paranasalsinuses
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PARANASAL SINUS PATHOLOGIES
Presented by Dr. Cathrine Diana PG-III
contents Paranasal sinuses
Introduction
Development
Anatomy
Physiology
Examination and investigations
Paranasal sinus pathologies
Classification
Description
Complications
Treatment
INTRODUCTION
Sinus (Latin) - fold or pocket.
Paranasal sinuses - four paired, hollow air filled spaces in various cranio-facial bones
Named after the bones in which they are located
INTRODUCTION Clinically, Divided into two groups:
1. Anterior group: maxillary, frontal, anterior and middle ethmoidal air cells. They all open in the middle meatus.
2. Posterior group: Posterior ethmoidal and the sphenoid sinus
DEVELOPMENT
Excavation of bone by air-filled sacs (pneumatic diverticula) from the nasal cavity.
Begins prenatally - continues through lifetime.
ANATOMY – MAXILLARY SINUS
MAXILLARY ANTRECHEA / ANTRUM OF HIGHMORE
Largest
Maxilla - under the eyes, on either side of the nose.
Pyramidal - base toward the lateral wall of nose and apex directed laterally into the zygomatic process.
Capacity of 15 ml (average).
FRONTAL SINUS Situated deep to the inner and outer table of
frontal bone
Drain- frontal recess to the middle meatus
Absent on one (15 %) or both sides (5 %)
Drainage pathway – naso- frontal duct-
frontal recess - situated at its floor – drains
into middle meatus (62%) or ethmoid
infundibulum (38%).
Ethmoid sinus
Thin-walled air cavities in the lateral masses
of ethmoid bone, between nose and the
eyes.
1. Anterior ethmoidal air cells –3- 11 drain
into either the ethmoidal infundibulum
or the frontonasal duct.
2. Bullar cells (middle ethmoidal air cells)
- usually <3 - open in ethmoidal
infundibulum.
3. Posterior group :- Up to 7 - usually drain
by a single orifice into the superior
meatus.
Agar nasi cells
They are the most anterior ethmoidal air cells. .
Its size influence the patency of the frontal recess and the anterior middle meatus.
Haller cells:
Also called infraorbital ethmoid cells.
Present in approx. 20 % pateints.
Clinical significance –
Become infected , with potential extension into orbit.
Narrows the maxillary ostium.
Onodi cells
These are posterior ethmoidal cells extending into the sphenoid bone ,either adjacent to or impinging upon the optic nerve.
When these Onodi cells abut or surround the optic nerve, the nerve is at risk when surgical excision of these cells is performed.
It is also a potential cause of incomplete sphenoidectomy.
SPHENOID SINUS
Body of sphenoid - behind the nose, in the center of the skull.
Rarely symmetrical and separated by a thin bony septum.
Ostium of the sphenoid sinus is situated in the upper part of its anterior wall and drains into sphenoethmoidal recess.
Average size – 2 x 2 x 2 cm.
According to Congdon sphenoid pneumatization can be as follows
Conchal – 5 %
Presellar – 23 %
Post-sellar – 67%
ANATOMY - LATERAL NASAL WALL
3 projections - superior, middle and inferior concha.
Meatus - space below each concha.
Inferior meatus: nasolacrimal duct
Middle meatus:
Maxillary sinus
Frontal sinus
Anterior ethmoid sinuses
Superior meatus: posterior ethmoid sinuses
Sphenoethmoidal recess: sphenoid sinus
OSTEOMEATAL COMPLEX
It is a common channel that links
the frontal sinus, anterior and
middle ethmoid sinuses and the maxillary
sinus to the middle meatus. It is composed
of five structures:
Maxillary ostium
Infundibilum
Ethmoidal bulla
Uncinate process
Hiatus semilunaris
PHYSIOLOGY – SINUS EPITHELIUM
Respiratory epithelium - ciliated pseudostratified columnar epithelium, goblet cells, and submucosal glands
Produce a protective mucous blanket - traps bacteria and noxious materials, which are carried by ciliary motion to the ostium and into the nose for elimination
Ciliary movements: 50- 300 cilia/ cell; 8-20 beat/ second.
For maximum ciliary activity:
Humidity: >85%, Temperature: 18- 40 degree C, pH: 7- 8.
The orientation of the cilia within a given sinus is specific as secretions are propelled towards the natural sinus ostia and from there to the nasopharynx and oropharynx where they are subsequently cleared by swallowing.
SINUS HEALTH Composition of gas content in the maxillary sinus is similar to venous
blood, with high CO2 and lower O2 level compared to breathing air.
