Exam:

• Open speculum up-and-down to avoid pressure on septum
• Co-axial lighting (head mirror) is ideal, use otoscope in a pinch
• The first turbinate you see is the inferior turbinate
• Red mucosa = inflammation; blue color = irrelevant
• Polyps found above and medial to inferior turbinate polyps in children: think cystic fibrosis
• Airflow is primarily along the nasal floor
• Septal deviations, C-shaped deformities, spurs
• Septal perforations (Wegener's, midline granuloma previous septal surgery, cocaine abuse?)

A: Frontal sinus

B: Sphenoid sinus

C: Superior concha (turbinate

D: Middle concha (turbinate)

E: Inferior concha (turbinate)

F: Auditory tube opening

Everything drains under the middle turbinate except:

• tears - nasolacrimal under inferior turbinate
• posterior ethmoids and sphenoid drain more postero-superior

Embryology:

• Developmental stages of maxillary and frontal sinuses

Sinus Films:

• Of questionable usefulness in patient with obvious symptoms
• Not needed for diagnosis of nasal fracture:
• "If it looks broken - it is,
• if it doesn't - it isn't,
• if you're not sure - wait"
• Common radiologic abnormalities:
  • Air-fluid levels suggest an acute process
  • Opacification = secretions, polyps, etc.
  • (Ethmoids should be slightly darker than orbits)
  • Thickened mucosa (check lateral maxillary wall): Suggests chronic inflammation
  • Maxillary sinus retention cysts
    • Very frequent finding
    • Harmless unless symptomatic
  • Frontal sinus mucocele
    • Nasofrontal duct obstruction (head injury?)
    • Potentially serious problem
    • Look for loss of scalloped edge

• Standard views:
  The goal is to place sinuses close to the film and at an angle that temporal bone shadows are not superimposed

• Water's - best for maxillary sinus (Ethmoids and frontals too far from film

• Caldwell - best for ethmoids and frontal sinus (Temporal bones overlie maxillary)

• Lateral - sphenoid, frontal(?), maxillary (?)

• Submentovertical ("bucket-handle") - ethmoids; Fluid in maxillary sinus will also layer out

Acute Sinusitis:

• Diagnosis:
• Pain from paranasal sinusitis is often referred in a predictable distribution.

• Purulent rhinorrhea
• Pain, increase with palpation/percussion
• Periorbital edema
• Sensitive teeth or gums (irritation dental roots)

• Treatment:
  • Antibiotics:
    • Amoxicillin Erythromycin-sulfisoxazole
    • Cefaclor Trimethoprim-sulfamethoxazole
      • To cover: Streptococcus pneumonia
      • Hemophilus
      • Moraxella catarrhalis
  • Steam inhalation/humidifier - Mainly for liquification of secretions
  • Decongestants:
    • Topical (e.g. Afrin) for short-term
    • Systemic
      Pseudoephedrine (e.g. Sudafed, 30-60 mg Q6H)
      Phenylpropanolamine
      Phenylephrine
  • Antihistamines: (see allergy section below)
    Most "cold remedies" are a combination of decongestants and sedating antihistamines with the idea that the side effects of jitteriness and sleepiness will cancel each other out.
  • Nasal irrigation (The Proetz Maneuver)

• Surgical drainage (rarely used): for pain relief or unresponsive infection. Options for maxillary sinus include:
  • cannulate ostia
  • puncture anterior wall (under lip)
  • puncture nasal wall under turbinate

• Diagnosis:
  • Is it really sinusitis? vs. tension or migraine headaches or temporomandibular joint arthritis etc.
  • Is allergy a component? (see allergy section below)
  • Is it vasomotor rhinitis?
    • Profuse rhinorrhea,
    • Often precipitated by cold air or eating
    • Treatment: ipatromium bromide (Atrovent®)
  • Is it post-nasal drip causing sore throat, hoarseness
• Treatment, medical: (see allergy section below)
• Treatment, surgical:
  • Caldwell-Luc: Approach maxillary sinus via sublabial incision, open anterior bony wall

Frontal section through the maxillary sinus after a Caldwell-Luc procedure

• Nasoantral window: Make communication between maxillary sinus and nasal cavity under the inferior turbinate; this is outside of the normal ciliary flow pattern and they usually close within 1-2 years
• Ethmoidectomy: Break down the partitions between the many air cells; external and intranasal approaches
• Frontal sinus obliteration:

A bicoronal or brow incision may be used.

