Otorhinolaryngology

Acute Rhinitis Chronic Rhinitis Acute Rhinosinusitis Chronic Rhinosinusitis Nasal endoscope Surgery
The Third Affiliated Hospital of Sun Yat-sen University Zhang Gehua gehuazh@hotmail.com

Schedule

Introduction Anatomy Acute rhinitis Chronic Rhinitis Actue Rhinosinusitis Chronic Rhinosinusitis Nasal endoscope surgery Conclusion & Questions

3 min 5min 5min 5min 20 min 20 min 15 min 10 min

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Acute Rhinitis

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Definition
Acute Rhinitis: An acute condition which affects the nasal mucous caused by inflammation.
Characterized------ runny nose and stuffiness, usually caused by the common cold

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Symptoms

latent period: 1~3days Course: 710days Sore throat Discomfort in the nose Sneezing, Runny nose (watery & clear ---thicker & yellow -green) Mild fever Mild cough Others: Headaches, Decrease in ability to smell, Nasal obstruction
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Complications

Sinuses (maxillary sinusitis, frontal sinusitis and some other kinds of sinusitis) Middle ear (otitis) Eye mucosa (conjunctivitis) Other respiratory organs (pharyngitis, laryngitis, tracheitis, bronchitis, pneumonia)

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Treatment

Decongestants: which help open clogged nasal passages (<7days) Antihistamines: which help dry a runny nose Cough syrups: which may make coughing easier by thinning secretions or suppressing cough Antibiotics:

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Chronic Rhinitis
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Definition

Chronic rhinitis is usually an extension of acute rhinitis caused by inflammation or an infection.

------It also may occur with diseases such as syphilis,

tuberculosis, rhinoscleroma , rhinosporidiosis, leishmaniasis, blastomycosis, histoplasmosis, and

leprosy.

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Symptoms

nasal obstruction
pus-filled discharge from the nose

frequent bleeding

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Treatment

Medication:
Decongestants Chinese medicine nasal spray (nasonex, flonex)

Surgery: partial inferior turbinectomy inferior turbinate ablation....

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Rhinosinusitis
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Anatomy

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Anatomy
Frontal sinus

eye Uncinate process Middle turbinate

Maxillary sinus Inferior turbinate

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Sinus Drainage Schema

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Sinus Drainage
Anterior group
Maxillary Anterior ethmoid Frontal Middle meatal

Posterior group
Sphemoid Sphenoethmiodal recess Posterioe ethmoid Supper meatal Olfacotory cleft

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Denitions of rhinosinusitis
------based on the duration clinical signs and symptoms

Acute rhinosinusitis: <4 weeks

Subacute rhinosinusitis : 4 to 12 weeks

Chronic rhinosinusitis : >12 weeks Recurrent acute rhinosinusitis: 4 episodes/yr (each episode lasting 7 to 10 days plus no intervening signs of CRS) Acute exacerbation of chronic rhinosinusitis :sudden worsening of CRS, return to baseline after treatment
1996,American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS)

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Definition
Acute Rhinitisinusitis: Inammatory and/or infectious condition of 1 or more of the
paranasal sinus cavities.

Acute rhinosinusitis (ARS) implies that the duration of the condition is less than 1 month.

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Epidemiology

0.5 to 2% of cold result in ARS (acute rhinosinusitis)

Up to 1 in 20 URI (upper respiratory tract infections) lead to ABRS (acute bacterial rhinosinusitis)
One billion cases of acute viral rhinosinusitis can be anticipated annually 20 million cases of ABRS are expected annually Approximately 2% of people with acute viral rhinosinusitis go on to develop ABRS The diagnosis of ABRS accounted for 21% and 9% of all adult and pediatric antibiotic prescriptions, respectively Affects 32 million US adults annually
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Cost

Resulted in 11.7 million ofce visits as well as 1.2 million hospital outpatient unit visits Generated direct annual costs in excess of $3.4 billion in that same year

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Pathogenesis
Viral:
Rhinovirus Influenza A and B viruses Parainfluenza virus Respiratory symcytial virus Adenovious.