Sinus health depends on:
1. Mucous secretion of normal viscosity, volume, and composition
2. Normal muco-ciliary flow to prevent mucous stasis and subsequent infection
3. Open sinus ostia to allow adequate drainage and aeration.
Negative factors:
Dryness of air, Cigarette, Temperature variations, hypoxia, hypercapnia, Hypertonic/ hypotonic fluids, Dehydration, pH changes, diseases (like Cystic fibrosis and Primary ciliary dyskinesia), Drugs (phenylephrine, adrenaline, lidocaine, atropine, antihistaminic), Infections, Anatomic obstruction (septal deviation, enlarged or irregular turbinate), Foreign bodies and Nasal polyps.
PATHOPHYSIOLOGICAL STAGES OF
SINUS DISEASES
Initial phase: - reversible
Ostium obstruction phase
Bacterial phase
Chronic phase
Osteomeatal complex obstruction
↓
Decreased ventilation of the sinuses
↓
Decreased drainage of the sinuses
↓
pO2 decrease, pCO2 increase, mucous stasis
↓
Inflammation and viscous mucous, ciliary movement slowing
↓
Stasis and proteolytic enzymes
↓
Ciliary damage
↓
Anaerobic microorganisms
↓
More damage
FUNCTIONS OF SINUS 1. Reduction of weight of skull
2. Increasing resonance of the voice
3. Providing a buffer against blows to the face.
4. Insulating sensitive structures like dental roots and eyes from rapid temperature fluctuations in the nasal cavity.
5. Humidifying and heating of inhaled air because of slow air turnover in this region.
6. Regulation of intranasal and serum gas pressures
7. Increasing surface area for olfaction
8. Contribute to facial growth
EXAMINATION
History and systemic clinical examination:
Check general signs of health
Systemic medical history, history of allergies, drug use and abuse
Occupation history
Examination of and neck for lumps or swollen lymph nodes
Examination Local examination of the nose,
face, and neck:
1. Anterior Rhinoscopy:
Examination of nose with a
nasal speculum to check
for abnormal areas, useful in
evaluation of nasal
obstruction.
2. Posterior rhinoscopy: With a
mouth mirror in the
nasopharynx
Examination - transillumination
Normal transillumination decreases chance of pus in the sinus.
No light reflex suggests mucopurulent material or thickening of nasal mucosa.
Inexpensive screening tool
Transillumination of Frontal Sinus
Transillumination of Maxillary Sinus
24
Examination - endoscopy Endoscopic examination/ Rhinoscopy:
nasoscope/rhinoscope is a thin, tube-like instrument with a light and a lens for viewing. A special tool on the nasoscope may be used to remove samples of tissue. The tissues samples are viewed under a microscope by a pathologist.
EXAMINATION – PLAIN RADIOGRAPHS
Plain radiographs:
to check for Sinus opacifications, Air-fluid level, Mass, Fractures
Caldwell view: PA view/ “forehead-nose” view to evaluate maxilla, maxillary and frontal sinus, ethmoid air cells, lamina papyracea
Water’s view: chin-nose” or “occipito-mental” view for evaluation of the paranasal sinuses.
submento-vertical” view to evaluate the sphenoid, the posterior ethmoids, the maxillary and frontal sinuses
CT SCANS CT scans: Excellent views of the sinuses, best for
osteomeatal complex and ethmoidal disease
“Limited CT Evaluation” – slice 3-4 mm
CT navigation:
A computer is used to identify the 3-dimensional location of a probe tip placed within the patient's nose or sinuses..
Improves anatomical identification and avoid damage to vital neighbouring structures such as the brain and eyes.
AXIAL CT
CORONAL CT
SAGITTAL CT
EXAMINATION
MRI:
Excellent soft tissue definition - evaluation of neoplastic disease.
MRI (magnetic resonance imaging) with gadolinium: Gadolinium is injected into a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture.
PET scan (positron emission tomography scan): A small amount
of radioactive glucose is injected into a vein. The PET scanner rotates
around the body and makes a picture of where glucose is being used
in the body. Malignant tumor cells show up brighter in the picture
because they are more active and take up more glucose than normal
cells do.
Stuckensen and colleagues found a sensitivity of 70%, 84%, and 66% and a specificity of 82%, 68%, and 74% for PET, ultrasound, and CT scan in terms of nodal metastasis
9. Histological examination:
Fine-needle aspiration (FNA) biopsy, Incisional biopsy and excisional biopsy are done from pathologic tissues.
10. Culture examination: Correlation of routine nasal culture and sinus culture is poor. Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture.