Scalp reflected, showing frontal periosteum.

Elevating periosteum to open the frontal sinus cavity.

• Endoscopic sinus surgery: Relieve obstruction at the osteomeatal complex, an area where flow from the frontal, maxillary and ethmoid sinuses can be obstructed
• Septoplasty (all incisions inside the nose)
• Polypectomy: Polyps will usually recur unless followed by medical therapy

Allergic Rhinitis:

• Symptoms:
  • Sneezing (very characteristic symptom for allergies)
  • Itchy ears, eyes, and palate
  • Congested ears
  • Runny nose, nasal congestion
  • Post-nasal drip (sore throat)
• Pathophysiology:
  • The mechanisms of inflammation are similar whether the etiology is allergic or infectious.

• Mast cells can be degranulated by:
  • Crosslinking of IgE on their surface by an allergen
  • Anaphylatoxins (C3a and C5a) from complement activation
  • Some drugs, e.g. morphine and codeine

• Treatment:
  • Allergen avoidance - mandates a detailed history
    • The biggest offenders are dust, pets, pollens, molds
    • Pollens: Is it seasonal? In south Texas, something is pollinating all the time. Need to know the local plants. Don't garden, keep car windows closed. Ragweed season is late August - October
    • Dust: "Does the vacuum cleaner (closets, attic, etc.) bother you. Dust mite feeds on human dander and grows whenever humidity is over 30% (seasonal in north USA). Carpeting is the major problem. Focus on cleaning the bedroom (8 hours sleep in a low allergen room helps). Wash bedding every 2 weeks in hot water. Polyester, not foam or feather pillows. Plastic cases on mattresses and pillow to keep dander out. No upholstered chairs, throw rugs, etc. Clear out bookcases and shelves. Blinds are preferable to curtains or drapes. Change air conditioning filters often (in-line electrostatic filters are good, "bug zapper-type" filters release ozone - bad for asthmatics). No feather dusters; damp dust cloth. Face masks during housecleaning. Avoid oscillating or ceiling fans that stir up dust.
    • Exposure to house dust during childhood potentiates development of dust allergy - New Engl J Med 1990, 322:502
    • Molds: "Do mildewy carpets bother you?" Cold fronts coming in over rice paddies north of Houston bring spores. Rain may clean air, but growth surges in the humidity which follows.
    • Pets: "outside dogs" still "count"
  • People are "more allergic" during their allergy season - i.e. they respond more strongly to any of the allergens during times when the nasal mucosa is inflamed and full of mast cells.
  • It may take 2 years to "acquire" new allergies to local allergen when people move
  • Children might outgrow their allergies, adults rarely do and may even develop sensitivity to things which did not bother them in the past
  • Skin tests or RAST tests must be correlated with symptoms history. Food allergies should diagnosed by history and diet challenge in adults
  • Anti-histamines - for the sneezing, scratchy throat, itchy eyes. Will have little effect on nasal congestion but may have drying effect.
    • Sedating (available without prescription)
      All cause sedation, some drying, and possible urinary retention. There are several chemical groups; Benadryl is more sedating, for an equivalent amount of "anti-allergy" effect than some of the others. Chlorpheniramine 4 mg PO Q 6 hours is an economical choice. Patients will overcome the sedating side effects with 2-3 weeks of REGULAR use.
    • Non-sedating (prescription only)
      Astemizole (Hismanal) 1 PO Q AM has a longer half life (blocks cutaneous reactivity to histamine for 3 weeks) than Terfenadine (Seldane) 1 PO BID. Price per day is the same for the two and they are more expensive than over-the-counter sedating antihistamines. Both are pregnancy Category C "no teratogenic effects..but use only if potential benefit outweighs potential risk..". Not approved for use in children under 12 years
    • Topical - available abroad, U.S. clinical trials underway, shows great promise as nasal spray and eyedrops
  • Decongestants - for congestion and rhinorrhea
    Histamine, leukotrienes and prostaglandins are released causing vasodilation, tissue edema, and increased mucus secretion. Anti-histamines will not block leukotriene and prostaglandin effects so that decongestants must be included in therapy.
    • Topical decongestants: vasoconstriction; tissue ischemia; release vasodilators; rebound vasodilation; persistent turbinate edema = rhinitis medicamentosa
    • Systemic - no rebound congestion
      All are adrenaline-type drugs and can exacerbate hypertension. Pseudoephedrine, 30-60 mg PO Q 6 hours is an economical choice. Cause "jitteriness" with excessive use
  • Highly allergic patients should carry and "Epi-pen" and use it promptly
  • Topical nasal steroids - "Best allergy medicine going"
    • Make the nasal mucosa an inhospitable site for mast cells. Blocks synthesis of both leukotrienes and prostaglandins, prevents influx of neutrophils
    • Brands:
      • Beconase and Vancenase = beclomethasone
      • Nasalide = flunisolide (fluorinated, more potent)
      • Decadron Turbinaire = dexamethasone (systemic effects)
      • Aerosol and aqueous preparations = same medicine; AQ more expensive, rarely needed
    • Are topical nasal steroids safe?
      • Systemic absorption is negligible
      • No hypothalamic-pituitary axis suppression except with Decadron
      • No mucosal abnormalities seen on biopsy after years of use
      • Approved for children above age of 6
      • No evidence of growth suppression in children
    • Place tip just inside nostril and sniff; 2 puffs each nostril BID
    • Warn patients:
      • No "instant decongestant"
      • May sting for first week
      • Takes 1-2 weeks for optimum effect
      • Discard when aerosol "sizzles"
  • Indications for systemic steroids = nasal polyps 30-40 mg daily 2 weeks
  • Cromolyn
    • As a single agent, less effective than steroids, but it is a good second drug to combine with steroid sprays. Two puffs each nostril BID or TID. Opticrom were good eyedrops but are off the market
  • Immunotherapy
    Weekly desensitization therapy to limited # allergens. Mechanism (?) -elevated IgG and suppress IgE antibodies. Can have potentially lethal reactions and should be administered under medical supervision

