ENT Rhinology

olfactory or nasal placode

bucconasal membrane which thins later and form primitive choannae.

• Frontal process
• zygomatic process
• alveolar process
• palatine process
• floor of the orbit
• body

• Maxillary (7 to 10 weeks)
• final size: 17-18 years

9-10 weeks of gestation

• 9-10 weeks of gestation, 6-7 folds appear on the lateral nasal wall:
• Nasoturbinal makes aggar nasi and uncinate process.
• Ethmoturbinals make aircells, middle, superior and supreme turbinates.
• Maxilloturbinal makes inferior turbinate

3rd intrauterine month as an invagination from sphenoethmoidal recess.

• 4th month of foetal age from frontal recess.
• It is the last to complete in adulthood.

• Anterior ethmoid
• posterior ethmoid
• sphenopalatine
• greater palatine
• superior labial

Parts of maxillary hiatus which are covered by only mucous membrane in front and behind ethmoid bulla. may contain maxillary accessory ostia.( mostly in the posterior one) and are considered to be due to infection ( like TM perforation)

• Lamina papiracea
• Skull base
• Middle turbinate
•  

Cilliated collumnar epithelium with goblet cells

Adults breathe preferentially from their nose, and positive pressure in the nose during expiration keeps the alveoli patent.

• vascular activity
• 4 to 12 hours

• Water and ions
• Glycoproteins (80% of dry weight)
• Enzymes circulatory proteins (complenet, CRP)
• Ig
• cells (WBC, EOS, ..)

• 9 outer pairs of microtubules around 1 inner pair. outer pairs have Dynein arms which has ATPase (lost in Kartagener's syn), 200 for each cell.
• Beat frequency 7-16Hz

• Dryness
• Hypo/Hypertonic solutions
• URTI (destroys epithelium)

It stimulates the cold receptors in the nose, causing apparent increase in airflow.

• Hyperthyroidism: rhinitis
• Hypothyroidism: nasal blockage (deposition of mucopolysaccarides)

• 1) 1-3mm
• 2) 4-7mm
• 3) 8-16mm
•  

• A genetic disease causing Bronchiestasis, nasal polyps, rhinosinusitis, Azoospermia.
• It is due to thick viscous mucus in nasal, pulmonary and epididimal spaces.

A nasal quality of the voice from some disease or defect of the nasal passages.

• Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant disorder typically identified by the triad of telangiectasia, recurrent epistaxis, and a positive family history for the disorder. Mostly in whites, m=f.
• The main areas of involvement: nasal mucosa, skin, the GI tract.
• Treatment: dermoplasty

• Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare neoplasm originating from olfactory epithelium.
• No sex discrimination.
• Bimodal peak of occurrence in the third and sixth decades of life.

• Non-Invasive FRS
• --Fungal Ball(FB)
• --Allergic Fungal Rhinosinusitis(AFRS)
• --Mixed FB/AFRS
• Invasive FRS
• --Acute Invasive Fungal Rhinosinusitis(AIFRS)
• --Chronic Invasive Fungal Rhinosinusitis(CIFRS)
• --Chronic Granulomatous Fungal Rhinosinusitis(CGFRS)

More in female adults, and Maxillary then Sphenoid.

The eosinophilic mucinous material admixed with eosinophils, acute inflammatory cells, eosinophilic debris and Charcot-Leyden crystals, sparse fungi or positive fungal cultures.

• Type I (IgE-mediated) hypersensitivity to fungi.
• Nasal polyposis.
• Characteristic radiographic findings.
• Eosinophilic mucin without fungal invasion into sinus tissue.
• Positive fungal stain of sinus contents removed at the time of surgery.

• removal of all the mucin
• oral steroid (prednisolone)
• No need topical/ systemic antifungal therapy

Invasion of fungal forms into submucosal with frequent angioinvasion and necrosis in a patient with symptoms of less than one-month duration.

Chronic inflammation and fibrosis in patient with long-standing symptoms(>3 month duration)

Invasion of fungal forms into submucosal often with surrounding chronic inflammation, fibrosis and granuloma production in patient with long-standing symptom(>3 month duration)

• Prednisolone 10 – 20mg/day for 2 weeks.
• Same dose on alternative days for another 2 weeks or more.

