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Line drawing of the sagittal view of the lateral nasal wall indicating
the approximate location of the major sensory nerves.
Diagnostics
Anamnesis (trauma). General examination of the face
Anterior and posterior rhinoscopy it is possible to see the deformity
of nasal septum either in cartilaginous or in bony parts or in both septum
parts:
S-like, arched, angled-like deformity; ridge or spur of the septum.
The anemization of a nasal mucous lining (by a cotton tip applicator
moistened with lidocain+adrenalin 1:10 solution) for best visualization of
deeper departments of the nasal cavity;
Probing of the nose after anemization by the cotton tip applicator.
X-ray.
Treatment
Nasal septum deformity is treated by a surgical
method only. Indications for septoplasty are the
nasal congestion and full airway obstruction, or
presence of other complications.
There are several variants and methods of
operation. The most accepted surgical methods are:
Radical submucous nasal septum resection (Killian
approach).
The sparing operations (Voyachec approach):
a/ mobilization;
b/ redresation;
c/ circular resection;
d/ partial resection
Clinic
Complications
Lymphadenitis of cervical lymphatic nodes.
Thrombosis of facial veins.
Thrombosis of cavernous sinus of brain is
the most serious complication of the
furuncle. It appears due to spreading of
inflammatory thrombosis from facial veins to
the cerebral sinuses (through anastomosis
between angular vein - the branch of facial
vein and ophthalmic vein from
cavernous sinus).
Treatment
1. Greasing of a skin by antiseptics ointments, or ointments with
antibiotics and corticosteroids.
2. Surgical incision of furuncle (after appearance of purulent apex) with
draining by rubber band.
3. Anti-inflammatory drugs.
4. Antibacterial therapy (antibiotics - better passing through blood brain
barrier).
5. Physical therapy procedures (fonoforesis with ointments) at the end of
disease.
Patients with the furuncle of nose must be treated in hospital.
Care of patient
Progressing edema of patients face soft tissue has to disturbance
medical personal, as well as changes of consciousness and septic sings:
fever with chills and sweating all over, strengthening of headache,
appearance of meningeal signs, dizziness, and vomits. Appearance of
such pathological sings indicates on development of intracranial
complications.
Prophylaxis
1. Tempering of organism.
2. Medical treatment of acute rhinitis.
3. Medical treatment of endocrine diseases (diabetes).
Pathogenic organisms:
viruses (adenoviruses, rhinoviruses) - at the beginning of the
disease (1-3 days);
staphylococci and streptococci;
Bacteria: H. influenza, Ps. aerogenosa, M. catarhalis.
Acute rhinitis is very contagious disease. The spreading way is
mainly air-drop, but contact transmission (through hands,
crockery, objects) is possible too. The incubation period is 1-3
days. The bacterial super infection often joins to the viral
infection (mainly gram positive cocci flora). The immunity to
viruses lasts out only short time after convalescence so its
possible to have reinfection of same virus.
Attend factors
Cooling of the organism;
Breathing with heated or dry air;
Other defects in the nose and throat (allergy, septum deformity)
Low general resistance of organism;
Stresses.
Diagnosis of Acute
Rhinosinusitis, Major and
Minor Factors
Major Factors
Minor Factors
Facial pain/pressure
Headache
Facial congestion/fullness
Fatigue
Nasal obstruction/blockage
Halitosis
Dental pain
Hyposmia/anosmia
Cough
Earpain/ pressure/
fullness
Fever
Clinic
can be divided in three stages:
1. Dry stage lasts from few hours to few days. At the beginning of disease
there is easy indisposition. Dryness and tickling in the nose, sneeze, easy
pain in the throat and feeling of head compression can be marked.
Progressing nasal congestion begins in the first stage and continues in
second and third stages. The mucous lining of the nasal cavity gets a
purple-red color and acutely infiltrates.
