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

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