Transcript The Frontal Sinuses

Nose
Anatomy of the Nose
External nose
It is a projecting triangular pyramid directed
downwards.
It has apex, root connected to the forehead
and base perforated by two nostrils.
Bones and Cartilages of the
nose
Nasal bones.
Maxillae.
Frontal bone (nasal process).
Upper lateral cartilages.
Lower lateral cartilages.
Septal cartilage.
The muscles of the nose are a part of facial muscles
and are supplied with facial nerve.
Nasal Cavity
Nasal Vestibule
It is the entrance to the nasal cavity, lined
with skin which is hair bearing.
Nasal cavity proper
They are two cavities separated by the nasal
septum, extending from the anterior nares
to the nasopharynx.The mucosa is Ciliated
Columnar Epithelium with Olfactory
epithelium at the roof.
The nasal septum
Medial Wall of the nasal cavity is composed of
the following:
1-Quadrilateral Cartilage ((Septal Cartilage)).
2-Perpendicular Plate of the Ethmoid bone.
3-The Vomer bone.
4-Nasal Crests of the Maxilla and the Palatine
bones.
The Lateral Wall
The Inferior Turbinate: is a separate bone
attached to the maxilla.
The Middle Turbinate.
The Superior Turbinate.
The middle and the superior turbinates are
parts of the ethmoid bones.
Bellow the inferior turbinate is the inferior
meatus which receives the nasolacrimal
duct opening.
The middle meatus lies bellow the middle
turbinate and receives the openings of
the maxillary, frontal and the anterior
ethmoidal sinuses.
The superior meatus receives the opening
of the posterior ethmoidal cells.
Above the superior turbinate is the
Sphenoethmoidal Recess which receives
the sphenoid sinus ostium.
The Roof of the nose is formed from anterior to
posterior from: the nasal bones, the cribriform
plate of the ethmoid bone and sphenoid bone.
The olfactory cleft area is lined with
olfactory epithelium (special sensory
epithelium) and occupies the area of the
cribriform plate, the superior turbinate
and the corresponding area of the
septum.
The floor is formed of the maxilla and the
palatine bones.
The Blood Supply
The external nose is supplied by branches of
the facial, the maxillary and the ophthalmic
arteries.
The venous drainage is through the facial,
maxillary and the ophthalmic veins, the
latter drains to the cavernous sinus.
The blood supply to the nasal cavity is
coming from the maxillary, facial, the
anterior and the posterior ethmoidal
arteries.
Little's area is the anteroinferior part of the
nasal septum where anastomosis of
vessels called Kiesselbach's plexus is
located and is the commonest site of
bleeding.
Nerve supply
The sensory innervations of the nose is supplied by
the trigeminal nerve, mainly through the maxillary
and the ophthalmic divisions.
The olfactory area is supplied by the olfactory nerve.
The nose also has sympathetic supply from the
upper deep cervical ganglion.
The parasympathetic supply comes from the
geniculate ganglion of the facial nerve.
THE PARANASAL SINUSES
They are Air Filled cavities within the bones
surrounding the nose and have openings or
ducts draining into the nose.
They are arranged in pairs and lined with
respiratory mucus membrane.
They comprise the maxillary, the frontal, the
ethmoid and the sphenoid sinuses.
The Maxillary Sinus
This is the largest Para nasal sinus; it occupies
the body of the Maxilla. It is also called the
ANTRUM. It has a roof which is the floor of
the orbit, a base or the medial wall, a floor
which is the alveolar process of the maxilla
and an apex.
The ostium is situated high on the medial wall
and it opens into the middle meatus, so the
drainage is dependant on the ciliary action of
the mucosa, not on gravity.
The Frontal Sinuses
They are situated in the frontal bone and are
divided into two parts by a septum.
The frontonasal duct of each sinus opens into
the middle meatus.
The Ethmoid Sinuses
They are situated in between the nasal
cavity medially and the orbit laterally
where a very thin bone (lamina
papyraceae) separates it from the orbit,
superiorly the sinuses are bounded by the
cranial cavity.
