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Page 1: Allergic Rhinitis

ALLERGIC RHINITISALLERGIC RHINITISDefinitionDefinition: IgE mediated hypersensitivity of the mucous : IgE mediated hypersensitivity of the mucous

membrane of the nose upon exposure to antigenic membrane of the nose upon exposure to antigenic substance.substance.

IncidenceIncidence: common, 10-20% of population.: common, 10-20% of population.

TypesTypes: 1. seasonal 2. perennial 3.perennial with seasonal : 1. seasonal 2. perennial 3.perennial with seasonal exacerbation.exacerbation.

EtiologyEtiology: :

Predisposing factorsPredisposing factors::

1. Genetic predisposition: 50% of cases occur in atopic 1. Genetic predisposition: 50% of cases occur in atopic patient (atopy: tendency to develop an exaggerated Ig E patient (atopy: tendency to develop an exaggerated Ig E antibody response).antibody response).

2. Temperature changes.2. Temperature changes.

3. psychgenic.3. psychgenic.

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Exciting factorsExciting factors::

1.1. inhalant: commonest factors e.ghouse dust, inhalant: commonest factors e.ghouse dust,

tree & grass pollens.tree & grass pollens.

2.2. Injestant: foods (milk, fish) & drugs ( aspirin, Injestant: foods (milk, fish) & drugs ( aspirin,

antihypertensive).antihypertensive).

3.3. Injectant: e.g penicillin.Injectant: e.g penicillin.

4.4. Infactant: fungal parasitic & bacterial antigen.Infactant: fungal parasitic & bacterial antigen.

5.5. Contactant: e.g face powder.Contactant: e.g face powder.

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PathogenesisPathogenesis::1.1. 11stst exposure exposure: : formation of IgE antibodies formation of IgE antibodies

which bind to specific sites on surface of which bind to specific sites on surface of mast cells.mast cells.

2.2. 2nd exposure2nd exposure:: +Ag-Ab reaction on +Ag-Ab reaction on surfaces of must cells with degranulation surfaces of must cells with degranulation of cells & release of chemical mediators: of cells & release of chemical mediators: e.g histamine, bradykinine, serotonine e.g histamine, bradykinine, serotonine resolution in local inflammatory reaction:resolution in local inflammatory reaction:

Vasodilation: plasma exudate.Vasodilation: plasma exudate. Increase glandular secretions.Increase glandular secretions. Cellular infiltrate (oesinophilis).Cellular infiltrate (oesinophilis). Smooth muscle contraction.Smooth muscle contraction.

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SymptomsSymptoms: : +ve family history in 50%.+ve family history in 50%.

1.1. Itching sensation.Itching sensation.

2.2. Paroxysmal sneezing.Paroxysmal sneezing.

3.3. Bilateral profuse watery discharge.Bilateral profuse watery discharge.

4.4. Bilateral alternating nasal obstruction.Bilateral alternating nasal obstruction.

5.5. Associated allergic symptoms e.g eye, skin or chest.Associated allergic symptoms e.g eye, skin or chest.

SignsSigns:: 1.1. Pale bluish edematous mucosa.Pale bluish edematous mucosa.2.2. Swollen edematous turbinates.Swollen edematous turbinates.3.3. Excessive mucoid secretions.Excessive mucoid secretions.4.4. Nasal polyps may be present.Nasal polyps may be present.

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InvestigationsInvestigations::

1.1. Skin- prick test: skin of forearm is pricked with a needle Skin- prick test: skin of forearm is pricked with a needle

passed in extract of different allergens. +ve test is passed in extract of different allergens. +ve test is

detected by centeral wheel surrounded by erythema.detected by centeral wheel surrounded by erythema.

2.2. Nasal challenge test: allergen applied inform of spray.Nasal challenge test: allergen applied inform of spray.

3.3. Radioallergosrbency test (RAST): incubation of patient Radioallergosrbency test (RAST): incubation of patient

serum with specific concentrations of antigens & level serum with specific concentrations of antigens & level

of IgE is by radioimmune.of IgE is by radioimmune.

4.4. High level of IgE by radioimmun.High level of IgE by radioimmun.

5.5. Nasal smear; full of oesinophilis.Nasal smear; full of oesinophilis.

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Treatment:Treatment:

1.1. Avoidance of exposure.Avoidance of exposure.

2.2. Immunotherapy: injection of gradually increasing dose Immunotherapy: injection of gradually increasing dose

of specific antigen over long period of time formation of of specific antigen over long period of time formation of

blocking antibodies.blocking antibodies.

3.3. Mast cell stabilizer e.g. sodium chromoglicate.Mast cell stabilizer e.g. sodium chromoglicate.

4.4. Antihistaminic: systemic & local (spray).Antihistaminic: systemic & local (spray).

5.5. Steroids: systemic (short course) &local spray.Steroids: systemic (short course) &local spray.

6.6. Surgery: Surgery:

- Reduction of size of turbinate.- Reduction of size of turbinate.

