520 likes | 755 Views
Nasal and sinus disease. Babak saedi M.D Assistant professor of Tehran university . Anatomy. Bony Structure. Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate. Nose and Para nasal sinuses. Arterial Supply. External Carotid Maxillary A.
E N D
Nasal and sinus disease Babak saedi M.D Assistant professor of Tehran university
Bony Structure Ethmoid Maxilla Palatine Lacrimal Pterygoid plate of Sphenoid Nasal Inferior Turbinate
Arterial Supply External Carotid Maxillary A. Sphenopalatine Internal Carotid Ophthalmic A. Ant. Ethmoid Post. Ethmoid Supraorbital Supratrochlear
The Nose • Vascular Supply - Anterior - branches of internal carotid - Posterior - distal branches of external carotid
Analysis of nose is very important Facial Analysis
Facial Analysis • Face: General • Divided in 1/3’s • trichion to NFA • NFA to subnasale • subnasale to menton
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
Sinus Anatomy Overview 7 bones 4 paired sinuses 4 turbinates 3 meati Drainage system Nervous supply Vascular supply Related structures
Sinus • Maxillary • Frontal • Ethmoid • Sphenoid
Ethmoid Bulla Uncinate Process Hiatus Semilunaris
EpistaxisAnterior • 90% (Little’s Area) Kisselbach’s plexus - usually children, young adults Etiologies • Trauma, epistaxis digitorum • Winter Syndrome, Allergies • Irritants - cocaine, sprays • Pregnancy
EpistaxisPosterior • 10% of all epistaxis - usually in the elderly • Etiologies • Coagulopathy • Atherosclerosis • Neoplasm • Hypertension (debatable)
EpistaxisManagement • Pain meds, lower BP, calm patient • Prepare ! (gown, mask, suction, speculum, meds and packing ready) • Evacuate clots • Topical vasoconstrictor and anesthetic • Identify source
EpistaxisManagement • Anterior Sites - Pressure +/- cautery and/or tamponade - all packs require antibiotic prophylaxis
Packing - anterior • BIPP impregnated gauze in layers
EpistaxisPosterior Packing • Need analgesia and sedation • require admission and 02 saturation monitoring
Packing - posterior • Inflatable balloons
EpistaxisComplications • severe bleeding • hypoxia, hypercarbia • sinusitis, otitis media • necrosis of the columella or nasal ala
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
Sinusitis Infectious or noninfectious inflammation of 1 or more sinuses • 4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells • Frontal • Maxillary • Ethmoid • Sphenoid
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
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
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
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 Differentiating Sinusitis from Rhinitis
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
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
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
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
Rhinoscopy Aids in Diagnosing • Nasal polyps • Septal deviation • Concha bullosa • Eustachian tube dysfunction • Causes of hoarseness • Adenoid hyperplasia • Tumors
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
Sx of Chronic Sinusitis • Nasal discharge • Nasal congestion • Headache • Facial pain or pressure • Olfactory disturbance • Fever and halitosis • Cough (worse when lying down)
Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown • Streptococcus pneumoniae • Haemophilus influenza • Moraxella catarrhalis • Staph aureus • Coagulase negative staphylococcus • Anerobic bacteria
Treatment of Chronic Sinusitis • Nasal steroid spray • Guafenesin • Decongestants • Steam inhalation • Nasal irrigation • Antibiotics with exacerbations
Complications of Sinusitis • Orbital • Diplopia, proptosis • Periorbital erythema, swelling • Bone • Periosteal abscesses • Brain • Intracranial abscesses causing neurologic symptoms
Nasal obstruction • Infection • Allergy • Adenoid hypertrophy • Nasoseptal deformity • Chronic sinusitis • Septal hematoma (abscess) • Foreign body • Neoplasm • Choanal atresia