Allergic Rhinitis

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one of the commonest ent disease

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  • Le allergie che provocano sinusiti possono essere debellate in vari modi, anche con i farmaci.
    Le sinusiti: http://www.giuseppespinelli.it/approfondimenti/sinusiti.html
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Allergic Rhinitis

  1. 1. ALLERGIC RHINITIS <ul><li>Definition : IgE mediated hypersensitivity of the mucous membrane of the nose upon exposure to antigenic substance. </li></ul><ul><li>Incidence : common, 10-20% of population. </li></ul><ul><li>Types : 1. seasonal 2. perennial 3.perennial with seasonal exacerbation. </li></ul><ul><li>Etiology : </li></ul><ul><li>Predisposing factors : </li></ul><ul><li>1. Genetic predisposition: 50% of cases occur in atopic patient (atopy: tendency to develop an exaggerated Ig E antibody response). </li></ul><ul><li>2. Temperature changes. </li></ul><ul><li>3. psychgenic. </li></ul>
  2. 2. <ul><li>Exciting factors : </li></ul><ul><li>inhalant: commonest factors e.ghouse dust, tree & grass pollens. </li></ul><ul><li>Injestant: foods (milk, fish) & drugs ( aspirin, antihypertensive). </li></ul><ul><li>Injectant: e.g penicillin. </li></ul><ul><li>Infactant: fungal parasitic & bacterial antigen. </li></ul><ul><li>Contactant: e.g face powder. </li></ul>
  3. 3. <ul><li>Pathogenesis : </li></ul><ul><li>1 st exposure : formation of IgE antibodies which bind to specific sites on surface of mast cells. </li></ul><ul><li>2nd exposure : +Ag-Ab reaction on surfaces of must cells with degranulation of cells & release of chemical mediators: e.g histamine, bradykinine, serotonine resolution in local inflammatory reaction: </li></ul><ul><ul><li>Vasodilation: plasma exudate. </li></ul></ul><ul><ul><li>Increase glandular secretions. </li></ul></ul><ul><ul><li>Cellular infiltrate (oesinophilis). </li></ul></ul><ul><ul><li>Smooth muscle contraction. </li></ul></ul>
  4. 4. <ul><li>Symptoms : +ve family history in 50%. </li></ul><ul><li>Itching sensation. </li></ul><ul><li>Paroxysmal sneezing. </li></ul><ul><li>Bilateral profuse watery discharge. </li></ul><ul><li>Bilateral alternating nasal obstruction. </li></ul><ul><li>Associated allergic symptoms e.g eye, skin or chest. </li></ul><ul><li>Signs : </li></ul><ul><li>Pale bluish edematous mucosa. </li></ul><ul><li>Swollen edematous turbinates. </li></ul><ul><li>Excessive mucoid secretions. </li></ul><ul><li>Nasal polyps may be present. </li></ul>
  5. 5. <ul><li>Investigations : </li></ul><ul><li>Skin- prick test: skin of forearm is pricked with a needle passed in extract of different allergens. +ve test is detected by centeral wheel surrounded by erythema. </li></ul><ul><li>Nasal challenge test: allergen applied inform of spray. </li></ul><ul><li>Radioallergosrbency test (RAST): incubation of patient serum with specific concentrations of antigens & level of IgE is by radioimmune. </li></ul><ul><li>High level of IgE by radioimmun. </li></ul><ul><li>Nasal smear; full of oesinophilis. </li></ul>