- Nasal polypectomy- Nasal polypectomy

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Vasomotor rhinitisVasomotor rhinitisIt is also called intrinsic rhinitis or non allergic perennial rhinitis. It may be It is also called intrinsic rhinitis or non allergic perennial rhinitis. It may be

related to drugs ( e.g. antihypertensive and contraceptive) or hormonal related to drugs ( e.g. antihypertensive and contraceptive) or hormonal

imbalance at menopause.imbalance at menopause.

Clinical pictureClinical picture::

1.1. Nasal obstruction and watery nasal discharge, which is often precipitated Nasal obstruction and watery nasal discharge, which is often precipitated

by temperature changes, and dusty atmosphere.by temperature changes, and dusty atmosphere.

2.2. Examination; shows swollen, edematous turbinates, with excessive Examination; shows swollen, edematous turbinates, with excessive

mucoid ecretios.mucoid ecretios.

Treatment :Treatment :

It is often unsatisfactory.It is often unsatisfactory.

1.1. Topical steroids may be beneficial.Topical steroids may be beneficial.

2.2. If the turbinates are markedly swollen we may do submucous dithermy or If the turbinates are markedly swollen we may do submucous dithermy or

submucosal injection of long acting steroids (vidion N1). submucosal injection of long acting steroids (vidion N1).

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Nasal polypsNasal polypsDefinitionDefinition: :

Projections of edematous. Pedunculated mucosa of the nose and/or Projections of edematous. Pedunculated mucosa of the nose and/or Paranasal sinuses.Paranasal sinuses.

TypesTypes: :

1- Ethmoidal 1- Ethmoidal 2- Antrochoanal2- Antrochoanal

Etiology:Etiology: 1. Allergy: 1. Allergy: * Most accepted cause.* Most accepted cause. * 90% of polyps → oesinophilia.* 90% of polyps → oesinophilia. * Allergic rhinitis, Usually present.* Allergic rhinitis, Usually present. * 20-40% → bronchial asthma.* 20-40% → bronchial asthma. 2. Inflammatory, chronic sinusitis. 2. Inflammatory, chronic sinusitis.

Etiology:Etiology:Inflammatory or retention cyst:Inflammatory or retention cyst:Arise from mucosa of maxillary Arise from mucosa of maxillary antrum antrum →→ directed posteriorly. directed posteriorly.After passage through sinus ostium After passage through sinus ostium →→ directed towards the choana directed towards the choana →→ nasopharynx. nasopharynx.

IncidenceIncidence::- Common.Common.- Age: adult.Age: adult.If occurs in a child 2-10yrs → cystic fibrosis, should be If occurs in a child 2-10yrs → cystic fibrosis, should be suspected. There are extensive nasal plyps leading to suspected. There are extensive nasal plyps leading to broadening of the nasal bridge due to distention before broadening of the nasal bridge due to distention before fusion of the nasal bones. There is very thick and fusion of the nasal bones. There is very thick and tenacious nasal discharge (Mucoviscidosis). Sweat test tenacious nasal discharge (Mucoviscidosis). Sweat test (sodium level) is diagnostic. It has a very high rate of (sodium level) is diagnostic. It has a very high rate of recurrence.recurrence.

- Sex: equal.- Sex: equal.

- Uncommon.Uncommon.- Age: young adult.Age: young adult.

- Sex: equalSex: equal

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Symptoms:Symptoms:Allergic:Allergic:-Bilateral gradual nasal obstruction.Bilateral gradual nasal obstruction.-Manifestation of allergic rhinitis.Manifestation of allergic rhinitis.

Inflammatory:Inflammatory:-PND: thick and purulent.PND: thick and purulent.-Unilateral or bilateral nasal obstruction and Unilateral or bilateral nasal obstruction and discharge.discharge.-Sinus headache.Sinus headache.

- Accumulated nasal - Accumulated nasal discharge in the obstructed discharge in the obstructed side.side.

Signs:Signs:Allergic:Allergic:-Bilateral, multiple, pale, glistening pedunculated Bilateral, multiple, pale, glistening pedunculated masses (grap-like growth) that fill the nasal bridge masses (grap-like growth) that fill the nasal bridge in long standing cases (Hypertolirism).in long standing cases (Hypertolirism).-Manifestations of allergic rhinitis.Manifestations of allergic rhinitis.

Inflammatory:Inflammatory:-Polyps: usually few pink, soft and arising mainly Polyps: usually few pink, soft and arising mainly from the middle meatus.from the middle meatus.-Purulent discharge: mainly from the middle Purulent discharge: mainly from the middle meatus. meatus.

Anterior rhinoscopy:Anterior rhinoscopy:-Swollen inferior turbinate.Swollen inferior turbinate.-Accumulated secretions.Accumulated secretions.-Sometimes Sometimes →→ polyp seen. polyp seen.

Posterior rhinoscopy:Posterior rhinoscopy:Single polyp appears in the Single polyp appears in the nasopharynx.nasopharynx.

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Investigations:Investigations:1.1. Culture and sensitivity.Culture and sensitivity.2.2. Allergic skin test.Allergic skin test.3.3. CT scan nose & paranasal sinuses.CT scan nose & paranasal sinuses.4.4. Biopsy from the ploys (macrophages or Biopsy from the ploys (macrophages or

eosinophilia). eosinophilia).

