Nose and paranasal sinuses Flashcards
Describe the development AND anatomy of the paranasal sinuses and nose
Development
We are not born with sinuses but they develop in childhood. In the newborn, the paranasal sinuses are limited to the ethmoid region. The rest of the sinuses aren’t developed until the age of 10-12
The Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity.
- The maxillary sinuses are located under the eyes;
- The frontal sinuses are above the eyes
- The ethmoidal sinuses are between the eyes
- The sphenoidal sinuses are behind the eyes
A nasal concha, (plural conchae), also called a turbinate or turbinal, is a long, narrow, curled shelf (shaped like an elongated seashell) of bone that protrudes into the breathing passage of the nose.
The turbinates divide the nasal airway into 4 groove-like air passages, and are responsible for forcing inhaled air to flow in a steady, regular pattern around the largest possible surface area of nasal mucosa, which, as a ciliated mucous membrane with shallow blood supply, cleans and warms the inhaled air in preparation for the lungs.
A nasal meatus is a nasal passage of the nasal cavity, of which there are three;
o the superior meatus
o middle meatus
o inferior meatus.
The nasal meatuses are located beneath each of the corresponding nasal conchae.
In the ethmoid bone, a curved lamina, the uncinate process, projects downward and backward from this part of the labyrinth;
The most important infectious diseases and neoplastic diseases involve the lateral wall of the nose and paranasal sinuses
Explain what is checked in a nasal endoscopy, and the CONNECTIONS in the nose
In an endoscopy all the meatuses (SM, MM, IM) and all the conchae/turbinate (ST,MT,IT) are checked.
The most important meatus is the middle meatus, because the most important sinuses are the maxillary sinus, frontal sinus, anterior and posterior ethmoid and THE OPENING OF THESE SINUSES ARE LOCATED ON THE MIDDLE MEATUS The OMC (Osteomeatal complex) is a region/space in the middle meatus, where there is the orifice to the maxillary sinus.
The sphenoid sinus has 1 singular orifice at the end of the SUPERIOR meatus -> this is the reason we can observe isolated sphenoidal sinusitis (because it isn’t involved with the middle meatus)
- Important clinical symptom in sinusitis
Endoscopy of the nasal cavity is relatively new. Allows us to do minimally invasive surgery and to visualize and reach deeper structures in the paranasal sinuses
Discuss the importance of CT scan
The 1st level exam for nose and paranasal sinuses is CT scan. X-ray is no longer used
Because a basic CT scan allows you to see all the parts of the paranasal structures, all the turbinates and meatuses. You can also see the septum, the maxillary sinus, orbits, lamina cribrosa. There is
a very narrow space between bones and brain.
CT scan is important for surgical preparation - allowing us to treat with a sparing surgery. As people have great variations in their nasal anatomy.
Fully Describe Rhinitis - it’s causes, symptoms, classification
Rhinitis is an inflammation of the nasal mucosa.
Rhinitis can be classified into: Infectious
(viral, fungal and bacterial) allergic, drug induced, hormonal, and nutritional, etc.
SYMPTOMS (of allergic rhinitis) • Nasal obstruction • Rhinorrea • Cough • Hyposmia • Sneezing • Cephalea • Nasal itching NOTE: in bacterial or viral rhinitis we also have fever and infectious symptoms
CLASSIFICATION
Intermittent (<4 days/week; < 4weeks) or
Persistent (>4 days/week; >4 weeks).
Based on symptoms: Mild (all of the following) Normal Sleep No limitations in daily activities Normal activity at work or school Mild symptoms
Moderate - Severe (1 or more of the following) Disturbance in sleep Limitations in daily activities Limitations at work or school Severe symptoms
Association with other symptoms
o When a nose pathology is present (i.e. Inflammatory disease) sometimes, the first symptom is the one affecting directly the inferior/upper respiratory tract.
o Conjunctivitis is commonly associated with allergic rhinitis.
o The nasopharynx maybe associated with adenoids, sleeping problem or otitis.
Describe the diagnosis and treatment of Rhinitis
The diagnosis of the allergic rhinitis is done not only by observing the SYMPTOMS (mentioned above), but also
through ENDOSCOPY.
Endoscopy reveals: white mucosa (not red) and enlarged turbinate.