  6. 6. <ul><li>Treatment: </li></ul><ul><li>Avoidance of exposure. </li></ul><ul><li>Immunotherapy: injection of gradually increasing dose of specific antigen over long period of time formation of blocking antibodies. </li></ul><ul><li>Mast cell stabilizer e.g. sodium chromoglicate. </li></ul><ul><li>Antihistaminic: systemic & local (spray). </li></ul><ul><li>Steroids: systemic (short course) &local spray. </li></ul><ul><li>Surgery: </li></ul><ul><li>- Reduction of size of turbinate. </li></ul><ul><li>- Nasal polypectomy </li></ul>
  7. 7. Vasomotor rhinitis <ul><li>It is also called intrinsic rhinitis or non allergic perennial rhinitis. It may be related to drugs ( e.g. antihypertensive and contraceptive) or hormonal imbalance at menopause. </li></ul><ul><li>Clinical picture : </li></ul><ul><li>Nasal obstruction and watery nasal discharge, which is often precipitated by temperature changes, and dusty atmosphere. </li></ul><ul><li>Examination; shows swollen, edematous turbinates, with excessive mucoid ecretios. </li></ul><ul><li>Treatment : </li></ul><ul><li>It is often unsatisfactory. </li></ul><ul><li>Topical steroids may be beneficial. </li></ul><ul><li>If the turbinates are markedly swollen we may do submucous dithermy or submucosal injection of long acting steroids (vidion N1). </li></ul>
  8. 8. Nasal polyps <ul><li>Definition : </li></ul><ul><li>Projections of edematous. Pedunculated mucosa of the nose and/or Paranasal sinuses. </li></ul><ul><li>Types : </li></ul><ul><li>Incidence : </li></ul><ul><li>Common. </li></ul><ul><li>Age: adult. </li></ul><ul><li>If occurs in a child 2-10yrs -> cystic fibrosis, should be suspected. There are extensive nasal plyps leading to broadening of the nasal bridge due to distention before fusion of the nasal bones. There is very thick and tenacious nasal discharge (Mucoviscidosis). Sweat test (sodium level) is diagnostic. It has a very high rate of recurrence. </li></ul><ul><li>- Sex: equal. </li></ul><ul><li>Uncommon. </li></ul><ul><li>Age: young adult. </li></ul><ul><li>Sex: equal </li></ul>Etiology: 1. Allergy: * Most accepted cause. * 90% of polyps -> oesinophilia. * Allergic rhinitis, Usually present. * 20-40% -> bronchial asthma. 2. Inflammatory, chronic sinusitis. Etiology: Inflammatory or retention cyst: Arise from mucosa of maxillary antrum -> directed posteriorly. After passage through sinus ostium -> directed towards the choana -> nasopharynx. 1- Ethmoidal 2- Antrochoanal
  9. 9. <ul><li>Signs: </li></ul><ul><li>Allergic: </li></ul><ul><li>Bilateral, multiple, pale, glistening pedunculated masses (grap-like growth) that fill the nasal bridge in long standing cases (Hypertolirism). </li></ul><ul><li>Manifestations of allergic rhinitis. </li></ul><ul><li>Inflammatory: </li></ul><ul><li>Polyps: usually few pink, soft and arising mainly from the middle meatus. </li></ul><ul><li>Purulent discharge: mainly from the middle meatus. </li></ul><ul><li>Anterior rhinoscopy: </li></ul><ul><li>Swollen inferior turbinate. </li></ul><ul><li>Accumulated secretions. </li></ul><ul><li>Sometimes -> polyp seen. </li></ul><ul><li>Posterior rhinoscopy: </li></ul><ul><li>Single polyp appears in the nasopharynx. </li></ul><ul><li>Symptoms: </li></ul><ul><li>Allergic: </li></ul><ul><li>Bilateral gradual nasal obstruction. </li></ul><ul><li>Manifestation of allergic rhinitis. </li></ul><ul><li>Inflammatory: </li></ul><ul><li>PND: thick and purulent. </li></ul><ul><li>Unilateral or bilateral nasal obstruction and discharge. </li></ul><ul><li>Sinus headache. </li></ul>- Accumulated nasal discharge in the obstructed side.
