Nose and Sinus Complications PDF

Complications of sinusitis  Anatomically ,the paranasal sinuses are closely adjacent to vital structures like orbit,brain.  Complications occures when there is extension of infection into or beyond the bony wall paranasal sinuses (3-5%). 5%).  The c...

Complications of sinusitis  Anatomically ,the paranasal sinuses are closely adjacent to vital structures like orbit,brain.  Complications occures when there is extension of infection into or beyond the bony wall paranasal sinuses (3-5%). 5%).  The complications usually occurs during an acute stage of rhinosinusitis.  Complications are more common in children.  Complications may be severe & life threatening.  Pathways of spread: 1. Direct spread through bony defect. 2. Spread to bony wall (osteomyelitis). (osteomyelitis) 3. Vascular spread( retrograde thrombophlebitis). 4. Spread allong the perineal space around olfactory neurons. Classification  Acute :  Orbital complica ons (60-75%). (60  Intracranial complica ons(15-20%). ons(15  Bony complica ons (5-10%). 10%).  Chronic:  Mucocele.  Pyocel.  Orbital complications:  It is the most common complications & seen most frequently as a complication of ethmoidal and frontal sinusitis due to close anatomical proximity.  Children more susceptible due to higher incidence of URI’s and sinusitis.  Five classifications: 1. Celluli s of the eyelids. 2. Orbital celluli s. 3. Sub-periosteal abscess. 4. Orbital abscess. 5. Cavernous sinus thrombosis.  Treatment  Medical treatment with IV antibiotics for preseptal cellulitis and for limited suppuration in the absence of raised intraocular pressure or impaired vision’  Surgical drainage is indicated if medical treatment fails to improve the infec on within 24-48 hours or if the patient has visual impairment or raised intraocular pressure.  Intracranial complications:  As acomplication of frontal , ethmoidal & sphenoid sinusitis and infection occur from direct extension or spreading thrombophlebitis.  These include: 1. Meningi s( m0st common). 2. Extra-dural abscess.(frontal sinusitis) 3. Subdural abscess.  4. Brain abscess( frontal lobe). 5. Cavernous sinus thrombosis.  Common signs and symptoms: Fever , headache , neck stiffness, nausea & vomiting , altered consciousness , change in memory and behaviour, seizure , hemiparesis.  IV antibiotic, lowering IC pressure ,drainage of purulent collection.  Bony(osteomyelitis)  Frontal sinusitis may cause osteomylitis in the diploic bone between inner and outer table of the skull with development of subperiosteal abscess (pus may form externally under periosteum) /Pott’s puffy tumour.  Cutaneous fistula may developed.  Intracranial complications are frequent.  Chronic 1)Mucocele: is a mucus-containing cyst completely filling a sinus and capable of expansion, it occurs most commonly in the frontal followed by the ethmoidal sinuses. It result from trauma ,polyp or tumor in the region of frontal recess. 2)Pyocele: When a mucocele become secondary infected. Fungal sinusitis o There has been an increase in the reported incidence of mycotic infections of the nose and paranasal sinuses. o The principle fungal organism causing fungal sinusitis belong to the Aspergillus and Mucor. o There are four different presentation of fungal sinusitis catigorised in to two main groups : I. Non-invasive : includes  Fungal ball ( Mycetoma ): presence of a mycelial mass confined to the lumen of the sinus cavity typically the maxillary antrum in immunocompetent patient.  Allergic fungal sinusitis: characterized by eosinophilia, nasal polyposis, presence of mucin with hyphae on histology. II. Invasive : includes   Chronic invasive fungal sinusitis : characterized by tissue invasion resulting in bone destruction and extension to the orbit and brain.  Acute fulminant fungal sinusitis: it is a rapidly progressive gangrenous necrosis of the soft tissue and bony structure, the patient is immunocompromised and neutropenic. o CT scan,MRI is the best modality for identifying fungal disease. o Treatment of Non-inasive fungal sinusitis is primarily surgical debridement and adequate drainage. o The management of invasive fungal sinusitis includes surgical excision of the necrotic tissue and bone with systemic antifungal agent Nasal Polyps  Definition : Pedunculated edematous sino - nasal mucosa which prolapsed through the meatus to the nasal cavity. It’s either ethmoidal polyps or maxillary /antrochoanal polyp. Ethmoidal polyps  Ethmoidal polyps originate in the region of the ethmoidal sinuses and project into the nasal cavity through middle & superior meatus.  Clinical pictures: o Symptoms :  Bilateral nasal obstruction.  Bilateral nasal discharge which could be mucoid or mucopurulent.   Anosmia.  Clinical pictures: o Signs:  Anterior rhinoscopy: The polyps are multiple ,bilateral, round ,smooth , pale, glistening (peeled grabes appearance), soft, not tender and moves backwards when probed, arise from superior and middle meatus.  These features differentiate the polyp from turbinate hypertrophy.  Investigations:  X-ray of the sinuses and CT scan if endoscopic ethmoidectomy is to be performed.  Treatment 1. Control of the predisposing factors(allergy). 2. Medical: Its usefull in small polyps by topical nasal steroids.  A patient with more extensive polyps is usually best treated with systemic steroids( Medical polypectomy). 3. Surgical: Nasal polyps tend to recur and about 50 % of pa ents eventually will need surgery:  Simple polypectomy: high recurrence rate.  Endoscopic sinus surgery. Antrochoanal/Maxillary polyp  Arises from the maxillary sinus and project from the ostium posteriorly to the nasopharynx.  