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Nose, Rhinosinusitis - Coggle Diagram

- - - - Class 1
        
        Vertical
        
        Chevallet
        
        Frontal trauma
      - Class 2
        
        Lateral trauma
        
        Jarjavay's fracture
        
        Lateral deviation of nose
        
        C-shaped fracture
        
        perpendicular plate of ethmoid and septal cartilage
      - Class 3
        
        High energy trauma
        
        telescoping of ethmoidal complex
        
        Telecanthus
        
        Perp. Plate rotated
        
        cartilage backwards
        
        Pig-like appearance
        
        Saddle deformity
    - - Nose deformity
        
        pain
        
        epistaxis
      - Nasal obstruction
      - CSF Rhinnnorhea
    - - Periorbital ecchymosis
      - Palpation shows
        
        tenderness
        
        Crepitus
        
        Step ladder deformity
      - Ant. rhinoscopy
        
        blood clot
        
        septal hematoma etc
    - - Epistaxis
      - CSF Rhinnorhea
      - Septal hematoma
    - - Clinical
      - X-ray only for medicolegal purposes
    - - Early
        
        Pre-edema
        
        within 4-6 hours
        
        Digital manipulation
        
        w(/o) anaesthesia
      - Intermediate
        
        Edema
        
        6hr - 6 days
        
        Loss of anatomical landmarks
        
        Given antiinflammatory
        
        ask to visit after 7-10 days
      - Late
        
        Post edema
        
        7-14 days
        
        LA/GA
        
        Walsham's Forceps
        
        mobilises fragments of lateral wall
        
        Asch's Forceps
        
        Septal fractures and dislocations
      - Very late
        
        after 3 weeks
        
        Adult
        
        Rhinoplasty
        
        6 mo. after
        
        GA
        
        Child
        
        Rhinoplasty
        
        after 18yo
      - Septal hematoma/ abscess
        
        urgent drainage
  - - - Trauma
      - Developmental error
      - Space occupying lesions
    - - Deviation
        
        C/S
        
        vertical/horizontal
      - Dislocation
        
        Maxillary crest
        
        Columella
      - Spur
        
        sharp angulated projection
        
        junction of vomer with septal cartilage
    - - Nasal obstruction
        
        paradoxical nasal obstruction
        
        Nasal valve
      - Anosmia
      - Mucosal changes
        
        crusting
        
        ulceration and bleeding
      - Ext. deformity
        
        nasal pyramid
      - Sluder's neuralgia
        
        Anterior ethmoidal nerve syndrome
    - - Deviation of nasal septum
      - Hypertrophy of inferior turbinate
      - Cottle test +ve
        
        outward and upward puling of cheek
        
        valve area
    - - clinical ground
      - Xray PNS
        
        DNS complications and diseases
    - - Simple deviation
      - Obstruction
        
        nasal decongestants
      - Impaction
        
        Criteria
        
        Under 18 and over 18
        
        Vertical line b/w
        
        Maxillary nasal process
        
        Frontal nasal process
        
        Deviation
        
        Anterior
        
        1 more item...
        
        Posterior
        
        1 more item...
  - - - Trauma
        
        Non surgical
        
        Surgical
        
        Sinuses
        
        FESS
        
        Hypophysectomy
      - Tumors
        
        Pituitary
        
        Vestibular schwannoma
        
        NP tumors
      - Congenital defects
      - Idiopathic
        
        CSF Otorhinnorhea
        
        Temporal bone fracture
        
        Ant. Cranial fossa
    - - Clear watery nasal discharge
        
        ^ by bending
        
        ^ by Valsalva etc
      - Sweet/Salty in mouth
      - Continuous headache
      - Halo sign/ Double target sign
        
        CSF mixed with blood
        
        flexible nasopharyngoscopy
        
        helps localise site of leak
    - - Estimation of B2 transferrin
        
        Estimation of B trace protein
      - Radiology
        
        High res CT
        
        traumatic cases
        
        MRI
        
        non trauma cases
      - Intrathecal dyes
        
        using flexible nasopharyngoscopy
    - - Conservative
        
        Antibiotic prophylaxis
        
        Strict bed red and elevation of head
        
        Spinal drain
      - Surgical
        
        Approaches
        
        FESS
        
        Transseptally
        
        Extracranially
        
        Covered in fascia lata
        
        or temporalis fascia
- - - - Basal type
        
        pedunculated intranasal swelling
      - Frontoethmoidal type
        
        subcut soft, cystic pulsatile swelling over root of nose
    - - Crying/Straining increase size
      - Coughing increases size
        
