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OTORHINOLARYNGOLOGY
1.1A NOSE & PARANASAL SINUSES
CHOANAL ATRESIA

Embryonic failure of the bucconasal membrane to rupture


prior to birth
Persistence of a bony plate or membrane

IMAGING STUDIES

Plain Films
Cheap, inaccurate, overlapping structures
CT Scan
More expensive, more accurate and detailed, no overlapping
of structures
MRI
Most expensive, accurate especially to extent of soft tissue
and fluid, poor in bone delineation

Infectious diseases
Endocrine changes or diseases
Hemorrhagic diathesis
Coagulopathies

Platelet Disorders
Thrombocytopenia

hypertension
Influenza, measles, typhus
Pheochromocytoma, pregnancy,
diabetes mellitus
Congenital: e.g. hemophilia A
and B, Willebrand diseas
Acquired: e.g. anticoagulant
therapy, hepatocellular
insufficiency
Idiopathic thrombocytopenic
purpura, platelet proliferation
disorders, platelet distribution
disorders

DISEASES OF THE NOSE & PARANASAL SINUSES


MANAGEMENT

Surgical Excision
Sclerosing agents
Propanolol
Vascular endothelial growth factor

KISSELBACHS PLEXUS in the Littles Area 90% of Epistaxis


Posteroinferior bleeding Sphenopalatine vessels
Roof of the nose from anterior and posterior ethmoid
arteries

EPISTAXIS

LOCAL CAUSES OF EPISTAXIS


CLASSIFICATION
EXAMPLES

Change in the nasal septum


Mucosal or vascular injury

Neoplasma

Perforation traumatic, iatrogenic


inflammatory: spurs or ridges
Foreign bodies, rhinoliths, trauma
(including nose picking), allergy,
acute rhinitis, traumatic aneurysm
of the internal carotid artery (very
rare)
Benign and malignant neoplasms
of the nose, paranasal sinuses and
nasopharynx

RHINOLITH
MANAGEMENT OF RHINOLITH

Endoscopic guided removal


Lateral Rhinotomy

Infection of the sebaceous glands


Staphylococcus aureus
Warm compress
I&D antibiotics

ORBITAL
- Orbital cellulitis
- Cavernous sinus thrombosis

VESTIBULITIS

Idiopathic

RHINOSINOGENIC COMPLICATIONS

SYSTEMIC CAUSES OF EPISTAXIS


CLASSIFICATION
EXAMPLES

Vascular and circulatory diseases

Atherosclerosis, arterial

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1.1A NOSE & PARANASAL SINUSES

OSTEOMYELITIS / SUBPERIOSTEAL
- Abscess

CAVERNOUS SINUS THROMBOSIS


Complications:
- Loss of vision 10%
- Ischemia of other organs
- Intracranial complications (meningitis, brain abcess)
Prognosis
- 30% mortality

ALLERGY
"ALLOS" - Other than
"ERGON" - reaction
Immediate hypersensitivity - very quick reaction of the immune
system to harmless foreign, substance, 5-15 minutes
Ex. Hay fever, asthma, food & drug allergy
Delayed hypersensitivity - Much slower reaction of the immune
system, 2 or more days.
Ex. Contact dermatitis2

Allergy

Symptoms
- Rhinorrhea
- Nasal obstruction
- Nasal itching
- Sneezing
Reversible spontaneous or with treatment
Localized to nose; affects both sides
Watery and clear nasal discharge
Boggy and pale turbinates

Very quick reaction of the immune system to harmless


foreign substance, 5-15 minutes, i.e. hay fever, astma, food
and drug allergy

Much slower reaction of the immune system, two or more


days, i.e. contact dermatitis

Rhinorrhea
Stuffiness / Nasal obstruction
Nasal itching
Sneezing

ALLERGENS
House dust mites - tiny insects that live in dust
Proteins in Danders - Dry skin of human / pets
Molds & Milder
Cockroach
Pollens - grass, flowers & trees
Food - milk, wheat, soy, eggs, nuts, seafoods

DELAYED HYPERSENSITIVITY

SYMPTOMS

RHINITIS MEDICAMENTOSA
Rebound vasodilation
Prolonged used of sympathomimetic decongestant nose drops
& nasal spray (oxymetazoline)
Initial vasoconstriction -> Vasodilation -> Nasal obstruction &
excessive mucous secretion
Discontinue medication & substitute topical steroids
(mometasone, flucasone, ciclesonide) for allergy
VASOMOTOR RHINITIS
Exact cause is unknown
Triggers:
- Dry atmosphere
- Air pollution
- Alcohol
- Spicy foods
- Strong emotions
Primary treatment: Avoiding triggers
- Decongestants
- Antihistamines
- Corticosteroid nasal sprays

ALLOS other than


ERGON reaction

IMMEDIATE HYPERSENSITIVITY

ATROPHIC RHINITIS
Atrophy of nasal mucosa
Loss of cilia
Etiology : Unknown
Symptoms: Crusting, viscid secretions, fetid nasal odor
Endoscopy: Broad nasal cavity lines with dry, crusted mucosa
Management:
- Nasal douche
- Medical (steroids, antibiotics)
- Surgical (submucous implantation of cartilage)

ALLERGIC RHINITIS

INTRACRANIAL
- Epidural, subdural and intracerebral abscesses
- Clinical manifestations are nonspecific

CLASSIFICATION OF ALLERGIC RHINITIS (ARIA - ALLERGIC


RHINITIS AND ITS IMPACT ON ASTHMA)
INTERMITTENT SYMPTOMS
PERSISTENT
< 4 days per week
<4 days/week
Or >4 weeks
And >4 weeks
MILD
MODERATE - SEVERE
Normal sleep
Abnormal sleep
No impairment of daily activities,
Impairment of daily activities, sport,
sport, leisure
leisure
No impairment at work and school
Impaired work and school
No troublesome symptoms
Troublesome symptoms
TREATMENT
Antihistamines
Steroids
SCIT (Subcutaneous immunotherapy)
SLIT (Sublingual immunotherapy)