-Sinus view: unilateral maxillary Sinus view: unilateral maxillary opacity.opacity.-CT scan. CT scan.

Treatment:Treatment:Allergic:Allergic: 1. 1. MedicalMedical → small early polyps. → small early polyps. * Systemic steroids.* Systemic steroids.

* Topical steroids.* Topical steroids.* Antibiotics ê 2ry infection.* Antibiotics ê 2ry infection.* Anti allergic treatment.* Anti allergic treatment.

2. 2. Surgery:Surgery:* Simple polypectomy.* Simple polypectomy.* Intranasal ethmoidectomy (endoscopic or * Intranasal ethmoidectomy (endoscopic or microscopic).microscopic).

- Preoperative & postoperative steroids should be given.- Preoperative & postoperative steroids should be given. - There is high rate recurrence 40% after surgery - There is high rate recurrence 40% after surgery

(9months (9months → → 2years).2years).InflammatoryInflammatory:: 1. 1. MedicalMedical::

* Antibiotics.* Antibiotics.* Decongestant.* Decongestant.* Mucolytics.* Mucolytics.

2. 2. SurgicalSurgical: Transnasal endoscopic sinus surgery : Transnasal endoscopic sinus surgery (FESS).(FESS).

Endoscopic removal of nasal, Endoscopic removal of nasal, nasopharyngeal, and sinus parts nasopharyngeal, and sinus parts through a wide middle meatal through a wide middle meatal antrostomy.antrostomy.N.B: N.B: in recurrent cases → radical in recurrent cases → radical antrum operation was done.antrum operation was done.

N.B:N.B: Differential diagnosis of unilateral Differential diagnosis of unilateral nasal mass:nasal mass: 1. Benign neoplasm especially 1. Benign neoplasm especially inverted, firm papillary polyps. inverted, firm papillary polyps. 2. Malignant neoplasm: unilateral, 2. Malignant neoplasm: unilateral, bad odor, soft, bleeding on touch bad odor, soft, bleeding on touch mass.mass. 3. Meningocele and 3. Meningocele and encephalocoele: soft, pulsating, encephalocoele: soft, pulsating, reddish, polyp with superior reddish, polyp with superior attachment to skull base.attachment to skull base.

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Paranasal sinusesParanasal sinusesAnatomy paranasal sinusesAnatomy paranasal sinuses

Air filled spacesAir filled spaces, 4 pairs on each side, within skull bones & open in the , 4 pairs on each side, within skull bones & open in the

Latebral wall of nose.Latebral wall of nose.

Lining:Lining: pseudostratified columnar ciliated epithelium which is continuous pseudostratified columnar ciliated epithelium which is continuous

with that of the nose through their ostia.with that of the nose through their ostia.

Arranged inArranged in 2 groups: 2 groups:

* * Anterior group:Anterior group: Maxillary, Forntal & Anterior sinuses. Maxillary, Forntal & Anterior sinuses.

* * Posterior group:Posterior group: Posterior ethmoid & Sphenoid sinuses. Posterior ethmoid & Sphenoid sinuses.

Maxillary sinus:Maxillary sinus:

• It is contained within the body of maxilla.It is contained within the body of maxilla.

• Development begins in the 3Development begins in the 3rdrd fetal month. fetal month.

• Pneumatization starts at bieth, growth continues to 18 years of age.Pneumatization starts at bieth, growth continues to 18 years of age.

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•Boundaries:Boundaries:• Anteriorly: cheek. Anteriorly: cheek. • Posteriorly: pterygopalaine fossa.Posteriorly: pterygopalaine fossa.• Roof: floor or orbit.Roof: floor or orbit.• Floor: palatine and alveolar process of maxilla.Floor: palatine and alveolar process of maxilla.• Medially: lateral nasal wall.Medially: lateral nasal wall.Level of floor of sinus varies with that of nasal floor, before age of 9 years Level of floor of sinus varies with that of nasal floor, before age of 9 years

sinus floor is at higher level, after the age of 9 years sinus floor is at lower sinus floor is at higher level, after the age of 9 years sinus floor is at lower level. level.

Maxillary sinus ostiumMaxillary sinus ostium::It is made by confluence of maxillary sinus mucosa and nasal mucosa. On It is made by confluence of maxillary sinus mucosa and nasal mucosa. On looking to the maxillary ostium from inside the sinus it will appear like an ellipse looking to the maxillary ostium from inside the sinus it will appear like an ellipse just below the junction of roof and medial wall half way between anterior and just below the junction of roof and medial wall half way between anterior and posterior walls.posterior walls.

Frontal sinus:Frontal sinus:• It is present between outer and inner tables of frontal bone.It is present between outer and inner tables of frontal bone.• it begins development after birth.it begins development after birth.• The two frontal sinuses may be of unequal size.The two frontal sinuses may be of unequal size.• The frontal sinus ostium lies in the most dependent area of the sinus.The frontal sinus ostium lies in the most dependent area of the sinus.• Frontal recess, is the space where frontal sinus opens.Frontal recess, is the space where frontal sinus opens.• The frontal sinus ostium and recess look an hour glass.The frontal sinus ostium and recess look an hour glass.