        Frustenberg Test
    - - CT
    - - Excision
        
        Repairing Boney defect
        
        Seal the defect
      - Endoscopically
  - - - Uni/Bi
      - 90% bony
        
        10% membranous
      - failure of buccopharyngeal membrane involution
    - - Unilateral
        
        More common
        
        undiagnosed adult life
        
        Breast feeding difficult
      - Bilateral
        
        Respiratory emergency
        
        Cyanosed during quiet periods
        
        Normal during crying
        
        Contrast to laryngomalacia
        
        Patency test
        
        No misting
        
        Methylene blue dye
        
        Soft red rubber catheter
      - Flexible Nasopharyngoscopy
      - CHARGE
        
        Colobomatous Blindness
        
        Heart Disease
        
        Atresia of Choana
        
        Retarded Growth
        
        Genital abnormality
        
        Ear abnormality
    - - Choanogram
      - CT
        
        membranous/bony
        
        thickness of atresia
    - - Unilateral
        
        Elective surgery
      - Bilateral
        
        Primary
        
        McGrovern's Technique
        
        Water's airway
        
        Laryngeal mask
        
        Endotracheal tube
        
        Tracheostomy
        
        Temporary air restoration
        
        Secondary
        
        Transnasal/ Transpalatal
        
        Tilly Lichtwitz trocar and cannula
        
        diamond paste burr
        
        or CO2 laser
        
        Opening maintained by sialistic tube
        
        3-6 weeks
- - - - Nose picking
        
        may cause cellulitis
        
        spontaneous evacuation of pus
        
        Rule out diabetes or immunocompromised
    - - Severe pain
      - Unsighty edematous
    - - Cellulitis
      - Septal/Alar abscess
      - CST
    - - FBG
        
        rules out DM
    - - Systemic antibiotics
      - Analgesics
      - Avoid nose picking, boil squeezing
      - Incision & drainage
        
        if abscess
      - Topical removal of S. Aureus
        
        from EAC and nail beds
- - - - recurrent use of topical decongestants
- - - - Superimposed bacteria
    - - Ischemic
        
        sneezing/shivering
        
        Sense of smell gone
      - Hyperemic
        
        rhinorrhea
        
        nasal obstruction
      - Sec. infection
        
        discharge becomes yellow/green
        
        Thickened discharge
      - Resolution
    - - Nasal obstruction
      - Discharge
      - Tenderness over the sinus
    - - Nasopharyngitis, pharyngitis, tonsillitis
      - Salpingitis Otitis Media
      - Bronchitis and pneumonia
    - - Prophylactic
      - Therapeutic
        
        Rest and warmth
        
        Analgesics
        
        Pseudoephedrine
        
        Antibiotics
        
        Antihistamines
        
        Local treatment
        
        Inhalation of steam
        
        Vasoconstrictors
  - - - Seasonal
      - Perennial
    - - Sneezing
      - Nasal discharge
      - Nasal obstruction
      - Itching
      - Wheezing
        
        chest tightness
    - - Bluish nasal mucosa
        
        maybe red due to sec. infection
      - Samter's Triad
    - - Recurrent rhinosinusitis
      - Nasal Polyps
      - Serous Otitis Media
      - Bronchial asthma
    - - Eosinophil count
        
        DLC
      - IgE levels
      - Nasal secretions
      - Nasal scrapings
      - Skin tests
      - RAST
    - - Avoidance of allergens
      - Drugs
        
        antihistamines
        
        Decongestants
        
        Corticosteroids
        
        Mast cell stabilizers
        
        Anticholinergics
        
        Antileukotrienes
      - Immunotherapy
        
        subcut/ subling
        
        1-2 weekly for 6-8 weeks
        
        4-8 weekly for 3-5yrs
      - Psychological issue
      - Vidian Neurectomy
  - - - Overactive PNS
    - - resemble allergic rhinitis
    - - nasal muscoa congested
        
        hypertrophied
    - - by exclusion
    - - Avoidance of factors
      - Avoidance of anxiety
      - Antihistamines
      - Nasal decongestants
      - Steroids
      - Vidian neurectomy
  - - - prolonged drying
      - factors
        
