the nose and paranasal sinuses - reda...
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THE NOSE AND
PARANASAL SINUSES Reda Kamel
Professor of Rhinology
Cairo University – Egypt
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The Nose & paranasal Sinuses:
• Anatomy.
• Physiology - Pathology.
• Symptoms = History.
• Signs = Examination.
• Investigations.
• Diagnosis & Differential diagnosis.
• Treatment: medical ± surgical
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The lateral nasal wall:
1. Inferior meatus:
nasolacrimal duct
2. Middle meatus:
• Maxillary sinus
• Frontal sinus
• Anterior ethmoid
3. Superior meatus:
posterior ethmoid
4. Sphenoethmoidal
recess: sphenoid sinus
Sagital section
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Ostiomeatal complex : OMC
HSI
Frontal ostium
Infundibulum Maxillary ostium
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Physiology= Function of the nose
• Respiratory airway
– Purification
– Humidification
– Conditioning
• Smell
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Pathology: Causes – Etiology of symptoms
Foreign body
Accident
Iatrogenic
Acute:
Specific:
Nonspecific:
Chronic:
Benign:
Malignant
1- Congenital
2- Traumatic
3- Inflammatory
4- Neoplastic
5- Others
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Symptomatology: Bilateral Obstruction Nasal
Bil. Choanal atresia
Foreign body
Accident: Fracture- Haematoma
Iatrogenic: Pack-Haematoma
Acute nonspecific: Common cold-Abscess
Acute specific: Diphtheria
Chronic nonspecific: At. - Hypertrophic
Chronic specific: $ – T.B. - Scleroma
Benign: Ostioma -papilloma
Malignant: Carcinoma - Sarcoma
Polyps Allergy
Deviated septum 1- Congenital
2- Traumatic
3- Inflammatory
4- Neoplastic
5- Others
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Symptomatology:Obstruction-Nasopharyngeal
Cyst
Foreign body
Accident
Iatrogenic: Pack
Acute nonspecific: Common cold
Acute specific: Diphtheria
Chronic nonspecific: At - Hypertrophic
Chronic specific: $ – T.B. - Scleroma
Benign: Angiofibroma
Malignant: Carcinoma - Sarcoma
Adenoid
1- Congenital
2- Traumatic
3- Inflammatory
4- Neoplastic
5- Others
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Nasal Discharge:
• Fetor secretions
1. Foreign body
2. Atrophic rhinitis
3. Sinusitis of dental
4. Oroantral fistula
5. Invasive fulminant fungal
sinusitis
6. Midline granuloma
7. Malignant tumors
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Investigations: Differential diagnosis
The state of the art
• Endoscopy
• CT:computed tomography [no Plain X-ray]
• Culture
• Biopsy
• Acoustic Rhinometry [anatomy]
• Rhinomanometry [physiology]
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Investigations: Differential diagnosis
CT Endoscopy
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Rhinitis: Rhinoscleroma
Reda Kamel, M.D.
Scleroma
Frisch gram –ve diplobacillus [Klebsiella
rhinoscleromatis] 1-Organism
Mucocutaneous [nasal] + extention 2-Site
Atrophic + Hypertrophic + Fibrotic 3-Stages
Crusting + obstruction + deformity 4-Symptoms
Roomy nose + nodules + stenosis 5-Signs
Biopsy [ Mikulicz cells+Russel bodies] +
culture 6-Investigations
Rifampicin, Streptomycin + Surgery
[canalization] 7-Treatment
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Rhinitis: Syphilis
Reda Kamel, M.D.
Syphilis
Treponema Pallidum [spirochetes] 1-Organism
Posterior bony part of septum [blood] 2-Site
1-Acquired [Primary+Secondary+Tertiary]
2-Congenital [early+late]
3-Stages
Painless ulcer + discharge + obstruction 4-Symptoms
Ulcer + mascerated mucosa + Gumma,
perforation, deformity 5-Signs
Biopsy + Serology tests 6-Investigations
Penicillin + surgery [deformity] 7-Treatment
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Rhinitis: Lupus vulgaris
Reda Kamel, M.D.
