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RHINOLOGY REVIEW part 2

RHINOLOGY REVIEW part 2. Marilene B. Wang, MD, FACS Professor UCLA Division of Head Neck Surgery Chief of Otolaryngology VA Greater Los Angeles Healthcare System. Sphenoid Sinus Distances. From Anterior Nasal Spine To Sphenoid Ostium 7 cm To Pituitary Fossa 8.5 cm.

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RHINOLOGY REVIEW part 2

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  1. RHINOLOGY REVIEWpart 2 Marilene B. Wang, MD, FACS Professor UCLA Division of Head Neck Surgery Chief of Otolaryngology VA Greater Los Angeles Healthcare System

  2. Sphenoid Sinus Distances • From Anterior Nasal Spine • To Sphenoid Ostium 7 cm • To Pituitary Fossa 8.5 cm

  3. Key Anatomic Landmarks in the Nose and Paranasal Sinuses • Middle turbinate • Lamina papyracea • Ethmoid fovea • Cribriform plate • Sphenoid

  4. Rhinosinusitis-Major factors • Facial pain/pressure • Nasal obstruction/blockage • Nasal discharge/purulence/discolored postnasal drip

  5. Rhinosinusitis-Major factors • Hyposmia/anosmia • Purulence in nasal cavity on examination • Fever (acute rhinosinusitis only)

  6. Rhinosinusitis-Minor factors • Headache • Fever • Halitosis • Fatigue

  7. Rhinosinusitis-Minor factors • Dental pain • Cough • Ear pain/pressure/fullness

  8. Categories of Rhinosinusitis • Acute • Subacute • Chronic • Recurrent, acute • Acute exacerbations of chronic

  9. Acute Rhinosinusitis • Duration up to 4 weeks • > 2 major factors • 1 major factor + 2 minor factors • Nasal purulence on exam

  10. SubacuteRhinosinusitis • Duration 4-12 weeks • >2 major factors • 1 major factor + 2 minor factors, or nasal purulence on exam • Complete resolution after effective medical therapy

  11. Chronic Rhinosinusitis • Duration > 12 weeks • History same as for subacute • Facial pain does not constitute suggestive history in absence of other nasal symptoms or signs

  12. Recurrent acute • >4 episodes/year + each episode last >7-10 days. • Absence of intervening signs of chronic rhinosinusitis

  13. Acute exacerbations of chronic • Sudden worsening of chronic rhinosinusitis • Return to baseline after treatment

  14. Factors Associated with Chronic Rhinosinusitis • Allergies • Immunodeficiency • Genetic/congenital

  15. Factors Associated with Chronic Rhinosinusitis • Endocrine • Neuromechanism

  16. Factors Associated with Chronic Rhinosinusitis • Anatomic • Neoplastic • Acquired mucociliary dysfunction

  17. Associated Factors • Microorganisms—viral, bacterial, fungal • Noxious chemicals, pollutants, smoke • Medications • Trauma • Surgery

  18. Microbiology of acute sinusitis (adults) • S. pneum (20-43%) • H. influenzae (22-35%) • Strep spp. (3-9%) • Anaerobes (0-9%) • M. catarrhalis (2-10%) • S. aureus (0-8%) • Other (4%)

  19. Microbiology of acute sinusitis (children) • S. pneum (25-30%) • H. influenzae (15-20%) • M. catarrhalis (15-20%) • S. pyogenes (2-5%) • Anaerobes (2-5%) • Sterile (20-35%)

  20. Recommended abx for adults with acute bacterial rhinosinusitis • Mild disease with no recent antimicrobial use • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef

  21. Switch if no improvement after 72 hours • Tequin, Levaquin, Avelox • Augmentin • Combination (Amox or clinda + Suprax)

  22. Abx for acute sinusitis if PCN-allergic • Bactrim • Doxycycline • Zithromax, Biaxin, Erythromycin • Switch to quinolone if no improvement in 72 hours

  23. If recent abx use • Quinolone • Augmentin • Clindamcin + rifampin • Consider IV abx

  24. Abx for acute sinusitis in children • Augmentin, Amoxicillin • Vantin • Ceclor • Omnicef • Switch if no improvement after 72 hours

