Chapter 13: Diseases of the Paranasal Sinuses Flashcards
1
Q
Concurrent exacerbation of sinus and pulmonary disease
A
Sinobronchial syndrome
2
Q
Sinuses present at birth
Only sinuses that are involved in childhood sinusitis
A
Maxillary and ethmoid
3
Q
- Start to develop from the anterior ethmoid sinuses at about 8 years old
- Become clinically important by 12 years old
- Continue to develop until 25 years old
A
Frontal sinuses
4
Q
Sinuses present at birth
Only sinuses that are involved in childhood sinusitis
A
Maxillary and ethmoid
5
Q
- Start to develop from the anterior ethmoid sinuses at about 8 years old
- Become clinically important by 12 years old
- Continue to develop until 25 years old
A
Frontal sinuses
6
Q
Starts pneumatizing at about 8-10 years of age and continues developing into late teens or early twenties
A
Sphenoid sinus
7
Q
Most often the cause of acute sinusitis
A
Streptococcus pneumoniae
8
Q
Symptoms of acute maxillary sinusitis
A
- Fever
- Malaise
- Vague headache
- Feeling of fullness in the face
- Pain the the teeth during sudden movements of the head
- Dull, throbbing cheek pain
- Mucopurulent secretion
- Irritative, nonproductive cough
9
Q
Predisposing factors: maxillary sinusitis
A
- Chronic nasal allergies
- Foreign bodies
- Deviated nasal septum
- Cleft palate
- Dental condition
10
Q
PE of maxillary sinusitis
A
- Pus in the nose (middle meatus)
- Pus or mucopurulent secretion (nasopharynx)
- Tenderness
- Decrease transillumination (if full of fluid)
- Xray: mucosal thickening—>complete opacification of the sinus due to severe mucosal swelling/accumulation of fluid filling the sinus
- Air-fluid level due to accumulation of pus
11
Q
Unreliable in sinusitis
A
Anterior nasal cultures
Posterior: more accurate, difficult to obtain
12
Q
Treatment of maxillary sinusitis
A
- Broad spectrum antibiotic
- Decongestants
- Hot packs/analgesic
13
Q
Management of edematous sinus ostium
A
Antral irrigation
14
Q
Route of insertion of the trocar for maxillary antral irrigation
A
Beneath the inferior turbinate after initial cocainization of the mucous membrane
15
Q
Alternate route for maxillary antral irrigation
A
Sublabial approach (needle is passed through the gingival buccal sulcus through the incisive fossa
16
Q
Most common cause of maxillary sinusitis (dental origin)
A
Extraction of a molar tooth (1st molar)
Small piece of bone lying between the apex of the tooth and the maxillary sinus is removed
17
Q
AKA antrum of Highmore
A
Maxillary antrum
18
Q
More common in children Orbital cellulitis (lateral wall of the ethmoid labyrinth, lamina papyracea is often dehiscent)
A
Ethmoid sinusitis
19
Q
Symptoms of ethmoid sinusitis
A
- Pain and tenderness between the eyes and over the bridge of the nose
- Nasal drainage
- Nasal obstruction
20
Q
Treatment of ethmoid sinusitis
A
- Systemic antibiotic
- Decongestant
- Topical vasoconstrictor sprays and drops
- Ethmoidectomy (development of impending complication and inadequate improvement)
21
Q
Almost associated with anterior ethmoid infection
A
Frontal sinusitis
22
Q
Frontal sinus develops from the…
A
Anterior ethmoid air cells
23
Q
Associated with characteristic head pain (above the eyebrow, present in the morning, becomes worse by midday—>lessen during the remainder of the waking hours
A
Frontal sinusitis
24
Q
Pathognomonic sign of frontal sinusitis
A
Excruciating tenderness to pressure and percussion over the infected sinus
25
Frontal sinusitis transillumination
Impaired
26
Frontal sinusitis Xray
Periosteal thickening, generalized opacity of the sinus/air-fluid level
27
Treatment of frontal sinusitis
1. Antibiotics
2. Decongestants
3. Vasconstrictor nasal drops
4. Drainage by frontal sinus trephine technique (failure to resolve)
28
Characterized by headache directed to the vertex of the skull
Sphenoid sinusitis
29
Pathologic changes in acute sinusitis (reversible)
1. Mucous membrane consist of polymorphonuclear infiltrates
2. Vascular congestion
3. Desquamation of the surface epithelium
30
Pathologic changes on chronic sinusitis (irreversible)
1. Mucosa is thicker, thrown into folds or pseudopolyps
2. Surface epithelium: desquamation, regeneration, metaplasia or simple epithelium
3. Microabscess formation
4. Granulation tissue
5. Healing by scar tissue are intermingled
6. Round cell and PMN infiltrate in the submucosal layers
31
Result of repeated acute sinusitis with incomplete resolution
Chronic hyperplastic sinusitis
32
Has tremendous resistance to disease as well as ability to heal itself
