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Presentation Transcript

Slide1: 

R و ما أوتيتم من العلم الا قليلا رضا كامل أستاذ أمراض الانف و الجيوب الانفية كلية الطب - جامعة القاهرة

Slide2: 

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

Slide3: 

R Allergy, polyps and Septum Reda Kamel Professor of Rhinology Cairo University – Egypt Undergraduate, The Nose, November, 2004

Investigations: Differential diagnosis: 

Investigations: Differential diagnosis The state of the art Endoscopy CT:computed tomography [no Plain X-ray] Culture Biopsy Acoustic Rhinometry [anatomy] Rhinomanometry [physiology] Reda Kamel, M.D.

Investigations: Differential diagnosis: 

Investigations: Differential diagnosis CT Endoscopy Reda Kamel, M.D.

Diagnostic Endoscopy: Advantages: 

Diagnostic Endoscopy: Advantages Nasal Speculum X Nasal Endoscopy The state of the art and gold standard R

Diagnostic Endoscopy: Advantages: 

Diagnostic Endoscopy: Advantages R

Diagnostic Endoscopy: Procedure: 

Diagnostic Endoscopy: Procedure R

Diagnostic Endoscopy: Pathology: 

Diagnostic Endoscopy: Pathology R

Computed tomography: Advantages: 

Computed tomography: Advantages Plain X-ray X Computed tomography The state of the art and gold standard R

Sinusitis: Acute sinusitis: 

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 Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

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 Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

Sinusitis: Acute sinusitis Predisposing factors: General: Low resistance Bad hygiene Overcrowding Allergy Local: nasal obstruction retained discharge infection Deviated septum Polypi Adenoids in children Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

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 Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

Sinusitis: Acute sinusitis Signs: Mucosal congestion, Purulent discharge at OMC Tenderness at the affected sinus Investigations: Endoscopy Tran-illumination Culture CT: complications only Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

Sinusitis: Acute sinusitis Treatment: Medical Antibiotics Analgesic Decongestant nasal drops Surgical Only in case of complications FESS Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

Sinusitis: Acute sinusitis Organism Patient Resistance Virulence Dr. TTT Chronic Cure Reda Kamel, M.D.

Sinusitis: Acute sinusitis: 

Sinusitis: Acute sinusitis Reda Kamel, M.D. Acute sinusitis Chronic sinusitis

Sinusitis: Chronic sinusitis: 

Sinusitis: Chronic sinusitis Healthy Sinus needs proper ventilation i.e. aeration and good drainage of the secretions. Reda Kamel, M.D.

Sinusitis: Mucociliary Clearance MCC: 

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. Reda Kamel, M.D.

Sinusitis: Mucociliary Clearance MCC: 

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. Reda Kamel, M.D.

Sinusitis: Ostiomeatal Complex OMC: 

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. Reda Kamel, M.D.

Ostiomeatal complex : OMC: 

Ostiomeatal complex : OMC

Ostiomeatal complex : OMC: 

Ostiomeatal complex : OMC R

Ostiomeatal complex : OMC: 

Ostiomeatal complex : OMC R HSI Frontal ostium Infundibulum Maxillary ostium

Chronic sinusitis:: 

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 R

Chronic sinusitis:: 

Chronic sinusitis: Investigations: Endoscopy CT: complications only Tran-illumination Culture R

Chronic sinusitis:: 

Chronic sinusitis: Ethmoiditis Polyps R

Chronic sinusitis:: 

Chronic sinusitis: CT Coronal cuts R

Sinusitis and the middle ear:: 

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. Reda Kamel, M.D.

Chronic sinusitis:: 

Chronic sinusitis: Treatment: Medical Antibiotics Decongestant nasal drops Mucolytics Surgical Only in case of failure of comprehensive medical therapy or complications FESS R

Sinusitis: Treatment: 

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. Reda Kamel, M.D.

Sinusitis: Treatment: 

Sinusitis: Treatment Conventional: Radical antrum operation: [Irreversible pathology theory]. Sublabial incision, removal of all the sinus mucosa and inferior meatal antrostomy. Reda Kamel, M.D.

Sinusitis: Treatment: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS All the sinuses are taken care of simultaneously Aim of work: To re-establish: Aeration. Drainage. Of the sinuses Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS OMC blockage Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS 1,a- Polypectomy: Removal of the polyps in the nose and middle meatus. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS Reda Kamel, M.D. 1,a- Polypectomy: Removal of the polyps in the nose and middle meatus.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS 1,b- Ethmoidectomy: Opening and removal of the bulla ethmoidalis [anterior ethmoids]. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS Reda Kamel, M.D. 1,b- Ethmoidectomy: Opening and removal of the bulla ethmoidalis [anterior ethmoids].

