Docstoc

CHRONIC RHINITIS

Document Sample
CHRONIC RHINITIS Powered By Docstoc
					ANATOMY, PHISIOLOGY and
DISEASES of the NOSE and
  PARANASAL SINUSES
Head of otolaryngology department
   Prof. Alexander I. Yashan
Anatomy of the nose
Line drawing of the key arterial
     vessels of the nose.
Line drawing of the sagittal view of the lateral nasal wall indicating
      the approximate location of the major sensory nerves.
Computerized axial tomography (CAT) radiograph of the
nose.Coronal section view of the osteomeatal unit.Note
              bilateral concha bullosa.
NASAL SEPTUM ANATOMY
NASAL SEPTUM DEFORMITY
      (DEVIATION)
   NASAL SEPTUM DEFORMITY
         (DEVIATION)
• This pathology meets in many people and practically it’s
  impossible to meet a person with not deviated nasal
  septum. Deformation of nasal septum long time can
  remain not noticed and cause not complaints. Only at
  violation of the nasal breathing or appearance of other
  symptoms its deformity is diagnosed.
• Attend factors
• Traumas of the nose (75 % of cases).
• Inconsistency between growth of nasal septum and nasal
  cavity. Nasal septum growths quicker then nasal cavity.
• Congenital deformity (rachitis).
• Compensate deformity (pressure on septum by
  hypertrophied nasal turbinates, or by tumor of the nose).
Clinic of Nasal septum DEFORMITY
•   One side or both sides nasal airway
    obstruction (heavy breathing through the
    nose) especially in horizontal position.
•   Nasal drainage.
•   Hyposmia.
•   Deformation of external nose (cosmetics).
•   Nose-bleeds.
                       Diagnostics
•Anamnesis (trauma). General examination of the face
Anterior and posterior rhinoscopy – it is possible to see the deformity
of nasal septum either in cartilaginous or in bony parts or in both septum
parts:
S-like, arched, angled-like deformity; ridge or spur of the septum.
•The anemization of a nasal mucous lining (by a cotton tip applicator
moistened with lidocain+adrenalin 1:10 solution) for best visualization of
deeper departments of the nasal cavity;
•Probing of the nose after anemization by the cotton tip applicator.
•X-ray.
  Complications – appears due to
    nasal congestion or due to
      pathological reflexes:
• Acute and chronic rhinitis (hypertrophy), vasomotor rhinitis;
• Acute and chronic sinusitis (due to deterioration of sinuses
  aeration and drainage);
• Acute and chronic otitis media (due to dysfunction of
  eustachian tube);
• Acute and chronic pharyngitis (due to breathing through
  the mouth);
• Acute and chronic laryngitis;
• Conjunctivitis (due to dysfunction of nasolacrimal canal);
• Reflex disorders of internal organs (bronchial asthma,
  asthmatic bronchitis, enuresis, and headache).
                 Treatment
• Nasal septum deformity is treated by a surgical
  method only. Indications for septoplasty are the
  nasal congestion and full airway obstruction, or
  presence of other complications.
• There are several variants and methods of
  operation. The most accepted surgical methods are:
• Radical submucous nasal septum resection (Killian
  approach).
• The sparing operations (Voyachec approach):
• a/ mobilization;
• b/ redresation;
• c/ circular resection;
• d/ partial resection
       FURUNCLE OF the NOSE
- inflammation of fat glands or hair
follicles, located in entrance of the
nose or on its external surface.
Pathogenic organisms: most
common are staphylococci and
streptococci.
Attend factors
1. Micro trauma of nasal skin (during
self cleaning).
2. Irritation of nasal skins by dischar-
ges due to acute rhinitis or sinusitis.
3. General furunclousis.
4. Diabetes or other metabolic
disorders.
                            Clinic
• Spontaneous pain in the nose especially in the site of furuncle.
• Fever.
• Edema of nasal skin and surrounding tissues.
• General inspection and anterior rhinoscopia
• Cone-shaped infiltrates on one of nostril’s walls or on the
  external surface of the nose.
• Painfulness and edema of the external nose and surrounding
  tissue: cheek, bridge of the nose, upper lip, eyelids.
• Redness of nasal skin, it is tense and very sensible.
• On a 3-5 day, and sometimes later, in the center of furuncle
  appears purulent cavity, with opening on apex. At the beginning
  pus is liquid dripping out, forming scab on the furuncle surface
  and masking real infiltrate. After removing of scab, thin hole can
  be revealed. Then contents of furuncle become jelly-like,
  forming shank (grey necrotic masses). It can be removed itself,
  either by doctor, or by the patient himself.
• It is categorically banned to squeeze out pus from the
  furuncle of nose, as it can result in intracranial
  complications (thrombosis of cavernous sinus).
           Complications
• Lymphadenitis of cervical lymphatic nodes.
• Thrombosis of facial veins.
• Thrombosis of cavernous sinus of brain is
  the most serious complication of the
  furuncle. It appears due to spreading of
  inflammatory thrombosis from facial veins to
