THE NOSE AND PARANASAL SINUSES Dr. Ali A. Muttalib Mohammed Assistant Professor/ Consultant Otolaryngologist Head of ENT Dept, College of Medicine, University of Mosul In charge, Mosul Centre, Iraqi Board of Otolaryngology Undergraduate, The Nose, 2013/2014

Pathology: Causes – Etiology of symptoms 1- Congenital 2- Traumatic Foreign body Accident Iatrogenic 3- Inflammatory Acute: Chronic: Specific: Nonspecific: 4- Neoplastic Benign: Malignant 5- Others

Inflammation of the Nose Ali A. Muttalib Assistant Professor of Otolaryngology Mosul Medical College R Undergraduate, The Nose, 2013/2014

Symptomatology: Bilateral Obstruction Nasal 1- Congenital Bil. Choanal atresia Deviated septum 2- Traumatic Foreign body Accident: Fracture- Haematoma Iatrogenic: Pack-Haematoma 3- Inflammatory Acute nonspecific: Common cold-Abscess Acute specific: Diphtheria Chronic nonspecific: At. - Hypertrophic Chronic specific: $ – T.B. - Scleroma 4- Neoplastic Benign: Ostioma -papilloma Malignant: Carcinoma - Sarcoma 5- Others Allergy Polyps

Skin: Furunculosis. Mucous Membrane a. Rhinitis: Acute :common cold (coryza). Chronic: Hypertrophic. Atrophic. b. Sinusitis: Acute. Chronic.

Furunculosis (nasal boil) Staphylococcal infection of the hair follicles of the nose due to interference with the vibrissae. Clinical Picture 1. Pain, tenderness, redness and swelling of the tip of the nose. 2. Headache + fever.

Complications -Cavernous sinus thrombophlebitis. -Septal abscess and cellulitis of the upper lip. Treatment -Squeezing must be avoided to prevent spread of infection through the valveless facial veins to the cavernous sinus. -Antistaphylococcal antibiotics; Cloxacillin and Flucloxacillin. -Lubrication of the infected area with an ointment like fucidic acid.

Acute Rhinitis (Coryza, common cold) Viral infection of the nasal mucosa by picorona virus, RSV or rhino virus. Transmission occurs by airborne droplets. Increased activity of the normal pathogenic bacteria of the nose can cause secondary infection.

Clinical Picture -Prodormal stage (mucosal ischaemia): Irritation, dryness and sneezing. -Acute stage (hyperaemia): Nasal obstruction, nasal secretion, fever and malaise. -Recovery stage: The discharge become thick, more purulent and the nose become more obstructed. Later the nasal passages reopened and normal breathing is reestablished.

Treatment -Bed rest and steam inhalation. -Decongestant nasal drops or sprays to promote drainage of secretions. -Analgesics and antihistamines. -Antibiotics is not normally necessary but is of value in preventing secondary bacterial infection.

Chronic Hypertrophic Rhinitis (Rhinitis Medicamentosa) This condition is frequently seen in patients with prolonged and excessive use of nasal decongestant drops (rhinitis medicamentosa).

Aetiology In this condition after the vasoconstrictor effect of the drops wears off, a rebound increase in mucosal swelling occurs requiring further use of the nasal drops. The ciliary action is lost and the patient therefore uses the drop with increasing frequency to achieve the same effect. Later a chronic nasal obstruction unresponsive to decongestant drops results. It is not recommended therefore that these agents are used for longer than 5 days.

Pathology The ciliated epithelium changes to stratified squamous or cuboidal epithelium. There is an increase in fibrous tissue and infiltration with round and plasma cells. Clinical Picture 1. Nasal obstruction, mouth breathing and snoring. 2. Nasal discharge and postnasal drip. 3. Mild headache and anosmia.

Examination -Swelling and redness of the mucous membrane. -Sticky and mucopurulent secretions. -Enlarged inferior turbinate and its posterior end has mulberry like appearance (purple and engorged).

Treatment -Treatment of the cause. -Medical: istonic alkaline nasal douche + topical and systemic steroids. -Surgical if no response to medical treatment by reduction of the size of the inferior turbinate by submucosal diathermy (SMD), cryosurgery, laser, and turbinectomy.

Atrophic Rhinitis A chronic inflammation of the nasal mucosa characterized by atrophy of the mucous membrane and underlying bone of the turbinate.

Aetiology -Idiopathic: young females. -Secondary: Infection: klebsiella ozaenae, chronic rhinitis. Extensive nasal surgery. Endocrine imbalance: The disease usually starts at puberty, involves females more than males and tends to cease after meanopause. Malnutrition: Deficiency of vitamin A,D or iron Autoimmune disease.