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Ethmoid sinuses:Ethmoid sinuses:• The ethmoid bone is divided into:The ethmoid bone is divided into:

• Two ethmoid labyrinth which form ethmoid sinuses on both sides.Two ethmoid labyrinth which form ethmoid sinuses on both sides.

• Cribiform plate of ethmoid which separates the nose from anterior Cribiform plate of ethmoid which separates the nose from anterior cranical fossa.cranical fossa.

• Perpendicular plate of ethmoid which forms part of nasal septum.Perpendicular plate of ethmoid which forms part of nasal septum.• The ethmoid sinus consists of 7-17 small air cells.The ethmoid sinus consists of 7-17 small air cells.• It is divided into anterior group and posterior group by basal lamella It is divided into anterior group and posterior group by basal lamella

(oblique part of middle turbinate).(oblique part of middle turbinate).

Sphenoid sinus:Sphenoid sinus:• It is lies within the sphenoid bone.It is lies within the sphenoid bone.• Pneumatization of sinus begins in the 3Pneumatization of sinus begins in the 3rdrd year. year.• The ostium lies high in the anterior wall and opens in the Spheno The ostium lies high in the anterior wall and opens in the Spheno

ethmoidal recess.ethmoidal recess.

Relations:Relations:• Roof: sella turcica.Roof: sella turcica.• Pos teriorly: optic nerve. Pos teriorly: optic nerve. Posterolalerally: ICA.Posterolalerally: ICA.

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Physiology of the paranasal Physiology of the paranasal sinusessinuses

Functions of the paranasal sinuses:Functions of the paranasal sinuses:1. Helps in resonating the voice.1. Helps in resonating the voice.

2. Lightens the weight of the skull.2. Lightens the weight of the skull.

3. Shock absoirption in trauma to the face or skull.3. Shock absoirption in trauma to the face or skull.

4. Assists in humidification and moistening the nasal cavity.4. Assists in humidification and moistening the nasal cavity.

Osteomeatal complex:Osteomeatal complex:Describe the area in which the frontal, maxillary & ethmoidal sinuses Describe the area in which the frontal, maxillary & ethmoidal sinuses drain. It is bounded by middle turbinate medially, lamina papyracea drain. It is bounded by middle turbinate medially, lamina papyracea laterally and basal lamella posteriorly and superiorly. Any mucosal laterally and basal lamella posteriorly and superiorly. Any mucosal thckcning or anatomical abnormality will affect these sinuses.thckcning or anatomical abnormality will affect these sinuses.

Mucociliary clearness:Mucociliary clearness:• The secretions of goblet cells & seromucinous glands form a mucous The secretions of goblet cells & seromucinous glands form a mucous

layer “mucous blanket” above the epithelium.layer “mucous blanket” above the epithelium.• Cilia carry this blanket towards the ostium of the sinus Cilia carry this blanket towards the ostium of the sinus →→ nose nose →→

nasopharynx. nasopharynx.

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SinusitisSinusitis Acute sinusitis Acute sinusitis Chronic sinusitis Chronic sinusitis

Definition:Definition:Acute inflammation of the mucous Acute inflammation of the mucous membrane lining the paranasal sinuses. membrane lining the paranasal sinuses. One or more may be involved.One or more may be involved.Usually rhniosinustis.Usually rhniosinustis.

Chronic inflammation of the mucous Chronic inflammation of the mucous membrane lining of the paranasal membrane lining of the paranasal sinuses with irreversible pathological sinuses with irreversible pathological changes. changes.

Etiology:Etiology:Exciting causes:Exciting causes:A) NasalA) Nasal Acute rhinitis; commonest cause.Acute rhinitis; commonest cause. Viral exanthemata.Viral exanthemata. Neglected F.B.Neglected F.B. Nasal packing.Nasal packing.B) DentalB) Dental Dental infection.Dental infection. Extraction of 2Extraction of 2ndnd premolar or 1 premolar or 1stst molar. molar.C) ExternalC) External Compound facial fracture.Compound facial fracture. Penetrating F.B. e.g. gunshot.Penetrating F.B. e.g. gunshot.Predisposing factors:Predisposing factors:A) Local: any nasal disease obstructing the A) Local: any nasal disease obstructing the sinus ostium e.g. D.S, nasal polyps.sinus ostium e.g. D.S, nasal polyps.B) General: low general resistance.B) General: low general resistance.Organism: Streptococcus pneumonia, Organism: Streptococcus pneumonia, haemophilus influenza & Anaerobes (dental haemophilus influenza & Anaerobes (dental origin). origin).

1) Repeated acute attacks with 1) Repeated acute attacks with incomplete resolution:incomplete resolution:

A.A. Persistent of predisposing factors Persistent of predisposing factors persistent obstruction of the persistent obstruction of the osteomeatal complex.osteomeatal complex.

B.B. Inadequate treatment with residual Inadequate treatment with residual infection.infection.

2) High virulence of organism.2) High virulence of organism.

3) Low body resistance. 3) Low body resistance.

