4 pdf - Nose - Muhadharaty

Lecture(4). Lecturer name: Dr. Sa`ad Y. Sulaiman

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.

Chronic Maxillary Sinusitis

Predisposing factors;

1) Nasal:

o Obstruction

the

drainage ostia due to
long-standing

blockage

(with

e.g.;

deviated

nasal

septum,

nasal

polyposis and enlarged
inferior turbinates).

o Recurrent acute

infection leads to
chronic state.

o Chronic irritation from

environmental gases.

(i.e

molar

and 2

and the 1

upper 2nd premolar

) The

of cases

(10

2) Dental

illary antrum and may

impinge closely on the floor of the max

teeth)

upper

and 7

indeed penetrate it. Root infection or dental abscesses are commonly the cause of

unresolved maxillary sinus infections. The organism here are mainly anaerobes, and

the secretion is characteristically fetid . Healing of this form of sinusitis 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:

 Symptoms:

Major symptoms

Minor symptoms

Nasal discharge (copious greenish,
yellowish post nasal discharge)

Fever

Nasal obstruction (due to swelling
of inferior turbinate )

Halitosis (bad mouth odor )

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).

In addition to the above symptoms, chronic irritation  in side the nose may

produce; vestibulitis due to chronic use of handkerchief, nose bleeds, otitis
media due to oedema of eustachian tube , granular pharyngitis and chronic
laryngitis.

 Signs:

Examination is often unhelpful, but we may see;

o  Generalized  inflammation  of the mucosa.
o  Purulent  secretion  or crusts.
o  If  a  vasoconstrictor  is  used  to  shrink  the  nasal  mucosa,  pus  may  be  seen

emanating from the middle meatus.

o Otitis media and granular pharyngitis may be present in the absence of any

specific nasal symptoms.

Investigation

1)Radiography:

X-Ray of paranasal sinus

is helpful in

the

diagnosis

sinusitis

(mucosal

thickening, polyps and fluid level may
present).

CT scan:

Coronal CT scan provide most information about the osteo-meatal

complex. Axial CT is indicated mainly for defining disease in the sphenoid or frontal
sinus.

Abnormal CT scan (P=polyp E=ethmoid

Normal CT scan MT= middle turbinate IT inferior

turbin

3) Endoscopic assessment

Endoscopic  assessment  has  now  become  routine  in  the  examination  of  the
nose  and  paranasal  sinuses.  There  are  several  important  features  to  be  looked
for;
a)  The  presence  of  pus  in  the
middle  meatus.

b)The cause of osteal obstruction

c) Sometimes biopsy is taken to confirm the diagnosis.

The key elements in the diagnosis are the history, the endoscopic assessment and the

findings on coronal CT.

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  treatments  of the  chronic  maxillary  sinusitis  include;

1) FESS (functional endoscopic sinus surgery ) is considered nowadays as the

procedure  of  choice  for  the  treatment  of  chronic  sinusitis.  The  basic
philosophy  of  FESS  is  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 arise in order of frequency in the frontal, ethmoidal,
maxillary and sphenoidal.

Aetiology;

polyps, trauma, tumours and 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

;

o In the early stages the patient is asymptomatic but, particularly in the frontal

type, a dull ache develops and a swelling appears at the supramedial aspect of
the orbit.

o The swelling is tender and feels rubbery, not as firm a consistency as bone.
o Increase in size thins the bone more and pressure may damage the optic nerve

or vasculature causing blindness.

o If infection supervenes it is called a pyocoele and has more sinister

consequences.

o With increase enlargement the eye may proptose.

Radiography of the sinus;



Thinning of the bone.



Displacement of the medial frontal sinus floor downwards.



Loss of scalloping of the superior border of the sinus.



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 ;

1) Endoscopic technique.

2) Radical frontal sinus operation.

3) Osteoplastic flap operation.

______________________________________________________

Tumors of the nose and paranasal sinuses

Tumors of the nose and paranasal sinuses can be subdivided into;
A.

Benign; e.g. Squamous papilloma (in the vestibule), osteoma (in frontal,

ethmoidal and maxillary sinus), Haemangiomas (on nasal septum) angiofibroma and
inverted papilloma.
B.

Malignant tumours (uncommon); Squamous carcinoma is the most common

followed  by adenocarcinoma,  malignant  melanoma,  ethesioneuroblastoma,  sarcoma
and lymphoma.  The maxillary  sinus  is the  most  common  site  for  development  of
malignancy.
*Malignant  tumours,  unlike  most  of  the other  head and  neck cancers,  do not usually
occur  in  heavy  smoking  or heavy  drinking  population.  They  may  occasionally  result
from  exposure  to environmental  carcinogens  (e.g.  adenocarcinoma  in  woodworkers)

* The  chief  symptoms  of nasal  malignancy  are unila teral  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  5

decade.

Site of origin;  lateral  wall  of the nose  (occasionally  from  the  septum)  with  extension
to the  ethmoid  and  maxillary  sinus.
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;  unilateral  sinus  opacity  with  bony  erosion.

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;

1)  Being  locally  aggressive  and causing  bony  erosion.
2)  Tendency  to undergo  malignant  change  in  about 2-5% of patient.
3)  There  may  be  coincidental  malignancy  elsewhere  in  the  upper  respiratory

tract.

4) It has high propensity for recurrence after removal.

Treatment; 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

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:

1. Conductive anosmia; is due to impaired transport of airborne

odorants to the olfactory cleft.

2. Neuronal anosmia; is due to impairment of olfactory epithelial

function or disrupted neuronal pathway.

Causes of olfactory dysfunction;

1. Obstructive nasal disease (23%): Include nasal polyposis, mucosal disease,

tumours and nasal deformity.

2. Postviral anosmia (19%): Due to viral injury to olfactory epithelium and more

common in those above age of 40.Hyposmia is more common than frank
anosmia. About one third recover some function over 3-6 months. No specific
treatment

3. Head trauma (15%): Due to shearing force on olfactory filaments, olfactory

bulb contusion or frontal lobe injury.

4. Toxins, drugs (3%): Aminoglycosides, formaldehyde, alcohol, nicotine,

organic solvents and direct application of zinc salts.

5. Miscellaneous (21%): Aging, neoplastic, psychologic, nutritional deficiencies

(e.g. vitamin A, thiamine) and other causes.

6. Idiopathic (21%).

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