Pathology The submucosal vessels undergo endarteritis and periarteritis and there is metaplasia of the ciliated columnar epithelium to non-ciliated cuboidal or stratified squamous epithelium with atrophy of the nasal glands. Clinical Picture Primary atrophic rhinitis is common in young females at puberty. -Nasal obstruction in spite of wide nasal passages due to lack of normal sensation of airflow. -Epistaxis, anosmia and headache.

Examination -Bad odour (fetor, ozaena) which is not appreciated by the patient who is anosmic. -Wide nasal passages (roomy nose). -Crustation due to ciliary destruction so the nasal secretions are no longer expelled from the nose.

Local antibiotic ointments to eliminate secondary infection. Treatment -Treatment of the cause. -Medical: Regular cleaning of the nose by alkaline nasal douche which can be made from a powder consisting of equal parts of sodium bicarbonate and sodium chloride. A teaspoonful of powder can be dissolved in 0.25 liter of warm water and used 2-3X/day. Crust formation is discouraged by the application of 25% glucose in glycerine. Local antibiotic ointments to eliminate secondary infection.

-Surgical if no response to medical treatment by surgical closure of the nostrils for one year (Young’s opearetion).

RHINOSINUSITIS Is the inflammatory condition of the mucous membrane lining the sinus. Sinusitis may be open or closed depending on whether the inflammatory products of sinus cavity can drain freely into the nasal cavity or not. A closed sinusitis causes more severe symptoms and is likely to cause complications. Sinusitis could be acute or chronic.

Sinusitis: Acute sinusitis Dr. TTT Organism Patient Virulence Resistence Chronic Cure

Sinusitis: Mucociliary Clearance MCC The MCC system of the upper respiratory tract is taking a predetermined pathway. The MCC of the maxillary sinus is in a star shape manner towards the natural ostium i.e. antigravity. The MCC of the frontal sinus is again towards the natural ostium.

Acute Rhinosinusitis Aetiology 1. Acute rhinitis, common cold and influenza. 2. Dental infection or extraction (premolars and molars). 3. Swimming and diving. 4. Fractures involving the sinus wall.

Bacteriology Most cases of sinusitis start as viral infections followed by bacterial invasion. The causative bacteria in order of frequency are Pneumococci, H. influenzae and Branhamella catarrhalis. E. coli and anaerobic infection associated with sinusitis of dental origin.

Clinical Picture One sinus can be affected, but it is more common that the whole sinuses share the infection. 1. Pain across the infected sinus a. Maxillary sinusitis; this sinus is affected more than other sinuses because of its high ostium. The pain is on the cheek accompanied by a feeling of fullness below the eyes. Pain on the upper teeth may be the first sign of sinusitis.

b. Ethmoidal sinusitits: the pain is deep behind the eyes b. Ethmoidal sinusitits: the pain is deep behind the eyes. The infection can extend to the orbit across the thin lamina papyracea leading to thickening and swelling of the medial part of the orbit.

c. Frontal sinusitis: it is usually associated with ethmoiditis c. Frontal sinusitis: it is usually associated with ethmoiditis. The pain is located above the eyes. It usually starts after waking up and subside later in the afternoon. The pain increases in bending forwards. Infection can cause oedema and puffiness over the upper eyelid. d. Sphenoidal sinusitis: it is particularly associated with infection of the posterior ethmoidal air cells. The pain is localized to the tip of the head and may produce pain over the distributions of the trigeminal nerve because of the close proximity of the nerve to the sinus

2. Nasal obstruction; because of pus and oedema. 3. Nasal discharge; from the anterior nares in infection of the anterior group of sinuses and from the posterior nares (choanae) in infection of the posterior ethmoidal and sphenoidal sinuses. 4. Pyrexia and malaise.

Examination 1. Tenderness over the infected sinus. 2. The mucous membrane is reddened and oedematous. Pus may be seen in the middle meatus in infection of the anterior group of sinuses or in the postnasal space if the posterior group is infected.

Investigation 1. Radiology a. X-ray: opacification or a fluid level. b. CT scan: when complications are expected or when major surgery is anticipated. 2. Bacteriology: by doing antral lavage and sending the pus for C/S (proof puncture). 3. Sinuscopy.