  10. 10. Treatment: Allergic: 1. Medical -> small early polyps. * Systemic steroids. * Topical steroids. * Antibiotics ê 2ry infection. * Anti allergic treatment. 2. Surgery: * Simple polypectomy. * Intranasal ethmoidectomy (endoscopic or microscopic). - Preoperative & postoperative steroids should be given. - There is high rate recurrence 40% after surgery (9months -> 2years). Inflammatory : 1. Medical : * Antibiotics. * Decongestant. * Mucolytics. 2. Surgical : Transnasal endoscopic sinus surgery (FESS). Endoscopic removal of nasal, nasopharyngeal, and sinus parts through a wide middle meatal antrostomy. N.B: in recurrent cases -> radical antrum operation was done. N.B: Differential diagnosis of unilateral nasal mass: 1. Benign neoplasm especially inverted, firm papillary polyps. 2. Malignant neoplasm: unilateral, bad odor, soft, bleeding on touch mass. 3. Meningocele and encephalocoele: soft, pulsating, reddish, polyp with superior attachment to skull base. <ul><li>Investigations: </li></ul><ul><li>Culture and sensitivity. </li></ul><ul><li>Allergic skin test. </li></ul><ul><li>CT scan nose & paranasal sinuses. </li></ul><ul><li>Biopsy from the ploys (macrophages or eosinophilia). </li></ul><ul><li>Sinus view: unilateral maxillary opacity. </li></ul><ul><li>CT scan. </li></ul>
  11. 11. Paranasal sinuses <ul><li>Anatomy paranasal sinuses </li></ul><ul><li>Air filled spaces , 4 pairs on each side, within skull bones & open in the Latebral wall of nose. </li></ul><ul><li>Lining: pseudostratified columnar ciliated epithelium which is continuous with that of the nose through their ostia. </li></ul><ul><li>Arranged in 2 groups: </li></ul><ul><li>* Anterior group: Maxillary, Forntal & Anterior sinuses. </li></ul><ul><li>* Posterior group: Posterior ethmoid & Sphenoid sinuses. </li></ul><ul><li>Maxillary sinus: </li></ul><ul><li>It is contained within the body of maxilla. </li></ul><ul><li>Development begins in the 3 rd fetal month. </li></ul><ul><li>Pneumatization starts at bieth, growth continues to 18 years of age. </li></ul>
  12. 12. <ul><li>Boundaries: </li></ul><ul><ul><li>Anteriorly: cheek. </li></ul></ul><ul><ul><li>Posteriorly: pterygopalaine fossa. </li></ul></ul><ul><ul><li>Roof: floor or orbit. </li></ul></ul><ul><ul><li>Floor: palatine and alveolar process of maxilla. </li></ul></ul><ul><ul><li>Medially: lateral nasal wall. </li></ul></ul><ul><ul><li>Level of floor of sinus varies with that of nasal floor, before age of 9 years sinus floor is at higher level, after the age of 9 years sinus floor is at lower level. </li></ul></ul><ul><li>Maxillary sinus ostium : </li></ul><ul><li>It is made by confluence of maxillary sinus mucosa and nasal mucosa. On looking to the maxillary ostium from inside the sinus it will appear like an ellipse just below the junction of roof and medial wall half way between anterior and posterior walls. </li></ul><ul><li>Frontal sinus: </li></ul><ul><li>It is present between outer and inner tables of frontal bone. </li></ul><ul><li>it begins development after birth. </li></ul><ul><li>The two frontal sinuses may be of unequal size. </li></ul><ul><li>The frontal sinus ostium lies in the most dependent area of the sinus. </li></ul><ul><li>Frontal recess, is the space where frontal sinus opens. </li></ul><ul><li>The frontal sinus ostium and recess look an hour glass. </li></ul>
  13. 13. <ul><li>Ethmoid sinuses: </li></ul><ul><li>The ethmoid bone is divided into: </li></ul><ul><ul><li>Two ethmoid labyrinth which form ethmoid sinuses on both sides. </li></ul></ul><ul><ul><li>Cribiform plate of ethmoid which separates the nose from anterior cranical fossa. </li></ul></ul><ul><ul><li>Perpendicular plate of ethmoid which forms part of nasal septum. </li></ul></ul><ul><li>The ethmoid sinus consists of 7-17 small air cells. </li></ul><ul><li>It is divided into anterior group and posterior group by basal lamella (oblique part of middle turbinate). </li></ul><ul><li>Sphenoid sinus: </li></ul><ul><li>It is lies within the sphenoid bone. </li></ul><ul><li>Pneumatization of sinus begins in the 3 rd year. </li></ul><ul><li>The ostium lies high in the anterior wall and opens in the Spheno ethmoidal recess. </li></ul><ul><li>Relations: </li></ul><ul><li>Roof: sella turcica. </li></ul><ul><li>Pos teriorly: optic nerve. Posterolalerally: ICA. </li></ul>