Bacterial:
Streptococcus pneumoniae Haemophilus inuenzae,

Moraxella catarrhalis Streptococcus intermedius, Streptococcus pyogenes, Staphylococcus aureus anaerobic bacteria

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Diagnosis
Viral URIs symptoms:

Rhinorrhea sneezing nasal airway obstruction facial congestion hyposmia sore throat cough eustachian tube dysfunction Fevers myalgias
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Diagnosis
Bacterial:

The clinical signs and symptoms lack sensitivity (69%) and specicity (64%). when a viral URI does not resolve after 10 days or is worsening at 5 to 7 days. signs and symptoms: ------nasal drainage ------facial pressure/pain ------decreased/absent olfaction ------fever, cough, fatigue, dental pain, and/or ear pressure.
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Complications
Orbital Complications Intracranial Complications

Preseptal Cellulitis Orbital Cellulitis Subperiosteal Abscess Orbital Abscess Cavernous Sinus Thrombosis

Meningitis Epidural Abscess Subdural Abscess Intracerebral Abscess

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Treatment

In the adult population with mild disease and no antibiotics in the prior 6 weeks the following choices may be considered: amoxicillin/clavulanate, amoxicillin, cefpodoxime proxetil, cefuroxime axetil, or cefdinir In patients with -lactam allergies, trimethoprim-sulfamethoxazole, docycline, azithromycin, clarithromycin, erythromycin, or telithromycin may be used Bacteriologic failure rates range from 20 to 25%. In those patients who have received antimicrobials in the prior 6 weeks, uoroquinolones or higher dose amoxicillin clavulanate may be considered Failure to respond to treatment within 72 hours requires a switch to another antimicrobial and/or reevaluation of the patient

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Treatment

In the pediatric population, the choices are similar to the adult population with 2 exceptions:
------dosing is based upon weight ------uoroquinolones are not an option in the pediatric population

A 10-day treatment course with 1 of the above antimicrobials is recommended An inappropriate antibiotic of insufficient duration may prolong infection and potentially morbidity of the disease.

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Definition

Chronic rhinosinusitis (CRS): is a clinical disorder that encompasses a heterogeneous group of infectious and inammatory conditions affecting the paranasal sinuses.

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Epidemiology

There were 18.3 million patient ofce visits for CRS despite many patients not seeking medical attention.(2001) CRS affects men and women equally, but subtypes of CRS appear to have different gender distributions. For example, CRS with NPs associated with aspirin-sensitivity has a female predominance of 2:1 Sinus disease is more common in the Midwest and South than in the northeast and western United States and the incidence is lower during the summer months compared to the other seasons.
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Sinusitis or Rhinosinusitis

Sinusitis was the commonly accepted terminology for

inammation of the paranasal Sinuses

Now------ Sinusitis has gradually been phased out in favor of rhinosinusitis because nasal inammation almost always coincides with inammatory paranasal sinus involvement.

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CRS without NP ------ ETIOLOGY AND PATHOPHYSIOLOGY

Anatomic Factors:
Heller cells, silent sinus syndrome or a narrow frontal sinus

Mucociliary Dysfunction:
------Intrinsic factors leading to ciliary dysfunction include primary ciliary dyskinesia or Kartagener syndrome. ------Extrinsic factors that disrupt mucociliary clearance include injury by environmental irritants, endogenous mediators of in ammation, or surgical trauma.

Bone Inflammation:
Bone may play an active role in the disease process and that, at a minimum; the inammation associated with CRS may spread through the Haversian system within the bone.