Epistaxis

• Usually located on anterior septum
• Try 15 minutes of pressure. Get hypertension under control
• Topical epinephrine/neosynephrine on pledgets as vasoconstrictor
• Pull pledgets out and look fast for the bleeding site
• Suction away blood and cauterize with silver nitrate
• Try packing nose lightly with Surgicel or gelfoam sponges soaked with topical thrombin
• Vigorous bleeds must be packed with antibiotic ointment-soaked gauze strips. Need good lighting and instruments for an adequate job. Avoid packing patients with coagulopathies who will invariably re-bleed when the pack is removed
• Intranasal balloons (e.g. Epistat) are easier to use but less consistently effective
• Persistent bleeding is then treated with posterior and anterior packs
• Leave packs in three days. Cover with antibiotics to prevent sinusitis
• If packing fails vessels must be ligated. If the responsible vessel cannot be identified then both maxillary artery and ethmoid arteries are ligated
• Blood supply of the lateral nasal wall.

Blood supply of the nasal septum.

• Juvenile nasoangiofibroma - epistaxis in boys
• Nasopharyngeal carcinoma -
  • early symptoms = serous otitis media, neck metastases
  • Chinese at higher risk
  • EBV genome in undifferentiated carcinoma
    • Squamous cell carcinomas
    • Inverting papillomas (occupational exposure?)

• Anosmia
  • Head injury, especially antero-posterior can shear off nerves as they cross the cribiform plate
  • Viral (influenza) infection can kill off nerves
  • Obstruction such as nasal polyps or septal deviation
• Hyposmia Advanced age
• Hyperosmia Addison's, pregnancy
• Cacosmia Infection (sinus, dental), hysteria

• Innervation anterior 2/3rds of tongue CN VII
• posterior tongue, pharynx CN IX
• 4 basic tastes - sweet, sour, bitter, and salt
• Altered taste is usually olfactory loss. Ask patient whether they can still taste sweet or salt. Check oral mucosal for lesions and adequacy of salivation. Medications such as sulfa drugs and anti-arthritics can cause altered taste sensations