Nose and Sinus. Mr Chris Brown. ENT Surgeon RVEEH JUNE Copyright Mr Chris Brown - not to be reproduced without permission of the author

Transcription

1 Nose and Sinus Mr Chris Brown ENT Surgeon RVEEH JUNE 2014

2 Overview Anatomy Physiology Common conditions sinusitis fungal disorders epistaxis trauma nasal polyps rhinitis deviated septum hyposmia Future directions

3 Anatomy

4 Anatomy

5 Anatomy 4 sinuses Frontal Maxillary Ethmoid Sphenoid Frontal

6 Ethmoid OMC osteomeatal complex (middle meatus) Maxillary Sphenoid

7 Physiology Mucus is transported out of the sinuses through natural openings Blockage of these openings can lead to sinusitis

8 Physiology Mucociliary clearance functioning cilia Innate immunity - lysozymes Cellular immunity pmns, lymphocytes

9 Sinusitis Definintion Inflammatory response involving the mucous membranes of the nasal cavity and paranasal sinuses Correct term actually rhinosinusitis

10 Sinusitis Acute rhinosinusitis < 4 weeks Chronic rhinosinusitis (CRS) > 12 weeks

11 Aetiology of CRS Predisposing factors Viral URTI % develop sinusitis Bacterial infections Streptococcus pneumonia Hemophilus influenza Moraxella catarrhalis Staphylococcus aureus Bacterial biofilms and superantigens Allergic rhinitis Immunodeficiencies Smoking Mucociliary disorders cystic fibrosis Anatomical factors Nasal polyps

12 Aetiology of CRS Biofilms Bacteria in polysaccharide matrix evade host defenses Antibiotics ineffective Forging a link between biofilms and disease Science 1999: 283; Potera Bacterial biofilms in surgical specimens of patients with chronic rhinosinusits Sanclement et al Laryngoscope 2005: 115 April

13 Aetiology of CRS Superantigens S.aureus IgE to staphylococcal and streptococcal toxins in patients with chronic sinusitis / nasal polyps Laryngoscope; Tripathi

14 Pathogenesis Inflammation Ostial obstruction Bacterial infection

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16 Symptoms The symptoms of CRS are varied, and include the following: facial pressure/pain/congestion/fullness nasal obstruction/blockage nasal discharge/post nasal drip other symptoms such as hyposmia/anosmia, headaches, halitosis, fatigue, dental pain, cough and ear pressure.

17 Symptoms Traditionally obstructed sinuses are thought to have referred pain to certain regions. This is a reasonable assumption but not foolproof. Maxillary sinus cheek/dental pain Ethmoid sinus pain between the eyes Frontal sinus forehead pain Sphenoid sinus vertex pain

18 Examination Examination of the nose can be achieved in various ways using an otoscope (cheapest) using a headlight with magnification (more expensive) using specialised endoscopes. This enables a more detailed evaluation of the posterior aspect of the nose

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22 Investigations for CRS CT scan sinuses Generally, a scan should be requested when Unsure of the diagnosis Patient not responding as expected to medical treatment Surgery is planned (as per ENT specialist) A plain sinus X-ray is no longer considered satisfactory as it is far inferior to the information obtained from a CT scan. MRI scans are rarely required in CRS.

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24 Investigations for CRS Swab result Not responding to medical therapy Guides further appropriate selection of an antibiotic. It is important that the swab is of mucopus visualised on nasal examination. A swab simply placed in the nose is of limited use due to bacteria already colonising the nose.

25 Investigations for CRS Allergy/immunology assessment Concomitant allergic disorders are more frequent than immunological disorders in patients with CRS. Blood tests (radioallergosorbent testing; RAST) or skin prick tests may be indicated Immunology assessment may also be indicated in patients that have features suggesting an immunodeficiency.

26 Diagnosis of CRS 1. Symptoms present for at least 12 consecutive weeks. 2. At least 2 of the following symptoms Anterior and/or posterior mucopurulent drainage Nasal obstruction Facial pain-pressure-fullness. 3. The presence of inflammation on examination of a decongested nose (discoloured mucus or oedema in the middle meatus) and/or CT scanning showing evidence of rhinosinusitis. Fokkens W, Lund V, Mullol J. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps A summary for otorhinolaryngologists. Rhinology 2007;45(2):

27 Complications of CRS Orbital complications Preseptal inflammation Orbital cellulitis Orbital cellulitis with SPA Orbital cellulitis with orbital abscess Cavernous sinus thrombosis

28 Complications of CRS Intracranial Meningitis Subdural abscess Epidural abscess Brain Abscess CST

29 Complications of CRS Other Complications of sinusitis Mucocoeles

30 Differential Diagnosis 1 Neuralgic pain migraine, cluster headaches and tension headaches. minimal other symptoms to suggest CRS. CT scan is within normal limits.

