Nasal and sinus diseaseNasal and sinus disease

Babak saedi M.DBabak saedi M.D

Assistant professor of Tehran Assistant professor of Tehran university university

AnatomyAnatomy

EthmoidMaxillaPalatineLacrimalPterygoid plate of

SphenoidNasal Inferior Turbinate

Bony Structure

Nose and Para nasal Nose and Para nasal sinusessinuses

Arterial Supply

External Carotid Maxillary A. SphenopalatineInternal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear

The NoseThe Nose

• Vascular SupplyVascular Supply

- Anterior - - Anterior - branches of branches of internal carotidinternal carotid

- Posterior - distal - Posterior - distal branches of branches of external carotidexternal carotid

Neurovascular Supply

Facial AnalysisFacial Analysis

Analysis of nose is Analysis of nose is very importantvery important

Facial AnalysisFacial Analysis

• Face: GeneralFace: General– Divided in 1/3’sDivided in 1/3’s

• trichion to NFAtrichion to NFA

• NFA to subnasaleNFA to subnasale

• subnasale to mentonsubnasale to menton

Function of Nose & Paranasal Function of Nose & Paranasal SinusesSinuses

• Humidifying and warming inspired airHumidifying and warming inspired air

• Regulation of intranasal pressureRegulation of intranasal pressure

• Increasing surface area for olfactionIncreasing surface area for olfaction

• Lightening the skullLightening the skull

• ResonanceResonance

• Absorbing shockAbsorbing shock

• Contribute to facial growthContribute to facial growth

7 bones4 paired sinuses4 turbinates3 meatiDrainage systemNervous supplyVascular supplyRelated structures

Sinus Anatomy Overview

SinusSinus

• MaxillaryMaxillary• Frontal Frontal • EthmoidEthmoid• Sphenoid Sphenoid

Fontanelles

Nasolacrimal Duct

Ethmoid BullaUncinate Process

Hiatus Semilunaris

EpistaxisEpistaxisAnteriorAnterior

• 90% (Little’s Area) Kisselbach’s 90% (Little’s Area) Kisselbach’s plexus - usually children, young plexus - usually children, young adultsadults

EtiologiesEtiologies• Trauma, epistaxis digitorumTrauma, epistaxis digitorum• Winter Syndrome, AllergiesWinter Syndrome, Allergies• Irritants - cocaine, spraysIrritants - cocaine, sprays• PregnancyPregnancy

EpistaxisEpistaxisPosteriorPosterior

• 10% of all epistaxis - usually in the 10% of all epistaxis - usually in the elderlyelderly

• EtiologiesEtiologies

• CoagulopathyCoagulopathy

• AtherosclerosisAtherosclerosis

• NeoplasmNeoplasm

• Hypertension (debatable)Hypertension (debatable)

EpistaxisEpistaxisManagementManagement

• Pain meds, lower BP, calm patientPain meds, lower BP, calm patient

• Prepare ! (gown, mask, suction, Prepare ! (gown, mask, suction, speculum, meds and packing ready)speculum, meds and packing ready)

• Evacuate clotsEvacuate clots

• Topical vasoconstrictor and Topical vasoconstrictor and anestheticanesthetic

• Identify sourceIdentify source

EpistaxisEpistaxisManagementManagement

•Anterior SitesAnterior Sites- Pressure +/- cautery - Pressure +/- cautery

and/or tamponadeand/or tamponade

- all packs require - all packs require antibiotic antibiotic prophylaxisprophylaxis

Packing - anteriorPacking - anterior

• BIPP BIPP impregnated impregnated gauze in gauze in layerslayers

EpistaxisEpistaxisPosterior PackingPosterior Packing

• Need analgesia Need analgesia and sedationand sedation

• require admission require admission and 02 saturation and 02 saturation monitoringmonitoring

Packing - posteriorPacking - posterior

• Inflatable Inflatable balloonsballoons

EpistaxisEpistaxisComplicationsComplications

• severe bleedingsevere bleeding

• hypoxia, hypercarbiahypoxia, hypercarbia

• sinusitis, otitis mediasinusitis, otitis media

• necrosis of the columella or necrosis of the columella or nasal alanasal ala

Osler-Weber-RenduOsler-Weber-Rendu

Scope of SinusitisScope of Sinusitis

• Affects 30-35 million persons/yearAffects 30-35 million persons/year

• 25 million office visits/year25 million office visits/year

• Direct annual cost $2.4 billion and increasingDirect annual cost $2.4 billion and increasing