Silver stained section showing invasive fungal sinusitis (aspergillus)
Allergic mucin of allergic fungal sinusitis
Classification
DEVELOPMENTAL VARIATIONS AND ANOMALIES
INFLAMMATORY/INFECTIOUS DISEASES
CYSTS
TUMORS
OTHER SURGICALLY RELEVANT CONDITIONS
Developmental variations and anomalies
Paradoxical curvature of middle turbinate
Concha bullosa in middle turbinate
Lateralization and pneumatisation of uncinate process
Variations of ethmoidal roof anatomy
Bulla ethmoidalis – torus ethmoidalis and giant bulla
Others: Agenesis of sphenoid sinus, pneumatisation of greater wings of sphenoid and crista galli.
DEVELOPMENTAL VARIATIONS AND
ANOMALIES
Paradoxical curvature:
Normally the convexity of the middle turbinate is directed medially toward the nasal septum.
When the convexity is directed laterally, it is termed a paradoxical middle turbinate .
Most authors agree that the paradoxical middle turbinate can be a contributing factor to sinusitis.
DEVELOPMENTAL VARIATIONS
AND ANOMALIES
Concha bullosa: When pneumatization involves the bulbous portion of the middle turbinate it is termed concha bullosa. If only the attachment portion of the middle turbinate is pneumatized, it is termed lamellar concha . A concha bullosa may obstruct the ethmoid infundibulum.
Variations of uncinate process
The uncinate process may be medialized, lateralized, or pneumatized/bent. Medialization occurs with giant bulla ethmoidalis. Lateralization of the uncinate process may obstruct the infundibulum. Pneumatization (uncinate bulla) can rarely cause obstruction of the infundibulum.
Variation of the ethmoidal roof anatomy The ethmoid roof is of critical importance for two
reasons.
most vulnerable to iatrogenic cerebrospinal fluid leaks.
anterior ethmoid artery is vulnerable to injury.
The depth of the olfactory fossa is determined by the height of the lateral lamella of the cribriform plate.
In 1962, Keros classified the depth of the olfactory fossa into three types, that is,
Keros type I: <3 mm
Keros type II: 4-7 mm
Keros type III: 8-16 mm - most vulnerable to iatrogenic injury.
Variations of sphenoid sinus … Agenesis of sphenoid sinus
Pneumatisation of other bones
The crista galli is normally bony.
When aerated, it may communicate with the frontal recess, causing obstruction of the ostium and thus lead to chronic sinusitis and mucocele formation
Bullae ethmoidalis
The bulla ethmoidalis is a prominent anterior ethmoid air cell.
Failure to pneumatise - torus ethmoidalis.
A 'giant bulla' may fill the entire middle meatus and force its way between the uncinate process and the middle turbinate.
INFLAMMATORY/ INFECTIOUS
CONDITIONS
POLYPS
SINUSITIS
GRANULOMATOUS DISEASES
POLYPS
They are fleshy outgrowths of the nasal mucosa that form at the site of dependent edema in the lamina propria of the mucous membrane, usually around the ostia of the maxillary sinuses.
usually start near the ethmoid sinuses and grow into the open areas.
Large polyps can block the sinuses or nasal airway.
Risk factors: Aspirin sensitivity (wheezing), Asthma, Acute and Chronic sinus infections, Cystic fibrosis, Hay fever (allergic rhinitis).
Clinical features:
Nasal obstruction and mouth breathing
Nasal congestion and postnasal drainage
Anosmia, hyposmia
Sneezing, rhinorrhea
Facial pain
Ocular itching
Bleeding polyps occur in rhinosporidiosis
Unilateral polyps occasionally occur in association with or represent benign or malignant tumors of the nose or paranasal sinuses, or in response to a foreign body.
Diagnosis:
physical examination - A developing polyp is teardrop-shaped; when mature, it resembles a peeled seedless grape.
CT scans
Treatment
1. Steroids –may shrink or eliminate polyps
Topical corticosteroid spray - mometasone [30 mcg/spray], beclomethasone [42 mcg/spray], flunisolide - given as 1 or 2 sprays bid in each nasal cavity
1-wk tapered course of oral corticosteroids.
2. Surgery :
FESS
Steroid therapy after surgery - to retard recurrence.
In severe recurrent cases- maxillary sinusotomy or ethmoidectomy, usually done endoscopically.