  14. 14. Physiology of the paranasal sinuses <ul><li>Functions of the paranasal sinuses: </li></ul><ul><li>1. Helps in resonating the voice. </li></ul><ul><li>2. Lightens the weight of the skull. </li></ul><ul><li>3. Shock absoirption in trauma to the face or skull. </li></ul><ul><li>4. Assists in humidification and moistening the nasal cavity. </li></ul><ul><li>Osteomeatal complex: </li></ul><ul><li>Describe the area in which the frontal, maxillary & ethmoidal sinuses drain. It is bounded by middle turbinate medially, lamina papyracea laterally and basal lamella posteriorly and superiorly. Any mucosal thckcning or anatomical abnormality will affect these sinuses. </li></ul><ul><li>Mucociliary clearness: </li></ul><ul><ul><li>The secretions of goblet cells & seromucinous glands form a mucous layer “mucous blanket” above the epithelium. </li></ul></ul><ul><ul><li>Cilia carry this blanket towards the ostium of the sinus -> nose -> nasopharynx. </li></ul></ul>
  15. 15. Sinusitis <ul><li>Etiology: </li></ul><ul><li>Exciting causes: </li></ul><ul><li>A) Nasal </li></ul><ul><li>Acute rhinitis; commonest cause. </li></ul><ul><li>Viral exanthemata. </li></ul><ul><li>Neglected F.B. </li></ul><ul><li>Nasal packing. </li></ul><ul><li>B) Dental </li></ul><ul><li>Dental infection. </li></ul><ul><li>Extraction of 2 nd premolar or 1 st molar. </li></ul><ul><li>C) External </li></ul><ul><li>Compound facial fracture. </li></ul><ul><li>Penetrating F.B. e.g. gunshot. </li></ul><ul><li>Predisposing factors: </li></ul><ul><li>A) Local: any nasal disease obstructing the sinus ostium e.g. D.S, nasal polyps. </li></ul><ul><li>B) General: low general resistance. </li></ul><ul><li>Organism: Streptococcus pneumonia, haemophilus influenza & Anaerobes (dental origin). </li></ul><ul><li>1) Repeated acute attacks with incomplete resolution: </li></ul><ul><li>Persistent of predisposing factors  persistent obstruction of the osteomeatal complex. </li></ul><ul><li>Inadequate treatment with residual infection. </li></ul><ul><li>2) High virulence of organism. </li></ul><ul><li>3) Low body resistance. </li></ul>Definition: Acute inflammation of the mucous membrane lining the paranasal sinuses. One or more may be involved. Usually rhniosinustis. Chronic inflammation of the mucous membrane lining of the paranasal sinuses with irreversible pathological changes. Acute sinusitis Chronic sinusitis
  16. 16. <ul><li>A) General: manifestations of septic focus, history of repeated acute attacks. </li></ul><ul><li>B) Local: </li></ul><ul><li>1- </li></ul><ul><li>2- </li></ul><ul><li>3- </li></ul><ul><li>4- Facial pain & headache: </li></ul><ul><li>Same. </li></ul><ul><li>Dull aching, periodic & recurrent. </li></ul><ul><li>5- Symptoms of descending infections: </li></ul><ul><li>Otitis media. </li></ul><ul><li>Recurrent pharyngitis. </li></ul><ul><li>Laryngitis & bronchitis. </li></ul><ul><li>6- Symptoms of complications. </li></ul><ul><li>Symptoms: </li></ul><ul><li>A) General: fever, history of acute rhinitis. </li></ul><ul><li>B) Local: </li></ul><ul><li>1- Nasal obstruction: unilateral or bilateral. </li></ul><ul><li>2- Nasal discharge: </li></ul><ul><li>Unilateral or bilateral. </li></ul><ul><li>Mucopurulent or purulent. </li></ul><ul><li>Postnasal drip  irritative cough. </li></ul><ul><li>3- Hyposmia: cacosmia (bad smell)  dental origin. </li></ul><ul><li>4- Facial pain & headache. </li></ul>1. Mucosa: congested, edematous with fibrosis. 2. Cilia: degeneration with loss of ciliary function. 3. Late cases: the mucosa is either atrophic or hypertrophic “irreversible pathology”. Pathology: Congestion & oedema of sinus mucosa  occlusion of sinus ostium  impairment of sinus drainage & mucociliary clearance  accumulation of secretions inside the sinus  stasis & infection with  pus formation.