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Pathology:Pathology:

Congestion & oedema of sinus mucosa Congestion & oedema of sinus mucosa occlusion of sinus ostium occlusion of sinus ostium impairment of sinus drainage & impairment of sinus drainage & mucociliary clearance mucociliary clearance accumulation accumulation of secretions inside the sinus of secretions inside the sinus stasis & stasis & infection with infection with pus formation. pus formation.

1. Mucosa: congested, edematous with 1. Mucosa: congested, edematous with fibrosis.fibrosis.

2. Cilia: degeneration with loss of ciliary 2. Cilia: degeneration with loss of ciliary function.function.

3. Late cases: the mucosa is either atrophic 3. Late cases: the mucosa is either atrophic or hypertrophic “irreversible pathology”.or hypertrophic “irreversible pathology”.

Symptoms:Symptoms:

A) General: fever, history of acute A) General: fever, history of acute rhinitis.rhinitis.

B) Local:B) Local:

1- Nasal obstruction: unilateral or 1- Nasal obstruction: unilateral or bilateral.bilateral.

2- Nasal discharge:2- Nasal discharge:-Unilateral or bilateral.Unilateral or bilateral.-Mucopurulent or purulent.Mucopurulent or purulent.-Postnasal drip Postnasal drip irritative cough. irritative cough.

3- Hyposmia: cacosmia (bad smell) 3- Hyposmia: cacosmia (bad smell) dental origin.dental origin.

4- Facial pain & headache. 4- Facial pain & headache.

A) General: manifestations of septic focus, A) General: manifestations of septic focus, history of repeated acute attacks.history of repeated acute attacks.

B) Local:B) Local:

1-1-

2-2-

3-3-

4- Facial pain & headache:4- Facial pain & headache:-Same.Same.-Dull aching, periodic & recurrent.Dull aching, periodic & recurrent.

5- Symptoms of descending infections:5- Symptoms of descending infections:-Otitis media.Otitis media.-Recurrent pharyngitis.Recurrent pharyngitis.-Laryngitis & bronchitis.Laryngitis & bronchitis.

6- Symptoms of complications. 6- Symptoms of complications.

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-On the affect sinus.On the affect sinus.-Sever, throbbing.Sever, throbbing.Coughing, bending forwards.Coughing, bending forwards.-Vacuum headache Vacuum headache frontal sinus ostium frontal sinus ostium obstruction with absorption of air obstruction with absorption of air periodic pain & headache.periodic pain & headache.5- Facial edema & swelling.5- Facial edema & swelling.6- Symptoms of complications.6- Symptoms of complications.

Signs:Signs:A) General: fever: higher in children.A) General: fever: higher in children.B) Local:B) Local:1- Tenderness over the affected sinus on 1- Tenderness over the affected sinus on deep pressure.deep pressure.2- Anterior rhinoscopy:2- Anterior rhinoscopy:•Mucosa: edematous & congested.Mucosa: edematous & congested.•Nasal discharge: middle meatus Nasal discharge: middle meatus anterior group.anterior group.3- Posterior rhinoscopy:3- Posterior rhinoscopy:•Nasal discharge:Nasal discharge:- Superior meatus - Superior meatus posterior group. posterior group.- Spheno ethmoidal recess - Spheno ethmoidal recess sphenoid. sphenoid.

Local:Local:1. 1. 2.2.3.3.

Sites of sins pain & tenderness in acute & Sites of sins pain & tenderness in acute & chronic sinusitis.chronic sinusitis.Maxillary: pain & tenderness over Maxillary: pain & tenderness over affected sinus.affected sinus.Ethmoidal:Ethmoidal:Pain Pain in between eyes. in between eyes.Tenderness Tenderness inner canthus. inner canthus.Frontal:Frontal:Pain Pain supra orbital & across supra orbital & across forehead.forehead.Tenderness Tenderness above eyebrow. Floor above eyebrow. Floor of sinus.of sinus.Sphenoid: pain Sphenoid: pain occipital. occipital.

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Investigations:Investigations:1)1) Laboratory: C. & S. from nasal discharge.Laboratory: C. & S. from nasal discharge.2)2) Nasal endoscopy: ostium visualization, pus in different areas, anatomical Nasal endoscopy: ostium visualization, pus in different areas, anatomical

variations.variations.3)3) Radiological:Radiological: * X-ray sinus view: mucosal thickening, fluid level.* X-ray sinus view: mucosal thickening, fluid level.* C.T scan nose & PNS: investigation of choice.* C.T scan nose & PNS: investigation of choice.

Treatment:Treatment:A) A) Medical:Medical: 1- 1- General:General: - Bed rest.- Bed rest. - Plenty of fluids.- Plenty of fluids.

- Antibiotics: for 10-- Antibiotics: for 10-14days.14days.

- Analgesics.- Analgesics. - Mucolytics.- Mucolytics.

2- 2- LocalLocal: - Decongestant nasal drops.: - Decongestant nasal drops. - Steam inhalation.- Steam inhalation.

B) B) Surgical:Surgical: Indication:Indication: aiming to Surgical drainage. aiming to Surgical drainage. 1) Failed medical ttt.1) Failed medical ttt. 2) Complications: present or 2) Complications: present or threatening. threatening.

