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Nose And Paranasal Sinuses

Francis B. Quinn, Jr., M.D., FACS

EXAMINATION:
Open speculum up-and-down to avoid pressing on septum (ouch!)
Co-axial lighting (head mirror) is ideal, use otoscope in a pinch (but don't let Dr. Q. see you!)
The first turbinate you see is the inferior turbinate
Red mucosa - inflammation; pale or blue color = allergy
Airflow is mostly along the nasal floor
Septal deviations, C-shaped deformities, spurs
Septal perforations (Wegener’s, midline granuloma previous septal surgery, cocaine abuse?)
Everything drains under the middle turbinate except:
tears - nasolacrimal under inferior turbinate
posterior ethmoids and sphenoid drain more postero-superior (good test question!)

 
SINUS FILMS:
Of little use in patient with obvious symptoms
Not needed for diagnosis of nasal fracture:
"If it looks broken - it is,
if it doesn’t - it isn’t
if you’re not sure - wait 'till swelling goes down (10 days maximum)"
Common radiologic abnormalities:
Air-fluid levels suggest an acute process
Opacification = secretions, polyps, tumor, etc.
(Ethmoids should be slightly darker than orbits)
Thickened mucosa (check lateral maxillary wall): Suggests chronic inflammation
Maxillary sinus retention cysts
Very frequent finding
Harmless unless symptomatic
Frontal sinus mucocele
Nasofrontal duct obstruction (head injury?)
Potentially serious problem
Look for loss of scalloped edge of frontal sinuses
Standard views: The goal is to place sinuses close to the film and at an angle that temporal bone shadows are not superimposed
Water’s - best for maxillary sinus (Ethmoids and frontals too far from film) (?test question?)
Caldwell -best for ethmoids and frontal sinus (Temporal bones overlie maxillary)
Lateral - sphenoid, frontal (?), maxillary(?)

 

ACUTE SINUSITIS:
Symptoms:
Purulent rhinorrhea
Pain, increase with palpation/percussion
Periorbital edema (watch out for periorbital cellulitis!)
Sensitive teeth or gums (irritation of dental roots)
Treatment:
Antibiotics:
Amoxicillin Erythromycin - sulfisoxazole
Cefaclor Trimethoprim - sulfamethoxazole
To cover: Streptococcus pneumonia
Hemophilus
Moraxella catarrhalis
Steam inhalation/humidifier - Mainly for liquefaction of secretions Decongestants:
Topical (e.g.Afrin) for short-term
Systemic:
Pseudoephedrine (e.g. Sudafed, 30-60 mg Q6H)
Phenylpropanolamine (sold otc, also as appetite suppressant - watch blood pressure)
Phenylephrine ("Neosynephrine")
Antihistamines:
Most "cold remedies" are a combination of decongestants and sedating antihistamines with the idea that the side effects of jitteriness and sleepiness will cancel each other out.
Surgical drainage (rarely used): for pain relief or unresponsive infection.
Options for maxillary sinus include:
cannulate ostia
puncture anterior wall (under lip)
puncture nasal wall under turbinate

 

CHRONIC SINUSITIS:
Diagnosis:
Is it really sinusitis? Vs. tension or migraine headaches or temporomandibular joint arthritis etc.
Is allergy a component? (see allergy section below)
Is it vasomotor rhinitis?
- Profuse rhinorrhea,
- Often precipitated by cold air or eating
- Treatment: ipatromium bromide (Atrovent‚ )
Is it post-nasal drip causing sore throat, hoarseness
Treatment, medical: (see allergy section below) Treatment, surgical:
Caldwell-Luc: Approach maxillary sinus via sublabial incision, open anterior bony wall
Nasoantral window:
Make communication between maxillary sinus and nasal cavity under the inferior turbinate; this is outside of the normal ciliary flow pattern and they usually close within 1-2 years
Ethmoidectomy:
Break down the partitions between the many air cells; external and intranasal approaches
Frontal sinus obliteration:
A bicoronal or brow incision may be used.
Endoscopic sinus surgery:
Relieve obstruction at the osteomeatal complex, an area where flow from the frontal, maxillary and ethmoid sinuses can be obstructed.
Septoplasty: (all incisions inside the nose)
Polypectomy: Polyps usually recur unless followed by medical therapy.