        Anemia
        
        Chronic rhinosinusitis
        
        Excessive surgical resection
        
        Syphillis
        
        Autoimmune disease
        
        Endocrine imbalance
      - Chronic inflammation
        
        Endarteritis
        
        periarterial fibrosis
        
        terminal arterioles
        
        Ciliated columnar epi
        
        replaced by
        
        Strat. squam
        
        Thick adherent crusts
        
        Sec. infection with saprophytic organisms
        
        Klebsiella Ozaena
        
        D. Bacillus
        
        P. Vulgaris
        
        E. Coli
    - - Ozaena
      - Nasal obstruction
        
        crusting
      - Epistaxis
      - Anosmia
    - - Generally depressed
        
        bad smell
      - Abnormally patent cavities
        
        roomy
      - Greenish/yellow/blackish crust
        
        shriveled turbinates
      - Septal perforation
        
        saddle nose
    - - Clinical
      - Xray to exclude sinus infection
      - Serological test to exclude syphillis
    - - Conservative
        
        Remove underlying cause
        
        Alkaline nasal douches
        
        25% glucose in glycerin
        
        decongestants avoided
        
        Estradiole
        
        Human placental extract
        
        KI
      - Surgical
        
        Young's Operation
        
        most common
        
        Modified youngs operation
        
        Lautenslager's operation
        
        submuc. inj.
        
        paraffin
        
        displace lat. nasal wall
        
        medially
        
        Surgical narrowing
        
        Teflon strips
        
        Bone/ cartilage
  - - - Dry hot dusty occupations
      - Def. of seromucinous glands
      - Anemia alcoholism
        
        factors
    - - discomfort
        
        irritation
      - Crusting
      - No smell!
    - - Dry and white mucous membranes
      - Crusting limited to ant. part of nasal cavity
    - - same as allergic rhinitis
    - - Remove underlying cause
      - Correction of anemia etc
      - Alkaline nasal douches
- - - - Acute subacute sinusitis
        
        medical treatment failed
    - - pt < 3yo
      - Thick bony wall
      - Acute maxillary sinusitis
        
        untreated by antibiotics
      - Previous trauma
        
        disturbed orbital floor
    - - Trendelenberg position
        
        15degree head flexion
        
        4%xylocaine w adrenaline pack in inf. meatus
        
        removed after 20 mins
      - TL T&C inf. meatus punctured
        
        direction kept outer to lateral canthus
        
        trocar removed aspiration done
      - Sinuses washed
        
        continuous watch for proptosis cheek swelling
    - - Hemorrhage
      - Air embolism
      - Penetration of orbital floor and proptosis
      - Penetration of soft tissue of cheeks and cellulitis
  - - - plus systemic diseases
    - - GA/LA
        
        Trendelengerg position 15 degree head
        
        Throat pack placed
      - Inf. turbinate elevated
        
        Hill's elevator
        
        then punctured
        
        Myle's retrograde antrum perforator
        
        same site as antral washout
      - Perforator removed and hole enlarged to 2cmx1cm
        
        edges made smooth
        
        inf. turbinate repositioned
    - - Hemorrhage
      - Sup. Alveolar nerve
      - Complete closure of antrostomy hole
        
        if window is too small
  - - - IMA not working
      - Antrochoanal polyp
      - Removal of foregin body
      - Closure of oroantral fistula
      - Dental cyst
      - Stabilisation of orbital floor fracture
      - Stabilisation of zygoma body
      - Approach to pterygopalatine fossa
        
        ligation of maxillary artery
        
        Vidian neurectomy
    - - Child <12
      - Disfigurement of facial skeleton
    - - GA
        
