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OTORHINOLARYNGOLOGY
1.1A NOSE & PARANASAL SINUSES

CHOANAL ATRESIA hypertension

 Embryonic failure of the bucconasal membrane to rupture Infectious diseases Influenza, measles, typhus
prior to birth Endocrine changes or diseases Pheochromocytoma, pregnancy,
 Persistence of a bony plate or membrane diabetes mellitus
Hemorrhagic diathesis Congenital: e.g. hemophilia A
IMAGING STUDIES  Coagulopathies and B, Willebrand diseas
 Plain Films Acquired: e.g. anticoagulant
- Cheap, inaccurate, overlapping structures therapy, hepatocellular
 CT Scan insufficiency
- More expensive, more accurate and detailed, no overlapping  Platelet Disorders Idiopathic thrombocytopenic
of structures  Thrombocytopenia purpura, platelet proliferation
 MRI disorders, platelet distribution
- Most expensive, accurate especially to extent of soft tissue disorders
and fluid, poor in bone delineation

DISEASES OF THE NOSE & PARANASAL SINUSES

MANAGEMENT
 Surgical Excision
 Sclerosing agents
 Propanolol
 Vascular endothelial growth factor

EPISTAXIS
 KISSELBACH’S PLEXUS in the Little’s Area – 90% of Epistaxis
 Posteroinferior bleeding – Sphenopalatine vessels
 Roof of the nose – from anterior and posterior ethmoid
arteries

LOCAL CAUSES OF EPISTAXIS

CLASSIFICATION EXAMPLES
Change in the nasal septum Perforation traumatic, iatrogenic
inflammatory: spurs or ridges
Mucosal or vascular injury Foreign bodies, rhinoliths, trauma
(including nose picking), allergy,
acute rhinitis, traumatic aneurysm
of the internal carotid artery (very
rare)
Neoplasma Benign and malignant neoplasms
of the nose, paranasal sinuses and
nasopharynx
Idiopathic
SYSTEMIC CAUSES OF EPISTAXIS
CLASSIFICATION EXAMPLES
Vascular and circulatory diseases Atherosclerosis, arterial
RHINOLITH
MANAGEMENT OF RHINOLITH
 Endoscopic guided removal
 Lateral Rhinotomy
VESTIBULITIS
 Infection of the sebaceous glands
 Staphylococcus aureus
 Warm compress
 I&D antibiotics
RHINOSINOGENIC COMPLICATIONS
 ORBITAL
- Orbital cellulitis
- Cavernous sinus thrombosis

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 ENT 1.1A NOSE & PARANASAL SINUSES

 INTRACRANIAL • “ALLOS” – other than

- Epidural, subdural and intracerebral abscesses • “ERGON” – reaction
- Clinical manifestations are nonspecific  Symptoms
- Rhinorrhea
 OSTEOMYELITIS / SUBPERIOSTEAL - Nasal obstruction
- Abscess - Nasal itching
- Sneezing
CAVERNOUS SINUS THROMBOSIS  Reversible spontaneous or with treatment
 Localized to nose; affects both sides
 Complications:
 Watery and clear nasal discharge
- Loss of vision – 10%
 Boggy and pale turbinates
- Ischemia of other organs
- Intracranial complications (meningitis, brain abcess)
IMMEDIATE HYPERSENSITIVITY
 Prognosis
- 30% mortality • Very quick reaction of the immune system to harmless
foreign substance, 5-15 minutes, i.e. hay fever, astma, food
ATROPHIC RHINITIS and drug allergy
 Atrophy of nasal mucosa DELAYED HYPERSENSITIVITY
 Loss of cilia • Much slower reaction of the immune system, two or more
 Etiology : Unknown days, i.e. contact dermatitis
 Symptoms: Crusting, viscid secretions, fetid nasal odor
SYMPTOMS
 Endoscopy: Broad nasal cavity lines with dry, crusted mucosa
 Management: • Rhinorrhea
- Nasal douche • Stuffiness / Nasal obstruction
- Medical (steroids, antibiotics) • Nasal itching
- Surgical (submucous implantation of cartilage) • Sneezing

RHINITIS MEDICAMENTOSA ALLERGENS

 Rebound vasodilation  House dust mites - tiny insects that live in dust
 Prolonged used of sympathomimetic decongestant nose drops  Proteins in Danders - Dry skin of human / pets
& nasal spray (oxymetazoline)  Molds & Milder
 Initial vasoconstriction -> Vasodilation -> Nasal obstruction &  Cockroach
excessive mucous secretion  Pollens - grass, flowers & trees
 Discontinue medication & substitute topical steroids  Food - milk, wheat, soy, eggs, nuts, seafoods
(mometasone, flucasone, ciclesonide) for allergy
CLASSIFICATION OF ALLERGIC RHINITIS (ARIA - ALLERGIC
VASOMOTOR RHINITIS RHINITIS AND ITS IMPACT ON ASTHMA)
 Exact cause is unknown INTERMITTENT SYMPTOMS PERSISTENT
 Triggers: < 4 days per week <4 days/week
- Dry atmosphere Or >4 weeks And >4 weeks
- Air pollution MILD MODERATE - SEVERE
- Alcohol Normal sleep Abnormal sleep
- Spicy foods No impairment of daily activities, Impairment of daily activities, sport,
- Strong emotions sport, leisure leisure
 Primary treatment: Avoiding triggers No impairment at work and school Impaired work and school
- Decongestants No troublesome symptoms Troublesome symptoms
- Antihistamines
- Corticosteroid nasal sprays TREATMENT
 Antihistamines
ALLERGY  Steroids
 "ALLOS" - Other than  SCIT (Subcutaneous immunotherapy)
 "ERGON" - reaction  SLIT (Sublingual immunotherapy)
 Immediate hypersensitivity - very quick reaction of the immune
system to harmless foreign, substance, 5-15 minutes SUBCUTANEOUS IMMUNOTHERAPY
Ex. Hay fever, asthma, food & drug allergy  Provides symptomatic relief
 Delayed hypersensitivity - Much slower reaction of the immune  Modifies allergic disease by targeting the underlying
system, 2 or more days. immunological mechanism
Ex. Contact dermatitis2  Efficacy and safety established
 Treatment of
ALLERGIC RHINITIS - Asthma
• Allergy - Allergic rhinitis / rhinoconjunctivitis