  17. 17. Local: 1. 2. 3. Sites of sins pain & tenderness in acute & chronic sinusitis. Maxillary: pain & tenderness over affected sinus. Ethmoidal: Pain  in between eyes. Tenderness  inner canthus. Frontal: Pain  supra orbital & across forehead. Tenderness  above eyebrow. Floor of sinus. Sphenoid: pain  occipital. <ul><li>Signs: </li></ul><ul><li>A) General: fever: higher in children. </li></ul><ul><li>B) Local: </li></ul><ul><li>1- Tenderness over the affected sinus on deep pressure. </li></ul><ul><li>2- Anterior rhinoscopy: </li></ul><ul><li>Mucosa: edematous & congested. </li></ul><ul><li>Nasal discharge: middle meatus  anterior group. </li></ul><ul><li>3- Posterior rhinoscopy: </li></ul><ul><li>Nasal discharge: </li></ul><ul><li>- Superior meatus  posterior group. </li></ul><ul><li>- Spheno ethmoidal recess  sphenoid. </li></ul><ul><li>On the affect sinus. </li></ul><ul><li>Sever, throbbing. </li></ul><ul><li> Coughing, bending forwards. </li></ul><ul><li>Vacuum headache  frontal sinus ostium obstruction with absorption of air  periodic pain & headache. </li></ul><ul><li>5- Facial edema & swelling. </li></ul><ul><li>6- Symptoms of complications. </li></ul>
  18. 18. A) Medical: 1- General: - Same. - Antibiotics: for 4weeks. 2- Local : - Same. - Control of local nasal Predisposing factors. - Nasal wash: alkaline nasal wash. B) Surgical: Indication: 1) Failed medical treatment (up to 4 weeks). 2) Presence of mechanical obstruction in the nose. Treatment: A) Medical: 1- General: - Bed rest. - Plenty of fluids. - Antibiotics: for 10-14days. - Analgesics. - Mucolytics. 2- Local : - Decongestant nasal drops. - Steam inhalation. B) Surgical: Indication: aiming to Surgical drainage. 1) Failed medical ttt. 2) Complications: present or threatening. <ul><li>Investigations: </li></ul><ul><li>Laboratory: C. & S. from nasal discharge. </li></ul><ul><li>Nasal endoscopy: ostium visualization, pus in different areas, anatomical variations. </li></ul><ul><li>Radiological: </li></ul><ul><li>* X-ray sinus view: mucosal thickening, fluid level. </li></ul><ul><li>* C.T scan nose & PNS: investigation of choice. </li></ul>
  19. 19. Procedure: Nowadays; -> drainage of the affected sinus by functional endoscopic sinus surgery (FESS). Old: 1. Maxillary: puncture & lavage. 2. Frontal: frontal trephine. 3. Ethmoid: fthnoidectomy. 4. Sphenoid: sphenocthmoidectomy. Procedure: According to he affected sinus Sphenoid Sphenoid sinusotomy External Sphenoethroidectomy Ethmoids Intranasal ethnoidectomy External Frontoethroidectomy. Frontal Endoscopic clearance of frontal recess. External frontal operation  opening sinus floor & removal of diseased mucosa. Maxillary Endoscopic middle meatal antrostomy  widening of the normal ostium. <ul><li>Repeated puncture & Lavage  up to 6 times. </li></ul><ul><li>Intranasal antrostomy. </li></ul><ul><li>Radical antrum operation. </li></ul>Recent “FESS” Old
  20. 20. Sinusitis in children <ul><li>Accidence : - Age: 5-8 yrs. </li></ul><ul><li>- Site: maxillary & ethmoid (commonest). </li></ul><ul><li>Etiology: </li></ul><ul><li>Predisposing factors: </li></ul><ul><li>Ciliary disorders e.g. kartagnar’s syndrome (Bronchitis Dectrocar) </li></ul><ul><li>Mucosal abnormality e.g. cystic fibrosis (Muwvisidrlin). </li></ul><ul><li>Source of infection: common e.g. URT infection & exanthemata. </li></ul><ul><li>Low immunity. </li></ul><ul><li>Organism : Strept. Pneumonia, H. influenza & moraxella catarrtalis. </li></ul><ul><li>Clinical picture: </li></ul><ul><li>Acute: as adult + high fever & complications are more especially orbital. </li></ul><ul><li>Chronic: less facial pain & headache than adult, descending infection & chronic irritative cough. </li></ul><ul><li>Treatment : </li></ul><ul><li>(A) Medical: as adult. </li></ul><ul><li>(B) Surgical: - No improvement after medical treatment. </li></ul><ul><li>- Presence of complication. </li></ul>