3. Removal of etiology – control of underlying allergy or infection.
SINUSITIS
Definition: Sinusitis is the inflammatory condition of the mucous membrane lining of the sinuses
RHINOSINUSITIS is a better term because:
Allergic or non-allergic rhinitis nearly always precedes sinusitis
Sinusitis without rhinitis is rare
Nasal discharge and congestion are prominent symptoms of sinusitis
Nasal mucosa and sinus mucosa are similar and are contiguous
Classifications ACCORDING TO DURATION:
1. Acute :infection lasting 4 weeks, symptoms resolve completely resolved
in < 30 days.
2. Subacute :infection lasting between 4 to 12 weeks, yet resolves
completely.
3. Recurrent: ≥ 4 discrete acute episodes per year, each completely resolved
in < 30 days but recurring in cycles, with at least 10 days between complete
resolution of symptoms and initiation of a new episode
4. Chronic: symptoms lasting more than 12 weeks.
ACCORDING TO PATHOGEN:
1. Bacterial: Hospital-acquired acute infections are more often
bacterial, typically involving Staphylococcus aureus, Klebsiella
pneumoniae, Pseudomonas aeruginosa
2. Viral: In immunocompetent patients - in the community is almost
always viral (eg, rhinovirus, influenza, parainfluenza).
antibiotics given for:
Mild to moderate sinus symptoms persisting for ≥ 10 days
Severe symptoms (eg, fever ≥ 39°, severe pain) for ≥ 3 to 4 days
Worsening sinus symptoms after initially improving from a typical
viral URI ("double sickening" or biphasic illness)
3. Fungal: Usually seen in immunocompromised patients because
of poorly controlled diabetes, neutropenia, or HIV infection. It is
clinically of 2 types:
Non-invasive fungal sinusitis:
Saprophytic fungal infestation/colonization
Allergic fungal rhinosinusitis (AFRS)
Saprophytic fungus balls (mycetoma)
Invasive fungal sinusitis –
Chronic invasive fungal sinusitis
Granulomatous invasive fungal sinusitis
Acute (fulminant) invasive fungal sinusitis
sinusitis According to source:
Primary
Secondary
According to number of sinuses involved:
Hemisinusitis –all sinuses on one side
Polisinusitis – several sinuses, but not all, are involved
Pansinusitis
According to source of infection:
Rhinogenous
Odontogenic
Traumatic
Hematogenic
Allergic
Risk factors:
1. Obstruction to drainage: most important
2. Defect of self-cleaning mechanism of the mucous membrane of sinus – infections causing immobility of the cilia, Increased viscosity of secretions, Immotile cilia syndrome, Prolonged exposure to cigarette smoke
3. Medications
First generation antihistamines (non sedating do not affect)
Anticholinergics, Aspirin, Anesthetic agents, Benzodiazepines
4. Immunodeficiency: Immunoglobulin deficiency (IgA, IgG), diabetes, HIV infection
5. Other factors: prolonged ICU stays, severe burns, cystic fibrosis, and ciliary dyskinesia.
Clinical Features:
1. Nasal congestion and discharge
2. Sore throat and postnasal drip
3. Pain or pressure.
4. Oedema of facial tissues.
5. Bad breath or loss of smell (hyposmia/anosmia).
6. Systemic symptoms: Malaise may be present. Fever and chills suggest an extension of the infection beyond the sinuses, rise in temperature, bad appetite, sleep disturbances, changes of the blood (leukocytosis), Productive cough (especially at night)
7. Complications – ocular, neurological, local
Diagnosis 1. Diagnosis is clinical;
2. CT and cultures - mainly for chronic, refractory, or atypical cases.
3. X-rays of the apices of the teeth
Clinical diagnostic criteria include 2major factors, I major and 2 minor factors or presence of pus in nasal cavity.
Major Factors Minor Factors
Facial pain/pressure Headache
Facial congestion/fullness Maxillary dental pain
Nasal drainage/discharge Cough
Postnasal drip Halitosis
Nasal obstruction/blockage Fatigue
Hyposmia/anosmia Ear pain/ pressure/ fullness
Fever (acute sinusitis only) Fever
Purulence in nasal cavity on examination (diagnostic by itself)
TREATMENT OPTIONS MEASURES TO ENHANCE DRAINAGE:
1. Heat therapy: Steam inhalation; hot, wet towels over the affected sinuses; and hot beverages
2. Topical vasoconstrictors/ Nasal decongestants:
Topical nasal sprays (limit use to 3-7 days) - Phenylephrine, Oxymetazoline, Naphthazoline, Tetrahydrozoline, Zylometazoline. Phenylephrine(0.25%) spray q 3 h or oxymetazoline q 8 to 12 h, are effective but should be used for a maximum of 5 days or for a repeating cycle of 3 days on and 3 days off until the sinusitis is resolved
CORTICOSTEROIDS: Corticosteroid nasal sprays can help relieve symptoms but typically take at least 10 days to be effective
3. Systemic vasoconstrictors: Systemic vasoconstrictors, such as pseudoephedrine 30 mg po (for adults) q 4 to 6 h, are less effective.
