Lecture’s Objectives Chronic Sinusitis Mucocele Tumors of the nose and paranasal sinuses Disorders of Smell

Chronic Sinusitis Definition : is defined as 8 weeks of persistent symptoms and signs of sinusitis that does not respond to appropriate and aggressive medical therapy . In this case the long-standing infection of the sinus will lead to irreversible change in the mucosa even when the original cause of infection is removed.

The most commonly affected sinus is the maxillary sinus because its osteum is high and not gravity dependant.

Pathophysiology Factors which impair the normal physiology of the paranasal sinuses are; (1) Obstruction of the sinus ostea a) Factors causing mucosal swelling b) Factors causing mechanical obstruction (2) Impaired function of the cilia Secondary.. Primary.. (3) Overproduction or change in the viscosity of secretions

Chronic Maxillary Sinusitis Predisposing factors: 1) Nasal: * Obstruction of the drainage ostia *Recurrent acute infection *Chronic irritation from environmental gases.

2) Dental( 10% of cases) The upper 2nd premolar and the 1st and 2nd molar impinge closely on the floor of the maxillary antrum and may penetrate it. .. Root infection or dental abscesses. .. Anaerobes. .. The secretion is characteristically fetid . .. Healing is impossible without dental treatment.

Pathology: Chronic sinusitis can be divided pathologically into: 1) Chronic hypertrophic sinusitis : there is hypertrophy of mucosa due to increase vascular permeability. 2) Chronic atrophic sinusitis: (less common) there is generalized flattening of the epithelium due to endarteritis obliterans of the arterioles.

Diagnosis:/ History Major symptoms Nasal discharge (copious greenish, yellowish post nasal discharge) Nasal obstruction (due to swelling of inferior turbinate ) Headache and facial pain (due to blockage of drainage ostea and build up of secretion) Anosmia( because air not reach the olfactory region) and cacosmia (i.e. unpleasant smell, due to chronic odiferous sepsis). b) Minor symptoms Fever Halitosis (bad mouth odor )

chronic irritation in side the nose may produce vestibulitis nose bleeds otitis media granular pharyngitis chronic laryngitis

Examination /often unhelpful Normal Generalized inflammation of the mucosa Purulent secretion or crusts. If a vasoconstrictor is used to shrink the nasal mucosa, pus may be seen emanating from the middle meatus. Otitis media and granular pharyngitis may be present in the absence of any specific nasal symptoms.

Investigation Radiography;

2) CT scan Coronal CT scan provide most information about the osteo-meatal complex

3) Endoscopic assessment: Important features to be looked for during endoscopy are; The presence of pus in the middle meatus. The cause of osteal obstruction . Sometimes biopsy is taken to confirm the diagnosis.

Treatment: The principle of treatment is to restore the normal mucosa to the sinus lining. If this is not possible, i.e. when the mucosa has been irreversibly changed, then the mucosa may need to be removed. At the stage of chronic changes medical treatment has been tried and is of no value.

Surgical treatment of the chronic maxillary sinusitis include; FESS (functional endoscopic sinus surgery ) to remove only the diseased areas in order to relieve the obstruction and so restore natural sinus drainage, ventilation and physiology.

. 2. Antral lavage. 3. Intranasal antrostomy. 4. Caldwell-Luc procedure .

Complication of chronic sinusitis; Mucoceles : Definition; A mucocele is a mucous-containing cyst completely filling a sinus and capable of expansion They arises in order of frequency in the frontal Frontoethmoidal ethmoidal maxillary sphenoidal sinuses

Aetiology 1) Polyps. 2) Trauma. 3) Tumours. 4) previous surgery particularly in the frontal recess. Over 30 years can elapse between the traumatic event and the clinical presentation of a mucocele.