        Trendelenberg and head position
        
        thorat pack
      - Incision in labiogingival sulcus
        
        lat. border of lat. incisor to first molar tooth
        
        mucoperiosteal flap elevated
        
        window of 1.5cm diameter is made with hammer and gouge
        
        above root of teeth
        
        large IMA 2cmx1cm is made
      - Wound closed with loose stitches
    - - Hemorrhage
      - Paresthesia
      - Oroantral fistula
      - Alteration in teeth sensation and discoloration
  - - - Chronic sinusitis with polyps
      - Dont do if only seeing eye
      - Procedure
        
        same prep
        
        Inf. turbinate outfractured
        
        ethmoidal air cells exenterated with Tilley Henckels forceps
        
        watch for yellow orbital fat
        
        checking for fat in saline
        
        Displaced turbinate repositioned
        
        ant. nasal packing
      - Complications
        
        Lamina papyracea injury
        
        Injury to dura
        
        CSF rhinnorhea
        
        Proptosis
        
        Visual Loss
    - - Chronic inflammation
        
        maxillary or ethmoidal sinus
        
        Orbital decompression
      - Only seeing eye then dont
      - Procedure
        
        same prep
        
        After Caldwell-Lucs
        
        closed Tilley Henckel forcep pushed
        
        upward backward medially at
        
        upper inner angle of antrum
        
        towards opposite parietal eminence
        
        Posterior and middle ethmoidal cells
        
        exenterated
        
        Same ending as intranasal
      - Complication
        
        same as Caldwell Luc
        
        same as intranasal
    - - Indications
        
        Chronic infection
        
        frontal or ethmoidal
        
        Orbital decompression
        
        Front sinus mucocele
        
        Ligation of anterior ethmoidal artery for epistaxis
        
        Transethmoidal hypophysectomy
        
        Dacrocystorhinostomy
        
        Repair of CSF leak
        
        Decompression of malignant exophthalmos
      - Procedure
        
        same prep
        
        curvilinear incision
        
        medial to medial canthus of eye
        
        periosteum divided elevated with periosteum elevator
        
        flap and lacrimal sac retracted
        
        ant. ethmoidal vessels ligated
        
        3 more items...
        
        fenestrated silastic tube 1cm diameter
        
        maintain patency of frontal sinus
        
        layers sutured
        
        throat pack removed
- - - - Cellulitis
      - Abscess
      - Osteomyelitis
      - Mucocele
    - - Cellulitis of eyelids
        
        Ethmoiditis
        
        Types
        
        Preseptal
        
        no spread
        
        Post septal
        
        Features
        
        Eyelids swollen red tender
        
        Normal
        
        Conjunctiva
        
        Eye vision movement
        
        Eyeball position
      - Extra periosteal abscess
        
        superficial to lamina papyracia
      - Orbital cellulitis
        
        Dangerous
        
        Features
        
        Severe pain
        
        Proptosis
        
        Swollen eyelids not red
        
        Conjunctiva swollen engorged
        
        Ophthalmoplegia
        
        Decrease in vision
        
        red color perception dec.
        
        Resembles CST
        
        but Unilateral
        
        Less toxic
        
        Absence of papilledema
      - Superior orbital fissure syndrome
        
        CNIII
        
        CNIV
        
        CNVI
      - Orbital apex syndrome
        
        SOF syndrome
        
        plus
        
        CNII
        
        CNV3
      - Investigations
        
        CT/MRI
      - Treatment
        
        Medical
        
        IV cephalosporins
        
        metro
        
        Systemic steroids
        
        Topical nasal decongestants
        
        CST then
        
        Anticoagulants given too
        
        Surgical
        
        Surgery for rhinosinusitis
        
        FESS
        
        Surgery for complication identified
    - - Extradural abscess
      - Subdural abscess
      - Meningitis
      - Brain abscess
      - CST
        
        Causes
        
        Infective organisms
        
        Extended from sphenoid sinus
        
        Danger area of face
        
        Facial vein
        
        angular vein
        
        sup. ophthalmic vein
        
        Pterygoid venus plexus
        
        innominate vein
        
        Immunocompromised
        
        Boil nose
        
        septal hematoma
        
        maxillary sinusitis
        
        Features
        
        Bilateral
        
        Swelling pain tenderness
        
        upper medial cheek
        
        upper lip
        
        Diplopia
        
        Severe pain in eyes
        
        headache
        
        NV
        
        Proptosis
        
        hyperemia and chemosis
        
        conjunctiva
        
        Papilledema
        
        vision loss
        
        Investigations
        
        MRI venogram
        
        High res contrast CR
        
        Treatment
        
        ICU admission
        
        Broad spectrum antibiotics
        
        Anticoagulants
        
        Systemic steroids