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Nose and paranasal sinuses diseases (Sinusitis (Symptoms and signs of…
Nose and paranasal sinuses diseases
Signs and symptoms
congestion (impaired nose patency), discharge
runny nose (rhinorrhea), postnasal drip
sneezing, hyposmia/anosmia
dryness in the nose, facial/head pain
fetid odor from the nose
epistaxis
deformation of the nose
Furunculus of the nasal vestibule / Nasal vestibulitis
Furunculus: Inflammation of the hair follicle
Vestibulitis: Diffuse dermatitis
Etiology: Staphylococcus aureus
Causes: nose picking; haircuts , chronic rhinosinusitis
- Recurrent – Diabetes mellitus
- Treatment: antiseptics, antibiotic with steroid ointment & NO SQUEZZE ! NO CUT!
Triangle of the death
spread of the infection via veins of the face to the cranial cavity
Warning symptoms:
furunculus of the nasl vestible and/or upper lip; septal abscess
swelling along facial vein
odema of the eyelids, fever
Treatment: general antibiotics; hospitalization
Nasal foreign bodies
Symptoms
:
unilateral obstruction
purulent discharge from the nose
foul smell from the nose
excoriation around nostril
epistaxis
RISK OF ASPIRATION WITH ACUTE RESPIRATORY DISTRESS
Diagnostics (if not visible or big FB)
Nasal encoscopy
X-ray/CT
Management
Removal under visual control
round FB with hook or loop
NOT USE TWEEZER!
Alternative:
-Fogarty catheter
-Possitive pressure technique (blow into mouth while occluding unaffected nostril)
Paranasal sinuses foreign bodies
Transnasal endoscopic removal External aproach (Caldwell-Luc)
Nonallergic Rhinitis
Types:
vasomotor rhinitis (irritant rhinitis)
rhinitis medicamentosa
structural rhinitis
hormonal rhinitis (pregnacy)
senile rhinits
Causes:
fumes
odors
temperature
atmospheric changes
smoke
Symptoms:
sneezing
congestion*
runny nose
postnasal drip
hyposmia
Management:
oral & inhaled medications
surgery (e.g. Polyps, deviated nasal septum)
Allergic Rhinitis
Types
seasonal, perennial
Causes:
pollen, dust mites
mold, animal dander
Symptoms:
sneezing, congestion
runny nose, itchy nose, throat, eyes
tearing, red eyes, eye swelling
hay fever
Management:
Avoiding allergens
Treatment:
oral medications (antihistaminics, cromones)
nasal steroids
immunotherapy (IgE -> IgG)
Mucocoele
Cyst-like structure
Blockage of the sinus ostium
Grow with destruction of bony walls
Causes:
Traumatic, Jatrogenic (sinus surgery), Tumours
Localization:
Frontal sinus , Maxillary sinus (after C-L operation)
Symptoms:
Headache, facial pain
Deformity of frontal region, cheek
Orbital mass
Double vision
Diagnostics: CT, MR
Complication: infection->mucopyocoele
intracranial penetration
Treatment :
Surgical – radical operation
(frontoethoidectomy, diilatation of natural ostium + nasal stent) - FESS
Sinusitis
Factors determinating function of the paranasal sinuses: osteomeatal complex region
mucociliary clearance & mucus membrane
Obstruction of osteomeatal complex region - causes:
Anatomical: deviated nasal septum, anormalies of lateral wall
Mechanical: polyps, tumors, foreign body
Mucosal oedema: infection, allergy, drug-induced rhinitis, barotrauma
Trauma: facial fractures, jatrogenic trauma
Congenital: ciliary dyskinesia, cystic fibrosis
Factors impairing mucociliary clearance and function of mucous membrane:
Enviromental: air temperature and humidity, tabbacco smoke
Patophysiological: hypoxia, hypercapnia, dehydratation, pH changes
Congenital disorders: cystis fibrosis, primary ciliary dyskinesia (Kartagener`s syndrome)
Pharmacological: decongestants, lidocaine
Bacterial infections: e.g. P.aeruginosa, H.influenzae
Mechanical: anatomical anormalies and variants, foreign body, nasal polyps
Immunological: chemotherapy, posttransplant, immuno-deficiency
an inflammation of the mucous membranes of one or more of the paranasal sinuses
sinusitis = rhinosinusitis
pathophysiology : impaired drainage and ventilation + infection
Classification
Kern 1984: Based on the time of lasting and morphological changes: Acute sinusitis – up to 3 weeks,
Subacute sinusitis – from 4 weeks to 3 months;
Mucosal changes are reversible.
