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 • • • • 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 • 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 • 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells – – – – 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 • • • • 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 • • • • • • • • • 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