• Added surgical costs: $1 billionAdded surgical costs: $1 billion

• Third most common diagnosis for which Third most common diagnosis for which antibiotics are prescribedantibiotics are prescribed

SinusitisSinusitis

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

– FrontalFrontal– MaxillaryMaxillary– EthmoidEthmoid– SphenoidSphenoid

Infectious or noninfectious inflammation of 1 or more sinuses

Ostiomeatal ComplexOstiomeatal Complex

• Ostiomeatal complex is that area under the Ostiomeatal complex is that area under the middle meatus (airspace) into which the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses anterior ethmoid, frontal and maxillary sinuses draindrain

• Posterior ethmoids drain into the upper Posterior ethmoids drain into the upper meatusmeatus

• Ostiomeatal complex is the functional Ostiomeatal complex is the functional relationship between the space and the ostia relationship between the space and the ostia that drain into itthat drain into it

Viral RhinosinusitisViral Rhinosinusitis

• Most upper respiratory infections are viralMost upper respiratory infections are viral

• Short lived, last less than 10 daysShort lived, last less than 10 days

• Sinus mucosa as well as nasal mucosa is Sinus mucosa as well as nasal mucosa is involvedinvolved

• Most will clear without antibioticsMost will clear without antibiotics

• Treatment: decongestants, nasal lavage, rest, Treatment: decongestants, nasal lavage, rest, fluidsfluids

Classification of Bacterial SinusitisClassification of Bacterial Sinusitis

• Acute bacterial sinusitisAcute bacterial sinusitis- infection lasting 4 - infection lasting 4 weeks, symptoms resolve completely (children weeks, symptoms resolve completely (children 30 days)30 days)

• Subacute bacterial sinusitisSubacute bacterial sinusitis- infection lasting - infection lasting between 4 to 12 weeks, yet resolves between 4 to 12 weeks, yet resolves completely (children 30-90 days)completely (children 30-90 days)

• Chronic sinusitisChronic sinusitis- symptoms lasting more than - symptoms lasting more than 12 weeks (children >90 days)12 weeks (children >90 days)

• Some guidelines add treatment failure + a Some guidelines add treatment failure + a positive imaging studypositive imaging study

Differentiating Sinusitis from Differentiating Sinusitis from RhinitisRhinitis

SinusitisSinusitis

Nasal congestionNasal congestion

Purulent rhinorrhea Purulent rhinorrhea

Postnasal dripPostnasal drip

HeadacheHeadache

Facial painFacial pain

AnosmiaAnosmia

Cough, feverCough, fever

RhinitisRhinitis

Nasal congestionNasal congestion

Rhinorrhea clearRhinorrhea clear

Runny noseRunny nose

Itching, red eyesItching, red eyes

Nasal creaseNasal crease

Seasonal symptomsSeasonal symptoms

Pathogenesis of Nasal ObstructionPathogenesis of Nasal Obstruction

• Viral upper respiratory infectionsViral upper respiratory infections

– Daycare centersDaycare centers

• Allergic and nonallergic stimuliAllergic and nonallergic stimuli

• Immunodeficiency disordersImmunodeficiency disorders

– Immunoglobulin deficiency (IgA, IgG)Immunoglobulin deficiency (IgA, IgG)

• Anatomic changesAnatomic changes

– Deviated septum, concha bullosa, polypsDeviated septum, concha bullosa, polyps

Treatment of Acute SinusitisTreatment of Acute Sinusitis

• Antihistamines recommended if allergy Antihistamines recommended if allergy presentpresent– Oral or topicalOral or topical

• DecongestantsDecongestants– Oral or topicalOral or topical

• Antibiotic when indicated (bacteria)Antibiotic when indicated (bacteria)

• Nasal irrigationNasal irrigation

• Guaifenesin 200-400 mg q4-6 hrsGuaifenesin 200-400 mg q4-6 hrs

• HydrationHydration

Antibiotics for Acute Bacterial Antibiotics for Acute Bacterial SinusitisSinusitis