Lupus
Attenuated TB bacilli of low virulence 1-Organism
Cartilaginous septum, mucocutneous
junction + skin 2-Site
Crusatation, nodules, ulceration, fibrosis 3-Stages
Discharge, obstruction, deformity 4-Symptoms
Crusatation, nodules [apple jelly nodules],
ulceration, fibrosis, deformity 5-Signs
Biopsy + culture 6-Investigations
Antituberculous drugs, Calceferol (vit. D) +
surgery [patency + deformity 7-Treatment
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Epistaxis:
Treatment:
• Vasoconstrictor pack
• Cautery
–Anterior
–Posterior: [Endoscopic]
• Merocel pack
• Nasal balloon
• Anterior nasal pack
• Posterior nasal pack
• Ligation of maxillary external carotid or ethmoid arteries, rare.
Sagital section
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Sinusitis: Acute sinusitis
• Organisms
1. Streptococcus Pneumoniae
2. Hemophilus Influenza
3. Morexella Catarallis
Organism Patient
Resistence Virulence
Dr.
TTT
Chronic Cure
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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.
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Sinusitis: Mucociliary Clearance MCC
• The maxillary sinus drains through the natural ostium towards the anterior ethmoids.
• The frontal sinus drains through the natural ostium towards the anterior ethmoids.
• The anterior ethmoids then drains into the middle meatus to the nasal cavity.
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Sinusitis: Ostiomeatal Complex OMC
• Blockage at the OMC [anterior ethmoid middle meatus complex] leads to secondary affection of the
maxillary and frontal sinuses.
• Lack of drainage and aeration leads to collection of secretions and formation of polyps i.e. chronic sinusitis.
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Sinusitis: Treatment
Conventional:
Every sinus alone:
• Inferior meatal antrostomy [IMA].
• [Theory of gravity]:
Opening in the inferior meatus.
• This is not effective and is the cause of recurrence due to MCC towards the natural ostium.
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Sinusitis: Treatment
Conventional:
• Radical antrum operation:
• [Irreversible pathology theory]. Sublabial incision, removal of all the sinus mucosa and inferior meatal antrostomy.
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Sinusitis: Treatment
Conventional:
• Radical antrum operation: This is not effective and is the cause of recurrence. Due to loss of the precious natural mucosa and healing by fibrosis with no effective MCC.
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Functional Endoscopic Sinus Surgery FESS
All the sinuses are taken care of simultaneously
Aim of work:
To re-establish:
1. Aeration.
2. Drainage.
Of the sinuses
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Functional Endoscopic Sinus Surgery FESS
All the sinuses are taken care of simultaneously
1- Ethmoidectomy ± Polypectomy.
2- Middle meatal antrostomy.
3- Frontal recess clearance.
4- Sphenoidotomy.
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Sinonasal polyps:
1- Inflammatory polyps
2- diffuse sinonasal polyps.
3- Allergic fungal sinusitis polyps
4- Antrochoanal polyp.
