nasal and sinus disease

1. Nasal and sinus disease Babak saedi M.D Assistant professor of Tehran university

2. Anatomy

4. Nose and Para nasal sinuses

6. The Nose Vascular Supply - Anterior - branches of internal carotid - Posterior - distal branches of external carotid

8. Facial Analysis Analysis of nose is very important

9. Facial Analysis Face: General Divided in 1/3�s trichion to NFA NFA to subnasale subnasale to menton

10. Function of Nose & Paranasal Sinuses Humidifying and warming inspired air Regulation of intranasal pressure Increasing surface area for olfaction Lightening the skull Resonance Absorbing shock Contribute to facial growth

12. Sinus Maxillary Frontal Ethmoid Sphenoid

16. EpistaxisAnterior 90% (Little�s Area) Kisselbach�s plexus - usually children, young adults Etiologies Trauma, epistaxis digitorum Winter Syndrome, Allergies Irritants - cocaine, sprays Pregnancy

17. EpistaxisPosterior 10% of all epistaxis - usually in the elderly Etiologies Coagulopathy Atherosclerosis Neoplasm Hypertension (debatable)

18. EpistaxisManagement Pain meds, lower BP, calm patient Prepare ! (gown, mask, suction, speculum, meds and packing ready) Evacuate clots Topical vasoconstrictor and anesthetic Identify source

19. EpistaxisManagement Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis

20. Packing - anterior BIPP impregnated gauze in layers

21. EpistaxisPosterior Packing Need analgesia and sedation require admission and 02 saturation monitoring

22. Packing - posterior Inflatable balloons

23. EpistaxisComplications severe bleeding hypoxia, hypercarbia sinusitis, otitis media necrosis of the columella or nasal ala

24. Osler-Weber-Rendu

25. Scope of Sinusitis Affects 30-35 million persons/year 25 million office visits/year Direct annual cost $2.4 billion and increasing Added surgical costs: $1 billion Third most common diagnosis for which antibiotics are prescribed Third most common diagnosis for which antibiotics are prescribed. Rhinosinusitis, like asthma is becoming more prevalent. McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:214-219Third most common diagnosis for which antibiotics are prescribed. Rhinosinusitis, like asthma is becoming more prevalent. McCraig LF, Hughes JM: Trends in antimicrobial drug prescribing among office based physicians in the US. JAMA 1995, 273:214-219

26. Sinusitis 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells Frontal Maxillary Ethmoid Sphenoid

27. Ostiomeatal Complex Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain Posterior ethmoids drain into the upper meatus Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

28. Viral Rhinosinusitis Most upper respiratory infections are viral Short lived, last less than 10 days Sinus mucosa as well as nasal mucosa is involved Most will clear without antibiotics Treatment: decongestants, nasal lavage, rest, fluids

29. Classification of Bacterial Sinusitis Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days) Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days) Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days) Some guidelines add treatment failure + a positive imaging study

30. Differentiating Sinusitis from Rhinitis Sinusitis Nasal congestion Purulent rhinorrhea Postnasal drip Headache Facial pain Anosmia Cough, fever Rhinitis Nasal congestion Rhinorrhea clear Runny nose Itching, red eyes Nasal crease Seasonal symptoms

31. Pathogenesis of Nasal Obstruction Viral upper respiratory infections Daycare centers Allergic and nonallergic stimuli Immunodeficiency disorders Immunoglobulin deficiency (IgA, IgG) Anatomic changes Deviated septum, concha bullosa, polyps

32. Treatment of Acute Sinusitis Antihistamines recommended if allergy present Oral or topical Decongestants Oral or topical Antibiotic when indicated (bacteria) Nasal irrigation Guaifenesin 200-400 mg q4-6 hrs Hydration

33. Antibiotics for Acute Bacterial Sinusitis Amoxicillin 500 mg tid for 10-14 days First line choice in most areas Local differences in antibiotic resistance occur Where beta-lactamase resistance is an issue Amoxicillin/clavulanate Cefuroxime Cefexim Cefprozil

34. Additional Antibiotics for Acute Bacterial Sinusitis Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days) If penicillin-allergic clarithromycin or azithromycin Erythromycin does not provide adequate coverage Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance Give prescription for antibiotic for 5 days, if no response switch to another, if responding refill for full 10 day course. Where co-pays are involved give entire 10 day prescription initially. Give prescription for antibiotic for 5 days, if no response switch to another, if responding refill for full 10 day course. Where co-pays are involved give entire 10 day prescription initially.

35. Rhinoscopy Aids in Diagnosing Nasal polyps Septal deviation Concha bullosa Eustachian tube dysfunction Causes of hoarseness Adenoid hyperplasia Tumors

36. Chronic Sinusitis Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children Eosinophilic inflammation or chronic infection Associated with positive CT scans Poor (if any) response to antibiotics

37. Sx of Chronic Sinusitis Nasal discharge Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down)

38. Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria Staph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS. Staph aureus, other streptococcal bacteria, pseudomonas, and E.coli are uncommon bacteria found in ABS.

39. CT Scan Maxillary and Ethmoid Sinuses

40. Sinusitis

41. Treatment of Chronic Sinusitis Nasal steroid spray Guafenesin Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations

42. FESS

43. Sinus endoscopy

47. Complications of Sinusitis Orbital Diplopia, proptosis Periorbital erythema, swelling Bone Periosteal abscesses Brain Intracranial abscesses causing neurologic symptoms Cellulitis can spread around the eye and cheek indicated by swelling and erythema. Symptoms of meningitis, severe headache, focal neurologic symptoms signal spread to intracranial areas. Cellulitis can spread around the eye and cheek indicated by swelling and erythema. Symptoms of meningitis, severe headache, focal neurologic symptoms signal spread to intracranial areas.

48. Nasal obstruction Infection Allergy Adenoid hypertrophy Nasoseptal deformity Chronic sinusitis Septal hematoma (abscess) Foreign body Neoplasm Choanal atresia

49. Looking at the turbinates: Diagnosis?

50. Nasal Polyp

51. Septal deviation

52. Allergic Rhinitis