A) A) Medical:Medical: 1- 1- General:General: - Same.- Same. - Antibiotics: for 4weeks.- Antibiotics: for 4weeks. 2- 2- LocalLocal: - Same.: - Same.

- Control of local nasal - Control of local nasal Predisposing factors.Predisposing factors.

- Nasal wash: alkaline - Nasal wash: alkaline nasal wash.nasal wash.

B) B) Surgical:Surgical: Indication:Indication: 1) Failed medical treatment (up to 4 1) Failed medical treatment (up to 4 weeks).weeks). 2) Presence of mechanical obstruction 2) Presence of mechanical obstruction in the nose.in the nose.

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Procedure:Procedure: Nowadays;Nowadays; →→ drainage of the affected drainage of the affected sinus by functional endoscopic sinus sinus by functional endoscopic sinus surgery (FESS).surgery (FESS).

Old:Old:

1. Maxillary: puncture & lavage.1. Maxillary: puncture & lavage.

2. Frontal: frontal trephine.2. Frontal: frontal trephine.

3. Ethmoid: fthnoidectomy.3. Ethmoid: fthnoidectomy.

4. Sphenoid: sphenocthmoidectomy.4. Sphenoid: sphenocthmoidectomy.

Procedure:Procedure:

According to he affected sinusAccording to he affected sinus

Recent “FESS”Recent “FESS”OldOld

MaxillaryMaxillaryEndoscopic middle meatal Endoscopic middle meatal antrostomy antrostomy widening of the widening of the normal ostium.normal ostium.

-Repeated puncture & Repeated puncture & Lavage Lavage up to 6 times. up to 6 times.-Intranasal antrostomy.Intranasal antrostomy.-Radical antrum operation. Radical antrum operation.

Frontal Frontal Endoscopic clearance of frontal Endoscopic clearance of frontal recess.recess.

External frontal operation External frontal operation opening sinus floor & opening sinus floor & removal of diseased mucosa.removal of diseased mucosa.

EthmoidsEthmoidsIntranasal ethnoidectomyIntranasal ethnoidectomyExternalExternal

Frontoethroidectomy.Frontoethroidectomy.

SphenoidSphenoidSphenoid sinusotomySphenoid sinusotomyExternalExternal

Sphenoethroidectomy Sphenoethroidectomy

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Sinusitis in childrenSinusitis in childrenAccidenceAccidence:: - Age: 5-8 yrs.- Age: 5-8 yrs.

- Site: maxillary & ethmoid (commonest).- Site: maxillary & ethmoid (commonest).Etiology:Etiology:Predisposing factors:Predisposing factors:- Ciliary disorders e.g. kartagnar’s syndrome (Bronchitis Dectrocar)Ciliary disorders e.g. kartagnar’s syndrome (Bronchitis Dectrocar)- Mucosal abnormality e.g. cystic fibrosis (Muwvisidrlin).Mucosal abnormality e.g. cystic fibrosis (Muwvisidrlin).- Source of infection: common e.g. URT infection & exanthemata.Source of infection: common e.g. URT infection & exanthemata.- Low immunity.Low immunity.OrganismOrganism: Strept. Pneumonia, H. influenza & moraxella catarrtalis.: Strept. Pneumonia, H. influenza & moraxella catarrtalis.Clinical picture:Clinical picture:Acute:Acute: as adult + high fever & complications are more especially as adult + high fever & complications are more especially

orbital.orbital.Chronic:Chronic: less facial pain & headache than adult, descending infection less facial pain & headache than adult, descending infection

& chronic irritative cough.& chronic irritative cough.TreatmentTreatment::(A) Medical:(A) Medical: as adult. as adult.(B) Surgical:(B) Surgical: - No improvement after medical treatment.- No improvement after medical treatment.

- Presence of complication. - Presence of complication.

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Orbital complicationsOrbital complications The commonest complication. 75% of orbital infections are due to The commonest complication. 75% of orbital infections are due to sinusitis.sinusitis.

AetiologyAetiology:: more common to occurs more common to occurs in ethmoditisin ethmoditis especially in especially in children. Less common t occurs children. Less common t occurs in in ethmoditis especially in children. ethmoditis especially in children. Less common with maxillary sinus.Less common with maxillary sinus.

Clinical pictureClinical picture:: 5 stages. 5 stages.

1-1- Preseptal cellulitis: Preseptal cellulitis:

. Mild inflammatory or reactionary edema of the "Preseptal . Mild inflammatory or reactionary edema of the "Preseptal connective tissue" due to proximity of infection in the ethmoids connective tissue" due to proximity of infection in the ethmoids →→ venous obstruction.venous obstruction.

. There is: eyelid edem.. There is: eyelid edem.

22- Subperiosteal abscess “extraperiosteal":- Subperiosteal abscess “extraperiosteal":

. Pus collection between the orbital periosteum & the lamina . Pus collection between the orbital periosteum & the lamina papyracea.papyracea.

.There is: .There is: - Severe pain- Severe pain - Mild Proptosis. - Mild Proptosis.

- Good general condition. - Mild limitation of eye movement.- Good general condition. - Mild limitation of eye movement.

