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Nasal and sinus disease

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Nasal and sinus disease

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  1. Nasal and sinus disease Babak saedi M.D Assistant professor of Tehran university

  2. Anatomy

  3. Bony Structure Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate

  4. Nose and Para nasal sinuses

  5. Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear

  6. The Nose • Vascular Supply - Anterior - branches of internal carotid - Posterior - distal branches of external carotid

  7. Neurovascular Supply

  8. Analysis of nose is very important Facial Analysis

  9. Facial Analysis • Face: General • Divided in 1/3’s • trichion to NFA • NFA to subnasale • subnasale to menton

  10. 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

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

  12. Sinus • Maxillary • Frontal • Ethmoid • Sphenoid

  13. Fontanelles

  14. Nasolacrimal Duct

  15. Ethmoid Bulla Uncinate Process Hiatus Semilunaris

  16. EpistaxisAnterior • 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults Etiologies • Trauma, epistaxis digitorum • Winter Syndrome, Allergies • Irritants - cocaine, sprays • Pregnancy

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

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

  19. EpistaxisManagement • Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis

  20. Packing - anterior • BIPP impregnated gauze in layers

  21. EpistaxisPosterior Packing • Need analgesia and sedation • require admission and 02 saturation monitoring

  22. Packing - posterior • Inflatable balloons

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

  24. Osler-Weber-Rendu

  25. 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

  26. 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

  27. 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

  28. 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

  29. 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 >90 days) • Some guidelines add treatment failure + a positive imaging study

  30. 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 Differentiating Sinusitis from Rhinitis

  31. 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

  32. 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

  33. 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

  34. 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

  35. Rhinoscopy Aids in Diagnosing • Nasal polyps • Septal deviation • Concha bullosa • Eustachian tube dysfunction • Causes of hoarseness • Adenoid hyperplasia • Tumors

  36. 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

  37. Sx of Chronic Sinusitis • Nasal discharge • Nasal congestion • Headache • Facial pain or pressure • Olfactory disturbance • Fever and halitosis • Cough (worse when lying down)

  38. Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown • Streptococcus pneumoniae • Haemophilus influenza • Moraxella catarrhalis • Staph aureus • Coagulase negative staphylococcus • Anerobic bacteria

  39. CT Scan Maxillary and Ethmoid Sinuses

  40. Sinusitis

  41. Treatment of Chronic Sinusitis • Nasal steroid spray • Guafenesin • Decongestants • Steam inhalation • Nasal irrigation • Antibiotics with exacerbations

  42. FESS

  43. Sinus endoscopy

  44. Complications of Sinusitis • Orbital • Diplopia, proptosis • Periorbital erythema, swelling • Bone • Periosteal abscesses • Brain • Intracranial abscesses causing neurologic symptoms

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

  46. Looking at the turbinates: Diagnosis?

  47. Nasal Polyp