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Lecture’s Objectives Chronic Sinusitis Mucocele Tumors of the nose and paranasal sinuses Disorders of Smell

Chronic Maxillary Sinusitis

Definition.. Predisposing factors: 1) Nasal: * Obstruction of the drainage ostia *Recurrent acute infection *Chronic irritation from environmental gases. 2) Dental: The upper 2nd premolar and the 1st and 2nd molar

Diagnosis:/ History

Major symptoms Nasal discharge Nasal obstruction Headache and facial pain Anosmia( because air not reach the olfactory region) and cacosmia (i.e. unpleasant smell, due to chronic odiferous sepsis). b) Minor symptoms Fever Halitosis (bad mouth odor )

chronic irritation in side the nose may produce

vestibulitis nose bleeds otitis media granular pharyngitis chronic laryngitis

Examination /often unhelpful

Normal Generalized inflammation of the mucosa Purulent secretion or crusts. Otitis media and granular pharyngitis

Investigation

Radiography;


2) CT scan  Coronal CT scan provide most information about the osteo-meatal complex

3) Endoscopic assessment:

Important features are; The presence of pus in the middle meatus. The cause of osteal obstruction . Sometimes biopsy is taken to confirm the diagnosis.

Treatment:

The principle of treatment is to restore the normal mucosa to the sinus lining. At the stage of chronic changes medical treatment has been tried and is of no value.

Surgical treatment of the chronic maxillary sinusitis include;

FESS (functional endoscopic sinus surgery ) to remove only the diseased areas in order to relieve the obstruction and so restore natural sinus drainage, ventilation and physiology.

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2. Antral lavage.

3. Intranasal antrostomy.

4. Caldwell-Luc procedure


Complication of chronic sinusitis;Mucoceles :
Definition; A mucocele is a mucous-containing cyst completely filling a sinus and capable of expansion They arises in order of frequency in the frontal Frontoethmoidal ethmoidal maxillary sphenoidal sinuses

Aetiology

1) Polyps. 2) Trauma (Surgical or Non-Surgical). 3) Tumours.

Frontoethmoidal mucocele

Clinical presentation; Starts asymptomatic dull ache swelling (supramedial aspect of the orbit). The swelling is tender and feels rubbery Increase in size thins the bone more and pressure may damage the optic nerve or vasculature causing blindness. Infection pyocoele / dangerous Increase enlargement proptosis.

Radiography of the sinus;

Thinning of the bone. Displacement of the medial frontal sinus floor downwards . Loss of scalloping . The intersinus septum may be displaced or eroded.

Treatment;

Is by evacuation of the contents of the sinus by ; Endoscopic technique. Radical frontal sinus operation. Osteoplastic flap operation

Radical frontal sinus operation.

Osteoplastic flap operation

Tumors of the nose and paranasal sinuses

Benign ; e.g. Squamous papilloma (in the vestibule) , osteoma (in frontal ,ethmoidal and maxillary sinus) and inverted papilloma .Malignant tumours ( uncommon); Squamous carcinoma (is the most common) followed by adenocarcinoma, malignant melanoma…etc


Squamous papilloma

Osteoma

About malignant tumours:
The maxillary sinus is the most common siteDo not usually occur in heavy smoking or heavy drinking population. …..(e.g. adenocarcinoma in woodworkers) The chief symptoms of nasal malignancy are unilateral obstruction with haemorrhage Men > woman , average age at presentation is 60

Inverted papilloma (Transitional cell papilloma or Schneiderian papilloma);

This lesion represents about 4% of all nasal neoplasms. It is the most common benign neoplasm of the nose and sinuses.

Aetiology; unknown. Sex; Male-female ratio 5-1. Age; most commonly in the 5th decade. Site of origin; lateral wall of the nose (occasionally from the septum) with extension to the ethmoid and maxillary sinus.

Clinical presentation;

Unilateral nasal polyp. The tumour is soft and friable and may become detached or bleed with hard nose blowing.
CT scan

Histopathological examination ;

The surface of the tumour is covered by transitional type of epithelium. The lesion is characterized by; Locally aggressive Tendency to undergo malignant change There may be coincidental URT malignancy. It has high propensity for recurrence after removal.

