What drains into inferior meatus?
Nasolacrimal gland
What drains into middle meatus?
- Middle- and anterior ethmoidal cells
2. maxillary- and frontal sinus
What drains into the superior meatus?
Sphenopalatine foramen and posterior ethmoidal cells. NB. Sphenoid sinus opens above the superior turbinate and a bit posteriorly.
How can you check if there is an inflammatory process?
Transillumination test. Check for maxillary sinus inflammation (no light = inflammation). Maxillary sinus can hold up to 15mL in an adult.
Acute & Chronic sinusitis - Predisposing factors
- Blockage of osteomeatal opening by polyp
- Septum deviation
- Choncha bullosa(trapped air cell in a turbinate)
- Mucosal thickening
Acute & Chronic sinusitis - definition
Acute < 10 days
Chronic > 3 months
Acute & Chronic sinusitis - Symptoms
Symptoms are usually BILATERAL(if unilateral -> think cancer). 1. Facial pain 2. Pressure sensation 3. Decreased smell sensation 4. Mucopurulent discharge 5. Polyps 6. Fever 7. Nasal obstruction 8. Headache CT-changes - need >2 to set diagnosis
Acute & Chronic sinusitis - how to check severity
VAS scale -> gives recommendation on how to treat
Acute & Chronic sinusitis - Treatment
- Functional endoscopic sinus surgery (FESS): Restores osteomeatal meatus physiological state and thus proper drainage of sinuses.
- Endoscopic sinus surgery (ESS): When there is need to remove excessive tissue(e.g. a polyp).
Acute & Chronic sinusitis - Complications
- Orbital fractures
- Emphysema
- Bleeding
- Blindness
- CSF leak
- Meningitis
- Empty nose syndrome (after surgery, patient still feel congested, however tha nasal passages are clear. Psychosomatic disease? e.g. like fantom leg.
- Injury to lacrimal gland
External approach of sinus surgery = Caldwell Luc’s operation. - Orbital - cellulitis, abscess
- CNS - meningitis, abscess
- Osteomyelitis - cavernous sinus thrombosis (= proptosis, chemosis and optalmoplegia)
Rhinitis - Cause
- Primary allergy -> tx: antihistamines(local or systemic), leukotriene inhibitors “-lukast”, intranasal steroids, nasal decongestants + avoidance of allergen.
- Infection
- Hormonal rhinitis (estrogens)
- Senile rhinitis
- Vasomotor rhinitis
- Rhinitis medicamentosa - due to rebound effect when stopping long term anticongestant tx.
- Atropic rhinitis -> crust and smell really bad. Patient dont know due to “merciful anosmia” - effect. Tx: Young’s operation.
- Chronic purulent rhinitis -> tx: longterm amoxicillin therapy. If no improvement start to look for signs of immunodeficiency, cystic fibrosis or mucociliary dysfunction.
ICF - Symptoms of discharge, and head trauma might be in history of patient. Quick test: Beta-2 transferrin + glucose (dipstick test) should be confirmed as they dont appear in nasal secretions. Blood containing CSF - halo sign. Beta 2 transferrin is most specific.
Acute Coryza (Common cold) - complications
Risk of acute sinusitis following.
Nasal vestibulitis
Carrier of S.pyogenes and their skin becomes infected. Tx: prolonged antiseptic/antibiotic ointment. Systemic flucloxacillin if really bad. In children - look for foreign body.
Nose bleed(Epistaxis) - Causes
- Local trauma (nose picking),
- Nasal septal deviation
- Iatrogenic
- Inflammation
- Foreign body
- Environmental factors (cold dry air)
- Malignancy
- HTN
- Blood disorders
- Ataxia teleangiectasia
Young boy with nosebleed, think of:
Juvenile angiofibroma
What to do with severe nosebleeds?
Get IV access and cross type blood just for security in case of fluid resuscitation.
Blood supply to nose.
- ICA -> ophtalmic artery -> anterior and posterior ethmoidal arteries. Supplies the anterior and posterior superior nasal cavity and septum.
- ECA -> Maxillary artery and facial artery.
Posterior nose-bleeds
10% - main source: Branches of sphenopalatine artery (Woodruff’s plexus)
Anterior nose-bleeds
90% - main source: Kiesselbachs plexus that supply Little’s area. Recieves branches from both ICA and ECA:
Anterior nose bleed - Treatment
- Pinch cartilaginous part of nose (10-12min)
- Nitrate application sticks for cauterization
- Sponge hemostatic pack
- Really severe that dont respond to above mentioned: ANTERIOR PACKING - should be kept for 48h. Hospitalization depend on state of patient.
Posterior nose bleed - Treatment
- Balloon catheter (NB-risk of necrosis)
- Posterior back + anterior
- keep posterior one for 72h(anterior for 48h) - Replace always due to risk of infection/sepsis. Still bleed? - Arterial ligation
- Embolization
- Endoscopic cauteriation(ESPAL)
Samter’s triad/Aspirin triad
Bronchial asthma + polyps + aspirin sensitivity
Tumors and cancers in nose- M:F ratio
M:F ratio = 2:1
Tumors and cancers in nose - Types
- Osteomas (Gardner syndrome if multiple)
- Inverted papilloma (malignant potential)
- Juvenile angiofibroma(adolescent males)
- SCC (80-85% - usually present late)
- Melanoma