  21. 21. Orbital complications <ul><li>The commonest complication. 75% of orbital infections are due to sinusitis. </li></ul><ul><li>Aetiology : more common to occurs in ethmoditis especially in children. Less common t occurs in ethmoditis especially in children. Less common with maxillary sinus. </li></ul><ul><li>Clinical picture : 5 stages. </li></ul><ul><li>1- Preseptal cellulitis: </li></ul><ul><li>. Mild inflammatory or reactionary edema of the &quot;Preseptal connective tissue&quot; due to proximity of infection in the ethmoids -> venous obstruction. </li></ul><ul><li>. There is: eyelid edem. </li></ul><ul><li>2 - Subperiosteal abscess “extraperiosteal&quot;: </li></ul><ul><li>. Pus collection between the orbital periosteum & the lamina papyracea. </li></ul><ul><li>.There is: - Severe pain - Mild Proptosis. </li></ul><ul><li> - Good general condition. - Mild limitation of eye movement. </li></ul><ul><li> - Chemosis. - Diminution of vision (reversible). </li></ul>
  22. 22. <ul><li>3 - Orbital cellulitis : </li></ul><ul><li>. Diffuse edema of the orbital contents & bacteria actively invaded the orbital </li></ul><ul><li>contents but pus formation does not occur. </li></ul><ul><li>. There is :-Sever pain. - ↑ Proptosis. </li></ul><ul><li> -Bad general condition - ↑ limitation of eye movement. </li></ul><ul><li> -Chemosis. -Diminution if vision condition (reversible). </li></ul><ul><li>4- Orbital abscess &quot;intraperoisteal“: </li></ul><ul><li>. Pus collection within the orbit. </li></ul><ul><li>. There is: -Sever throbbing pain. -Marked proptosis. </li></ul><ul><li>-Very bad general condition -Total ophthalmoplegia. </li></ul><ul><li> -Chemosis -Diminution of vision (irreversible). </li></ul><ul><li>5- Cavernous sinus thrombosis: </li></ul><ul><li>Due to thrombosis of the superior & inferior ophthalmic veins “retrograde thrombophilbitis”. </li></ul>
  23. 23. <ul><li>Investigations : </li></ul><ul><li>1 - Urgent CT scan of the paranasal sinuses & orbit. </li></ul><ul><li>2 - Fundus examination: Papilloedema (in cavernous sinus thrombosis). </li></ul><ul><li>Treatment: </li></ul><ul><li>1 - Hospita1ization. </li></ul><ul><li>2 - Treatment of orbita1 cellulitis: </li></ul><ul><li>-Massive antibiotics with daily: -Examination of visual acuity. </li></ul><ul><li>-CT scan. </li></ul><ul><li>-Surgical: * Drainage of Subperiosteal abscess. </li></ul><ul><li>* Indications: -Progressive ↓ of vision. </li></ul><ul><li>-Progressive symptoms over 24 hrs & no improvement after 48 hours. </li></ul><ul><li>-CT; shows subperiosteal collection. </li></ul><ul><li>3 - Surgical treatment of sinusitis. </li></ul>
  24. 24. Osteomylitis of skull <ul><li>Occurs in diploic bones -> frontal & maxillary. </li></ul><ul><li>Aetiolology : Direct extension of infection to bones or due to thrombophilbitis of diploic veins. </li></ul>Treatment : Hospitalization. 1. Massive antibiotics. 2. Surgical drainage of abscess. 3. Treatment of sinusitis. Plain X-ray & CT scan. Investigations: Plain X-ray & CT scan X-ray -> moth-eaten appearance of posterior wall. <ul><li>Clinical picture: </li></ul><ul><li>General: fever, toxemia. </li></ul><ul><li>Pain, Oedema & tenderness over forehead. </li></ul><ul><li>Frontal fluctuant swelling or fistula. </li></ul><ul><li>General: fever, toxemia. </li></ul><ul><li>Pain, Oedema, tenderness over cheek. </li></ul><ul><li>Subperiosteal abscess over canine fossa or oroantral fistula. </li></ul>Pathology : Osteomylitis -> subperiosteal abscess (Pott’s puffy tumour) -> fistula. Same Frontal osteomylitis Maxillary osteomylitis