  the cerebral sinuses (through anastomosis
  between angular vein - the branch of facial
  vein and ophthalmic vein – from
  cavernous sinus).
                             Treatment
• 1. Greasing of a skin by antiseptics ointments, or ointments with antibiotics
  and corticosteroids.
• 2. Surgical incision of furuncle (after appearance of purulent apex) with
  draining by rubber band.
• 3. Anti-inflammatory drugs.
• 4. Antibacterial therapy (antibiotics - better passing through blood brain
  barrier).
• 5. Physical therapy procedures (fonoforesis with ointments) at the end of
  disease.
• Patients with the furuncle of nose must be treated in hospital.
• Care of patient
• Progressing edema of patient’s face soft tissue has to disturbance medical
  personal, as well as changes of consciousness and septic sings: fever
  with chills and sweating all over, strengthening of headache, appearance
  of meningeal signs, dizziness, and vomits. Appearance of such
  pathological sings indicates on development of intracranial complications.
                                • Prophylaxis
• 1. Tempering of organism.
• 2. Medical treatment of acute rhinitis.
• 3. Medical treatment of endocrine diseases (diabetes).
          RHINITIS (COLD) -
 is inflammation of nasal mucus lining.
       Acute and Chronic rhinitis
              • ACUTE RHINITIS (COMMON COLD)
• is the most frequent human disease. An average adult suffers a
  common "cold" two to three times per year, more often in
  childhood and less often the older he gets as he develops more
  immunity. The common "cold" is caused by any number of
  different viruses, some of which are transmitted through the air,
  but most are transmitted from hand-to-nose contact. Once the
  virus gets established in the nose, it causes release of the body
  chemical histamine, which dramatically increases the blood flow
  to the nose, causing swelling and congestion of nasal tissues,
  and stimulating the nasal mucosa to produce excessive
  amounts of mucus.
• Acute rhinosinusitis: sudden in onset, lasting up
  to 4 weeks. Symptoms resolve after treatment.
• Subacute rhinosinusitis: acute rhinosinusitis that
  progresses 4 to 12 weeks. Symptoms eventually
  may be less severe than in the acute phase and
  still resolve after treatment.
• Recurrent acute rhinosinusitis: symptoms and
  physical findings of acute rhinosinusitis, lasting 1
  to 4 weeks. More than four episodes per year,
  with intervening symptom-free interludes.
          Pathogenic organisms:
• viruses (adenoviruses, rhinoviruses) - at the beginning of the
  disease (1-3 days);
• staphylococci and streptococci;
• Bacteria: H. influenza, Ps. aerogenosa, M. catarhalis.
• Acute rhinitis is very contagious disease. The spreading way is
  mainly air-drop, but contact transmission (through hands,
  crockery, objects) is possible too. The incubation period is 1-3
  days. The bacterial super infection often joins to the viral
  infection (mainly gram positive cocci flora). The immunity to
  viruses lasts out only short time after convalescence so it’s
  possible to have reinfection of same virus.
                           Attend factors
• Cooling of the organism;
• Breathing with heated or dry air;
• Other defects in the nose and throat (allergy, septum deformity)
• Low general resistance of organism;
• Stresses.
Diagnosis of Acute Rhinosinusitis,
    Major and Minor Factors
Major Factors                     Minor Factors
Facial pain/pressure              Headache
Facial congestion/fullness        Fatigue
Nasal obstruction/blockage        Halitosis
Nasal discharge/ purulence/       Dental pain
  discolored postnasal drainage
Hyposmia/anosmia                  Cough
Purulence in nasal cavity on      Earpain/ pressure/
  examination                       fullness
Fever
                     Clinic
         can be divided in three stages:
• 1. „Dry stage” lasts from few hours to few days. At the beginning of disease
  there is easy indisposition. Dryness and tickling in the nose, sneeze, easy
  pain in the throat and feeling of head compression can be marked.
  Progressing nasal congestion begins in the first stage and continues in
  second and third stages. The mucous lining of the nasal cavity gets a purple-
  red color and acutely infiltrates.
• 2. Stage of serosous excretions is characterized by abundant watery
  excretions from the nose. The patient also suffers from full nasal obstruction,
  headache, sub febrile temperature, and hyposmia. The nasal discharge is
  thin and plentiful, it irritates the skin around the nose. Then discharges
  become more tick. Second stage lasts 2-4 days.
• 3. Stage of mucous-purulent excretions. In this stage the quantity of
  excretions diminishes, they become mucus and purulent (adding of bacterial
  infection) . This stage lasts 2-4 days.
• In next 6-12 days (eventual phase) the symptoms of “lowering” infection can
  appear – causing the inflammation of throat and larynx, that shows up pain