50mg lyophilized powder, Reconstituted with 10ml Dextrose solution & further diluted with 490ml 5% dextrose solution given over 4 – 6 hrs.

• Fulminant invasive: 1.25-2.0mg/kg/day,total dose: 2.0 – 2.5g.
• Chronic invasive: 0.5 –1.0mg/kg/day total dose: 1.0-2.0g.
• Less severe forms: 0.5 – 0.75mg/kg/day EOD dose

• AmB lipid complex: 5mg/kg/day
• AmB colloidal dispersion: 3-5mg/kg/day
• Liposomal AmB: 1-5mg/kg/day

Rigors, chills , fever, Nausea, vomiting, Aches & pains, Thrombophlebitis, Normocytic normochromic anaemia, Nephrotoxicity

• Orally: 100mg – 400mg daily
• IV: 200mg b.d. for two days followed by 200mg/day

• Aspirin triad: aspirin intolerance, nasal polyps, Asthma.
• Treatment: low dose aspirin for desensitizing.

A mucocoele is an epithelial-lined, mucus-containing sac completely filling the sinus and capable of expansion. This is in contradistinction to a blocked sinus cavity which simply contains mucus.

The fronto-ethmoidal region IS by far the most commonly affected overall and the maxillary sinus the least, but a proportion of sphenoidal mucocoeles present to neurosurgeons and the number is therefore probably more common.

• Mucocoeles are thought to arise as a consequence of obstruction plus inflammation. Three main theories of pathogenesis are found in the literature:
• 1. pressure erosion;
• 2. cystic degeneration of glandular tissue;
• 3. active bone resorption and regeneration.

nasal obstruction due to expansion of the lesion into nasal cavity

• FESS
• Combined endoscopic and external approach
• Lynch-Howarth fronthoethmoidectomy
• Osteoplastic flap
•  

• Preseptal cellulitis
• Postseptal cellulitis or orbital cellulitis without abscess Subperiosteal abscess
• Orbital or intra periosteal abscess
• Cavernous sinus thrombosis

• Orbital
• Intracranial (meningitis, abscess)
• Bony (Pott's puffy tumour)
• Chronic (Mucocoele,pyocoele)

• 2%
• f/m=2/1
• 50y

• Nonallergic rhinitis with asthma and aspirin intolerance.
• Allergic fungal rhinosinusitis (90% of patients).
• Cystic fibrosis (40% patients, polyps in children).
• Kartagener's syn ( 40% of patients).
• Young's syn.
• Churg-strauss syn.

• osteomeatal complex
• 1) touching that mucosa releases the proinflammatory citokines
• 2) influence of special airflow and pressure in upper part of nose (narrow passage causes faster arflow and reduced pressure which sucks the fluid toward the mucosa)
• 3) Damage of thin regulatory nerve ending of the area by cytotoxic proteins of eosinophils causes abnormal vascular permeability and tissue edema.

The major part of the polyp surface is covered by a ciliated pseudostratified epithelium, but, in addition, transitional and squamous epithelia are found, especiallyin anterior polyps, influenced by the inhaled aircurrents.

• 0)No polyps
• 1) Restricted to middle meatus
• 2) Below middle turbinate
• 3) Massive polyposi

Nasal obstruction, crusting, rhinorrhoea, post-nasal discharge, recurrent sinus pressure or pain, epistaxis, headache, snoring and sleep apnoea.

crusting, epistaxis, whistling, dryness, emptiness in nose, and general discomfort

• Type:
• --Primary
• --Secondary
• Age:
• --Childhood < 16 years
• --Adult >16 years
• Location:
• --Anterior (Bleeding point anterior to piriform aperture)
• --Posterior (Bleeding point posterior to piriform aperture)

Due to prolonged bleeding time in presence of normal platelets count.

• 
• posterior to middle turbinate, spot for epistaxis in adult due to athersclerosis of feeding arteries.

• 1) low-moderate degrees of force causing depressed nose and Chevallet fracture in septal cartilage.
• 2) greater force: causing deviation and Jarjarvay fracture in septal cartilage.
• 3) naso-orbito-ethmoid: classic pig-like nose and telecanthus
•  

• Lateral
• Frontal:
• -Plane I: nasal spine
• -Plane II: Maxillary process
• -Plane III: orbital-ethmoidal

 

• A: solid central segment which medical canthus is attached to.
• B: More comminuted but still has a central segment for medial canthus.
• C: No solid bone for medial canthus to attach to.