The sinuses are divided into two groups, an
anterior group which drains into the
middle meatus and posterior group which
drains into the superior meatus.
The Sphenoid Sinuses
These occupy the body of the sphenoid bone
and are divided by a septum into two, each
sinus drains into the sphenoethmoidal
recess.
The Physiology of the Nose
1-It is an airway passage which moistens
and heats the inspired air due to high
vascularity of the mucus membrane.
2-The mucus contains antibodies which act
as a defense mechanism.
3-It filters the inspired air from foreign
bodies.
4-It adds resonance to sound.
5-Olfaction, the sense of smell.
Symptoms and Signs of Nasal
diseases
Nasal block.
Nasal discharge ((Rhinorrhoea)) and
postnasal drip.
Bleeding from the nose ((Epistaxis))
Sneezing and itching.
Nasal pain, facial pain and headache.
External deformity.
Disorders of smell
Anosmia .
Hyposmia.
Hyperosmia (increased sense of smell).
Cacosmia (perception of bad smell).
Signs like external deformity, scars, masses
and other skin lesions are readily seen by
simple examination.
Examination of the nose is done by using
Nasal Speculum and Good light .This is
Called Anterior Rhinoscopy.
Deviated nasal septum, abnormality of the
mucosa, bleeding vessels, and character
of the secretions, nasal masses and
polyps.
Postnasal examination is done by
Nasopharyngeal Mirror. This is called
Posterior Rhinoscopy.
ENDOSCOPIC EXAMINATION OF THE NOSE IS
POSSIBLE BY USING FLEXIBLE AND RIGID
ENDOSCOPES.
Investigations of the nose
X-ray paranasal sinuses.
CT scan.
MRI scan.
Skin prick test for allergy.
TRAUMA TO THE NOSE
Nasal bone Fracture
Caused by external force, blow and fall from
height or assault.
Presented with Pain, Swelling, Bruises,
Epistaxis, Nasal block, External deformity or
Deviation.
On Examination:
Septum for the presence of septal haematoma,
especially in Children.
Septal haematoma is accumulation of blood
between the mucus membrane(the mucoperichondrium) and the cartilage of the nasal
septum.
When present, the haematoma needs urgent
drainage; otherwise septal abscess may
develop which may result in cartilage necrosis.
The correction of nasal bone fracture is needed
when there is recent and apparent deformity or
deviation of the external nose.
This is usually done after 5 to 7 days after the
subsidence of edema and good assessment of
the nose is possible and before healing of the
fracture which makes its reduction difficult.
EPISTAXIS
It is defined as Bleeding from the nose.
It is usually Anterior bleeding.
Can be posterior or both anterior and
posterior bleeding depending on the site
and severity of bleeding.
The commonest site of bleeding is Little's area
which has high vascularity.
CAUSES
A-Local causes:
1-Trauma like fracture nose and nose picking.
2-Upper respiratory tract infections.
3-Acute or Chronic rhinitis.
4-Postoperative.
5-Foreign bodies.
6-Tumours ((benign or malignant)) of the nose
and para nasal sinuses like Angiofibroma .
B-Systemic Causes:
1- Hypertension, atherosclerosis and blood
vessels abnormalities.
2- Clotting mechanism defects like
hemophilia and thrombocytopenia.
3- Anticoagulant drugs like heparin and
warfarin.
4-Antiplatelet drugs like aspirin.
5- Hormonal Changes like in pregnancy and
puberty.
The cause may be unknown, this is called
Idiopathic
MANAGEMENT OF EPISTAXIS
1. Local treatment
Mild and intermittent bleeding: pinching of the nose and
application of ice on the forehead.
Local antibiotic cream or ointment is applied locally.
Cautery is done when there is obvious area of dilated
vessels and this can be either chemical cautery or
electrical cautery.
If the bleeding is severe and not controlled with the
above measures, then PACKING of the nose is
needed.
