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THE NOSE AND PARANASAL SINUSES
Reda Kamel Professor of Rhinology Cairo
University Egypt
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• Undergraduate, The Nose, November, 2004

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Sinusitis, cysts, Tumors
Reda Kamel Professor of Rhinology Cairo
University Egypt
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• Undergraduate, The Nose, November, 2004

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Investigations Differential diagnosis

• The state of the art
• Endoscopy
• CTcomputed tomography no Plain X-ray
• Culture
• Biopsy
• Acoustic Rhinometry anatomy
• Rhinomanometry physiology

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Investigations Differential diagnosis
Endoscopy
CT
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Diagnostic Endoscopy Advantages

• Nasal Speculum X Nasal Endoscopy
• The state of the art and gold standard

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Diagnostic Endoscopy Advantages
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Diagnostic Endoscopy Procedure
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Diagnostic Endoscopy Pathology
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Computed tomography Advantages

• Plain X-ray X Computed tomography
• The state of the art and gold standard

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Sinusitis Acute sinusitis

• Definition
• Acute inflammation of the mucous membrane of the
  nose and paranasal sinuses
• Causative organisms
• Streptococcus Pneumoniae
• Hemophilus Influenza
• Morexella Catarallis
• Pathology
• Acute catarrhal sinusitis
• Acute Suppurative sinusitis

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Sinusitis Acute sinusitis

• Etiology
• Nasal
• Acute rhinitis
• Foreign body
• Nasal pack
• Diving swimming
• Dental Infection extraction of the 2nd
  premolar and 1st molar tooth ? Oro-antral
  fistula !
• Traumatic
• Fracture maxilla
• Foreign body in sinus

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Sinusitis Acute sinusitis

• Predisposing factors
• General
• Low resistance
• Bad hygiene
• Overcrowding
• Allergy
• Local
• nasal obstruction retained discharge
  infection
• Deviated septum
• Polypi
• Adenoids in children

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Sinusitis Acute sinusitis

• Symptoms
• General fever, headache, malaise, anorexia.
• Local
• Nasal obstruction
• Mucopurulent discharge, anterior posterior
  foetid in dental origin
• Smell affection
• Pain over the affected sinus referred

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Sinusitis Acute sinusitis

• Signs
• Mucosal congestion,
• Purulent discharge at OMC
• Tenderness at the affected sinus
• Investigations
• Endoscopy
• Tran-illumination
• Culture
• CT complications only

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Sinusitis Acute sinusitis

• Treatment
• Medical
• Antibiotics
• Analgesic
• Decongestant nasal drops
• Surgical
• Only in case of complications FESS

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Sinusitis Acute sinusitis

Dr. TTT
Organism
Patient
Resistance
Virulence
Chronic
Cure
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Sinusitis Acute sinusitis
Acute sinusitis
Chronic sinusitis
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Sinusitis Chronic sinusitis

• Healthy Sinus needs proper ventilation i.e.
  aeration and good drainage of the secretions.

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Sinusitis Mucociliary Clearance MCC

• The MCC system of the upper respiratory tract is
  taking a predetermined pathway.
• The MCC of the maxillary sinus is in a star
  shape manner towards the natural ostium i.e.
  antigravity.
• The MCC of the frontal sinus is again towards
  the natural ostium.

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Sinusitis Mucociliary Clearance MCC

• The maxillary sinus drains through the natural
  ostium towards the anterior ethmoids.
• The frontal sinus drains through the natural
  ostium towards the anterior ethmoids.
• The anterior ethmoids then drains into the
  middle meatus to the nasal cavity.

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Sinusitis Ostiomeatal Complex OMC

• Blockage at the OMC anterior ethmoid middle
  meatus complex leads to secondary affection of
  the maxillary and frontal sinuses.
• Lack of drainage and aeration leads to
  collection of secretions and formation of polyps
  i.e. chronic sinusitis.