4. Nasal irrigation:
Commercial buffered sprays, Bulb syringe, waterpik and ceramic
irrigators with lavage tip or disposable enema bucket
Washes away irritants and moistens the dry nose.
cumbersome and uncomfortable - better for patients with recurrent
sinusitis.
ANTIHISTAMINICS: recommended if allergy present. They can be oral or topical
HYDRATION
5. Mucoactive drugs:
main purpose - increase the ability to expectorate sputum and/or decrease mucus hypersecretion.
1. Expectorants: hypertonic saline, iodine containing compounds, guaifenesin (glyceryl guaiacolate), ion channel modifiers (tricyclic nucleotides)
2. Mucoregulators: carbocysteine, anticholinergic drugs, glucocorticoids, macrolide antibiotics
3. Mucolytics: classic mucolytic (N-Acetyl Cysteine), peptide mucolytic, non destructive mucolytics
4. Mucokinetics: bronchodialators, ambroxol
a) Nebulization: best form of physiotherapy. Can be done using compressors or ultrasonic nebulisers. Normal saline solutions are nebulized which has a hydrating effect on the mucous lining. Ultrasonic nebulisers can set the rate according to need.
b) Laser therapy: used directly over the sinuses to reduce inflammation
c) Ultrasound therapy: sound waves are conducted through a hypoallergenic gel to reduce inflammation and loosen the accumulated mucous.
d) Short-wave diathermy
e) Rinoflow therapy: new option, basically micronized endotracheal wash. Used in sinusitis, rhinitis, pharyngitis, laryngitis and secretory otitis media.
Antibiotics and antifungal drugs:
Amoxicillin 500 mg tid for 10-14 days - First line
Beta-lactanase resistance - Amoxicillin/clavulanate, Cefuroxime, Cefpodoxime, Cefprozil
Surgery
Indications:
Sinusitis unresponsive to antibiotic therapy
Necrotic sinusitis
Orbital complications (abscess and phlegmon of orbit)
Intracranial complications (meningitis, brain abscess)
Rhinogenic sepsis
Odontogenic sinusitis combined with maxillary osteomyelitis.
Approaches:
1. Removal of etiology
2. Fess
3. Caldwell-luc procedure
4. Intranasal antrostomy
5. Radical surgeries
Removal of etiology:
Treatment of affected tooth.
Caldwell luc approach may be used.
Intra-nasal antrostomy may be needed.
Caldwell - luc
Caldwell-Luc is the fenestration of the anterior wall
of the maxillary sinus and the surgical drainage of
this sinus into the nose via an antrostomy.
a middle meatus antrostomy is being utilized as a
more physiologic antrostomy..
Denkers procedure
FESS:
Functional endoscopic sinus surgery (FESS) is the mainstay in the surgical treatment of sinusitis and nasal polyps, including bacterial, fungal, recurrent acute, and chronic sinus problems.
Nasal endoscopes through the nostrils to avoid cutting the skin.
Telescope diameters - 4mm (adult use) and 2.7mm (pediatric use)
Viewing angles - 0 degrees to 30, 45, 70, 90, and 120 degrees
Carry: High definition cameras attached to monitors, tiny articulating instruments - cutting, suction, biopsy, curettage
All the sinuses can be accessed at least to some degree by means of FESS.
Extended approaches: Paranasal sinuses are found to a relatively low-morbidity approach to selected tumors even inside the skull or brain. This can be divided into approaches to: anterior cranial fossa, mid cranial fossa, posterior cranial fossa, infratemporal fossa (incl. pterygopalatine fissure), sella turcica, orbital access, and optic nerve access.
Complications:
Proximity of the sinuses to the eyes, optic nerves, brain and internal carotid arteries
Serious risks are rare occurrences
Before FESS 2 months after FESS
Principal element - granuloma formation - a conglomerate of macrophages, epithelioid cells, and multinucleated giant cells.
1. Infectious:
spirochetes (syphilis, yaws)
mycobacteria [tuberculosis, leprosy]
bacterial [rhinoscleroma]
fungus [aspergillus]
2. Inflammatory
Wegener granulomatosis
sarcoidosis,
Churg-Strauss syndrome
cocaine induced midline destructive lesions
Granulomatous diseases
Cysts
Mucocele and Pyocele
Retention cyst
Pseudocyst
Post-operative maxillary cyst
Mucocele and pyocele
Mucocele:
formed when drainage of mucus from one of the paranasal sinuses becomes blocked by obstruction of its ostium.