31 Differential Diagnosis 2 Fungal sinusitis Fungal ball/mycetoma double densities within the involved sinus, which is considered pathognomonic for the disease. surgery is indicated to remove the fungal ball. antifungal agents are not required.

32 Differential Diagnosis 3 Tumours atypical features unilateral symptoms or signs abnormal CT scans

33 Management Nasal saline douching Topical Steroids Oral antibiotics Concomitant treatment of predisposing factors eg allergic rhinitis

34 Nasal irrigations 1. Simple 2. Safe 3. Effective 4. Minimal side effects Management Nasal irrigations: good or bad Opinions 2004: Jan Brown et al

35 Management Mechanism of action Simple removal of mucus Removal of antigenic proteins Effect on ciliary beat frequency Does increasing CBF increase mucociliary clearance Nasal irrigations: good or bad Opinions 2004: Jan Brown et al

36 Management Variables Tonicity hypotonic, isotonic, hypertonic Buffering alkaline - bicarbonate Sterile vs non sterile Solution ringer lactate Additives antibacterial, xylitol, antifungal agents Home produced vs commercial packages Nasal irrigations: good or bad Opinions 2004: Jan Brown et al

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39 Management Topical intranasal corticosteroid sprays They are considered safe (lowest dose necessary should be used) Some delay in onset of action Using the opposite hand for the opposite nostril helps direct the spray towards the middle meatus The head tilted slightly forward is sufficient, and whether the patient inhales or not is not paramount. The most important factor is patient compliance. A minimum trial for at least one month is reasonable

40 Management Oral antibiotics Oral antibiotics are frequently used in patients with CRS Randomised control trials showing the effectiveness in CRS are limited. Choice of antibiotic is best guided by anticipated micro-organisms in the absence of meaningful culture/swab results. Antibiotics should be given as a continuous course. Macrolides are thought to have both an antibacterial effect as well as an anti inflammatory effect so their use is appealing. Duration of treatment is debatable and can be anywhere from 3-6 weeks to 3 months

41 Management Allergic rhinitis Environmental Medication Imunotherapy

42 Management Other Numerous other modalities exist, all with varying benefits. Decongestant sprays (prolonged use causes rhinitis medicamentosa and so should be avoided) Decongestant tablets Mucolytics, antihistamines (sprays and tablets), and other sprays (eg anticholinergic). Avoidance of smoking is important. Other modalities include adding various agents to topical saline douches, such as xylitol and mupirocin

43 Management Nasal polyps Prednisolone is typically employed in patients with nasal polyps Samter s triad consists of nasal polyposis, asthma and aspirin sensitivity

44 Management Surgery Surgery in CRS is reserved for those patients who fail medical treatment. What constitutes failed medical treatment is controversial. Functional endoscopic sinus surgery (FESS) involves the placement of minimally invasive endoscopes/instruments into the nose to open, drain and ventilate the sinuses whilst preserving normal sinus tissue. Evidence based surgery for CRS includes substantial level 4 evidence with supporting level 2 evidence that FESS is effective in improving symptoms and/or quality of life in patients with CRS.25

45 Management Surgery Evolving techniques include the use of balloon catheters to dilate sinus openings. Day case surgery is now feasible due to the development of dissolving nasal packing and other minimally invasive techniques Major complications occur in less than 1% of cases Revision surgery may be required, especially in patients with nasal polyposis.

46 SUMMARY OF KEY POINTS Rhinosinusitis is the preferred term rather than sinusitis Chronic rhinosinusitis consists of at least 12 weeks of symptoms Medical therapy includes nasal saline douching, intranasal corticosteroids and oral antibiotics Consider CT scanning in those patients not responding to medical treatment or when the diagnosis is unclear.