Biofilms:
Recent investigations have found that bacteria such as P. aeruginosa form biolms in the sinuses that may lead to recalcitrant sinus disease

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CRS with NP ------ ETIOLOGY AND PATHOPHYSIOLOGY

Allergic Fungal Rhinosinusitis: Eosinophilic Chronic Rhinosinusitis Ig E Independent Fungal Inflammation Aspirin-Sensitive Nasal Polyposis

Bacterial Superantigen

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Symptoms

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Symptoms

History of URI or allergic rhinitis, History of previous episodes of sinusitis

Pressure, pain, or tenderness over sinuses (Increased pain in the morning, subsiding in the afternoon) Nasal obstruction or congestion, causing difficulty breathing through nose Malaise, Low-grade temperature
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Symptoms

Persistent nasal discharge, often purulent Postnasal drip Cough, worsens at night Mouthing breathing, snoring Sore throat, bad breath Headache Ear pain
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Clinical Presentations

Periorbital edema Cellulitis Nasal mucosa is reddened or swollen Percussion or palpation tenderness over a sinus

Nasal discharge, thick, sometimes yellow or green

Postnasal discharge in posterior pharynx Difficult transillumination

Swelling or boggy pale turbinates

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Evaluation

History and Physical Examination:

Nasal obstruction, nasal congestion, and postnasal discharge are the most common symptoms Tenderness to palpation or percussion in the periorbital, forehead, or cheek areas.

Nasal Endoscopy:
allows the assessment of mucosal hyperemia, edema, the gross appearance and sites of origin of NPs, and septal deformities or other anatomic abnormalities impacting sinus drainage.

Laboratory: Allergy testing, Elevated IgE Radiology: coronal CT scan, MRI

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Diagnosis

Nasal endoscopy Imaging studies (CT scanning) Nasal and sinus cultures An allergy test

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Diagnosis
Anterior group
Maxillary Anterioe ethmoid Frontal Middle meatal

Posterior group
Sphemoid Sphenoethmiodal recess Posterioe ethmoid Supper meatal

Olfacotory cleft

Sign
Pus Middle meatal Anterior sinus Olfacotory cleft Posterior sinus

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Complications of Sinusitis
Ear infection Asthma flare ups Orbital cellulitis or abscess, Vision problems Meningitis, Brain abscess Cavernous sinus thrombosis Subdural empyema

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Management

Antimicrobial Therapy
Systemic Corticosteroid Therapy Topical Corticosteroid Therapy Antileukotriene Therapy Other Medical and Ancillary Therapies

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Prevention

Avoid upper respiratory infections Carefully manage your allergies

Avoid cigarette smoke and polluted air

Use a humidifier

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Endoscopic Sinus Surgery

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What is ESS

Endoscopic sinus surgery ------ is a procedure used to remove blockages in the sinuses . This surgery does not involve cutting through the skin, as it is performed entirely through the nostrils. Therefore, most people can go home the same day.

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Advantages
Is less painful Leaves no visible scars Causes less bleeding Creates less discomfort after surgery Requires less packing in the nose after surgery Has a faster recovery period Has a higher success rate

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Surgical Technique
Uncinectomy Ethomoidectomy Sphenoidotomy with Ethomoidectomy Frontal Recess Surgery (Draf Type 1) Frontal Sinusotomy (Draf Type 2) Maxillary Antrostomy

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Postoperative Care

Medical therapy-----antibiotic, saline spray, oral steroids Local management of the postoperative cavity:
-----remove nasal package (48 h after operation) -----nasal endoscopy and cleaning of the cavity (around 1 week after operation)

Follow up-----at least 6 months!

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Follow up after ESS

2008 2008 2008 2008 7 2009 7 14 8 31 18 6 1 2008 9 10 8 8

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Complications

Hemorrhage CSF leak Orbital injury Nasolacrimal duct injury Recurrence

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pituitary adenoma resection

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Adenoidectomy

adenoidal hypertrophy

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Thank for
your attention

gehuazh@hotmail.com

85253045

85252239

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