Mucoperiosteal lining of the paranasal sinus
33
Will lead to an incomplete regeneration of the surface ciliated epithelium--->failure to remove sinus secretions--->further infection
Failure to adequately treat acute or recurrent sinusitis
34
Caused of drainage obstruction
1. Adenoid hypertrophy
2. Tumors of the nose and nasopharynx
3. Deviated septum
Most common: nasal polyposis (from allergic rhinitis)
35
1. Peculiar form of nasal polyp
2. Arises from the mucosa near the maxillary sinus ostium
3. Occludes the ostium and grows by proliferation and edema into the "bilobed structure" ( one lobe remains in the sinus and the other enters the nose and passes into the nasopharynx)
Antrochonal polyp
36
Predispose to sinus infection
Nasal allergies
37
Surgical intervention for chronic maxillary sinusitis
Nasoantrostomy (formation of a nasoantral window)
38
An opening is made into the maxillary sinus through the inferior meatus (to allow gravitational drainage and ventilation--->regeneration of healthy mucous membrane within the maxillary sinus)
Nasoantrostomy
39
The epithelium of the maxillary sinus cavity is removed completely and a drainage antrostomy is performed at the termination of the procedure
Caldwell-Luc operation
40
Caldwell-Luc procedure
1. Incision in the canine fossa and removing a portion of the bone of the anterior wall of the sinus
2. Opening can be enlarged
3. And opening is made to replace the compromised natural ostium
4. Ventilation and drainage of the sinus can then occur through the inferior meatus or the natural ostium if resolution of the sinus disease opens the natural ostium
5. Completed by closure of the oral incision
41
A technique that allows the surgeon excellent visualization and magnification of the nasal anatomy and normal sinus ostia
Endoscopic sinus surgery
42
The source of the recurrent infection in chronic sinusitis
1. Ethmoid infundibulum
| 2. Frontal recess
43
Causes the apposing mucosae in ethmoid infundibulum and frontal recess to press together--->interference with normal mucociliary transport--->mucous retention and enhanced viral/bacterial growth
Inflammation
44
Almost always associated with chronic maxillary or chronic frontal disease
Accompany chronic nasal polyposis
Chronic ethmoiditis
45
Removal of the tissues from which the polyps originate reduces the rate of recurrent diseases
Ethmoidectomy
1. Intranasal
2. Transantral
3. External route
46
Clinical features of chronic frontal sinusitis
1. Frontal head pain (constant)
| 2. Puffiness and tenderness of the skin over the sinus
47
Ethmoidectomy
1. External
| 2. Intranasal
48
1. Performed through an incision on the lateral side of the nose
2. Soft tissues and periosteum, including the lacrimal sac and medial canthus are elevated
3. At the completion of the procedure, the ethmoid cells have been replaced by one large cell that opens into the nose
External ethmoidectomy
49
Accomplishes the same objective but is performed with instruments that reach the ethmoid cells through the nares and middle meatus
Intranasal ethmoidectomy
50
Complications of frontal sinusitis
1. Subperiosteal abscess
2. Osteitis
3. Osteomyelitis
51
1. Accomplished through an incision on the lateral aspect of the nose
2. Soft tissues are elevated and the ethmoid air cells are removed in an external ethmoidectomy
3. The nasofrontal duct is enlarged and a tube stent is placed from the nose into the frontal sinus
4. Tube helps maintain the patency of the newly created duct and may be left in place for several weeks
Frontoethmoidectomy
52
1. Performed through a brow incision or a coronal incision
2. Anterior wall of the sinus in incised
3. Sinus mucosa is removed, the nasofrontal ducts are plugged, and the sinus is filled with fat
Frontal sinus obliteration
53
Sinuses present at birth
| Only clinically important sinuses until the 2nd decade of life
1. Ethmoid
| 2. Maxillary
54
Common sequelae of URTI in children
Mucosal edema and loss of cilia--->occlusion of the sinus ostia--->sinus is absorbed and replaced by an effusion that easily becomes infected
55
Mechanical factors contribute to poor airway physiology and stasis of secretions
1. Adenoid hypertrophy
2. Foreign bodies
3. Choanal atresia and stenosis
56
Congenital immunologic defects associated with sinusitis in children
1. Kartagener's syndrome
2. Down's syndrome
3. Hurler's syndrome
4. Dysglobulinemias
57
More frequently in sinusitis of children of all ages
Hemophilus influenzae
58
Symptoms of sinusitis in children
1. Persistent mucopurulent nasal drainage