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS Reda Kamel, M.D. 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.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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.. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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.. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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.. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

FESS: 

FESS Endoscopic Pansinus Surgery Debrider video

Functional Endoscopic Sinus Surgery FESS: 

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. Reda Kamel, M.D.

Functional Endoscopic Sinus Surgery FESS: 

Functional Endoscopic Sinus Surgery FESS Complications of FESS 1- Orbital: optic nerve injury … 2- Intracranial: CSF leak … 3- Bleeding 4- Adhesions 5- Recurrence Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: Orbital Cranial Intracranial Septic focus Descending infection Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: A- Orbital Sub-periosteal abscess Orbital cellulitis Panophthamitis Cavernous sinus thrombosis Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: B- Cranial: [Frontal] Osteomyelitis Subperiosteal abscess [Pott’s puffy tumor] Fistula Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: C- Intracranial: Extradural abscess Meningitis Cavernous sinus thrombosis Brain abscess Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: D- Descending Infection: Acute otitis media Pharyngitis Laryngitis Bronchitis Asthma GIT troubles Reda Kamel, M.D.

Sinusitis: Complications: 

Sinusitis: Complications Spread of infection: E- Septic focus: Definition Septic foci General Local Reda Kamel, M.D.

Sinusitis: Complications: 

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. Reda Kamel, M.D.

Cysts of the Sinonasal area: 

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:

Cysts of the Sinonasal area: 

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

Nasal Allergy: Pathogenesis: 

Nasal Allergy: Pathogenesis Antigen-antibody reaction Histamine release [Mast cell degranulation] Vasodilatation, oedema, exudate, eosinophilic infiltrate Nasal blockage, Discharge, Itching, Sneezing

Nasal Allergy: Predisposing factors: 

Nasal Allergy: Predisposing factors Heriditary Psychogenic Autoimmune

Nasal Allergy: Allergen: 

Nasal Allergy: Allergen Seasonal: Inhalants: Pollens – Hay fever Perennial: Inhalants: Pollens, molds, insects, House dust mites Ingestants: Egg, fish, milk Contact ants: latex Injectants: pecicillin, insulin

Nasal Allergy: Symptoms: 

Nasal Allergy: Symptoms Nasal obstruction: intermitent Anterior nasal drip: watery Sneezing Itching Headache

Nasal Allergy: Signs: 

Nasal Allergy: Signs Mucosa: pale blue, edematous Secretions: profuse, watery Inferior turbinate: hypertrophied posterior end Polypi: ethmoidal, OMC

Nasal Allergy: Investigations: 

Nasal Allergy: Investigations Skin test: Prick test To prove allergy To identify antigen To define degree of sensetivity To plan immunotherapy Nasal smear cytology: eosinophils Blood examination: eosinophilia Radio-Allergo-Sorbent-Test [RAST] Nasal provocation test [challenge test]

Nasal Allergy: Treatment: 

Nasal Allergy: Treatment Avoidance of the antigen Pharmacotherapy: (local-systemic) Antihistaminics Vasoconstrictors Stereroids Surgery: Inferior turbinate reduction Polyp: shaving - FESS Immunotherapy video

Sinonasal polyps:: 

Sinonasal polyps: Pedunculated edematous mucosa of the nose

Sinonasal polyps:: 

Sinonasal polyps: 1- Inflammatory polyps 2- diffuse sinonasal polyps. 3- Allergic fungal sinusitis polyps 4- Antrochoanal polyp.

Sinonasal polyps:: 

Sinonasal polyps:

Sinonasal polyps:: 

Sinonasal polyps: 1- Inflammatory polyps Reda Kamel, M.D.

Inflammatory Sinonasal polyps:: 

Inflammatory Sinonasal polyps: Ethmoiditis Polyps

Sinonasal polyps:: 

Sinonasal polyps: CT Coronal cuts

Sinonasal polyps:: 

Sinonasal polyps:

Sinonasal polyps:: 

Sinonasal polyps: 1- Inflammatory polyps 2- diffuse sinonasal polyps. Reda Kamel, M.D.