• Amoxicillin 500 mg tid for 10-14 daysAmoxicillin 500 mg tid for 10-14 days– First line choice in most areasFirst line choice in most areas

– Local differences in antibiotic resistance occurLocal differences in antibiotic resistance occur

• Where beta-lactamase resistance is an issueWhere beta-lactamase resistance is an issue

– Amoxicillin/clavulanateAmoxicillin/clavulanate

– CefuroximeCefuroxime

– CefeximCefexim

– CefprozilCefprozil

Additional Antibiotics for Acute Additional Antibiotics for Acute Bacterial SinusitisBacterial Sinusitis

• Amoxicillin should be considered because of its Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)qid in adults for 10 to 14 days)

• If penicillin-allergic clarithromycin or azithromycin If penicillin-allergic clarithromycin or azithromycin

• Erythromycin does not provide adequate coverageErythromycin does not provide adequate coverage

• Trimethoprim/suflamethoxazole and Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant erythro/sulfisoxazole have significant pneumococcal resistancepneumococcal resistance

Rhinoscopy Aids in DiagnosingRhinoscopy Aids in Diagnosing

• Nasal polypsNasal polyps

• Septal deviationSeptal deviation

• Concha bullosaConcha bullosa

• Eustachian tube dysfunctionEustachian tube dysfunction

• Causes of hoarsenessCauses of hoarseness

• Adenoid hyperplasiaAdenoid hyperplasia

• TumorsTumors

Chronic SinusitisChronic Sinusitis

• Symptoms present longer than 8 weeks or Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 4/year in adults or 12 weeks or 6 episodes/year in childrenepisodes/year in children

• Eosinophilic inflammation or chronic infection Eosinophilic inflammation or chronic infection

• Associated with positive CT scansAssociated with positive CT scans

• Poor (if any) response to antibioticsPoor (if any) response to antibiotics

Sx of Chronic SinusitisSx of Chronic Sinusitis

• Nasal dischargeNasal discharge

• Nasal congestionNasal congestion

• HeadacheHeadache

• Facial pain or pressureFacial pain or pressure

• Olfactory disturbanceOlfactory disturbance

• Fever and halitosisFever and halitosis

• Cough Cough ((worse when lying down)worse when lying down)

Bacteria Involved in Chronic Bacteria Involved in Chronic Sinusitis Role of Viruses is Sinusitis Role of Viruses is UnknownUnknown• Streptococcus pneumoniae Streptococcus pneumoniae

• Haemophilus influenzaHaemophilus influenza

• Moraxella catarrhalisMoraxella catarrhalis

• Staph aureusStaph aureus

• Coagulase negative staphylococcusCoagulase negative staphylococcus

• Anerobic bacteriaAnerobic bacteria

CT Scan Maxillary and Ethmoid CT Scan Maxillary and Ethmoid Sinuses Sinuses

SinusitisSinusitis

Treatment of Chronic SinusitisTreatment of Chronic Sinusitis

• Nasal steroid sprayNasal steroid spray

• GuafenesinGuafenesin

• DecongestantsDecongestants

• Steam inhalationSteam inhalation

• Nasal irrigationNasal irrigation

• Antibiotics with exacerbationsAntibiotics with exacerbations

FESSFESS

Sinus endoscopySinus endoscopy

Complications of SinusitisComplications of Sinusitis

• OrbitalOrbital– Diplopia, proptosisDiplopia, proptosis

– Periorbital erythema, swellingPeriorbital erythema, swelling

• BoneBone– Periosteal abscessesPeriosteal abscesses

• BrainBrain– Intracranial abscesses causing neurologic Intracranial abscesses causing neurologic

symptomssymptoms

Nasal obstructionNasal obstruction

• InfectionInfection• AllergyAllergy• Adenoid hypertrophyAdenoid hypertrophy• Nasoseptal deformityNasoseptal deformity• Chronic sinusitisChronic sinusitis• Septal hematoma (abscess)Septal hematoma (abscess)• Foreign bodyForeign body• NeoplasmNeoplasm• Choanal atresia Choanal atresia

Looking at the turbinates: Looking at the turbinates: Diagnosis?Diagnosis?

Nasal PolypNasal Polyp

Septal deviationSeptal deviation

Allergic RhinitisAllergic Rhinitis