2. Stage of serosous excretions is characterized by abundant watery
excretions from the nose. The patient also suffers from full nasal obstruction,
headache, sub febrile temperature, and hyposmia. The nasal discharge is
thin and plentiful, it irritates the skin around the nose. Then discharges
become more tick. Second stage lasts 2-4 days.
3. Stage of mucous-purulent excretions. In this stage the quantity of
excretions diminishes, they become mucus and purulent (adding of bacterial
infection) . This stage lasts 2-4 days.
In next 6-12 days (eventual phase) the symptoms of lowering infection can
appear causing the inflammation of throat and larynx, that shows up pain
in a throat, hoarse of voice, cough and others like that.
If in an inflammatory process spreads to paranasal sinuses, pain in the area
of their projection appears (brow, bridge of the nose, cheeks). If
inflammation spreads to the Eustachian tube, fullness in the ear and hearing
loss appear.
Complications
Acute sinusitis.
Acute otitis media.
Acute pharyngitis.
Acute laryngitis.
Acute tonsillitis
Pneumonias and others like that.
Furuncle of the external nose.
Possible transition in chronic rhinitis.
Medical Treatment
At the beginning of disease his development can be stopped by
means sudorific medication (hot mustard baths on feet, for
children - paraffin socks). Decongestants drops in the nose
(0,1 % solutions of naphthyzin, galazolin, sanorin, rhinozolin).
These medications improve the nasal breathing, save
permeability of opening between paranasal sinuses and nasal
cavity, and reduce mucous lining edema of the Eustachian tube.
The term of decongestants drops administration must not
exceed a 1 week. More prolonged use of these medications
can develop the medicinal rhinitis.
Antihistamines and decongestants help relieve the symptoms of
a "cold," but time alone cures it. In persons with headache
analgesics are prescribed (paracetamol, analgil, ascofen and
others like that). Medications in the aerosol packing are used:
ingalipt, cameton; and also inhalation of hot air and irrigation of
nasal cavity by antiseptic solutions (decoctions of medical
flowers and leafs - 10 g on 200 the ml boiled water). Physical
therapy procedures are also applied.
Rhinitis in newborns
is always heavy disease, as their protective mechanism is not
enough developed. Babies carry difficulty of the nasal breathing
heavier, than senior children, as, except for violation of breathing, a
cold hinders still and pectoral feeding.
This disease presents a special danger to babies. The nasal
meatuses in infants are very narrow, and nasal obstruction is very
likely to follow even a minor swelling of the mucosa.
Apart from disorders due to the absence of nasal respiration, such
as excitability, broken sleep, etc., nasal obstruction may often lead
to emaciation of the baby, which is unable to suck at the breast
normally
Clinic
The temperature of body is often high. There can be meningeal
symptoms, quite often the violated function of the digestion system
is observed (vomits, diarrhea). At the heavy cases the inflammation
of pharyngeal tonsil can occurred (adenoiditis). Other
complications are the inflammations of ear, throat, lungs and
others like that.
diagnostic
The anemization probe is used. The nasal lining is
smeared by vasoconstrictor solutions (adrenalin,
naphthyzin and others like that). In patients with
catarrhal rhinitis the nasal lining become thinner and
nasal breathing becomes better; in patients with
hypertrophy rhinitis the hypertrophy places do not
change and breathing either not becomes better, or
get better only in insignificant measure.
Chronic hypertrophy rhinitis can complicate by
appearance of polypes, especially when allergy
present, so chronic polipous rhinosinusitis can
develop. In rare cases malignant growth can occur, so
a morphological examination is needed.
Medical Treatment
This may be local or general. Above all, the underlying
cause of disease should be found out and should be
eradicated, if possible. Liquidation of inflammation focus,
that can be located near to the nose or alongside should be
done (medical treatment of carious teeth, chronic tonsillitis,
adenoids, chronic sinusitis and others like that). The
presence of any nasal deformity should be eradicated.