  in a throat, hoarse of voice, cough and others like that.
• If in an inflammatory process spreads to paranasal sinuses, pain in the area
  of their projection appears (brow, bridge of the nose, cheeks). If
  inflammation spreads to the Eustachian tube, fullness in the ear and hearing
  loss appear.
              Complications
•   • Acute sinusitis.
•   • Acute otitis media.
•   • Acute pharyngitis.
•   • Acute laryngitis.
•   • Acute tonsillitis
•   • Pneumonias and others like that.
•   • Furuncle of the external nose.
•   • Possible transition in chronic rhinitis.
                 Medical Treatment
• At the beginning of disease his development can be stopped by
  means sudorific medication (hot mustard baths on feet, for
  children - paraffin “socks”). Decongestants drops in the nose
  (0,1 % solutions of naphthyzin, galazolin, sanorin, rhinozolin).
  These medications improve the nasal breathing, save
  permeability of opening between paranasal sinuses and nasal
  cavity, and reduce mucous lining edema of the Eustachian
  tube.
• The term of decongestants drops administration must not
  exceed a 1 week. More prolonged use of these medications
  can develop the medicinal rhinitis.
• Antihistamines and decongestants help relieve the symptoms of
  a "cold," but time alone cures it. In persons with headache
  analgesics are prescribed (paracetamol, analgil, ascofen and
  others like that). Medications in the aerosol packing are used:
  ingalipt, cameton; and also inhalation of hot air and irrigation of
  nasal cavity by antiseptic solutions (decoctions of medical
  flowers and leafs - 10 g on 200 the ml boiled water). Physical
  therapy procedures are also applied.
            Rhinitis in newborns
• is always heavy disease, as their protective mechanism is not
  enough developed. Babies carry difficulty of the nasal breathing
  heavier, than senior children, as, except for violation of
  breathing, a cold hinders still and pectoral feeding.
• This disease presents a special danger to babies. The nasal
  meatuses in infants are very narrow, and nasal obstruction is
  very likely to follow even a minor swelling of the mucosa.
• Apart from disorders due to the absence of nasal respi-ration,
  such as excitability, broken sleep, etc., nasal ob-struction may
  often lead to emaciation of the baby, which is unable to suck at
  the breast normally
• Clinic
• The temperature of body is often high. There can be meningeal
  symptoms, quite often the violated function of the digestion
  system is observed (vomits, diarrhea). At the heavy cases the
  inflammation of pharyngeal tonsil can occurred (adenoiditis).
  Other complications are the inflammations of ear, throat, lungs
  and others like that.
   Medical Treatment Rhinitis in
            newborns
• Decongestant drops in the nose (0,01-0,05
  % solution of adrenalin, nazivin, rhinozolin)
  to maintain the nasal cavity passability
  during breast-feeding. Before feeding the
  secretion from the nasal cavity is sucked
  by a bulb.
                • Prophylaxis
• Out contact of child with virus infect
  patient.
  CHRONIC RHINITIS (CHRONIC COLD)
is chronic unspecific inflammation of nasal mucus lining.
  • Reasons
  • Repeated attacks of acute rhinitis.
  • The prolonged action of external harmful factors
    (dust, gases, overheated air and others like that).
  • Infection lesion located near to the nose
    (adenoids, sinusitis, tonsillitis, carious teeth).
  • Nasal septum deformity.
  • Disease of internal organs (hearts, stomach,
    kidneys and others like that).
  • Deep damages of mucous lining due to acute
    infectious diseases (scarlet fever, diphtheria and
    others like that).
  • Constitutional inclination.
      Chronic catarrhal rhinitis.
• Its symptoms are basically the same, though not so marked
  as those of acute rhinitis. Patients complain of nasal
  obstructions and nasal discharge. The obstruction is not
  constant and is worse on lying down. When the patient turns
  in bed, the upper nostril opens up and the lower nostril
  closes. The discharge may be abundant or poor; sometime it
  may be mucus, sometime – purulent; may be postnasal
  discharge. Although there can be dryness, hyposmia,
  headache, disorders of sleep.
• Rhinoscopia reveals the diffuse edema of nasal mucous
  lining and its diffuse redness. In some cases the inferior
  turbinate may be so congested and swollen that is
  impossible to see deeper parts of the nose. To make visible
  inner parts of nasal cavity it’s necessary to do anemization
  of mucous lining by application of 0,1 % adrenalin solution .
     Chronic hypertrophy rhinitis
• is more common in males. The principle deference of this
  disease from catarrhal rhinitis is the development of fibrous
  tissues in the submucosal layer of the nose, particularly over
  the inferior turbinate. The disease is characterized by diffuse
  or limited hyperplasia of mucous lining. This fibrous tissue