 

ALLERGIC RHINITIS:
Symptoms:
Sneezing (very characteristic symptom for allergies)
Itchy ears, eyes, and palate
Congested ears
Runny nose, nasal congestion
Post-nasal drip (sore throat)
Pathophysiology:
The mechanisms of inflammation are similar whether the etiology is allergic or infectious.
Treatment:
Allergen avoidance - mandates a detailed history
The biggest offenders are dust, pets, pollens, molds
Pollens: Is it seasonal? In south Texas, something is pollinating all the time. Ragweed season is late August - October.
Dust: Dust mite feeds on human dander and grows whenever humidity is over 30% (seasonal in north USA). Carpeting is the major problem.
Molds: Cold fronts coming in over rice paddies north of Houston bring spores. Rain may clean air, but growth surges in the humidity which follows.
Pets: "outside dogs" still are allergenic
Skin tests or RAST tests must be correlated with symptoms history. Food allergies should be diagnosed by history and diet challenge in adults. (Controversial subject!)
Anti-histamines = for the sneezing, scratchy throat, itchy eyes. Will have little effect on nasal congestion but may have drying effect.
Sedating (available without prescription)
All cause sedation, some drying, and possible urinary retention.
There are several chemical groups; Benadryl is more sedating, for an equivalent amount of "anti-allergy" effect than some of the others.
Chlorpheniramine 4 mg PO Q 6 hours is an economical choice.
Patients will overcome the sedating side effects with 2-3 weeks of REGULAR use.
Non-sedating (prescription only) Claritin, Zyrtec Not approved or use in children under 12 years.
Topical - available abroad, U.S. clinical trials underway, shows great promise as nasal spray and eyedrops.
Decongestants - for congestion and rhinorrhea
Histamine, leukotrienes and prostaglandins are released causing vasodilation, tissue edema, and increased mucus secretion. Anti-histamines will not block leukotriene and prostaglandin effects so that decongestants must be included in therapy.
Topical decongestants: vasoconstriction; tissue ischemia; release vasodilators; rebound vasodilation; persistent turbinate edema = rhinitis medicamentosa
Systemic - no rebound congestion
All are adrenaline-type drugs and can exacerbate hypertension. Pseudoephedrine, 30-60 mg PO Q 6 hours is an economical choice. Cause "jitteriness" with excessive use.
Highly allergic patients should carry and "EpiPen" and use it promptly.
Topical nasal steroids - "Best allergy medicine going"
Make the nasal mucosa an inhospitable site for mast cells. Blocks synthesis of both leukotrienes and prostaglandins, prevents influx of neutrophils.
Brands:
Beconase and Vancenase = beclomethasone
Nasalide = flunisolide (fluorinated, more potent
Decadron Turbinaire = dexamethasone (systemic effects)
Indications for systemic steroids = nasal polyps 30-40 mg daily 2 weeks
Cromolyn:
As a single agent, less effective than steroids, but it is a good second drug to combine with steroid sprays. Two puffs each nostril BID or TID. Opticrom were good eyedrops but are off the market.
Immunotherapy
Weekly desensitization therapy to limited # allergens. Mechanism (?) -elevated IgG and suppress IgE antibodies. Can have potentially lethal reactions and should be administered under medical supervision.

 

EPISTAXIS:
Usually located on anterior septum in children; in adults, anywhereTry 15 minutes of pressure. Get hypertension under control
Topical epinephrine/Neo-Synephrine on pledgets as vasoconstrictor
Pull pledgets out and look fast for the bleeding site
Suction away blood and cauterize with silver nitrate
Try packing nose lightly with Surgicel or Gelfoam sponges soaked with topical thrombin
Vigorous bleeds must be packed with antibiotic ointment-soaked gauze strips. Need good lighting and instruments for an adequate job. Avoid packing patients with coagulopathies who will invariably re-bleed when the pack is removed
Intranasal balloons (e.g. Epistat) are easier to use but less effective
Persistent bleeding is then treated with posterior and anterior packs
Leave packs in three days. Cover with antibiotics to prevent sinusitis
If packing fails vessels must be ligated. If the responsible vessel cannot be identified then both maxillary artery and ethmoid arteries are ligated.

 
TUMORS:
Juvenile nasoangiofibroma - epistaxis in boys
Nasopharyngeal carcinoma -
early symptoms = serous otitis media, neck metastases
Chinese at higher risk
EBV genome in undifferentiated carcinoma
Squamous cell carcinomas
Inverted papillomas

 

OLFACTION:
Anosmia
Head injury, especially antero-posterior can shear off nerves as they cross the cribriform plate
Viral (influenza) infection can kill off nerves
Obstruction such as nasal polyps or septal deviation
Hyposmia Advanced age
Hyperosmia Addison’s, pregnancy
Cacosmia Infection (sinus, dental), hysteria

 
TASTE:
Innervation anterior 2/3rds of tongue CN VII
posterior tongue, pharynx CN IX
4 basic tastes - sweet, sour, bitter, and salt
Altered taste is usually olfactory loss. Ask patient whether they can still taste sweet or salt. Check oral mucosal for lesions and adequacy of salivation. Medications such as sulfa drugs and anti-arthritics can cause altered taste sensations

Last Update: 11/19/98, 10:50.
nose-paranasal-sinus.htm