2. Recurrent or persistent laryngitis
3. Chronic cough (nocturnal)
59
Complication of sinusitis occurs more frequently in children than adults
Facial cellulitis of sinus origin
60
Treatment of sinusitis in children
1. Antibiotics
| 2. Surgical drainage (reserved for complications or unresolved infections)
61
Predominantly responsible for orbital complications
Ethmoid sinuses
62
Five stages of orbital complication
1. Mild inflammatory or reactionary edema
2. Orbital cellulitis
3. Subperiosteal abscess
4. Orbital abscess
5. Cavernous sinus thrombosis
63
Occur in the orbital contents as a result of the proximity of infection in the ethmoid sinuse
Mild inflammatory or reactionary edema
64
Pus collected between periorbital and bony orbital wall causes proptosis and chemosis
Subperiosteal abscess
65
1. Pus has broken through periosteum and has intermingled with the orbital contents
2. Associated with the more serious unilateral sequelae of optic neuritis and blindness
3. Diminished extraocular movements of the involved eye and chemosis are characteristic signs along with increased proptosis
Orbital abscess
66
1. Due to spread of bacteria through venous channels to the cavernous sinus, where a septic thrombophlebitis develops
2. Consist of total ophthalmoplegia, chemosis, severe impairment of vision, patient prostration and signs of meningitis due to proximity to CN 2, 3, 4 and 6 and brain
Cavenous sinus thrombosis
67
Treatment of the orbital complications of sinusitis
1. Large doses of IV antibiotics
| 2. Surgical approach to release the pus from the abscess cavities
68
1. Mucus-containing cyst
2. Most frequently seen in maxillary sinus
3. Referred to as mucous retention cysts
4. May enlarge and by pressure atrophy, erode the surrounding structures
5. Present as swelling of the forehead or nasal bridge or may displace the eye laterally
6. Sphenoid sinus: diplopia and impairment of vision by pressure on the neighboring nerves
Mucocele
69
Infected mucocele
Pyocele
70
1. One of the most severe complications of sinusitis
2. Infection from the paranasal sinuses may spread along the preformed venous channels or directly from the neighboring sinuses such as through the posterior wall of the frontal sinus or through the cribriform plate near the ethmoid air cell system
Acute meningitis
71
1. Is a collection of pus between the dura and internal table of the skull
2. Commonly follows frontal sinusitis
3. Present only with headache until the collection of pus is sufficient to cause a rise of ICP
Extradural abscess
72
1. Is a collection of pus between the dura mater and arachnoid or the surface of the brain
2. Intractable headache and spiking fever with some signs of meningeal irritation
Subdural abscess
73
Usually develops by directly extending thrombophlebitis
Brain abscess
74
Usual site of formation of brain abscess
Termination of the involved perforating veins which extend through the dura and arachnoid mesh to the juncture between the gray and white substance of the cerebral cortex
75
Signs that the infection is localizing in the cerebral hemisphere
1. Lack of appetite
2. Loss in weight
3. Moderate cachexia
4. Low grade afternoon fever
5. Recurring headache
6. Occasional unexplained nausea and vomiting
76
Treatment of severe intracranial suppurative infection
1. Intensive antibiotic therapy
2. Surgical drainage of abscessed cavities
3. Prevention of spread of the infection
77
Most common source of osteomyelitis and subperiosteal abscess of the frontal bone
Frontal sinus infection
78
Xray of osteomyelitis and subperiosteal abscess
Erosion of the bony margins and loss of the intrasinus septa in an opacified sinus
Advanced stage: moth-eaten appearance of the margins of the sinus, indicating that the infection has spread beyond the sinus
79
Spread of infection into the calvarium--->elevation of pericardium
Pott's puffy tumor
80
Treatment of osteomyelitis and subperiosteal abscess
1. Large doses of antibiotics
2. Incision of the periosteal abscess
3. Trephination of the frontal sinus
81
Any pathologic condition that causes edema of the mucosa near a sinus ostium predisposes a patient to the development of...
Barosinusitis
82
1. Autosomal recessive
2. Situs inversus, bronchiectasis, sinusitis
3. Absence or hypoplasia of one or more of the sinuses, recurrent infection and nasal polyposis
Kartagener's syndrome
83
1. Autosomal recessive
2. Situs inversus, bronchiectasis, sinusitis
3. Aka mucoviscidosis
4. Most reliable diagnostic test: sweat test
Cystic fibrosis