Contents: clear serous fluid, thick mucoid material, or, if hemorrhage has occurred, thick brown material
Pyocele/mucopyocele:
Infected mucocele
Contents: mixture of mucus and pus from which a causative organism may or may not be seen on smear or subsequently cultured.
Pathogenesis:
Blockage of the ostium pressure develops within sinus
expansion of the sinus space erosion, and displacement of bone.
Encroachment of the mucocele upon contiguous structure
Sinus lining – remains normal or becomes attenuated to undergo
metaplasia to low cuboidal or squamous cells.
Most commonly: frontal and anterior ethmoid sinuses
Etiology: chronic inflammation, osteomas, fractures, tumors, polyps, scarring, and congenital abnormalities.
Management
Decompression by complete removal and curettage
Marsupialisation via endoscopic approach through the middle meatus
Prophylactic Nasofrontal duct obstruction
Retention cyst and Pseudocyst: Together called antral cyst or mucosal cyst
Indistinguishable on radiological or clinical examination.
Quite common.
Mostly - single cysts, but in a few instances - they may be multiple and bilateral.
Clinical features:
Usually asymptomatic – discovered during radiographic examination
Symptoms – similar to chronic sinusitis
Sometimes an antral cyst may produce a swelling
Diagnosis :CT based
Spherical, ovoid or dome-shaped radiopacities that have a smooth and uniform outline
narrow or broad base.
Size from minute to very large
Usually remain static
Many regress spontaneously
POST-OPERATIVE MAXILLARY CYST
(SURGICAL CILIATED CYST OF MAXILLA)
Delayed complication arising years after surgery of maxillary sinus.
Causes:
Caldwell–Luc procedure including a nasal antrostomy
Gun- shot injuries
Fractures of the malar–maxillary complex
Mid-face osteotomies.
Clinical features:
Pain, discomfort or swelling in the cheek or face, or intra-orally in the palate or alveolus.
Pus discharge.
Radiographs - well-defined radiolucent area closely related to the maxillary sinus.
Treatment: enucleation.
TUMORS
0.2% of all malignancies
80% - maxillary sinus.
Men>> women.
40 and 70 years.
Carcinomas >> sarcomas
Metastases are relatively rare.
Tumours of the sphenoid and frontal sinuses are extremely rare - no standard staging system
Most common - squamous cell carcinoma
WHO HISTOLOGICAL CLASSIFICATION OF NASAL AND PNS TUMORS
TNM CLASSIFICATION OF CARCINOMAS OF NOSE AND PARANASAL SINUSES
.
Risk factors:
1. Woodworking (carpentry), Shoemaking, Metal-plating, Flour mill or bakery work.
2. Human papillomavirus (HPV) infection
3. Male
4. Older than 40 years.
5. Smoking.
Clinical features
No signs or symptoms in the early stages.
later:
Blocked sinuses that do not clear, or sinus pressure.
Headaches or pain in the sinus areas.
Rhinitis and epistaxis
A lump or sore inside the nose that does not heal.
A lump on the face or roof of the mouth.
Numbness or tingling in the face.
Swelling or other trouble with the eyes, such as double vision or the eyes pointing in different directions.
Pain in the upper teeth, loose teeth, or dentures that no longer fit well.
Pain or pressure in the ear.
Treatment
1. Surgery: For all stages of paranasal sinus and
nasal cavity cancer.
Transfacial approaches
1. lateral rhinotomy/ weberfergussen incision
2. diffenbech extension
3. Lynch extension with the modification
External ethmoidectomy/frontoehtmoidectomy
Bicoronal with Mid face degloving
Subcranial approach
Acess osteotomies
Trans oral approach:
Caldwell lue
Denker
Janson – horgan approach
Trans nasal:
Transseptal approach
Endoscopic approaches
Draw backs of endoscopic approach -Not indicated in case of extensive involvement
Trans orbital extension
Scar tissue due to previous surgery
in case to reduce the bony fracture
TRANSORAL ROBOTIC SURGERY New advances in technology facilitate minimal access
To avoid large transcervical or face-splitting incisions.
Transoral robotic surgery allows access to tumors within the posterior oral cavity and oropharynx via multiple robotic arms and a high-definition/ magnification camera.
The operator sits at a separate console and via remote control can operate the various instruments.
