Diseases of the Nose & Sinuses Khalid H. Al-Sebeih, Khalid H. Al-Sebeih, MD, MD, FRCSC, ABO FRCSC, ABO Assistant Professor, Department of Assistant Professor, Department of Surgery Surgery Faculty of Medicine, Kuwait University. Faculty of Medicine, Kuwait University. Department of Otolaryngology, Sabah Department of Otolaryngology, Sabah Hospital Hospital
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Diseases of the Nose & Sinuses Khalid H. Al-Sebeih, MD, FRCSC, ABO Assistant Professor, Department of Surgery Faculty of Medicine, Kuwait University. Department.
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Diseases of the Nose & Sinuses
Khalid H. Al-Sebeih, Khalid H. Al-Sebeih, MD, FRCSC, MD, FRCSC, ABOABO
Assistant Professor, Department of Surgery Assistant Professor, Department of Surgery
Faculty of Medicine, Kuwait University.Faculty of Medicine, Kuwait University.
Department of Otolaryngology, Sabah HospitalDepartment of Otolaryngology, Sabah Hospital
Nasal obstruction caused by overuse of topical decongestants or a systemic medications.
Rebound vasodilatation after prolonged vasoconstriction with topical agents
Tx: discontinuation of the offending medication antihistamine-decongestant combinations topical nasal corticosteroids +/- tapering oral
prednisone dosage for 7 to 10 days. gentle submucosal Kenalog-40 injection!!
Rhinitis Medicamentosa
Allergic Rhinosinusitis Type I hypersensitivity reaction.
Occur 2 to 5 minutes of antigen-antibody reaction.
A second (late) phase: result of mediator release from cells (neutrophils, eosinophils) and occurs about 4 to 6 hours after the acute phase.
Sx: tching, sneezing, rhinorrhea, and postnasal drainage (throat-clearing and cough). Seasonal or perennial, & linkage with known exposure to allergens.
“allergic shiners”and puffiness around the eyes. high arched palate, prominent pharyngeal lymphoid
Dx Nasal smears (Hansel’s stain) eosinophils (> 25% of
the cells). total IgE Skin test
Allergic Rhinosinusitis
Management: Level I: Prevention and Control of Symptoms.
Environmental Control First-line Pharmacotherapy:
a) Antihistamines compete with histamine for H1-receptor sites on the target organs during the allergic response
b) Decongestants are sympathomimetic substances that cause vasoconstriction within turbinate stroma, producing shrinkage of congested tissue (Pseudoephedrine & Phenylpropanolamine)
c) Cromolyn nasal spray stabilizes and protects mast cells from degranulation
Level II: Recognition and Management of Complicating Factors Treat other types of rhinitis: vasomotor, medicamentosa…
Allergic Rhinosinusitis
Level III: Corticosteroids for Control of Severe or Chronic Symptoms
Level IV: Immunotherapy symptoms are not controlled with
pharmacotherapy, allergens that cannot be avoided, symptoms span two or more allergy seasons, willing to cooperate in a program of immunotherapy
parenteral administration of antigens formation of allergen-specific IgG-blocking antibodies compete with IgE antibodies for target sites on mast cells or basophils.
Allergic Rhinosinusitis
Paranasal Sinusitis 3 factors essential to normal physiology of the paranasal
sinuses: patency of the ostia, function of the cilia, & quality of the nasal glandular secretions.
Most significant pathophysiology that produces sinusitis: mucosal edema in and around the sinus ostium:
Hypooxygenation of the involved sinus. Ciliary function is disturbed stagnation of the secretion. Local host resistance factors are diminished
darainage & perfect milieu for the growth of bacterial pathogens
Inflammation (e.g. allergic rhinitis, URTI..) increased secretions and edema in the sinonasal mucosa.
Classification1. Acute: infectious lasting from 1 day up to 4
weeks. Management is medical, and rarely surgical treatment.
2. Subacute: infection lasts from 4 weeks to 3 months. inflammatory process is still reversible Medical management.
3. Chronic: sinusitis persists longer than 3 months. Results from acute sinusitis that has been either inadequately treated or completely untreated. The process is irreversible surgical treatment is indicated.
Paranasal Sinusitis
Acute sinusitis: Bacterial:
Adults: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus pyogenes groups ABC, and Haemophilus influenzae (gram-negative).
Children: S. pneumoniae, Branhamella catarrhalis (formerly known as Neisseria catarrhalis), Haemophilus influenzae, Streptococcus pyogenes groups A and C, and Streptococcus pyogenes a-hemolytic type
Paranasal Sinusitis
Management 1. Antibiotics clinical improv. In 2-3 days, Ab should continue for 10-14 days
Penicillin G Amoxicillin Cefaclor Trimethoprim sulfate Erythromycin sulfate Augmentin
2. Analgesics3. Mucolytics4. Saline irrigations5. Topical decongestion edema around the ostia oxygenation and facilitate drainage (reverse the
hypoxia)6. Shrinkage and suction with Argyrol: packing the nose removal of pus & oxygenation7. Surgical management: presence of mucopurulent material in immunosuppressed pt , pt with acute
max. sinusitis, no Improvement or worsening of symptoms.
Complications Mucocele
chronic, cystic lesion of the paranasal sinuses. Expand slowly and concentrically bony erosion & extrasinus expansion.
Most common in the frontal sinus.
Sx: frontal headache and proptosis, displacement of the globe in a downward and outward direction and diplopia but no nasal obstruction and rhinorrhea
Tx: surgery
Complications classification (Chandler):
1. Inflammatory edema — lid edema; no limitation of extraocular movement with normal acuity
2. Orbital cellulitis — diffuse edema of orbital contents; no discrete abscess formation
3. Subperiosteal abscess —purulent collection beneath periosteum of lamina papyracea; displacement of globe downward and laterally
4. Orbital abscess—purulent collection within orbit; proptosis and chemosis with ophthalmoplegia and decreased vision