  25. 25. Intracranial complications <ul><li>1. Meningitis: the most common intracraninal complication. </li></ul><ul><li>2. Extradural abscess: occurs with frontal sinusitis & osteomylitis. Both 1 & 2 are similar to that of chronic ear. </li></ul><ul><li>3. Bruin abscess : Similar to that of chronic ear, with personality changes as a localizing sign. </li></ul><ul><li>4. Cavernous sinus thrombosis </li></ul><ul><li>Etiology : infection from: </li></ul><ul><li>1- Dangerous area of the face (boil & septal abscess). Facial veins -> ophthalmic vs. -> CS. </li></ul><ul><li>2- * Sinus infection. </li></ul><ul><li>* Orbital cellulitis. </li></ul><ul><li>3- Latera1 sinus thrombosis. </li></ul><ul><li>4- Pharyngeal suppuration e.g. Quinsy. -> pterygoid venous plexus -> CS. </li></ul>
  26. 26. <ul><li>Clinical picture: </li></ul><ul><li>- 1 General: high fever, toxemia, rigors. sever headache. Then, there is rapid deterioration of general condition. </li></ul><ul><li>-2 Venous obstruction of eye: Eyelid Oedema, Chemosis & Proptosis. </li></ul><ul><li>3- Cr. nerve affection: * Total ophthalmoplegia. </li></ul><ul><li>* Pain in distribution of ophthalmic division of 5 th nerve. </li></ul><ul><li>4- ↑ ICT , then coma & death if untreated. </li></ul><ul><li>Investigation : MRI , angiography & MRA . </li></ul><ul><li>Treatment : Mortality is 30% if untreatc 25Id of infection (meanings & brain tissue). </li></ul><ul><li>- Hospitalization. </li></ul><ul><li>- Antibiotics & anticoagulant. </li></ul><ul><li>- Treatment of sinus disease. </li></ul>
  27. 27. Complications of sinusitis <ul><li>Classification </li></ul><ul><li>A . Orbital complications. </li></ul><ul><li>B . Cranial complications : </li></ul><ul><li>1. Osteomylitis. </li></ul><ul><li>2. Subperiosteal abscess ( Pott's puffy tumour ). </li></ul><ul><li>3. Fistula formation . </li></ul><ul><li>C . Intracranial: </li></ul><ul><li>1. Extradural abscess . </li></ul><ul><li>2. Meningitis . </li></ul><ul><li>3. Cavernous sinus thrombosis . </li></ul><ul><li>4. Brain abscess ( frontal lobe). </li></ul><ul><li>N . B . Cranial and intracranial complications often follow acute frontal sinusitis . </li></ul>
  28. 28. <ul><li>D . Descending infection : </li></ul><ul><li>1. Acute otitis media . </li></ul><ul><li>2. Laryngitis . </li></ul><ul><li>3. Pharyngitis . </li></ul><ul><li>4. Bronchitis and asthmatic attacks . </li></ul><ul><li>5. Gastro-intestinal troubles as anorexia and dyspepsia . </li></ul><ul><li>E . General : </li></ul><ul><li>Symptoms of septic focus as arthritis and nephritis. </li></ul><ul><li>F . Mucocel </li></ul>
  29. 29. Mucocel <ul><li>Definition : </li></ul><ul><li>an expansion of a sinus by accumulation of mucoid secretion . </li></ul><ul><li>Etiology : </li></ul><ul><li>1 . Chronic fronto-etmoiditis . </li></ul><ul><li>2 . Osteoma obstructing the ostium . </li></ul><ul><li>3 . Post traumatic ostial stenosis . </li></ul><ul><li>Pathology : </li></ul><ul><li>- Sites -> frontal -> frontoethomidal -> sphenoid. </li></ul><ul><li>- Mechanism: Ostium obstruction -> secretions retention -> cysti expansion & thinning out of walls -> wall destroyed with displacement of surroundings . </li></ul>
  30. 30. <ul><li>Clinical picture: </li></ul><ul><li>Swelling: - Site : * Inner canthus (ethmoid). </li></ul><ul><li>* Medial ½ of orbital roof (frontal) . </li></ul><ul><li>- Slowly progressive . </li></ul><ul><li>- Painless . </li></ul><ul><li>- Hard or egg - shell crackling sensation. </li></ul><ul><li>- Proptosis; the direction depends on the affected sinus. </li></ul><ul><li>- When infected, forms mucopyocele : * Skin over -> inflamed . </li></ul><ul><li>* Tenderness. </li></ul><ul><li>* Rupture -> fistula formation . </li></ul><ul><li>Investigations : </li></ul><ul><li>1 . X - ray sinus view -> - Opacification . </li></ul><ul><li> - Loss of scalloped appearance of the frontal sinus . </li></ul><ul><li>2 . CT scan . </li></ul><ul><li>Treatment : Surgery; evacuation of mucocel with adequate drainage to avoid recurrence. </li></ul>

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