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JUNIOR SURGERY LECTURE
Nose And Paranasal Sinuses

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

• BE SURE TO READ THE FOLLOWING Web pages from the
  American Academy of Otolaryngology/Head and Neck Surgery -- Core Curriculum
  http://www.entlink.net/education/curriculum/ .
  
  • "Rhinosinusitis"
    
  • "Anatomy and Physiology of the Paranasal Sinuses"
    

• 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, 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:
• Anosmia
• 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? (tension or migraine headaches or temporomandibular joint arthritis, etc.)
• Is allergy a component?
• Is it vasomotor rhinitis?
  - Profuse rhinorrhea,
  - Often precipitated by cold air or eating
  - Treatment: ipatromium bromide (Atroventâ )
• Is it post-nasal drip causing sore throat, hoarseness?
• Treatment, medical: decongestants, anti-microbials
  
• 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
• 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 for 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 number of 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, anywhere. Try 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 2/3 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: 08/11/2000
nose-paranasal-sinus.htm