- Chemosis. - Chemosis. - Diminution of vision (reversible). - Diminution of vision (reversible).

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33- Orbital cellulitis- Orbital cellulitis::. Diffuse edema of the orbital contents & bacteria actively invaded . Diffuse edema of the orbital contents & bacteria actively invaded

the orbitalthe orbitalcontents but pus formation does not occur.contents but pus formation does not occur.. There is. There is:-Sever pain. :-Sever pain. -- ↑ ↑ Proptosis.Proptosis.

-Bad general condition -Bad general condition - - ↑↑ limitation of eye movement. limitation of eye movement. -Chemosis. -Chemosis. -Diminution if vision condition -Diminution if vision condition

(reversible). (reversible).

4-4- Orbital abscess "intraperoisteal“: Orbital abscess "intraperoisteal“:. Pus collection within the orbit. . Pus collection within the orbit. . There is:. There is:-Sever throbbing pain. -Sever throbbing pain. -Marked proptosis. -Marked proptosis. -Very bad general condition -Total ophthalmoplegia.-Very bad general condition -Total ophthalmoplegia.

-Chemosis -Chemosis -Diminution of vision -Diminution of vision (irreversible).(irreversible).

5-5- Cavernous sinus thrombosis: Cavernous sinus thrombosis:Due to thrombosis of the superior & inferior ophthalmic veins Due to thrombosis of the superior & inferior ophthalmic veins

“retrograde thrombophilbitis”.“retrograde thrombophilbitis”.

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InvestigationsInvestigations::

11- Urgent CT scan of the paranasal sinuses & orbit.- Urgent CT scan of the paranasal sinuses & orbit.

22- Fundus examination: Papilloedema (in cavernous sinus - Fundus examination: Papilloedema (in cavernous sinus thrombosis).thrombosis).

Treatment:Treatment:

11- Hospita1ization.- Hospita1ization.

22- Treatment of orbita1 cellulitis:- Treatment of orbita1 cellulitis:

-Massive antibiotics with daily:-Massive antibiotics with daily: -Examination of visual acuity.-Examination of visual acuity.

-CT scan.-CT scan.

-Surgical:-Surgical: * Drainage of Subperiosteal abscess.* Drainage of Subperiosteal abscess.

* Indications:* Indications: -Progressive -Progressive ↓↓ of vision. of vision.

-Progressive symptoms over 24 -Progressive symptoms over 24 hrs & hrs & no improvement after 48 hours. no improvement after 48 hours.

-CT; shows subperiosteal -CT; shows subperiosteal collection.collection.

33- Surgical treatment of sinusitis.- Surgical treatment of sinusitis.

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Osteomylitis of skullOsteomylitis of skullOccurs in diploic bones Occurs in diploic bones →→ frontal & maxillary. frontal & maxillary.

AetiolologyAetiolology: Direct extension of infection to bones or due to thrombophilbitis : Direct extension of infection to bones or due to thrombophilbitis of diploic veins.of diploic veins.

Frontal osteomylitisFrontal osteomylitisMaxillary osteomylitisMaxillary osteomylitis

PathologyPathology: Osteomylitis : Osteomylitis → → subperiosteal abscess (Pott’s puffy subperiosteal abscess (Pott’s puffy tumour) tumour) →→ fistula. fistula.

SameSame

Clinical picture:Clinical picture:-General: fever, toxemia.General: fever, toxemia.-Pain, Oedema & tenderness over Pain, Oedema & tenderness over forehead.forehead.-Frontal fluctuant swelling or fistula.Frontal fluctuant swelling or fistula.

-General: fever, toxemia.General: fever, toxemia.-Pain, Oedema, tenderness over Pain, Oedema, tenderness over cheek.cheek.-Subperiosteal abscess over canine Subperiosteal abscess over canine fossa or oroantral fistula.fossa or oroantral fistula.

Investigations: Investigations: Plain X-ray & CT Plain X-ray & CT scan X-ray scan X-ray →→ moth-eaten appearance moth-eaten appearance of posterior wall. of posterior wall.

Plain X-ray & CT scan.Plain X-ray & CT scan.

TreatmentTreatment: Hospitalization.: Hospitalization.1. Massive antibiotics.1. Massive antibiotics.2. Surgical drainage of abscess.2. Surgical drainage of abscess.3. Treatment of sinusitis.3. Treatment of sinusitis.

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Intracranial complicationsIntracranial complications1. Meningitis: the most common intracraninal complication.1. Meningitis: the most common intracraninal complication.

2. Extradural abscess: occurs with frontal sinusitis & 2. Extradural abscess: occurs with frontal sinusitis & osteomylitis. Both 1 & 2 are similar to that of chronic ear.osteomylitis. Both 1 & 2 are similar to that of chronic ear.

3. Bruin abscess : Similar to that of chronic ear, with 3. Bruin abscess : Similar to that of chronic ear, with personality changes as a localizing sign.personality changes as a localizing sign.

4. Cavernous sinus thrombosis4. Cavernous sinus thrombosis

EtiologyEtiology:: infection from: infection from:

1- Dangerous area of the face (boil & septal abscess). Facial 1- Dangerous area of the face (boil & septal abscess). Facial veins veins → → ophthalmic vs. ophthalmic vs. →→ CS. CS.