Extensive Sinonasal polyps:: 

Extensive Sinonasal polyps: Extensive polyps [end] Extensive polyps [CT]

Extensive Sinonasal polyps:: 

Extensive Sinonasal polyps:

Sinonasal polyps:: 

Sinonasal polyps: 1- Inflammatory polyps 2- diffuse sinonasal polyps. 3- Allergic fungal sinusitis polyps Reda Kamel, M.D.

Allergic Fungal Sinusitis: 

Allergic Fungal Sinusitis R video

Allergic Fungal Sinusitis :: 

Allergic Fungal Sinusitis :

Sinonasal polyps:: 

Sinonasal polyps: 1- Inflammatory polyps 2- diffuse sinonasal polyps. 3- Allergic fungal sinusitis polyps 4- Antrochoanal polyp Reda Kamel, M.D.

Antrochoanal polyp:: 

Antrochoanal polyp: 1- Inflammatory polyps 2- diffuse sinonasal polyps. 3- Allergic fungal sinusitis polyps 4- Antrochoanal polyp Sagital section Reda Kamel, M.D.

Antrochoanal polyp: 

Antrochoanal polyp R

Antrochoanal polyp:: 

Antrochoanal polyp:

Deviated Nasal Septum:: 

Deviated Nasal Septum: Significant deviation of nasal septum causing nasal obstruction Most common cause is accidental. Causes: Congenital Traumatic Inflammatory Neoplastic Others Reda Kamel, M.D.

Deviated Nasal Septum:: 

Deviated Nasal Septum: It may be DS: S or C shape Spur or crest Dislocation. Symptoms: causing bilateral or unilateral obstruction Signs: - Septal deformity + turbinate hypertrophy Reda Kamel, M.D.

Deviated Nasal Septum:: 

Deviated Nasal Septum: Sequelae: Sinusitis Epistaxis Anosmia Vacuum headache Reda Kamel, M.D.

Deviated Nasal Septum:: 

Deviated Nasal Septum: Investigations: Endoscopy CT Acoustic rhinometry Rhnomanometry Reda Kamel, M.D.

Deviated Nasal Septum:: 

Deviated Nasal Septum: Treated by Submucous resection [SMR]: Perforation. Haematoma Abscess Adhesions Depressed nose Hemorrhage Reda Kamel, M.D.

Deviated Nasal Septum:: 

Deviated Nasal Septum: Treated by Submucous resection [SMR] Septoplasty: release of the cartilage. Endoscopic mini septal surgery. Reda Kamel, M.D.

Septal Perforation:: 

Septal Perforation: Most common cause is iatrogenic after SMR operation. Causes: Congenital Traumatic SMR, cauterization, picking, FB, cocaine Inflammatory Abscess, granuloma Neoplastic Others Reda Kamel, M.D.

Septal Perforation:: 

Septal Perforation: In tuberculosis, the perforation is anterior [cartilaginous], In Syphilis, the perforation is posterior [bony]. Symptoms: if any Irritation Epistaxis, crusting Whistling sound Treated by transnasal endoscopic repair or open rhinoplasty approach. Sagital section Reda Kamel, M.D.

Septal Perforation:: 

Septal Perforation: Treated by Alkaline lotion Antibiotic ointment Surgery Silastic button Transnasal endoscopic repair Open rhinoplasty approach. Sagital section Reda Kamel, M.D.

Septal Haematoma:: 

Septal Haematoma: Accumulation of blood between the nasal septum cartilage and muco-perichondrium. Causes Trauma SMR Blood disease Reda Kamel, M.D.

Septal Haematoma:: 

Septal Haematoma: Symptoms: Bilateral nasal obstruction Signs: bilateral nasal swelling, red, fluctuant, smooth Complications: Perforation Thickening Reda Kamel, M.D.

Septal Haematoma:: 

Septal Haematoma: Treatment: Incision [Vertical + transverse] Evacuate Pack Antibiotic Reda Kamel, M.D.

Septal Abscess:: 

Septal Abscess: Causes: Haematoma Fever Symptoms: General: fever, headache,… Local: Bilateral obstruction Pain Signs: Bilateral swelling, tender Tenderness Reda Kamel, M.D.

Septal Abscess:: 

Septal Abscess: Complications; Cartilage necrosis & perforation Cavernous sinus thrombosis Depressed nose Treatment Incision Evacuate Pack Antibiotic Reda Kamel, M.D.

Knowledge is power: 

Knowledge is power R