  contracts in different places (mostly on inferior turbinate) so
  mucus surface becomes irregular. Patients suffer from the
  abundant nasal secretion and obstruction, headache and
  hyposmia. Excretion from the nose is mainly mucus, and it
  becomes purulent when pathogenic organisms change.
• On rhinoscopia in common cases the nasal cavity is filled by
  abundant, thick, viscid, yellowish discharges. After
  cleaning (by blowing patient's nose) the mucosal lining
  looks congested, swollen and deep in colour. The
  turbinates are enlarged and hypertrophied particulary the
  inferior one, so it hampers to inspect the inner parts of nasal
  cavity. Surface of mucous lining is irregular, pitted and
  looks mulberry-shaped or mulberry-shaped
                   diagnostic
• The anemization probe is used. The nasal lining is
  smeared by vasoconstrictor solutions (adrenalin,
  naphthyzin and others like that). In patients with
  catarrhal rhinitis the nasal lining become thinner and
  nasal breathing becomes better; in patients with
  hypertrophy rhinitis the hypertrophy places do not
  change and breathing either not becomes better, or
  get better only in insignificant measure.
• Chronic hypertrophy rhinitis can complicate by
  appearance of polypes, especially when allergy
  present, so chronic polipous rhinosinusitis can
  develop. In rare cases malignant growth can occur, so
  a morphological examination is needed.
       Chronic atrophy rhinitis
• is more common in females. Atrophy of nasal mucous lining is main
  characteristic of this disease. Mucous membrane loses some of its
  mucous glands also it sheds (теряет) ciliated epithelium and in many
  places it undergoes metaplasia turning into squamous stratified
  epithelium. The dis-ease is often accompanied by diminished mucous
  secre-tion which tends to dry into crusts, but has no bad smell (in
  contrast to ozaena). The olfactory nerves become atrophic.
• Symptoms. A young female patient suffers of constant dry-ness in
  the nose and nasopharynx. Another common com-plaint is a feeling
  of foreign body in the nose or dull pressure at the nasal root.
  Paradoxical to the wide nasal meatuses, nasal obstruction appears
  due to the crusts accumulation on the surface of turbinates and nasal
  septum. After self removing of this crusts the little bleeding can occur.
  The headache, hyposmia or anosmia (full or partial loss of smell)
  can present. In may cases the atrophic process spreads to the
  pharynx and larynx, so dryness of the throat can occur.
• On rhinoscopia the reduction or absence of secretion and formation
  of crust in the nose can be observed. The nasal cavity fills with
  yellowish or green crusts or scabs. After removal of the crusts, the
  nasal passages are seen to be very wide and in anterior rhinoscopy
  offer a clear view of the posterior wall of the nasopharynx. The nasal
  mucous membrane appears dry, very thin, and pale (not red).
               Medical Treatment
• This may be local or general. Above all, the underlying
  cause of disease should be found out and should be
  eradicated, if possible. Liquidation of inflammation focus,
  that can be located near to the nose or alongside should
  be done (medical treatment of carious teeth, chronic
  tonsillitis, adenoids, chronic sinusitis and others like that).
  The presence of any nasal deformity should be eradicated.
  Physician should advise patients to avoid the harmful
  factors of external environment (even to change the
  unhealthy job), to eliminate smoking of tobacco, drinking
  and to keep to a diet. If necessary, medical treatment of
  internal diseases is administrated (hearts, stomach,
  kidney, and others like that). If allergy present, the expose
  of allergen is needed to avoid the contact with it.
  Antiallergic medical treatment is prescribed. Antihistamines
  and decongestants help relieve the symptoms of a "cold".
  In cases with fever, antibiotics may have to be used after
  culture and sensitivity test of the nasal discharge have
  been done.
          Chronic catarrhal rhinitis.
• Local treatment consists of prescribing astringent and vasoconstrictor drops.
  Decongestants drops or sprays in the nose (0,1 % solutions of naphthyzin,
  galazolin, sanorin, rhinozolin, and so on) and anti-inflammatory prescription
  nasal sprays (argyrols, polydexa, izofra) is prescribed, with duration no
  more than 1 week. These medications improve the nasal breathing, save
  permeability of opening between paranasal sinuses and nasal cavity, and
  reduce mucous lining edema of the Eustachian tube.
• For thinning secretions, especially for older persons, more fluids drinking
  (eliminating caffeine, and avoiding diuretics - fluid pills) may be recomended.
  Mucous-thinning agents such as guaifenesin (Humibid, Robitussin) may also
  thin secretions.
• Irrigating of the nasal cavity by sodium chloride solution (a 1 tea-spoon on a
  1 glass of water), can be advised. The patient breathes in the nose the