Physician should advise patients to avoid the harmful
factors of external environment (even to change the
unhealthy job), to eliminate smoking of tobacco, drinking
and to keep to a diet. If necessary, medical treatment of
internal diseases is administrated (hearts, stomach, kidney,
and others like that). If allergy present, the expose of
allergen is needed to avoid the contact with it. Antiallergic
medical treatment is prescribed. Antihistamines and
decongestants help relieve the symptoms of a "cold". In
cases with fever, antibiotics may have to be used after
culture and sensitivity test of the nasal discharge have been
done.
The treatment of those patients may only be symptomatic, it aims to irritate nasal mucous
membrane to increase production of mucus. It relieves dryness and crusting in the nose by
alkaline douches with subsequent application of iodine glycerol solution, ointments or menthol oil.
The nose may also be cleansed of crusts by warm alkaline spray. Below are the formulae of the
alkaline solution and some of the drops and ointments commonly used:
Rp. Jodi puri 0.05-0.1 ""
Kalii jodati 0.2
Glycerini
Aq. destill. aa 5.0
01. Menthae pip. gtt. 1
DS. Five drops in each nostril twice a day
#
Rp. Mentholi crystallisati 0.1
01. Provincialis 20.0
DS. Five drops in each nostril twice a day
#
Rp. Natrii bicarbonici 60.0
Natrii biborici 30.0
Natrii chlorati 10.0
01. Menthae pip. gtt. V
M. f. pulv.
DS. One teaspoonful in a glass of water for a nasal douche
enzymes (0,001 g tripsin on 50 ml isotonic solution) or mineral waters (Glade of cvasova,
Borgom and others like that. ). After cleaning conduct instilyatsii vegetable butters with
tocoferolom and retinolom; useful butters of sea-buckthorn and wild rose. Appoint electroforez
nicotine acid or potassium of iodide on the area of neck or nose and navcolonosovih bosoms.
Enough effective there is in the conditions of warm moist climate.
Neurovegetative form of
vasomotor rhinitis
describes a nonallergic "hyperirritable nose" that
feels congested, blocked, or wet.
The mucosa of the nose have an abundant supply
of arteries, veins, and capillaries, which have a
great capacity for both expansion and
constriction. Normally these blood vessels are in
a half-constricted, half-open state. But when a
person exercises vigorously, his/her hormones of
stimulation (i.e., adrenaline) increase. The
adrenaline causes constriction or squeezing of
the nasal mucosa so that the air passages open
up and the person breathes more freely.
Attend factors
VASOMOTOR RHINITIS
Rhinitis" means inflammation of the nose
and nasal mucosa. "Vasomotor" means
blood vessel forces. Two forms are
distinguished:
Neurovegetative;
Allergic.
Clinic.
Vasomotor rhinitis is characterized by intermittent attacks with
very brief and sometimes long periods of relief. The attacks, very
violent at times, are accompanied by prolonged paroxysms of
sneezing, nasal obstruction and profuse, mostly watery,
discharge from the nose or postnasal drip. Many patients have
additional symptoms of lacrimation, itching of the eyes, nasal
interior and hard palate, and headache.
Rhinoscopia.
Turbinates may be enlarged.
Edema of nasal mucous lining.
Mucus-watery or foamy excretions in nasal meatuses a
generous amount.
Bluish or cyanotic color of nasal mucous lining with white or gray
spots on it (Voyachec spots).
In the intervals between the attacks, all morbid symptoms may
utterly disappear, so there may be no rhinoscopic sign at all. But
in protracted cases, the swelling of the nasal mucosa may
become stable or turn into hyperplasia, as in chronic rhinitis.