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Ostiomeatal complex OMC
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Ostiomeatal complex OMC
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Ostiomeatal complex OMC






Frontal ostium
HSI
Infundibulum
Maxillary ostium
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Chronic sinusitis

• Symptoms
• Nasal obstruction
• Mucopurulent discharge, anterior posterior
  foetid in dental origin
• Smell affection
• Headache
• Signs
• Mucosal congestion at OMC
• Purulent discharge at OMC

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Chronic sinusitis

• Investigations
• Endoscopy
• CT
• Tran-illumination
• Culture

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Chronic sinusitis
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Ethmoiditis
Polyps
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Chronic sinusitis

• CT
• Coronal cuts

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Sinusitis and the middle ear

• Pus from the paranasal sinuses pass posteriorly
  towards the nasopharynx.
• Passage of the pus along the Eustachian tube
  orifice leads to secondary otitis media.
• Treatment of the chronic sinusitis properly
  leads to spontaneous cure of the ear.

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Chronic sinusitis

• Treatment
• Medical
• Antibiotics
• Decongestant nasal drops
• Mucolytics
• Surgical
• Only in case of failure of comprehensive medical
  therapy or complications FESS

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Sinusitis Treatment

• Conventional
• Every sinus alone
• Inferior meatal antrostomy IMA.
• Theory of gravity
• Opening in the inferior meatus.
• This is not effective and is the cause of
  recurrence due to MCC towards the natural ostium.

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Sinusitis Treatment

• Conventional
• Radical antrum operation
• Irreversible pathology theory. Sublabial
  incision, removal of all the sinus mucosa and
  inferior meatal antrostomy.

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Sinusitis Treatment

• Conventional
• Radical antrum operation This is not effective
  and is the cause of recurrence. Due to loss of
  the precious natural mucosa and healing by
  fibrosis with no effective MCC.

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Functional Endoscopic Sinus Surgery FESS

• All the sinuses are taken care of simultaneously
• Aim of work
• To re-establish
• Aeration.
• Drainage.
• Of the sinuses

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Functional Endoscopic Sinus Surgery FESS

• All the sinuses are taken care of simultaneously
• 1- Ethmoidectomy Polypectomy.
• 2- Middle meatal antrostomy.
• 3- Frontal recess clearance.
• 4- Sphenoidotomy.

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Functional Endoscopic Sinus Surgery FESS

• OMC blockage

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Functional Endoscopic Sinus Surgery FESS

• 1,a- Polypectomy
• Removal of the polyps in the nose and middle
  meatus.

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Functional Endoscopic Sinus Surgery FESS

• 1,a- Polypectomy
• Removal of the polyps in the nose and middle
  meatus.

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Functional Endoscopic Sinus Surgery FESS

• 1,b- Ethmoidectomy
• Opening and removal of the bulla ethmoidalis
  anterior ethmoids.

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Functional Endoscopic Sinus Surgery FESS

• 1,b- Ethmoidectomy
• Opening and removal of the bulla ethmoidalis
  anterior ethmoids.

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Functional Endoscopic Sinus Surgery FESS

• 2- Middle meatal antrostomy MMA
• Widening of the natural maxillary ostium in the
  middle meatus.
• Cleaning of the maxillary sinus off the
  secretions and polyps.
• The maxillary sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 2- Middle meatal antrostomy MMA
• Widening of the natural maxillary ostium in the
  middle meatus.
• Cleaning of the maxillary sinus off the
  secretions and polyps.
• The maxillary sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 2- Middle meatal antrostomy MMA
• Widening of the natural maxillary ostium in the
  middle meatus.
• Cleaning of the maxillary sinus off the
  secretions and polyps.
• The maxillary sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 2- Middle meatal antrostomy MMA
• Widening of the natural maxillary ostium in the
  middle meatus.
• Cleaning of the maxillary sinus off the
  secretions and polyps.
• The maxillary sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 3- Frontal recess clearance
• Cleaning of the frontal recess at the frontal
  ostium off the polyps.
• Cleaning of the frontal sinus off the secretions
  and polyps.
• The frontal sinus mucosa is left intact
  frontal ostium not touched.