  heated solution from the tea-pot spout, or from the built palm. Nasal
  irrigations may alleviate thickened secretions. These can be performed two
  to four times a day either with a nasal douche device or a Water Pik with a
  nasal irrigation nozzle.
• In patients with diffuse swelling of the nasal mucous membrane the
  injections of glucocorticoid solutions (dexamethazone, hydrocortisone est.)
  in the inferior turbinate (once in 2-3 days) are effective.
• Also the physiotherapeutic procedures should be prescribed (endonazal
  electrophorus of calcium chloride or zinc sulfate, ultrasonic therapy, UShF,
  appliques of dirt).
     Chronic hypertrophy rhinitis.
• Conservative treatment, as a rule, has only temporal effect in
  such patients. The injections of glucocorticoid solutions in the
  inferior turbinate are useful. If they are not effective after 3-4
  times, more vigorous surgical procedures are performed.
  Places of hyperplasia of mucous lining are removed by
  means of:
• Chemicals (chemiocaustics) – solutions of silver nitrate,
  chromic or trichlor-acetic acids (10 %) are applied to
  pathological tissue.
• Galvanocautery – cauterization with a special instrument -
  pointed electrocauter.
• Criodestruction (by liquid nitrogen).
• Resection of part of the inferior turbinate by surgical
  instruments (nasal scissors, conсhotom, nasal snare
  (петля)).
•
                 Chronic atrophy rhinitis.
    The treatment of those patients may only be symptomatic, it aims to irritate nasal mucous
    membrane to increase production of mucus. It relieves dryness and crusting in the nose by
    alkaline douches with subsequent application of iodine glycerol solution, oint-ments or menthol
    oil. The nose may also be cleansed of crusts by warm alkaline spray. Below are the formulae of
    the alkaline solution and some of the drops and ointments commonly used:
•   Rp. Jodi puri 0.05-0.1 ""
•   Kalii jodati 0.2
•   Glycerini
•   Aq. destill. aa 5.0
•   01. Menthae pip. gtt. 1
•   DS. Five drops in each nostril twice a day
•   #
•   Rp. Mentholi crystallisati 0.1
•   01. Provincialis 20.0
•   DS. Five drops in each nostril twice a day
•   #
•   Rp. Natrii bicarbonici 60.0
•   Natrii biborici 30.0
•   Natrii chlorati 10.0
    01. Menthae pip. gtt. V
    M. f. pulv.
•   DS. One teaspoonful in a glass of water for a nasal douche
•   enzymes (0,001 g tripsin on 50 ml isotonic solution) or mineral waters (“Glade of cvasova”,
    “Borgom” and others like that. ). After cleaning conduct instilyatsii vegetable butters with
    tocoferolom and retinolom; useful butters of sea-buckthorn and wild rose. Appoint electroforez
    nicotine acid or potassium of iodide on the area of neck or nose and navcolonosovih bosoms.
    Enough effective there is in the conditions of warm moist climate.
      Neurovegetative form of
        vasomotor rhinitis
• describes a nonallergic "hyperirritable nose" that
  feels congested, blocked, or wet.
• The mucosa of the nose have an abundant supply
  of arteries, veins, and capillaries, which have a
  great capacity for both expansion and
  constriction. Normally these blood vessels are in
  a half-constricted, half-open state. But when a
  person exercises vigorously, his/her hormones of
  stimulation (i.e., adrenaline) increase. The
  adrenaline causes constriction or squeezing of
  the nasal mucosa so that the air passages open
  up and the person breathes more freely.
            Attend factors
•   Frequent acute inflammatory processes of
    upper airways;
•   Violation of the vegetative nervous
    system;
•   Nasal septum deformity;
•   The prolonged foreign body in nasal
    cavity;
•   The protracted supercooling of organism;
•   Digestive apparatus disorders.
    VASOMOTOR RHINITIS
• „Rhinitis" means inflammation of the nose
  and nasal mucosa. "Vasomotor" means
  blood vessel forces. Two forms are
  distinguished:
• Neurovegetative;
• Allergic.
                           Clinic.
• Vasomotor rhinitis is characterized by intermittent at-tacks with
  very brief and sometimes long periods of relief. The attacks,
  very violent at times, are accompanied by prolonged
  paroxysms of sneezing, nasal obstruction and pro-fuse,
  mostly watery, discharge from the nose or postnasal drip.
  Many patients have additional symptoms of lacrimation,
  itching of the eyes, nasal interior and hard palate, and
  headache.
• Rhinoscopia.
• Turbinates may be enlarged.
• Edema of nasal mucous lining.
• Mucus-watery or foamy excretions in nasal meatuses a
  generous amount.
• Bluish or cyanotic color of nasal mucous lining with white or
  gray spots on it (Voyachec spots).
• In the intervals between the attacks, all morbid symptoms may
  utterly disappear, so there may be no rhinoscopic sign at all.
  But in pro-tracted cases, the swelling of the nasal mucosa may
  become stable or turn into hyperplasia, as in chronic rhinitis.
Sinusitis
Sinus Anatomy and Diseases