47 Fungal sinusitis Four types Fungal ball Allergic fungal sinusitis Chronic fungal sinusitis Acute invasive fungal sinusitis

48 Fungal sinusitis Fungal ball One sinus Surgery

49 Fungal sinusitis Allergic fungal sinusitis Nasal polyps Surgery Oral steroids

50 Fungal sinusitis Acute invasive fungal sinusitis Unstable diabetics or Immunocompromised % mortality Treatment Surgery Aggressive medical management amphotericin B correct underlying problem

51 Fungal sinusitis Acute invasive fungal sinusitis

52 Hyposmia Normal smell perception of odor by the nose taste perception of salty, sweet, sour and bitter by the tongue flavor combination of above

53 Hyposmia Physiology Danger fire, gas, spoiled foods Biological child / mother bonding Enjoyment perfume, food, flowers

54 Hyposmia

55 Hyposmia Pathological anosmia complete inability to smell hyposmia decreased ability to smell dysosmia altered perception of smell phantosmia no stimulus - altered P parosmia stimulus altered P

56 Hyposmia

57 Hyposmia

58 Hyposmia Treatment Think could it be CNS Steroids Safety fire, food, gas

59 Future directions

60 Future directions

61 Future directions

62 Future directions

63 Future directions

64 Future directions

65 Future directions Xylitol Natural sugar Lowers salt concentration of the mucus lining the airway ( trachea, sinuses) Upregulates antimicrobial factors already present Injected xylitol with pseudomonas and compared it to pseudomonas and saline

66 Future directions Mean % of PAO1 retrieved from each solution after 20 minutes in maxillary sinus % of inoculation retrieved saline xylitol solution (containing PAO1) placed in maxillary sinus p = n = 11 rabbits

67 Trauma Fractured Nose If patient thinks crooked probably is broken. Exclude septal haematoma X-ray little use (?medicolegal reason) Driver s licence 3 week window to fix

68 Trauma Septal haematoma In association with trauma/recent septoplasty Nasal obstruction Boggy swelling Palpation of septum Saddle nose Surgical drainage required

69 Epistaxis Classification Anterior vs posterior Anatomical basis Comfort level

70 Epistaxis Little s area confluence of blood vessels anterior septum

71 Epistaxis History Age Duration Quantity tissues, towels, bucket! Which side? Out the front or down the back Aspirin, warfarin Co-morbidities

72 Epistaxis Examination Overall this looks bad General PR, BP, pulse oximetry Left or right side Anterior or posterior bleed

73 Epistaxis Equipment is crucial Protection

74 Epistaxis Light source

75 Epistaxis Suction, Speculum, Nasal forceps if packing the nose

76 Epistaxis Decongestant Phenylephrine & lignocaine

77 Epistaxis Room, assistant

78 Epistaxis Be familiar with equipment Don t learn how to use light source, hold a nasal speculum and understand the normal anatomy of the nose on a posterior bleed!

79 Epistaxis Treatment Overall IV access, resuscitation FBE Clotting G and H

80 Epistaxis Left or right sided Lean the patient forward bleeding from both sides packed both sides

81 Epistaxis Silver nitrate

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84 Epistaxis

85 Epistaxis Endoscopic sphenopalatine artery ligation for posterior bleeds Very effective Discharged same/next day Gets the pack out of the nose, and gets the patient out of the hospital

86 Epistaxis

87 Epistaxis

88 Thank you

89 CHRONIC RHINOSINUSITIS Rhinosinusitis is inflammation of the nose and the paranasal sinuses Acute rhinosinusitis < 4 weeks in duration Chronic rhinosinusitis > 12 weeks Aetiology Bacterial infection (+/- in association with URTI) Streptococcus pneumonia, Hemophilus influenza, Moraxella catarrhalis Rhinitis allergic, non allergic (eg smoking) Anatomical factors, Immunodeficiencies, Ciliary disorders eg. cystic fibrosis Bacterial biofilms, Staphylococcal superantigens, Fungi Other metabolic derangements eg. aspirin sensitivity Diagnosis Of Chronic Rhinosinusitis 1. Symptoms present for at least 12 consecutive weeks 2. At least 2 of the following symptoms Anterior and/or posterior mucopurulent drainage Nasal obstruction Facial pain-pressure-fullness 2. Inflammation on examination of a decongested nose (discoloured mucus or oedema in the middle meatus) and/or CT scanning showing evidence of rhinosinusitis Imaging CT scan when Unsure of diagnosis Patient not responding to medical treatment Surgery planned Complications of Sinusitis Eye - Preseptal cellulitis, Orbital cellulitis, Subperiosteal abscess, Orbital cellulitis, CST Brain Meningitis, Subdural abscess, Epidural abscess, Brain Abscess Other - Mucocoele Management Nasal saline douching, Topical steroids, Oral antibiotics Concomitant treatment of predisposing factors eg allergic rhinitis Surgery for failed medical treatment Nasal Polyposis Prednisolone Samter s Triad nasal polyps, asthma, aspirin sensitivity Mr Christopher Brown, ENT Surgeon special interest nasal and sinus disorders