Diagnosis?
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Nasal Polyp
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Septal deviation
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Allergic Rhinitis