Treatment
The treatment of allergic rhinitis is normally medical treatment of:
- Antihistamine drugs (systemic, nasal, oral), -
- Steroids (nasal, systemic) and
- Nasal decongestant
Nasal irrigation - performed to dischage the secretions of the nose and restart muco-cilliary clearance.
Surgical:
The turbinate can be treated with a very small non-invasive device with:
Argon plasma - it is a very easy device to use and it takes a few seconds. It’s a gas laser the provokes a superficial scar on the turbinate
Fully describe Adenoid hypertrophy and their surgical treatment
Hypertrophy of the Adenoids is the most common cause of nasal obstruction in children. The adenoids are the nasopharyngeal tonsils (lymphatic tissue)
Classified based on the dimension of the lymphatic tissue
Grade 1
Very Small, no contact with the surrounding tissue.
Grade 2
The lymphatic tissue involves the Torus Tubarius
Grade 3
When the adenoids come directly to the vomer and the choana
Grade 4
Adenoids touch the soft palate
NOTE: in grade 3 and 4, the size of the adenoids is important and can cause difficulty breathing - therefore these grades have surgical indication
Surgical Treatment
- In the past was a blind procedure
- These days surgery is endoscopic adenoidectomy - only takes a few minutes
Fully describe Rhinosinusitis and it’s clssification
It is an inflammation of the nose and the paranasal sinuses.
It is characterized by 2 or more symptoms, one of which would be either nasal blockage/obstruction/congestionor nasal discharge. We will have facial pain/pressure and reduction/loss of smell.
And either Endoscopic signs or CT scan changes
Endoscopic signs:
- Nasal polyps
- And/or mucopurulent discharge from the middle meatus (important to check the middle meatus)
- And/or oedema/mucosal obstruction
CT scan changes: Offers you the possibility to check not only the osteomeatal complex but also
which sinuses are involved.
Symptoms are divided into major and minor symptoms.
Major symptoms: • Facial pain • Nasal obstruction • Mucopurulent discharge • Anosmia/hyposmia
Minor symptoms: • Headache • Fever • Halitosis (bad breath) • Cough • Reflex Otagia
Bacteria involved with rhinosinusitis:
We have the infernal trio: H. Influenza, Streptococcus, Moraxella Catarrhalis. Both Gram+ and Gram- can be involved.
CLASSIFICATION
• Acute: < 12 weeks with complete relief of symptoms
• Acute recurrent: Multiple episodes with complete relief symptoms between episodes.
• Chronic: o > 12 weeks o No complete relief of symptoms between episodes and if you perform endoscopy you will see: o Persistent mucosal thickening o Possible exacerbation of the symptoms.
You must remember the classification because the treatment is different for each classification of rhinosinusitis.
Describe the treatment of Acute Rhinosinusitis
Therapy: The medical therapy is: • Oral antibiotics • Topical steroids • Topical steroids + Antibiotics
In case of more advanced acute rhinosinusitis:
• Systemic steroids + antibiotics
• Nasal irrigations
Describe the complications of Acute Rhinosinusitis
COMPLICATIONS We have 3 types of complications - Orbital complications - Intracranial complications - Osseous complications
Orbital complications
Include: preseptal cellulitis, orbital cellulitis, subperiosteal, and intraorbital abscess.
Important to recognize in children!! Because the only sinus children have is the ethmoid one - which is separated from the orbital cavity by the papyracca lamina - a thin bony structure. Sometimes ethmoiditis presents directly as an orbital complication in children
If you do a CT scan, you will see the continuity between the infectious process and the lamina papyracca near the orbit. PROMPT SURGERY IMMEDIATELY to drain pus
Intracranial complications
This is the most important one. It includes epidural or subdural abscesses, brain abscess, meningitis, encephalitis, and vascular complications. They may present with nonspecific signs and symptoms and their diagnosis requires a high index of suspicion
e.g the frontal sinus’ posterior wall is thin and is in direct contact with meninges
Osseous complications Result from osteomyelitis of the facial skeleton associated with the progress of inflammation and may present as:
- Potts Puffy tumour or,
- A frontocutaneous fistula.
It is only in the frontal sinus as it is a complication not of the posterior wall, but of the anterior wall. There is osteomyelitis of the frontal bone that is called “Pott’s puffy tumor”; a very bulky lesion surrounded with red skin and sometimes there is a fistula that naturally evacuates the pus directly through the skin.