Chronic sinusitis – lasting above 3 months;
Irreversible mucosal changes
Lund 1995: Based on pathophysiological processes:
Acute sinusitis – inlammation, with complete resolution after treatment
Acute recurrent sinusits – reapeted episodes acute sinusitis, without permament mucosal changes after conservative treatment
Chronic sinusitis – persistent inflammation, which can not be eliminated with conservative treatment
Symptoms and signs of acute sinusits
General symptoms: (Cold- like: acute onset, fever, weakness)
Local symptoms:
nasal obstruction
nasal discharge
postnasal secretion
severe „sinus” headache
facial pain (between eyes, maxillary or frontal pain )
dental or upper jaw pain
cough, vomiting (especially in children)
Examination
mucosal oedema and congection of the nose
purulent secretion in nasal cavities and/or in nasopharynx
tenderness over the sinuses` walls
mild swelling of the eyelids
Symptoms and signs of chronic sinusitis
Generally less severe:
nasal obstruction
facial pain or headache (nonspecific)
intermittent rhinorrhea or postnasal secretion
hyposmia/anosma(poor smell)
chronic fatigue
foul smelling (anaerobic infection)
Examination
purulent secretion in nasal cavities or in nasopharynx
mucosal oedema and congection
Symptoms of acute and chronic sinusitis are nonspecific
Diagnosis
Basic diagnostic tools:
history and examination
endoscopy
X-ray (in acute sinusitis only)
CT scan - (chronic sinustis or complication of acute sinusItis) gold stander
Supplementary diagnostic:
Leukocyte count, CRP, ESR
Microbiological studies
MRI scan (certain diagnoses e.g. mycosis, intracranial complication)
Further diagnostic:
Allergy diagnosis
Nasal biopsy
ANCA (if Wegener`s granuloma susp.)
Ciliary dysfuction tests (saccharin test, electron microscopy studies)
Ultrasound, Transillumination (historical, not helpful)
Microbiology
Aerobic bacteria
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Anaerobic bacteria
Bacteroides
Fusobacterium
Peptostreptococcus
Fungi
Aspergillus
Mucor
Differential diagnosis
Viral rhinitis, Allergic & Nonallergic chronic rhinitis, Drug-induced rhinitis, Abnormalities (ciliary dyskinesia, cystic fibrosis, meningocele)
Mechanical causes (foreign bodies, septal deviation)
Benign and malignant tumors
Secondary rhinitis (Wegener`s syndrom, sarcoidosis, aspirin sensivity, mycosis
Conservative treatment
antibiotics (at least 10 days)
amoxicillin / beta-lactamase inhibitors;
2nd or 3rd generation cephalosporins;
clindamycin, metronidazole (anaerobes)
alternatives: macrolides, doxycycline, fluorquinolone
topical steroids
decongestants
topical (for <3-6 days; e.g. xylometazoline, oxymetazoline, naphazoline)
oral ( e.g pseudoephedrine)
mucolytics (e.g. acetylocysteine)
antihistamines (only in allergic condition)
Maxillary sinus puncture
gold standard for diagnosis of acute bacterial sinusitis
an invasive procedure not popular with patients
diagnostic
assesment of sinus volume and patency of ostia
material for bacterial cultures
therapeutic
evacuation of secretion
sinus lavage
drugs can be directed applied
Surgical treatment
Acute sinusitis (evacuation of secretion)
Beck`s drill of frontal sinus
endonasal endoscopic drainage
Chronic sinusitis
no results after conservative treatment
resumption of sinus drainage and ventilation
removal of invalid mucous membrane
functional endoscopic sinus surgery (FESS)
external approach (radical sinus surgery)
Nasal polyps
hyperplastic oedematous connective tissue with some seromucous glands and inflammatory cells
Neutrophilic (chronic sinusitis)
unilateral, maxillary, Adult rare, Neoplasm, surgery
Eosinophilic (allergic)
bilateral, Ethmoidal, Children rare, Cilliary dysfunction , Cystic fibrosis, Corticosteroids, Surgery
Aspirin triad (Samter`s triad)
hypersensitivity to ASA/NSAIDs.
chronic rhinosinusitis with nasal polyps.
bronchial asthma
Paranasal sinus mycosis
Causes
long-lasting treatment with antibiotics
systematic corticosteroids
immunodeficiency
diabetes mellitus
etiology: fungi
classification: a. non-invasive. b. invasive
Treatment:
Endoscopic sinus surgery
Radical debridement/sinus surgery
Corticosteroids in AFS
Systemic antifungal
Matar