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Functional Endoscopic Sinus Surgery FESS

• 3- Frontal recess clearance
• Cleaning of the frontal recess at the frontal
  ostium off the polyps.
• Cleaning of the frontal sinus off the secretions
  and polyps.
• The frontal sinus mucosa is left intact
  frontal ostium not touched..

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Functional Endoscopic Sinus Surgery FESS

• 3- Frontal recess clearance
• Cleaning of the frontal recess at the frontal
  ostium off the polyps.
• Cleaning of the frontal sinus off the secretions
  and polyps.
• The frontal sinus mucosa is left intact
  frontal ostium not touched..

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Functional Endoscopic Sinus Surgery FESS

• 3- Frontal recess clearance
• Cleaning of the frontal recess at the frontal
  ostium off the polyps.
• Cleaning of the frontal sinus off the secretions
  and polyps.
• The frontal sinus mucosa is left intact
  frontal ostium not touched..

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Functional Endoscopic Sinus Surgery FESS

• 4- Sphenoidotomy
• Widening of the natural sphenoid ostium.
• Cleaning of the sphenoid sinus off secretions
  and polyps.
• The sphenoid sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 4- Spenoidotomy
• Widening of the natural sphenoid ostium.
• Cleaning of the sphenoid sinus off secretions
  and polyps.
• The sphenoid sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 4- Spenoidotomy
• Widening of the natural sphenoid ostium.
• Cleaning of the sphenoid sinus off secretions
  and polyps.
• The sphenoid sinus mucosa is left intact.

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Functional Endoscopic Sinus Surgery FESS

• 4- Spenoidotomy
• Widening of the natural sphenoid ostium.
• Cleaning of the sphenoid sinus off secretions
  and polyps.
• The sphenoid sinus mucosa is left intact.

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FESS
video
Endoscopic Pansinus Surgery Debrider
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Functional Endoscopic Sinus Surgery FESS

• All the sinuses are taken care of simultaneously
• 1- Ethmoidectomy Polypectomy.
• 2- Middle meatal antrostomy.
• 3- Frontal recess clearance.
• 4- Sphenoidotomy.

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Functional Endoscopic Sinus Surgery FESS
Complications of FESS 1- Orbital optic nerve
injury 2- Intracranial CSF leak 3-
Bleeding 4- Adhesions 5- Recurrence
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Sinusitis Complications

• Spread of infection
• Orbital
• Cranial
• Intracranial
• Septic focus
• Descending infection

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Sinusitis Complications

• Spread of infection
• A- Orbital
• Sub-periosteal abscess
• Orbital cellulitis
• Panophthamitis
• Cavernous sinus thrombosis

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Sinusitis Complications

• Spread of infection
• B- Cranial Frontal
• Osteomyelitis
• Subperiosteal abscess Potts puffy tumor
• Fistula

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Sinusitis Complications

• Spread of infection
• C- Intracranial
• Extradural abscess
• Meningitis
• Cavernous sinus thrombosis
• Brain abscess

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Sinusitis Complications

• Spread of infection
• D- Descending Infection
• Acute otitis media
• Pharyngitis
• Laryngitis
• Bronchitis
• Asthma
• GIT troubles

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Sinusitis Complications

• Spread of infection
• E- Septic focus
• Definition
• Septic foci
• General
• Local

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Sinusitis Complications

• Spread of infection
• E- Septic focus
• Definition A focus of infection causing
  bacteraemia or toxaemia due to absorption of
  toxics and bacteria
• Septic foci Tonsils, sinuses, teeth, appendix,
  Gall bladder, Prostate, fallopian tube.
• General Rapid fatigue, ill health, anorexia,
  loss of wieght
• Local optic neuritis, iritis, carditis,
  prostatitis, oovaritis, arthritis, ostiomyelitis,
  myocytis, fascitis.