It tends to be dumb-bell in shape with a constriction where they pass the ostium of the sinus. Therefore, it has two compartments; maxillary(antral) and nasal portions.  Aetiology  It is unknown but may be inflammatory as it has NO relation to allergy.  Clinical Pictures o Symptoms: Unilateral nasal obstruction, the obstruction is greater in expiration than inspiration due to ball- like(valve) effect of the polyp. Unilateral nasal discharge and postnasal drip. o Signs: Anterior rhinoscopy : unilateral , single ,pale, soft polyp, some times just the stalk of the polyp can be seen. Posterior rhinoscopy to visualize the polyp.  Investigations : X-ray and CT sacn of the paranasal sinuses.  Treatment  There is NO medical treatment.  Endoscopic removal (ESS)of the polyp including the maxillary portion , it has a high incidence of recurrence. In recurrence a Cald-Wel-Luc operation can be performed. Tumors of the nose and sinuses Benign Tumors  Osteoma  Definition : benign osteogenic tumor slowly growing and contain mature bone. It is most frequently found in the frontal sinus, ethmoidal and maxillary sinuses.  Clinical Pictures: They are frequently silent and diagnosed incidently. If the frontonasal duct is obstructed, it causes headache or facial pain and may leads to frontal mucocele. Craniofacial deformity& displacement of the orbit.  Investigations: Radiology: X.ray and CT scan shows dense, well-delineated radiopaque lesion.  Treatment Asymptomatic: observation. Symptomatic: external frontoethmoidectomy.  Papilloma  It arises either from the skin of the nasal vestibule (squamous papillomas) or from the respiratory mucosa (inverted papilloma). A. Squamous papilloma  It is a warty like growth either sessile or pedunculated.  Site : skin of vestibule.  It is removed by an elliptical incision and the base is cauterized to prevent recurrence.  They can also be treated by cryosurgery or LASER. B. Inverted Papilloma  It’s a benign tumour but locally destructive.  This tumor reoresent 4% of all nasal tumors.  It arises from the lateral wall of the nose at the junction between skin & nasal mucosa.  It is named so because microscopically the epithelium grows towards underlying stroma rather than on the surface.  The exact etiology remains uncertain, although a link to human papilloma virus (HPV) has been reported.  Clinical Picture  Symptoms: Mostly seen between 40-70 years with male predominance. It is rare before adulthood. The usual presentations are unilateral nasal obstruction. Other associated symptoms include rhinorrhea,postnasal drainage, headache/facial pain, and epistaxis. Larger tumors may extend into the sinuses causing obstruction and infection, or may compress the orbit leading to diplopia, proptosis, and even blindness.  Signs: Physical examination usually reveals a unilateral polypoid mass of the lateral nasal wall filling the nasal cavity. Grossly, it tends to have an irregular friable appearance and often bleeds with manipulation.  Investigations 1. Imaging: Computed tomography (CT) and magnetic resonance imaging(MRI) are complementary and both are needed to plan the appropriate surgical approach, MRI allows for excellent delineation of the tumor from the surrounding soft tissues, orbital or intracranial involvement. 2. Biopsy.  Treatment Adequate local excision (medial maxillectomy) by lateral rhinotomy approach or Midfacial Degloving.. Endoscopic excision may be done by experienced surgeon.  Prognosis Inverted Papilloma histologically it is benign, but locally aggressive in nature due to : local bony destruction and erosion. High propensity for recurrence. Malignant transformation(squamous cell carcinoma).  Close follow-up by endoscope for long period to exclude recurrence, malignant transformation ( 5 and 15%).  Intermediate tumor Malignant Tumors  Definition: A rare tumor more common in male , eldarly above 60 years.  Site : Involving mainly the maxillary sinus(60%), nasal cavity( 30%), and ethmoid/sphenoid sinuses.  Histology: Squamous cell carcinoma (80%), adenocarcinoma , sarcoma ( in young age group).  Aetiology  Unknown. Exposure to hard wood dust (Adenocarcinoma) and nickel (Squamous cell carcinoma) play a role to develop this tumour. Spread : Local (Direct): Maxillary- down ( alveolus), up ( orbit) , posterior ( pterygoplatine fossa), anterior (cheek ) , Ethmoid- up( brain), medial( olfactory nasal cavity) , lateral( orbit). Lymphatic : Submandibular and retropharyngeal lymph node then to upper deep cervical lymph node. Blood : lung ,liver,bone,brain. Prognosis : bad due to close relation to the brain and orbit.  Clinical Pictures  Symptoms of primary tumour: Unilateral nasal obstruction. Blood stained discharge.  Symtoms of local spread : Toothache or loosening of the teeth (downward). Proptosis and diplopia( upward). Facial swelling ( anterior spread). Trismus ( posterior).  Symptoms of lympha c spread(15%): Neck swelling.  Symptoms of blood distant spread( lung, liver,bone,brain).  Examination o Anterior rhinoscopy : unilateral fleshy, friable mass& bleed on touch. o Neck examinaion : Cervical lymphadenopathy. o General examination to exclude distant metastasis.  Investigations o Radiology: CT / Contrast ( site, size,extension,bone destruction and lymphatic involvement) , MRI ( Intracranial and orbital spread). o Biopsy through nasal endoscopy..  Treatment Combined treatment i.e. surgery and DXT.  Curative : - Surgery. - Postoperative radiotherapy/ chemotherapy.  Palliative : - Pain killer -Debulking the tumor( surgery, radiotherapy, chemotherapy!!).  Suregery: o Maxillectomy ( medial ,total). o Radical neck dissection for lymphatic involvement.