   A background to Functional
   Endoscopic Sinus Surgery
                  Basic Anatomy

• Two cavities divided by
  the septum; each with
  medial and lateral nasal
  walls
• Four paranasal sinuses in
  pairs
• Normal Function =
  ventilation and drainage
• Ventilation requires
  healthy ostia and
  pathways
• Normal Drainage
  depends on secretion
  and transport of mucus
     The function of the para-nasal sinuses


• Largely speculative
• The pneumatised cavities of the bone of the skull reduce
  weight
• During normal respiration the air is warmed and
  moistened during its passage in the nose
• The sinuses are lined by mucosa and cilia that assist in
  self-cleaning and defense
                    Sinus Drainage

Two distinct transportation
  routes along the lateral
  nasal wall:
• anterior and
• posterior osteomeatal
  complex

• Both pathways drain into
  the nasopharynx
             Osteomeatal Complexes

Anterior
• Ethmoid Sinus Cells
• Frontal Sinus and Recess
• Ethmoidal Infidubulum
• Middle Meatus
• Maxillary Sinus and Ostium
• Uncinate Process
Posterior
• Posterior Ethmoid Sinus
• Sphenoid Sinus
                 Ethmoidal Labyrinth

• Six to ten air-containing
  cells; total volume of
  approx. 3ml; fully formed
  at birth
• Anterior and posterior
  chambers are
  distinguished with
  different drainage
  pathways
• Ethmoid Bulla - Largest
  anterior ethmoid cell
• Agger Nasi Cell - anterior
  bulge caused by the
  insertion of the middle
  turbinate
                  Ethmoidal Sinus Boundaries