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Cysts of the Sinonasal area

• Congenital cyst Dermoid cyst, midline, nasal
  bridge, punctum
• Developmental nasoalveolar cyst, nasopalatine
  cyst
• Odontogenic cysts
• Dental cyst Dental caries adults
• Dentigerous cyst un-erupted tooth children
• Others
• Haemorrhagic bone cyst unlocular
• Aneurysmal bone cyst multilocular
• Mucocele

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Cysts of the Sinonasal area

• Congenital cyst
• Developmental
• Odontogenic cysts
• Others
• Mucocele
• cystic expansion of the ethmoid or frontal
  sinuses or both
• Caused by ostium obstruction or retention cyst of
  a gland in sinus
• Soft, cystic swelling with egg-shell crackling
  sensation
• Proptosis down, lateral or both
• Treatment endoscopic marsupialization

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Sinonasal tumors Classification

• 1- Benign
• A- Epithelial -Papilloma -Inverted
  papilloma -Adenoma
• B-Non-epithelial -Hemangioma -Ostioma
  -Fibrous dysplasia
• -Chondroma -Meurofibroma
• 2- Intermediate
• A-Epithelial -Ameloblastoma
• B-Non-epithelial -Giant cell tumor
• 3- Malignant
• A-Epithelial -Squamous cell ca Adenoid
  cystic ca
• -Melanoma Olfactory neuroblastoma
• Mucoepidermoid tumor Anaplatic ca
• B-Non-epithelial -Ostiosarcoma Angiosarcoma
  Rhabdomyosarcoma -Fibrosarcoma

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Sinonasal tumors Symptoms

• 1-Benign
• Nasal
• Extension
• Expansion
• 2-Malignant
• Nasal
• Extension
• Erosion
• Lymph nodes
• Metastasis

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Sinonasal tumors Symptoms

• A- Nasal
• Obstruction
• Discharge
• Headache
• Pain
• Bleeding
• Bad odor

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Sinonasal tumors Symptoms

• B- Extension
• Medialnasal
• Inferiororal
• Lateralorbital, fossa
• Superiorcranial
• Anteriorsublabial
• Posterior nasopharynx

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Sinonasal tumors

• Investigations
• Endoscopy
• CT MRI
• Biopsy

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Sinonasal tumors

• Inverted Papilloma
• Lateral nasal wall
• Recurrence
• Malignant association
• Malignant transformation
• Endoscopic Excision

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Conservative Transnasal Endoscopic Surgery in
Inverted Papilloma
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Transnasal Endoscopic Medial Maxillectomy
Inverted Papilloma
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Sinonasal tumors
Haemangioma Epistaxis 1- Capillary Septal
polyp Endoscopic excision 2- Cavernous Lateral
wall mass Endoscopic excision 3-Telangiectasia Her
idofamilial Multiple nodules Osler-Rendo
disease Endoscopic Laser
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Sinonasal tumors

• Ostioma
• Hard
• 1- Cancellous
• -Ethmoidal
• -Endoscopic excision
• 2- Compact
• -Frontal
• -External approach
• Gardner syndrome
• Multiple
• Intestinal polyposis

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Transnasal Endoscopic Surgery in Sinonasal Osteoma
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Transnasal Endoscopic Surgery in Sinonasal Osteoma
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Sinonasal tumors

• Fibrous dysplasia
• Bone fibrous tissue
• Developmental
• 1- Mono-ostotic
• 2- Poly-ostotic
• Stops after ossious maturity
• Shaving if symptoms
• Albright Syndrome
• Polyostotic unilateral
• Pigmentation endocrinology

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Fibrous dysplasia
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Sinonasal tumors

• Squamous cell carcinoma
• Wood Nickel
• Bleeding on touch
• Bad prognosis
• Operable
• External approach
• Radiotherapy
• Chemotherapy
• In-operable
• Palliative therapy

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Sinonasal tumors
Squamous cell carcinoma
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Knowledge is power
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