Electrocautery, laser, and standard dissection instruments can be used with the robot.
Advantages include surgical access via minimal approaches, resulting in definitive pathologic assessment while minimizing transection and resection of critical swallowing musculature
Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316
Trans oral Robotic surgery more-precise movements in narrow spaces and the capability to work
around corners.
This result in preservation of maximum amount of healthy muscular and neurovascular tissue which helps the patient swallow on their own sooner and discharged home earlier.
1. Radiation therapy: External radiation therapy, Internal radiation
therapy - depending on the type and stage of the cancer being treated.
IMRT:
Intensity-modulated radiation therapy (IMRT) can deliver high doses of radiation with precision while minimizing damage to surrounding tissues.
IMRT can conform to the irregular shape of a tumor, delivering higher doses directly to the tumor cells and potentially destroying more tumor cells.
The technique requires more precise planning due to the sharp dose falloff gradient between the gross tumor and the surrounding normal tissue.
IMRT provides locoregional control (90%) and is well tolerated by patients.
Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316
Chemotherapy:
Systemic chemotherapy: When chemotherapy drug is given PO, IV or IM the drugs enter the bloodstream and can reach cancer cells throughout the body
Regional chemotherapy: When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity, the drugs mainly affect cancer cells in those areas.
Combination chemotherapy is treatment using more than one anticancer drug.
The way the chemotherapy is given depends on the type and stage of the cancer being treated.
Intra arterial cisplastin therapy: As a primary therapy, the complete response rate was 83.3%, The 2-year local control rate was 63.0%, and the 2-year overall survival rate was 75.5%. The 2-year preservation rate of the hard palate was 97.1%, that of the eyeball was 97.2%, and that of visual function was 94.4%. This treatment regimen can contribute to improving the quality of life of patients without reducing the curability of the therapy.
Int. J. Oral Maxillofac. Surg. 2015; 44: 697–704.
Other surgically relevant conditions
Oro-antral communication/fistula
Antral foreign bodies
Hypertrophied maxillary sinus
Oro-Antral Fistula (oaf) Oro-antral communication: it is an abnormal connection between oral
and Antral cavities.
Oro-antral fistula: long standing oro-antral communication when left open, epithelializes to form a patent fistula between the two cavities.
Types:
ALVEOLOSINUSAL
PALATO-SINUSAL
VESTIBULO-SINUSAL
Oro-Antral Communications
CAUSES:
Extraction – maxillary posterior teeth
Cysts, tumors
Osteomyelitis
Radiation therapy
Trauma
Implant denture
CLINICAL FEATURES:
Some patients are asymptomatic
Unpleasant tasting discharge and odor
Reflux of fluids and foods into the nose from mouth
Leakage of air
Difficulty in smoking and blowing air
Development of chronic sinusitis in infected cases
Diagnosis:
Valsalva maneauver
Mirror fog test
Cotton wisp test
Nasal regurgitation of fluid
Radiographs: Sinus floor discontinuity, Sinus opacity, Focal alveolar atrophy, Associated periodontal disease
Oro-Antral Communications (UL7)
Treatment:
Immediate treatment: Primary purpose is closure of defect and prevention of sinusitis through:
Suturing across the defect with/without periodontal pack, warm saline rinses, antibiotic and antihistaminic therapy with decongestants.
Size < 5mm: non-invasive intervention (spontaneous closure by blood clot)
Size > 5mm, and > 48 hours - : surgical closure : small defects – local flaps; large defects – regional/distant flaps.
Obturators
Buccal Advancement Flap most common.
Described by Rehrmann & made popular by Berger.
Trapezoidal sliding flap – Moczair
buccal osteoperiosteal flap
Oro-Antral Communications
Palatal flaps
1. Palatal rotational advancement flap most common
2. V-shaped palatal flap (kruger) &
3. Split-thickness palatal flap (ito & hara).
Oro-Antral Communications
Combination flaps
Inverted periosteal flap
Tongue flap, temporalis flap
BFP closure
PRF membrane coverage
Autologous bone grafts: press-fit technique
Autologous cartilage grafts: auricular cartilage, auricular cartilage
Alloplastic materials
Transplantation of a mature wisdom tooth (followed by root canal treatment of the tooth 5 - 6 weeks later)
Laser bio-stimulation (over 5 days)
Oro-Antral Communications
ANTRAL FOREIGN BODIES:
Gutta-percha points, tooth roots, impression materials, dental burs, bone pieces , implants etc.. Treatment has been direct explored by Caldwell-Luc approach, with or without nasal antrostomy. FESS may be done for sinusitis.