• Lateral fracture: Jarjaway
• Frontal fracture: Chevallet
•  

• Le Fort 1: runs above the floor ofthe nasal cavity, through the nasal septum,maxillary sinuses and inferior parts of the medialand lateral pterygoid plates.
• Le Fort 2: This is a fracture which runs from the floor of the maxillary sinuses superiorly to the infraorbital margin and through the zygomaticomaxillary suture. Within the orbit it passes across the lacrimal bone to the nasion. The infraorbital nerve is often damaged by involvement in this fracture.
• Le Fort 3: This represents a disconnection of the facial skeleton from the cranial base. The fracture traverses the medial wall of the orbit to the superior orbital fissure and exits across the greater wing of the sphenoid and zygomatic bone to the zygomaticofrontal suture. Posteriorly, the fracture line runs inferior to the optic foramen, across the lesser wing of the sphenoid to the pterygomaxillary fissure and sphenopalatine foramen. The arch of the zygoma is also broken.

• enophthalmos and hypoglobus (depressed pupillary level). Enophthalmos is most apparent when the contralateral eye is normal.
• Other signs include supratarsal hollowing, hooding of the eye, narrowing of the palpebral fissure width and an infraorbital nerve deficit.
• A small fracture of the orbital floor can lead to a trap door phenomenon. If the orbital fat or inferior oblique muscle becomes trapped in the fracture configuration, then interference with muscular function results in diplopia on upward gaze.

• CSF
• perilymph
• aqueous humour (secreted from the ciliary epithelium, a structure supporting the lens)

0.25 mL of 5 percent fluorescein is mixed with 10 mL of CSF from a routine lumbar puncture, the mixture is introduced via a spinal needle and the patient is placed in the Trendelenberg position for approximately one hour.Then, endoscopic examination is performed, and if positive the fluorescein can be seen coming from the defect. The use of a blue filter on the endoscope light source can increase the ease of detection.

• systemic granulomatoisis with unknown origin, more in USA and scandinavia, f/m 2/1, more in black (12 times whites), 30-50 years old, involves LRT (lower respiratory tract) more.
• Nasal involvement: stuffiness, obstruction,crusting, blood stained discharge...
• Extrapulmonary sites: Lymph nodes, skin, liver, eye
• Ix: ACE (83%), ESR, CXR, CT, MRI
• Tx: Steroid, Methotrexate, hydroxychloroquine

A condition, characterized by granulomatous inflammation involving the respiratory tract and necrotizing vasculitis affecting small- to medium-sized vessels (e.g.capillaries, venules, arterioles and arteries) with necrotizing glomerulonephritis.

• coexistence of vasculitis and granulomas disease.
• It classically involves a triad of lower airway, lung and kidney.

• general: malaise, pyrexia, weight losseye: conjunctivitis, proptosis
• ear: AOM, OME
• Face: FN palsy
• nose: septal perforation, crusting, blood stained discharge
• Mouth: gingival lesions
• trachea: crusting, narrowing, stridor
• lungs: lesions seen in CXR
• kidney: segmental glumerulonephritis, casts
• Skin: skin lesions in distal legs, arms

• cANCA
• pANCA
• ESR
• CRP
• ACE (TRO sarcoidosis)
• UFEME (casts)
• biopsy not conclusive, but must be done
• CT, MRI

• Prednisolone: 60-80mg/d
• Cyclophosphamide: 2m/kg (can cause leukopenia,allopecia)
• Azathioprine: 200mg/d
• Low dose antibiotic (Co-Trimoxazole)?

• Granulomatous reaction to cholesterol crystals precipitated in the tissues are presumed to result from haemorrhage and/or trauma.
• The lesion may affect the maxilla or frontal sinuses producing expansion of the bone, cosmetic deformity and displacement of adjacent structures, such as the globe.

• epiphora
• mucocoele
• pyocoele
• recurrent dacrocystitis

• 20% neonates (95% resolve by 1 year)
• 10% in age 40
• 35-40% at age 90

• Syringing and probing
• Massage of sac
• Nasal endoscopic examination
• Dacrocystogram
• Dacryocintigraphy

• KTP/532 (best): can go through felxible fiber, vaporizes bone, good coagulation, no scattering
• Ho:YAG
• Diode lasers

• Mitomycin C (MMC)
• 5 fluorouracil (5FU)

permanent indwelling ceramic tube in nasolacrimal sac after eDCR as a permanent draining channel.

