Transcript Nasal and sinus disease - Tehran University of Medical

Nasal and sinus disease
Babak saedi M.D
Assistant professor of Tehran
university
Anatomy
Bony Structure
Ethmoid
Maxilla
Palatine
Lacrimal
Pterygoid plate of
Sphenoid
Nasal
Inferior Turbinate
Nose and Para nasal sinuses
Arterial Supply
External Carotid
Maxillary A.
Sphenopalatine
Internal Carotid
Ophthalmic A.
Ant. Ethmoid
Post. Ethmoid
Supraorbital
Supratrochlear
The Nose
• Vascular Supply
- Anterior - branches
of internal carotid
- Posterior - distal
branches of
external carotid
Neurovascular Supply
Facial Analysis
Analysis of nose is very
important
Facial Analysis
• Face: General
– Divided in 1/3’s
• trichion to NFA
• NFA to subnasale
• subnasale to menton
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
Sinus Anatomy Overview
7 bones
4 paired sinuses
4 turbinates
3 meati
Drainage system
Nervous supply
Vascular supply
Related structures
Sinus
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Maxillary
Frontal
Ethmoid
Sphenoid
Fontanelles
Nasolacrimal Duct
Ethmoid Bulla
Uncinate Process
Hiatus Semilunaris
Epistaxis
Anterior
• 90% (Little’s Area) Kisselbach’s plexus usually children, young adults
Etiologies
• Trauma, epistaxis digitorum
• Winter Syndrome, Allergies
• Irritants - cocaine, sprays
• Pregnancy
Epistaxis
Posterior
• 10% of all epistaxis - usually in the elderly
• Etiologies
• Coagulopathy
• Atherosclerosis
• Neoplasm
• Hypertension (debatable)
Epistaxis
Management
• Pain meds, lower BP, calm patient
• Prepare ! (gown, mask, suction, speculum,
meds and packing ready)
• Evacuate clots
• Topical vasoconstrictor and anesthetic
• Identify source
Epistaxis
Management
• Anterior Sites
- Pressure +/- cautery
and/or tamponade
- all packs require
antibiotic prophylaxis
Packing - anterior
• BIPP
impregnated
gauze in layers
Epistaxis
Posterior Packing
• Need analgesia and
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sedation
require admission and
02 saturation
monitoring
Packing - posterior
• Inflatable
balloons
Epistaxis
Complications
• severe bleeding
• hypoxia, hypercarbia
• sinusitis, otitis media
• necrosis of the columella or nasal
ala
Osler-Weber-Rendu
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
Sinusitis
Infectious or noninfectious inflammation of 1 or more sinuses
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4 paranasal sinuses, each lined with pseudostratified
ciliated columnar epithelium and goblet cells
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Frontal
Maxillary
Ethmoid
Sphenoid
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
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
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 3090 days)
• Chronic sinusitis- symptoms lasting more than 12
weeks (children >90 days)
• Some guidelines add treatment failure + a positive
imaging study
Differentiating Sinusitis from Rhinitis
Sinusitis
Rhinitis
Nasal congestion
Nasal congestion
Purulent rhinorrhea
Rhinorrhea clear
Postnasal drip
Runny nose
Headache
Itching, red eyes
Facial pain
Nasal crease
Anosmia
Seasonal symptoms
Cough, fever
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
Treatment of Acute Sinusitis
• Antihistamines recommended if allergy present
– Oral or topical
• Decongestants
– Oral or topical
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Antibiotic when indicated (bacteria)
Nasal irrigation
Guaifenesin 200-400 mg q4-6 hrs
Hydration
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
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
Rhinoscopy Aids in Diagnosing
• Nasal polyps
• Septal deviation
• Concha bullosa
• Eustachian tube dysfunction
• Causes of hoarseness
• Adenoid hyperplasia
• Tumors
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
Sx of Chronic Sinusitis
• Nasal discharge
• Nasal congestion
• Headache
• Facial pain or pressure
• Olfactory disturbance
• Fever and halitosis
• Cough (worse when lying down)
Bacteria Involved in Chronic Sinusitis
Role of Viruses is Unknown
• Streptococcus pneumoniae
• Haemophilus influenza
• Moraxella catarrhalis
• Staph aureus
• Coagulase negative staphylococcus
• Anerobic bacteria
CT Scan Maxillary and Ethmoid Sinuses
Sinusitis
Treatment of Chronic Sinusitis
• Nasal steroid spray
• Guafenesin
• Decongestants
• Steam inhalation
• Nasal irrigation
• Antibiotics with exacerbations
FESS
Sinus endoscopy
Complications of Sinusitis
• Orbital
– Diplopia, proptosis
– Periorbital erythema, swelling
• Bone
– Periosteal abscesses
• Brain
– Intracranial abscesses causing neurologic symptoms
Nasal obstruction
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Infection
Allergy
Adenoid hypertrophy
Nasoseptal deformity
Chronic sinusitis
Septal hematoma (abscess)
Foreign body
Neoplasm
Choanal atresia
Looking at the turbinates:
Diagnosis?
Nasal Polyp
Septal deviation
Allergic Rhinitis