Frontoethmoidal mucocele Clinical presentation; In the early stages the patient is asymptomatic In the frontal type , a dull ache develops and a swelling appears at the supramedial aspect of the orbit. The swelling is tender and feels rubbery Increase in size thins the bone more and pressure may damage the optic nerve or vasculature causing blindness. Infection pyocoele / dangerous Increase enlargement proptosis.

Radiography of the sinus; Thinning of the bone. Displacement of the medial frontal sinus floor downwards . Loss of scalloping . The intersinus septum may be displaced or eroded. CT scan is important in determining the anatomy and extent of the lesion.

Treatment; Is by evacuation of the contents of the sinus by ; Endoscopic technique. Radical frontal sinus operation. Osteoplastic flap operation

Radical frontal sinus operation.

Osteoplastic flap operation

Tumors of the nose and paranasal sinuses Benign ; e.g. Squamous papilloma (in the vestibule) , osteoma (in frontal ,ethmoidal and maxillary sinus) , Haemangiomas (on nasal septum) angiofibroma and inverted papilloma . Malignant tumours ( uncommon); Squamous carcinoma (is the most common) followed by adenocarcinoma, malignant melanoma, ethesioneuroblastoma, sarcoma and lymphoma.

Squamous papilloma

Osteoma

About malignant tumours: The maxillary sinus is the most common site Do not usually occur in heavy smoking or heavy drinking population. …..(e.g. adenocarcinoma in woodworkers) The chief symptoms of nasal malignancy are unilateral obstruction with haemorrhage Men > woman , average age at presentation is 60 Tumours of the skin of the nose are probably the most common of the facial cancer.

Inverted papilloma (Transitional cell papilloma or Schneiderian papilloma); This lesion represents about 4% of all nasal neoplasms. It is the most common benign neoplasm of the nose and sinuses.

Aetiology; unknown. Sex; Male-female ratio 5-1. Age; most commonly in the 5th decade. Site of origin; lateral wall of the nose (occasionally from the septum) with extension to the ethmoid and maxillary

Clinical presentation; Unilateral nasal polyp → unilateral nasal obstruction and sinusitis of all groups. The tumour is soft and friable and may become detached or bleed with hard nose blowing.

X-Ray and CT scan of the sinuses;

Histopathological examination ; The surface of the tumour is covered by alternating layers of squamous and columnar epithelium, i.e. transitional type of epithelium. The lesion is characterized by; Being locally aggressive and causing bony erosion. Tendency to undergo malignant change in about 2-5% of patient. There may be coincidental malignancy elsewhere in the upper respiratory tract . It has high propensity for recurrence after removal.

Treatment Is by adequate local excision usually through lateral rhinotomy approach.

Disorders of smell The olfactory cleft occupies the upper third of the nasal cavity in the area between the superior turbinate, cribriform plate and corresponding area of the septum and is lined by specialized olfactory epithelium (this is a specialized pseudostratified neuroepithelium containing the primary olfactory receptors and has a golden yellow color ).

Terminology; Anosmia; Inability to detect odors. Hyposmia; Decreased ability to detect odors. Parosmia; Altered perception of smell in the presence of an odor. Phantosmia; Smelling of nonexistent odor . ( Both parosmia and phantosmia are associated with epilepsy and olfactory hallucination of schizophrenia ). Cacosmia ; Unpleasant smell, due to chronic odiferous sepsis.

Classification of olfactory dysfunction: Conductive anosmia; Is due to impaired transport of airborne odorants to the olfactory cleft. Neuronal anosmia; Is due to impairment of olfactory epithelial function or disrupted neuronal pathway.

Causes of olfactory dysfunction; Obstructive nasal disease (23%) : Postviral anosmia (19%): Head trauma (15%): Toxins, drugs ( 3% ):e.g. Aminoglycosides, formaldehyde, alcohol, nicotine, … Miscellaneous (21% ): Aging, neoplastic, psychologic, nutritional deficiencies (e.g. vitamin A , thiamine ) and other causes. Idiopathic ( 21% ).

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