• Superiorly - related to skull
  base
• Laterally - lamina papyracea
  separates it from the orbit
• Posteriorly - related to the
  sphenoid sinus; optic nerve
  runs close to posterior sinus
• Medially - related to superior
  and middle turbinates
                         Frontal Sinus

• Not well formed at birth,
  growth is completed by age
  14-18years
• Septum between two sides
• Drains via the frontal recess to
  the middle meatus
• Frontal recess – narrow space
  with high clinical significance –
  hourglass shaped with its
  narrowest portion at the frontal
  sinus opening
• Posterior boundary – anterior
  cranial fossa
                             Maxillary Sinus

• Largest Sinus with average
  size of 15ml
• The pair often develops
  asymmetrically
• The sinus usually consists of
  one chamber only
• The ostium opens into the
  nose in the middle meatus
• Superior boundary is the
  orbital wall, the floor is related
  to tooth roots
                     Sphenoid Sinus

• Most posterior of all sinuses
• Marked individual variations in
  shape and size with capacity
  of 0.5 - 3ml
• May be totally absent in 3-5%
  of patients
• Does not begin to develop until
  the age of 6 yo
• Can present with intra-sinus
  septations
• Drains with the posterior
  ethmoid cells to nasopharynx
                        Turbinates
• Bony shelves in the nasal
  cavity
• Inferior, middle and
  superior (at times,
  supreme)
• Airflow and defense
  mechanism
• Only inferior and middle
  turbinates are seen with
  speculum
• Examined for colour,
  masses, discharge,
  swelling and lesions
                    Middle Turbinate

• Part of middle meatues
  where maxillary, frontal
  and anterior ethmoid
  sinuses drain
• Any deviation and
  disease can obstruct
  natural drainange
  pathways
• Swollen turbinates with
  inflammed mucosa often
  indicate unlerlying
  diseases
                   Inferior Turbinate
• Easily visible via
  speculum view
• Examination is often
  under headlight
• Enlargement of turbinate
  can cause chrosnic nasal
  obstruction
• Bone can thickens and
  mucosa can swell to
  narrow nasal airspace
                        Sinus Mucosa

• Sinuses are Lined with
  Cilia Which Beat to
  Transport Mucous
  Through and Out of the
  Sinuses
• Bacterial Infection Can
  Cause Changes to Occur
  Including Swelling of the
  Mucousal Lining
• Cilia Cease to Function
  Properly
• Ostium Closes trapping
  Mucous Inside Sinus
  Cavity
                    Ethmoidal Prechambers

• Drainage of the
  maxillary,ethmoid and
  frontal sinuses via their
  ostia and very narrow
  chambers before entering
  the middle meatus -
  ethmoidal infindibulum
  and the frontal recess
• Bacterial infection,
  allergies, polyps etc. can
  cause swelling and
  stenosis of these very
  narrow channels
   Key Role of Ethmoidal Prechambers


• The stenosis will obstruct   • In these instances the
  the normal muco-ciliary        disease is caused by the
  actions                        obstruction of the
• Due to poor ventilation        prechambers, the larger
  the retained mucus             sinuses are secondarily
  provides an excellent          involved
  growth medium for
  bacterial and viral growth
           Symptoms of Sinus Disease


•   Facial and head pains; pressure
•   Nasal Discharge
•   Nasal Obstruction
•   Abnormalities of smell
•   Conjunctivitis - common in children
•   Generalised symptoms: Lethargy and fever
                    Pathogenesis


•   Viruses
•   Bacteria
•   Mixed infections with fungi present
•   Allergies
•   Diseased tooth roots
•   Anatomical variations – deviated septum, uncinate
    process, turbinates, pneumatised ethmoid bulla and
    agger nasi etc.
                         Diagnosis



•   Anterior and posterior rhinoscopy
•   Nasoendoscopy
•   Radiography
•   CT Scans, MRI
•   Bacteriologic examinations of secretions
                            Treatment



Conservative
• Decongestants
• Antibiotics
• Aspiration and lavage
• Irrigation (maxillary and frontal sinuses)

Surgical
• Minimally invasive sinus surgery
                        Summary

• Complex Anatomy
• Four interconnected sinuses
• Turbinates – large
  importance
• Distint drainages pathways
• Change in mucosa and
  obstruction of pathways can
  be an underlying cause for
  sinus disease

				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:104
posted:9/29/2012
language:Unknown
pages:68