Sinusitis
Basic Anatomy
Two cavities divided by the
septum; each with medial
and lateral nasal walls
Four paranasal sinuses in
pairs
Normal Function =
ventilation and drainage
Ventilation requires healthy
ostia and pathways
Normal Drainage depends
on secretion and transport
of mucus
Largely speculative
The pneumatised cavities of the bone of the skull reduce
weight
During normal respiration the air is warmed and
moistened during its passage in the nose
The sinuses are lined by mucosa and cilia that assist in
self-cleaning and defense
Sinus Drainage
Two distinct transportation
routes along the lateral
nasal wall:
anterior and
posterior osteomeatal
complex
Both pathways drain into
the nasopharynx
Osteomeatal Complexes
Anterior
Ethmoid Sinus Cells
Frontal Sinus and Recess
Ethmoidal Infidubulum
Middle Meatus
Maxillary Sinus and Ostium
Uncinate Process
Posterior
Posterior Ethmoid Sinus
Sphenoid Sinus
Ethmoidal Labyrinth
Six to ten air-containing
cells; total volume of approx.
3ml; fully formed at birth
Anterior and posterior
chambers are distinguished
with different drainage
pathways
Ethmoid Bulla - Largest
anterior ethmoid cell
Agger Nasi Cell - anterior
bulge caused by the
insertion of the middle
turbinate
Frontal Sinus
Not well formed at birth,
growth is completed by age
14-18years
Septum between two sides
Drains via the frontal recess to
the middle meatus
Frontal recess narrow space
with high clinical significance
hourglass shaped with its
narrowest portion at the frontal
sinus opening
Posterior boundary anterior
cranial fossa
Maxillary Sinus
Largest Sinus with average
size of 15ml
The pair often develops
asymmetrically
The sinus usually consists of
one chamber only
The ostium opens into the
nose in the middle meatus
Superior boundary is the
orbital wall, the floor is related
to tooth roots
Sphenoid Sinus
Most posterior of all sinuses
Marked individual variations in
shape and size with capacity
of 0.5 - 3ml
May be totally absent in 3-5%
of patients
Does not begin to develop until
the age of 6 yo
Can present with intra-sinus
septations
Drains with the posterior
ethmoid cells to nasopharynx
Turbinates
Bony shelves in the nasal
cavity
Inferior, middle and
superior (at times,
supreme)
Airflow and defense
mechanism
Only inferior and middle
turbinates are seen with
speculum
Examined for colour,
masses, discharge,
swelling and lesions
Middle Turbinate
Part of middle meatues
where maxillary, frontal
and anterior ethmoid
sinuses drain
Any deviation and
disease can obstruct
natural drainange
pathways
Swollen turbinates with
inflammed mucosa often
indicate unlerlying
diseases
Inferior Turbinate
Easily visible via
speculum view
Examination is often
under headlight
Enlargement of turbinate
can cause chrosnic nasal
obstruction
Bone can thickens and
mucosa can swell to
narrow nasal airspace
Sinus Mucosa
Sinuses are Lined with
Cilia Which Beat to
Transport Mucous Through
and Out of the Sinuses
Bacterial Infection Can
Cause Changes to Occur
Including Swelling of the
Mucousal Lining
Cilia Cease to Function
Properly
Ostium Closes trapping
Mucous Inside Sinus
Cavity
Ethmoidal Prechambers
Drainage of the
maxillary,ethmoid and
frontal sinuses via their
ostia and very narrow
chambers before entering
the middle meatus ethmoidal infindibulum
and the frontal recess
Bacterial infection,
allergies, polyps etc. can
cause swelling and
stenosis of these very
narrow channels
Pathogenesis
Viruses
Bacteria
Mixed infections with fungi present
Allergies
Diseased tooth roots
Anatomical variations deviated septum, uncinate
process, turbinates, pneumatised ethmoid bulla and
agger nasi etc.
Diagnosis
Treatment
Conservative
Decongestants
Antibiotics
Aspiration and lavage
Irrigation (maxillary and frontal sinuses)
Surgical
Minimally invasive sinus surgery
Summary
Complex Anatomy
Four interconnected sinuses
Turbinates large
importance
Distint drainages pathways
Change in mucosa and
obstruction of pathways can
be an underlying cause for
sinus disease