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- Hypersensitivity RHINOSINUSITIS
 Numerous controlled clinical trials  A group of disorders generally characterized by inflammation of
mucosa of the nose and para-nasal sinuses
SUBLINGUAL IMMUNOTHERAPY
 Small doses of allergen sublingually ACUTE RHINOSINUSITIS
 Boost tolerance allergen  An inflammatory condition involving the paransal sinuses, as
 2009 World Allergy Organization (WAO) well as the lining of the nasal passages, which last up to 4
 Widely accepted in Europe, South America, and Asia weeks (28 days)
 Safety nor the efficacy yet to be considered by the US FDA  Most common pathogens
- Streptococcus pneumoniae
SLIT VS SCIT - Haemophilus influenzae
 SLIT Cochrane meta-analysis demonstrated efficacy in control - Moraxella catarrharalis
of rhinitis symptoms in patients older than 12 years - Staphylococcus aureus
 Safety profile: Much safer than subcutaneous IT - Anaerobic bacteria
 SCIT: Scandanavian study compared the effectiveness and  Inflammation and edema formation causes increased secretion
safety of injection therapy with SLIT using birch pollen antigens which are retained in the sinuses
 No difference between subcutaneous and sublingual in terms of  Symptoms: Severe nasal discharge
efficacy  Rhinoscopy: Greenish or purulent foul smelling nasal discharge
over congested turbinates
ACUTE RHINITIS  X-ray: Air fluid level, mucosal thickening, mucosal opacification
 Viral
- Transient signs and symptoms CHRONIC SINUSITUS
- Self limiting  Inflammation of the nasal cavity and paranasal sinuses and/or
- Both sides, watery and clear discharge, congested turbinates the underlying bone that has been present for at least 12 weeks
- Rhinovirus and Coronavirus  Symptoms:
 Bacterial - Nasal congestive/obstructive or blockage
- Follows viral infection - Facial pain or pressure
- Pneumococcus, Staphylococcus - Discolored discharge (Anterior or Post-nasal drip)
 Streptococcus - Hyposia or anosmia
- Thick, yellow-green discharge  Fungal
- May be one side, congested turbinates and mucosa - Aspergillosis
- Antibiotics are warranted - Mucormycosis
- Rhinoscoridosis
CHRONIC RHINITIS  Bacterial
FUNGAL - Tuberculosis
 Aspergillosis - Leprosy
 Mucormycosis - Rhinoscleroma
- Sarcoidosis
 Rhinoscoridosis
- Syphilis
- Actinomycosis
BACTERIAL
 Follows bacterial infection
 Pneumococcus, Staph, Strep
 Thick, yellow-green discharge
 May be one side, congested turbinates and mucosa
 Antibiotics are warranted

VASOMOTOR RHINITIS
 Exact cause is unknown
 Triggers
- Dry atmosphere
- Air pollution
- Alcohol
- Spicy foods
- Strong emotions
TUMORS OF NOSE & PARANASAL SINUSES
 Primary treatment: Avoiding triggers
NASAL POLYPOSIS
 Decongestants
 Presence of bilateral, smooth, semitranslucent pearly white
 Antihistamines
to pinkish, pedunculated masses arising from the muscosa
 Corticosteroid Nasal Sprays
surrounding the ostiomeatal complex

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CLASSIFICATION OF NASAL POLYPS (MACKAY) - Neck mass

GRADE CLINICAL FINDINGS  Neurological
0 Absence polyps - Facial Pain
1 Polyps do not prolapse beyond the
most anterior part of the middle MANAGEMENT
turbinate (requires nasal  Radiotherapy
endoscopy)  Chemotherapy
2 Polyps extend below the middle  Combination
turbinate and are visible with nasal
speculum SCCA
3 Polyps are massive and occlude the MANAGEMENT
entire nasal cavity  Surgery is still the mainstay

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

PRINCIPLES FOR THE STAGING OF SINONASAL TUMORS

REGIONS SUBREGIONS
Nasal cavity Nasal floor and roof
Upper Level Maxilloethmoid angle, ethmoid cells,
sphenoid sinus, frontal sinus
Midlevel Inferior, superior and medial portions of
maxillary sinus
Tumor Stage Tumor Extent Example: maxillary
sinus carcinoma
T1 1 subregion Floor of maxillary sinus
T2 > 1 subregion or 1 Floor and medial
region portion of maxillary
sinus
T3 Invasion of Invasion of nasal cavity
adjacent region
T4 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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