  25. If PCN-allergic • Bactrim • Macrolide

  26. If recent abx use (children) • Augmentin • Rocephin • Bactrim, macrolide • Consider IV abx if no improvement

  27. Other symptomatic therapies • Afrin for 3 days • Normal saline sprays • Decongestants • Antihistamines • ?Steroids

  28. Complications of sinusitis • Periorbital cellulitis • Preseptal cellulitis/abscess • Orbital cellulitis • Orbital abscess • Cavernous sinus thrombosis

  29. Allergic Rhinitis • Widespread affliction—the most common allergic disease • Affects 10-30% of American adults— • >20 million people, adults and children • Results in missed work and school days, poor quality of life

  30. Symptoms of allergic rhinitis • Allergic salute • Shiners • Itchy, red conjunctiva • Sneezing • Post-nasal drip, rhinorrhea, congestion

  31. Common allergens--indoor • Dust • Mold, mildew • Plants • Animal dander • Feathers/down

  32. Common allergens--outdoor • Pollen • Smog • Trees, grasses, weeds • Dust, fertilizer, chemicals

  33. Associated diseases • Asthma • Allergic fungal sinusitis • Cystic fibrosis • Mucociliary dysfunction • Connective tissue disorders (Wegener’s granulomatosis, sarcoid)

  34. Associated diseases • Nasal polyposis • Samter’s triad (aspirin sensitivity, nasal polyps, asthma) • Cocaine use

  35. Chronic rhinosinusitis • Antibiotics • Antihistamines • Nasal steroids • Normal saline irrigations • Allergy evaluation +/- immunotherapy

  36. Chronic rhinosinusitis • Sinus CT scan • Consider anatomic factors—septal deviation, nasal polyps, concha bullosa, ostio-meatal blockage

  37. Indications for sinus surgery • Nasal polyposis • Anatomic blockage—deviated septum, enlarged turbinate, concha bullosa • Mucocele • Orbital abscess

  38. Indications for sinus surgery • Fungal sinusitis—allergic vs. invasive (mucor) • Tumor of nasal cavity or sinus

  39. Indications for sinus surgery • Chronic, recurrent sinusitis • Failure to respond to maximal medical therapy • Obtain cultures

  40. Surgical Complications—common, minor • Nasal congestion • Headache/sinus pain • Fatigue • Prolonged bleeding/crusting

  41. Complications—major, rare • Breach of lamina papyracea—damage to extraocular muscles, periorbital ecchymoses • Damage to optic nerve—blindness • Breach of cribriform—CSF leak • Meningitis

  42. Long-term management • May be a lifelong disease • Allergy control—antiihistamines, nasal steroids, immunotherapy • Oral steroids—judiciously • Antibiotics for acute exacerbations

  43. Long-term management • Environmental control—avoid carpet, damp, mold, older homes, smog • Saline irrigations

  44. Long-term management • Alternative therapies—acupuncture, stress management, herbal remedies • Pain management • Multi-disciplinary effort—work with allergy, infectious disease, neurology/pain management services

  45. Allergy Review • 4 types of allergic reactions (Gell and Coombs) • Type 1 – IgE • Type 2 - IgG--antigen • Type 3 – Immune complex • Type 4 – Delayed hypersensitivity

  46. Type 1 • Mast cells bind IgE via their Fc(ε) receptors • Mast cell degranulates and releases mediators--produce allergic reactions • Hypersensitivity usually appears on repeated contact with the allergen. • Examples of type I allergic reactions • Anaphylaxis, atopic asthma, atopic eczema, drug allergy, hay fever

  47. Type 2 • Antibody (IgG or IgM) directed against antigen on an individual's own cells, or against foreign antibody (after blood transfusion) • Cytotoxic action by killer cells, or to lysis mediated by the complement system. • Autoimmune hemolytic anemia, Goodpasture's syndrome, hemolytic disese of the newborn, myasthenia gravis, pemphigus

  48. Type 3 • Immune complexes (antigen and usually IgG or IgM) deposited in the tissue • Complement is activated and polymorphonuclear cells are attracted, causing local tissue damage and inflammation. • Polyarteritis nodosa, post-streptococcal glomerulonephritis , systemic lupus erythematosus

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