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Sinonasal polyps:
Inflammatory polyps
Ethmoid Origin
Inflammatory, sinusitis Etiology
Adult Age
Equal Sex
Common Incidence
P, pus + D, pus + O, Uni/bilateral + H, eye 6Symptoms
Polyps + Pus + congestion [OMC] Signs
CT+Endoscopy+Culture+Biopsy[neutrophyls] Investigation
Antibiotics +- FESS Treatments
Uncommon Recurrence
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Extensive Sinonasal polyps:
Extensive sinonasal polyps
Mainly Ethmoid Origin
Allergic or non-allergic Etiology
Adult Age
Equal Sex
Common Incidence
O, bilateral + D, watery + Sneezing+ Anosmia Symptoms
Polyps, bilateral+discharge, watery+Pale
mucosa
Signs
CT+Endoscopy+Skin test+Biopsy [eosinophyl Investigation
Corticosteroids+- FESS Treatments
Common Recurrence
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Allergic Fungal Sinusitis :
Allergic Fungal Sinusitis
Ethmoid and maxillary Origin
Allergic Etiology
Adult Age
Equal Sex
Uncommon Incidence
O, unilateral + D, mucin + proptosis Symptoms
Polyps, unilateral+discharge, mucin Signs
CT+Endoscopy+Skin test+Biopsy [eosinophyl Investigation
Corticosteroids+- FESS Treatments
Common Recurrence
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Antrochoanal polyp:
Antrochoanal polyp
Maxillary Origin
Retention cyst Etiology
Young adult Age
Equal Sex
Uncommon Incidence
O, unilateral + D, mucous Symptoms
One polyp, unilateral+discharge, mucous Signs
CT+Endoscopy Investigation
Endoscopic removal Treatments
Uncommon Recurrence
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Fungal Sinusitis:
1- Non-Invasive:
A-Fungal ball.
B-Allergic fungal sinusitis.
2- Invasive:
A-Fulminant Fungal sinusitis.
B-Indolent fungal Sinusitis.
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Fungal Ball:
Ball
Competent Immunity
Maxillary Site
Aspirgillus Cause
D + P Symptoms
Pus Signs
CT Investigations
Endoscopic removal Treatment
Good, uncommon recurrence Prognosis
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Allergic Fungal Sinusitis:
AFS
Allergy Immunity
Ethmoidal and maxillary Site
Allergy Cause
O, Unilateral + D, mucin + Proptosis Symptoms
Polyps, unilateral + D, mucin Signs
CT+Endoscopy+Skin test+Biopsy
[eosinophyls]
Investigations
Corticosteroids +- FESS Treatment
Common recurrence Prognosis
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Fulminant Fungal Sinusitis:
Fulminant
Immune compromized Immunity
Any site Site
Mucormycosis Cause
Pain+headache+fever+Proptosis+cranial_ Symptoms
Black debris Signs
CT+Endoscopy+biopsy Investigations
Antifungal+Debridment+General Dis Treatment
Bad, lethal in short time Prognosis
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Indolent Invasive Fungal Sinusitis:
Indolent Fungal Sinusitis
Immune competent Immunity
Ethmoid Site
Asergillosis Cause
Obstruction, unilateal Symptoms
Nasal mass, unilateral Signs
CT+endoscopy+Biopsy Investigations
Antifungal+Debridment Treatment
Bad Prognosis
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Sinonasal tumors: Classification
1- Benign:
A- Epithelial: -Papilloma -Inverted papilloma -Adenoma
B-Non-epithelial: -Hemangioma -Ostioma -Fibrous dysplasia
-Chondroma -Meurofibroma
2- Intermediate:
A-Epithelial: -Ameloblastoma
B-Non-epithelial: -Giant cell tumor
3- Malignant:
A-Epithelial: -Squamous cell ca –Adenoid cystic ca
-Melanoma – Olfactory neuroblastoma
–Mucoepidermoid tumor –Anaplatic ca
B-Non-epithelial: -Ostiosarcoma –Angiosarcoma –
Rhabdomyosarcoma -Fibrosarcoma
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Sinonasal tumors: Symptoms:
1-Benign:
• Nasal
• Extension
• Expansion
2-Malignant:
• Nasal
• Extension
• Erosion
• Lymph nodes
• Metastasis
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Sinonasal tumors: Symptoms:
A- Nasal:
• Obstruction
• Discharge
• Headache
• Pain
• Bleeding
• Bad odor
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Sinonasal tumors: Symptoms:
B- Extension:
• Medial:nasal
• Inferior:oral
• Lateral:orbital, fossa
• Superior:cranial
• Anterior:sublabial
• Posterior: nasopharynx
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Sinonasal tumors:
Investigations
• Endoscopy
• CT & MRI
• Biopsy
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Knowledge is power
R