• H: hereditary
• E: endocrine
• R: Racial
• N: Nutritional
• I: Infections
• A: autoimmune

metaplasia in the nasa epithelium, from ciliated columnar to non keratinized squamous epithelium.

• brown/black/green nasal crusting
• Thick purulant discharge and foul smell anosmia
• headache
• epistaxis
• nasal obstruction
• atrophy of turbinates

• purulant RS
• surgery
• RT
• DNS

• coccobacillus fetidus ozaena
• deiphteroid bacilli
• Klebsiella ozaenae

A mild version of atrophic rhinitis

• Medical:
• nasal douching (Na bicarb, Na Diburate, Na Cl, 1:1:2 in warm water)+ glucose in glycerin 25% solution
• Rifampicin 600mg/OD x 12/52
• Surgical:
• Young's op
• Modified Young's op

increasing the size of meningocele-meningomyelocele when baby cries

• agger nasi
• haller's cell
• onody's cell

• Holman-Miller sign
• Juvenile Nasophaygeal Angiofibroma (JNA)

• I: limited to nasopharynx, nasal cavity
• II: invading ptrygomaxillary fossa , paransal sinuses with bony destruction
• III: Invading infratemporal fossa, orbit and parasellar region, lateral to cavernous sinus
• IV: Invading to cavernous sinus, optic chiasma, pituitary fossa

• 
• from medial canthus to angle of mandible
• Maxillary tumours below this line have better prognosis than above it

• 
• lateral rhinotomy

• 
• papilla lacrimalis
• punctum
• vertical segment of canaliculus 2mm 90 degree bend horizontal segment: 8mm
• common canaliculus
• ampula (sinus of Maier)
• Enter to NL sac, through Rosenmuller valve
• fundus 5mm above medial canthus
• sac body 10mm
• valve of krause in midway
• NLD 12mm bony, 5mm membraneous
• Hasner valve

• 1. Single cell above agger nasi
• 2. more than 2 cells above agger nasi
• 3. Single cell from agger nasi to frontal sinus
• 4. An isolated cell within frontal sinus

• Osteoma (the most common)
• Inverted papilloma (the most commonly operated one)

• m>3F
• 50 HPV 6,11,16,18
• Unilat nasal blockage, watery rhinorrhea
• hyperplastic ribbons of basement membrane that grow endophytically into underlying stroma
• Biopsy, Gadolinium MRI

• 1. nasal cavity
• 2. ethmoid cavity, medial and superior wall of maxilla
• 3. Inferior and lateral wall of maxilla, frontal and sphenoid sinus
• 4. anything beyond, including malignancy
•  

• 1) Around 21 days after exposure: Chancre, regional LMP, malaise, fever.
• 2) 6-10 weeks: systemic disease, with catarrhal rhinitis, crusting, wound on nasal vestibule, mucous patches on pharynx, rash, pyrexia
• 3) Gumma (commonest in nose), with pain, swelling and obstruction of bony septum.

• Catarrhal rhinitis: Most common lesion of syphilis in infants, which soon becomes purulant, and causes wound on vestibule, upper lip.Gumma, atrophic rhinitis, saddle nose deformity happens in puberty.
• Others: hutchinson;s teeth, moon's molars, corneal opacity, SNHL.

• chronic rhinosinusitis;
• acute recurrent rhinosinusitis;
• nasal polyposis;
• mucocoeles;
• allergic fungal sinusitis and mycetoma;
• repair of cerebrospinal fluid (CSF) leaks;
• orbital and optic nerve decompression;
• repair of blow-out fractures;
• dacrocystorhinostomy;
• choanal atresia;
• hypophysectomy;
• septal and turbinate surgery;

• FESS
• Antral washout
• Inferior meatal antrostomy
• Caldwell-Luc Intranasal ethmoidectomy
• Transantral ethmoidectomy (Jansen Horgan procedure, combination of Caldwell-Luc and access to ethmoids)

CSF filled hernial sac, lined and covered by meninges.If it contains brain tissue, is referred to as meningoencephalocoele.