Air Fluid Level in Maxillary Sinus

Bilateral Maxillary, Unilateral Ethmoid RS Coronal CT through Ostiomeatal Complex, with Maxillary, Anterior Ethmoid and Lower Frontal Sinuses Visible (most valuable single CT “cut”) Normal Bilateral Maxillary, Unilateral Ethmoid RS

Treatment 1. Treat the cause. 2. Medical: a. Analgesics; aspirin + codeine. b. Antibiotics; broad spectrum antibiotics. amoxycillin, augmentin or cefuroxime. If the patient is allergic  erythromycin or cortrimoxazole. In infection of dental origin metronidazole should be added. The treatment should last for ten days. The new generations of quinolones (Levofloxacin, Moxifloxacin) are recently used and has the advantage of single daily dose.

c. Local decongestants to shrink the mucosa and assist sinus drainage, e.g. ephidrine, xylometazoline (Otrivin) and naphazoline (Nasophrine). The drops should be installed in head down position and the treatment should last for not more than five days.

3. Surgical: if no response to medical treatment. a. Maxillary antral lavage (antral wash) as this is the conductor of orchestra. If this sinus infection settles, oedema of the middle meatus disappears and permits adequate drainage of the anterior group of sinuses. b. Frontal sinus drainage  trephine (external drainage).

Chronic Sinusitis A long standing inflammation of the sinus mucosa and these changes are irreversible. Chronic sinusitis has recently been defined as 8 weeks of persistent symptoms and signs or 4 episodes/year of recurrent acute sinusitis, each lasting at least 10 days, in association with persistent changes on CT scan 4 weeks after adequate medical therapy.

Predisposing Factors I. Local 1.Local nasal abnormality, e.g. polyps or septal deviation and adenoid hypertrophy. 2. Recurrent acute sinusitis. 3. Dental abscess or root infection. II. General 1. Immunodeficiency diseases. 2. Mucociliary disorders: Kartagener’s syndrome.

Pathology The ciliated epithelium is replaced by stratified or cuboidal epithelium. There is increase in fibrous tissue and infiltration with round and plasma cells. Bacteriology It is mixed aerobic and anaerobic infection. Streptococci including the anaerobic ones are common. Proteus, E. coli and pseudomonous are often secondary invaders.

Clinical Picture -Nasal and postnasal discharge which may be mucopurulent. -Nasal obstruction due to swelling of the inferior turbinate and secretions. -Anosmia and cacosmia. - Local pain and Headache are less marked, often described as dullache and the timing is lost. -These purulent secretions can lead to otitis media, pharyngitis and chronic laryngitis.

Examination Mucopurulent discharge and crusts by anterior rhinoscopy. Endoscopic examination of the nose is important to evaluate the nose and paranasal sinuses, especially the area of the middle meatus which is the site of the drainage of the sinuses.  Investigations -Radiology: X-ray and CT scan shows thickening of the mucosa lining the sinuses with polyp formation. -

Normal CT and CT of chronic sinusitis

Chronic sinusitis

Treatment The principle is to achieve aerations of the sinuses to restore the ciliary ability. -Treat the cause. -Medical treatment +Nasal toilet by alkaline nasal douche. +Antibiotics: augmentin+metronidazole. +Topical steroids (sprays or drops) to reduce mucosal swelling. -Surgical: if there is no response to medical treatment by endoscopic sinus surgery.

Complications of Sinusitis Routes of Spread -Direct spread; through bony wall as through lamina papyracea from ethmoidal sinusitis leading to orbital complications or through the floor of the anterior cranial fossa to the frontal lobe from frontal sinusitis. -Venous spread; through the facial and superior ophthalmic veins to the cavernous sinus. -Lymphatic spread; to the submandibular and deep cervical lymphnodes. -Perineural spread; through olfactory fibers across the cribriform plate.

Acute -Orbital complications; it is seen most frequently as a complication of ethmoidal sinusitis. These include: 1. Cellulitis of the eyelids. 2. Sub-periosteal abscess. 3. Orbital cellulites. -Intracranial complications; complicate frontal and ethmoidal sinusitis. These include: 1. Meningitis and encephalitis. 2. Intracranial abscesses 3. Cavernous sinus thrombophlebitis

Orbital cellulitis

-Bony a. Ostetis  compact bone  (maxillary). b. Osteomylitis  diploic bone  (frontal): Pus may form externally under periosteum (Pott’s puffy tumour). -Respiratory tract complications Pharyngitis, tonsillitis, otitis media and bronchitis. Chronic Mucocele and pyocele: collection of mucous inside the sinus occurs when the ostia became blocked. Pyocele forms when a mucocele become secondary infected. Mucocele occurs most commonly in the frontal followed by the ethmoidal sinuses.

Frontal osteomylitis

Frontoethmoidal mucocele

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