Packing can be either anterior OR posterior and anterior
packing.
2. Treatment of the underlying cause when
present, stop or decrease the dose of the
anticoagulant drug, treat sinusitis …etc.
3. Resuscitation in case of shock because of
the bleeding.
I.V. fluid, blood transfusion may be needed.
4. Other methods to control epistaxis
We may rarely need ligation of the artery to
control epistaxis
If facilities are available, embolization of the
bleeder under radiographic control may be
of great benefit.
Vestibulitis
Inflammation of the vestibular skin.
Usually secondary to conditions causing long term or
chronic discharge from the nose.
There is excoriation of the vestibular skin and
sometimes painful fissuring and bleeding (epistaxis).
Treatment of the underlying cause and topical antibiotic
cream or ointment till subsidence of the condition.
Another form of vestibulitis is the BOIL, which is a
staphylococcal infection of hair follicles. In addition to
local treatment; it may need anti-staphylococcal
antibiotic like cloxacillin.
Foreign Bodies in the Nose
This is a problem of young children who tend to
push objects into the nose.
F.B. can be organic or non organic.
Manifested by nasal block, discomfort and
sometimes if the F.B. is present for long time,
there is unilateral foul smelling discharge which
is characteristic for F.B.
Management is removal which sometimes needs
general anesthetic when the F.B. is deep in the
nose and difficult to remove in the
uncooperative child.
Acute Rhino sinusitis
The Common Cold or Coryza
It is usually viral infection of the mucus membrane
of the nose
Accompanied by general inflammation of the nose
and sinuses.
Predisposing factors include exposure to cold,
fatigue, poor nutrition, nasal obstruction and
chronic nasal and sinus infections.
All ages are affected with higher incidence in
children.
Spread of infection is by droplet, dust and eating.
Clinical Features
Incubation period of 1 to 3 days.
Sensation of discomfort in the nose and attacks
of sneezing, chills and low grade pyrexia.
Nasal discharge and nasal block (inflammation
and swelling of the nasal mucus membrane.
The discharge to start with is watery from, and
then it changes to mucopurulent when
secondary bacterial infection ensues.
Mucosal swelling results in obstruction of sinus
ostia, causing Sinusitis and associated
headache.
Management
The disease is self limiting and needs
supportive measures like good nutrition and
bed rest together with simple analgesics
and local or systemic nasal decongestants.
Antibiotics are indicated when there are
complications like:
acute otitis media, acute tonsillitis, acute
sinusitis, and chest infection.
Acute Sinusitis
Acute infection and inflammation of Para
nasal sinuses.
It is usually caused by acute rhinitis but it can be
dental in origin (spread of infection from the
teeth).
The commonest sinuses to be involved are the
maxillary and the ethmoids, but all sinuses can be
affected and this is called Pan Sinusitis.
Predisposing factors include nasal block from nasal
septal deviation, adenoids, polyps and allergic
rhinitis.
Clinical features are similar to those of acute
rhinitis (nasal block, nasal discharge of
mucopurulent material) but the symptoms are
more severe, there may be headache and
tenderness on pressure on the affected sinuses.
Diagnosis is done by the clinical features and
aided by radiology ((X-ray of the Para nasal
sinuses)).
Treatment includes rest, antibiotic and nasal
decongestants.
Complications of Sinusitis
1. Orbital complications
Spread of infection to the eye is usually from the
ethmoid sinuses through the Lamina Papyracea
which is very thin bone separating the ethmoid
from the eye.
It is the commonest complication which is mainly
in children.
If the condition is early then is treated with
hospital admission, observation and antibiotics.
If the situation is severe with abscess then
surgery is needed.
2. Osteomyelitis
It affects diploic bones like the frontal sinus.
It is treated with antibiotics and surgery of no
response.
3-Intracranial complications
Meningitis, Cortical venous thrombosis,
Cavernous Sinus thrombosis and Brain
Abscess.