SUBCUTANEOUS IMMUNOTHERAPY
Provides symptomatic relief
Modifies allergic disease by targeting the underlying
immunological mechanism
Efficacy and safety established
Treatment of
- Asthma
- Allergic rhinitis / rhinoconjunctivitis

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1.1A NOSE & PARANASAL SINUSES

- Hypersensitivity
Numerous controlled clinical trials

SUBLINGUAL IMMUNOTHERAPY
Small doses of allergen sublingually
Boost tolerance allergen
2009 World Allergy Organization (WAO)
Widely accepted in Europe, South America, and Asia
Safety nor the efficacy yet to be considered by the US FDA

SLIT VS SCIT
SLIT Cochrane meta-analysis demonstrated efficacy in control
of rhinitis symptoms in patients older than 12 years
Safety profile: Much safer than subcutaneous IT
SCIT: Scandanavian study compared the effectiveness and
safety of injection therapy with SLIT using birch pollen antigens
No difference between subcutaneous and sublingual in terms of
efficacy
ACUTE RHINITIS
Viral
- Transient signs and symptoms
- Self limiting
- Both sides, watery and clear discharge, congested turbinates
- Rhinovirus and Coronavirus
Bacterial
- Follows viral infection
- Pneumococcus, Staphylococcus
Streptococcus
- Thick, yellow-green discharge
- May be one side, congested turbinates and mucosa
- Antibiotics are warranted
CHRONIC RHINITIS
FUNGAL

Aspergillosis
Mucormycosis
Rhinoscoridosis

Follows bacterial infection


Pneumococcus, Staph, Strep
Thick, yellow-green discharge
May be one side, congested turbinates and mucosa
Antibiotics are warranted

BACTERIAL

VASOMOTOR RHINITIS
Exact cause is unknown
Triggers
- Dry atmosphere
- Air pollution
- Alcohol
- Spicy foods
- Strong emotions
Primary treatment: Avoiding triggers
Decongestants
Antihistamines
Corticosteroid Nasal Sprays

RHINOSINUSITIS
A group of disorders generally characterized by inflammation of
mucosa of the nose and para-nasal sinuses
ACUTE RHINOSINUSITIS
An inflammatory condition involving the paransal sinuses, as
well as the lining of the nasal passages, which last up to 4
weeks (28 days)
Most common pathogens
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrharalis
- Staphylococcus aureus
- Anaerobic bacteria
Inflammation and edema formation causes increased secretion
which are retained in the sinuses
Symptoms: Severe nasal discharge
Rhinoscopy: Greenish or purulent foul smelling nasal discharge
over congested turbinates
X-ray: Air fluid level, mucosal thickening, mucosal opacification
CHRONIC SINUSITUS
Inflammation of the nasal cavity and paranasal sinuses and/or
the underlying bone that has been present for at least 12 weeks
Symptoms:
- Nasal congestive/obstructive or blockage
- Facial pain or pressure
- Discolored discharge (Anterior or Post-nasal drip)
- Hyposia or anosmia
Fungal
- Aspergillosis
- Mucormycosis
- Rhinoscoridosis
Bacterial
- Tuberculosis
- Leprosy
- Rhinoscleroma
- Sarcoidosis
- Syphilis
- Actinomycosis

TUMORS OF NOSE & PARANASAL SINUSES


NASAL POLYPOSIS

Presence of bilateral, smooth, semitranslucent pearly white


to pinkish, pedunculated masses arising from the muscosa
surrounding the ostiomeatal complex

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1.1A NOSE & PARANASAL SINUSES

CLASSIFICATION OF NASAL POLYPS (MACKAY)


GRADE
CLINICAL FINDINGS
0
Absence polyps
1
Polyps do not prolapse beyond the
most anterior part of the middle
turbinate (requires nasal
endoscopy)
2
Polyps extend below the middle
turbinate and are visible with nasal
speculum
3
Polyps are massive and occlude the
entire nasal cavity

INVERTING PAPILLOMA
Benign
Locally invasive
May resemble nasal polyp but may contain areas of carcinoma
Inverts into the surface epithelium
Treatment: Surgical excision

ANGIOFIBROMA
Benign
Young male
Originates in the nasal chamber near nasopalatine foramen
Symptom: Severe epistaxis, and nasal obstruction

- Neck mass
Neurological
- Facial Pain

Radiotherapy
Chemotherapy
Combination

MANAGEMENT

SCCA
MANAGEMENT

Surgery is still the mainstay

PRINCIPLES FOR THE STAGING OF SINONASAL TUMORS


REGIONS
SUBREGIONS

Nasal cavity
Upper Level
Midlevel
Tumor Stage
T1
T2

T3
T4

Nasal floor and roof


Maxilloethmoid angle, ethmoid cells,
sphenoid sinus, frontal sinus
Inferior, superior and medial portions of
maxillary sinus
Tumor Extent
Example: maxillary
sinus carcinoma
1 subregion
Floor of maxillary sinus
> 1 subregion or 1
Floor and medial
region
portion of maxillary
sinus
Invasion of
Invasion of nasal cavity
adjacent region
Tumor crosses
Skull base, cranial
organ boundaries
nerves, orbit, sphenoid
sinus, frontal sinus,
skin

NASOPHARYNGEAL CA
SYMPTOMS OF NPCA

Nasal
- Obstruction
- Sanguineous discharge
Ear
- Deafness
- Pain
Eye
- Preptosis
- Diplopia
Neck

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