2-2- * Sinus infection.* Sinus infection.

* Orbital cellulitis.* Orbital cellulitis.

3- Latera1 sinus thrombosis.3- Latera1 sinus thrombosis.

4- Pharyngeal suppuration e.g. Quinsy. 4- Pharyngeal suppuration e.g. Quinsy. → → pterygoid venous pterygoid venous plexus plexus → → CS.CS.

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Clinical picture:Clinical picture:

--11 General: high fever, toxemia, rigors. sever headache. Then, there is General: high fever, toxemia, rigors. sever headache. Then, there is

rapid deterioration of general condition.rapid deterioration of general condition.

-2-2Venous obstruction of eye: Eyelid Oedema, Chemosis & Proptosis.Venous obstruction of eye: Eyelid Oedema, Chemosis & Proptosis.

3- Cr. nerve affection:3- Cr. nerve affection: * Total ophthalmoplegia.* Total ophthalmoplegia.

* Pain in distribution of ophthalmic division of * Pain in distribution of ophthalmic division of

5 5thth nerve. nerve.

4- 4- ↑ ↑ ICTICT, then , then comacoma & death if untreated. & death if untreated.

InvestigationInvestigation: : MRIMRI, angiography & , angiography & MRAMRA..

TreatmentTreatment: : Mortality is 30% if untreatc 25Id of infection (meanings Mortality is 30% if untreatc 25Id of infection (meanings

& brain tissue).& brain tissue).

--Hospitalization.Hospitalization.

--Antibiotics & anticoagulant.Antibiotics & anticoagulant.

--Treatment of sinus disease.Treatment of sinus disease.

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Complications of sinusitisComplications of sinusitisClassificationClassification

AA. . Orbital complications.Orbital complications.

BB.. Cranial complications Cranial complications::1. Osteomylitis.1. Osteomylitis.2.2. Subperiosteal abscess Subperiosteal abscess ((Pott's puffy tumourPott's puffy tumour).).3.3. Fistula formationFistula formation..

CC. . Intracranial:Intracranial:1.1. Extradural abscessExtradural abscess..2.2. MeningitisMeningitis..3.3. Cavernous sinus thrombosisCavernous sinus thrombosis..4.4. Brain abscess Brain abscess ((frontal lobe).frontal lobe).

NN..BB.. Cranial and intracranial complications often follow acute Cranial and intracranial complications often follow acute frontal sinusitisfrontal sinusitis..

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DD. . Descending infectionDescending infection::1.1. Acute otitis mediaAcute otitis media..2.2. LaryngitisLaryngitis..3.3. PharyngitisPharyngitis..4.4. Bronchitis and asthmatic attacksBronchitis and asthmatic attacks..5.5. Gastro-intestinal troubles as anorexia Gastro-intestinal troubles as anorexia and dyspepsiaand dyspepsia..

EE. . GeneralGeneral::Symptoms of septic focus as arthritis and Symptoms of septic focus as arthritis and nephritis.nephritis.

FF. . MucocelMucocel

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MucocelMucocelDefinitionDefinition::

an expansion of a sinus by accumulation of mucoid secretionan expansion of a sinus by accumulation of mucoid secretion..

EtiologyEtiology::

11. . Chronic fronto-etmoiditisChronic fronto-etmoiditis..

22. . Osteoma obstructing the ostiumOsteoma obstructing the ostium..

33. . Post traumatic ostial stenosisPost traumatic ostial stenosis..

PathologyPathology::

--SitesSites →→ frontal frontal →→ frontoethomidal frontoethomidal →→ sphenoid. sphenoid.

--Mechanism:Mechanism: Ostium obstruction Ostium obstruction →→ secretions retention secretions retention →→

cysti expansion & thinning out of walls cysti expansion & thinning out of walls →→ wall destroyed with wall destroyed with

displacement of surroundingsdisplacement of surroundings..

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Clinical picture:Clinical picture:

Swelling:Swelling: -- Site Site:: * Inner canthus (ethmoid).* Inner canthus (ethmoid).

* Medial * Medial ½½ of orbital roof (frontal) of orbital roof (frontal)..

-- Slowly progressive Slowly progressive..

-- Painless Painless..

-- Hard or egg Hard or egg--shell crackling sensation.shell crackling sensation.

-- Proptosis; the direction depends on the affected Proptosis; the direction depends on the affected sinus.sinus.

--When infected, forms mucopyoceleWhen infected, forms mucopyocele:: * Skin over * Skin over → → inflamedinflamed..

* Tenderness.* Tenderness.

* Rupture * Rupture →→ fistula formation fistula formation..

InvestigationsInvestigations::11. . XX--ray sinus view ray sinus view →→ --OpacificationOpacification..

--Loss of scalloped appearance of the frontal sinusLoss of scalloped appearance of the frontal sinus..

22. . CT scanCT scan..

TreatmentTreatment::Surgery; evacuation of mucocel with adequate drainage to Surgery; evacuation of mucocel with adequate drainage to avoid recurrence.avoid recurrence.