Discuss the CT scan observations and treatment of Acute recurrent rhinosinusitis
You may see a middle turbinate with a bulla (there is air inside the middle turbinate) - this anatomical alteration results in a very narrow space therefore there is less ventilation of the frontal sinus.
Treatment
We perform a very easy surgery to reduce this anatomical variation with an endoscopic surgery or balloon sinuplasty which is a new technique.
Describe Chronic Rhinosinusitis and it’s treatment
Chronic rhinosinusitis is clinical syndrome characterized by persistent symptomatic, inflammation of the mucosa of the nose and paranasal sinuses.
Diagnosis is based on clinical symptoms, endoscopy and CT scan
Isolated sphenoid sinusitis: It is the only case in which the diagnosis is based only on the CT scan. It is impossible to do the diagnosis only by
endoscopy.
Treatment:
The treatment is surgery. It is done endoscopically and the surgery is called: F.E.S.S. (Functional Endoscopic Sinus Surgery).
The treatment is customized directly to the patient. You perform the diagnosis, you do the CT scan and you only treat the region involved in the inflammatory chronic disease based on the CT scan.
Discuss Dental Sinusitis
This is a special, isolated maxillary sinusitis.
It is due to the migration of the implant directly from the maxillary bone to the maxillary sinus.
In this case you perform a non-invasive surgery and you treat the patient endoscopically going directly to the maxillary sinus and removing the fixture.
Fully describe Fungal rhinosinusitis
Fungal rhinosinusitis can be of 2 types:
- Invasive (rare)
- Non-invasive - fungal ball (most frequent)
Fungal ball:
It is a fungal colonization, without the invasion of the mucosa of the sinus.
Normally there is 1 single sinus (usually maxillary sinus 80% of the cases) that is involved
It is either due to the dysventilation theory (i.e. functional blockage of the sinusal ostium and the middle ostium/meatus is occupied with the fungus inside the sinus), or due to the odontogenic theory (infection of a tooth)
Symptoms
• Maxillary pain (most important pain)
• Cacosmia - A perceived malodorous smell
• Odontoiatric symptoms
• Other symptoms are: Cephalea (typical fungus bone of the sphenoid sinus), ocular symptoms.
Treatment
Surgery - complete resolution of the condition
Describe Nasal Polyposis, the 5 types and treatment
Nasal polyposis is an inflammatory disease of the nasal mucosa.
- Antro-choanal polyp,
Affects children. Appears as a white soft lesion in the endoscopic view.
Treatment is surgery (no response to medical treatment), the same instrument that is used for adenoids is used here. Procedure lasts few minutes
< 12 years a pure endoscopic approach;
>12 years Endoscopic + cranial fossa
- Choanal / Solitary polyp
It has the same characteristic as a tumour of the nose, vertical papilloma or malignant lesion of the nose.
General rule: Monolateral lesion of the nose => biopsy.
- Polyposis with chronic rhinosinusitis
The most important and the most common polyposis.
Treatment of the polyposis is mainly systemic or local steroids or surgery.
Surgery
- Endoscopically with general anesthesia - despite the fact that nasal polyps have a 90% chance of reoccurrence after surgical treatment, the endoscopic procedure helps the patient to breathe normally and it is minimally intrusive.
- Micro-debrider in local anesthesia - more commonly used.
- Polyposis with chronic rhinosinusitis with eosinophilia
same as polyposis + chronic rhinosinusitis.
5. Polyposis with specific pathologies • Cystic fibrosis • Asthma • Ciliary dyskinesia • ASA Intolerance • Young syndrome
In these cases, normally we do very small surgeries just to treat the polyps in the nose (to restart or reperform) and to allow the patient to start breathing normally again. It doesn’t matter if you do not treat the polyps in the maxillary sinuses because in a few weeks, the patient will suffer again the presence of the polyps (recurrence).
Describe the vascularisation of the nasal cavity
Internal carotid: The anterior and posterior ethmoidal arteries vascularize the upper part of the nose; they are branches of the ophthalmic artery which is a branch of the internal carotid artery.
• External carotid artery: offers from the maxillary artery, the greater palatine artery which goes from the hard palate directly to the anterior part of the turbinate. The maxillary artery also gives branches of the sphenopalatine artery, which go to the posterior part of the middle, inferior and superior turbinate.
The facial artery => superior labial artery=> septal branch => anterior part of Litt’s area of the
septum.