HYPERTROPHIED MAXILLARY SINUS:
Not pathology but causes difficulty in implant supported rehabilitation of posterior maxilla, with the risk of subsequent development of sinus pathologies. The management includes direct and indirect sinus lifting.
Oro-Antral Communications (UL8)
Complications
Because of the proximity of the paranasal sinuses to the eyes and brain, complications of sinusitis are divided into
orbital,
neurological and
local complications.
Orbital complications
highest frequency - in children under 6 years of age.
Infection usually originates from the ethmoids and occurs through:
(1) direct extension through the orbital wall
(2) retrograde spread through veins between the sinuses and the orbit.
Lymphatic spread – not significant
Orbital complications 1. Preseptal cellulitis, or periorbital cellulitis
2. Orbital cellulitis and edema
3. Subperiosteal abscess
4. orbital abscess
5. Cavernous sinus thrombosis: direct extension or retrograde thrombophlebitis (via the ophthalmic vein) of ethmoid or sphenoid infections.
restriction of extra ocular mobility, proptosis, chemosis, and visual loss
cranial neuropathies and signs of meningitis
Neurological complications
Less frequently than orbital
Most commonly related to the frontal or sphenoid sinuses.
Via - direct spread or retrograde thrombophlebitis.
A – osteomyelitis B - periorbital abscess C – epidural abscess D – subdural abscess E – brain abscess F – meningitis G - septic thrombosis of superior sagittal sinus
Local complications
Osteomyelitis - complication of frontal sinusitis.
Tender, doughy, erythematous swelling over the forehead.
Treatment of choice - surgical eradication of the affected bone under antibiotic coverage.
REFERENCES 1. References:
2. Peterson’s principles of oral and maxillofacial surgery
DISEASES of the SINUSES Diagnosis and Management- DAVID W. KENNEDY, MD, FACS
1. WHO classification of head and neck tumors
2. PL Dhingra - Disease of ear, nose & throat 4th edition
3. Rosai and Ackerman’s Surgical Pathology (9th edition)
4. David L. Daniels et.al. The Frontal Sinus Drainage Pathway and Related Structures, AJNR: 24, August 2003.
5. Interactive Atlas. http://uwmsk.org/sinusanatomy2/axial/axial.html
6. (Adapted from Chow AW, Benninger MS, Brook I, et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Diseases 54 (8):1041–5 (2012).)
7. Thompson and Patterson: Fungal disease of the nose and paranasal sinuses:J Allergy Clin Immunol 2012;129:321-6.
8. Multiplanar Sinus CT: A Systematic Approach to Imaging Before Functional Endoscopic Sinus Surgery Jenny K. Hoang, James D. Eastwood, Christopher L. Tebbit, and Christine M. Glastonbury American Journal of Roentgenology 2010 194:6, W527-W536
Raef S. Ahmed, Roger Ove, Jun Duan, Richard Popple, Glenn B. Cobb Intensity-modulated radiotherapy (IMRT) for carcinoma of the maxillary sinus: A comparison of IMRT planning systems Medical Dosimetry, Volume 31, Issue 3, Autumn 2006, Pages 224-232
Management of rhinomaxillary mucormycosis with Posaconazole in immunocompetent patients Sachin Rai *, Shikha Yadav, Dinesh
Kumar, Vijay Kumar, Vidya Rattan Journal of Oral Biology and Craniofacial Research xxx (2016) xxx
Modified transnanal endoscopic maxillectomy: a novel surgery style of maxillary malignant tumor Yonghua Bi1,2, Shuangba He1, Tao Guo1, Jingwu Sun Int J Clin Exp Med 2016;9(6):11361-11366
Modified double-layered flap technique for closure of anoroantral fistula: Surgical procedure and case reportAlberto Merlinia, Joseph Garibaldia, Matteo Piazzaia, Luca Giorgisb, British Journal of Oral and Maxillofacial Surgery 54 (2016) 959–961
Repair of Oroantral Communication by Use of a Combined Surgical Approach Functional Endoscopic Surgery and Buccal Advancement Flap/Buccal Fat Pad Graft Timothy Adams, DDS,* Daniel Taub, DDS, MD,y and Marc Rosen, MD. J Oral Maxillofac Surg 73:1452-1456, 2015
An Update on Squamous Carcinoma of the Oral Cavity,Oropharynx, and Maxillary SinusJoshua E. Lubek, DDS, MDa,*, Lewis Clayman, DMD, MD Oral Maxillofacial Surg Clin N Am 24 (2012) 307–316
Thank you
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