Treatment

Is by adequate local excision usually through lateral rhinotomy approach.

The olfactory cleft occupies the upper third of the nasal cavity in the area between the superior turbinate, cribriform plate and corresponding area of the septum and is lined by specialized olfactory epithelium (this is a specialized pseudostratified neuroepithelium containing the primary olfactory receptors and has a golden yellow color ).
Disorders of smell

Terminology;

Anosmia; Inability to detect odors. Hyposmia; Decreased ability to detect odors. Parosmia; Altered perception of smell in the presence of an odor. Phantosmia; Smelling of nonexistent odor . ( Both parosmia and phantosmia are associated with epilepsy and olfactory hallucination of schizophrenia ). Cacosmia ; Unpleasant smell, due to chronic odiferous sepsis.

Classification of olfactory dysfunction:

Conductive anosmia; Is due to impaired transport of airborne odorants to the olfactory cleft. Neuronal anosmia; Is due to impairment of olfactory epithelial function or disrupted neuronal pathway.

Causes of olfactory dysfunction;

Obstructive nasal disease (23%) : Postviral anosmia (19%): Head trauma (15%):Toxins, drugs ( 3% ):e.g. Aminoglycosides, formaldehyde, alcohol, nicotine, … Miscellaneous (21% ): Aging, neoplastic, psychologic, nutritional deficiencies (e.g. vitamin A , thiamine ) and other causes.Idiopathic ( 21% ).

A patient presented external swelling of the upper two third of the nose following car accident 24 hours ago. Treatment requires: A. Immediate rhinoplasty. B. Immediate packing and external splint. C. no more than antibiotic and pain killer. D. reassessment after edema subside

1. Septal haematoma 2. Septal Abscess 3. Septal deviation

Disorders of nasal septum

4. Ulceration and perforation of the septum

Causes: Trauma; surgical, repeated cautery, digital trauma (nose picking) Malignant disease. Chronic inflammation; TB, syphilis Poisons; industrial, cocaine addicts, topical corticosteroid, topical decongestants. Idiopathic.

Cerebrospinal fluid (CSF) Rhinorrhoea

Nasal trauma+Clear rhinorrhoea =CSF leak. Aetiology 1) Trauma: fracture of the base of the skull e.g. the cribriform plate and the posterior wall of the frontal sinus 2) Spontaneous: Destructive lesion involving the floor of the anterior cranial fossa

Diagnosis;

Clinical Picture 1) Watery fluid drips from the nose which increase in bending forward. 2) Meningitis. Examination Handkerchief test: Nasal endoscope to see the site of the lesion. Investigations 1) Identification of glucose in the secretion. 2) Injection of radioactive material into CSF via lumber puncture. 3) CT. scan of the base of the skull.

Treatment;

Medical (Conservative); Bed rest in the head up position. Avoidance of coughing ,sneezing, nose blowing and straining. Reduction of CSF production rate by drugs ( acetazolamide , frusemide ) or by repeated lumber puncture. Prophylactic antibiotics to prevent development of meningitis. Surgical treatment; If no response after 10-14 days--- craniotomy with repair of dura with fascia lata.

Oroantral fistula

Definition; a fistula that communicates the oral cavity with the maxillary sinus. Aetiology 1) Dental extraction , particularly of the 1st upper molar teeth. 2) Malignant tumours of the antrum. 3) Penetrating wound. 4) Fistula following Caldwell-Luc operation.

Choanal Atresia

Congenital atresia of the posterior nares due to persistence of the bucconasal membrane. The obstruction either composed of bone (most commonly) or membrane. F>M Unilateral 60%( usually Rt.) noticed after years. Bilateral (neonatal emergency) associated with other congenital anomaly.


Examination
1. mirror test and cotton test. 2. Plastic catheter or probe. 3. Fibroptic endoscopy

Investigations

Contrast radiography by instillation of radioopaque substance in the affected side. CT scan to see the thickness of a bony atresia.

Treatment

Bilateral  oral airway  surgical intervention.Unilataral  elective perforation of the occlusion usually prior starting of school.

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