TRACHEOSTOMY It is an operation in which the windpipe is opened from the front of neck or Surgical creation of an opening into the trachea Indications for tracheostomy 1. Upper airway obstruction: to relieve upper airway obstruction  Infection : laryngeal infection  Neoplasm: carcinoma of larynx and pharynx  Trauma: laryngo-tracheal injuries  Foreign body in larynx  Neurological : B/L vocal cord palsy 2. Respiratory insufficiency : who needs prolong ventilation  Comatose patient without cough reflex: head and chest injuries, poisoning  Neurological condition: myasthenia garvis, poliomyelitis  COPD  Pneumonia 3. Tracheobronchial toileting  Accumulation of secretion in lower respiratory tract prevent proper gas diffusion at alveoli  Tracheostomy allows frequent and adequate pulmonary aspiration  Pulmonary edema  Congestive heart failure  Chronic lung disease and infections Types of Tracheostomy  Depending upon the urgency  Emergency  acute laryngeal obstruction demanding urgent relief.  Elective  Temporary  Permanent Technique  Position / Anaesthesia Tracheostomy Tubes  Metal tubes  Non-metal tubes Types of Tracheostomy Tubes  Portex tube (with cuff)  prevent aspiration  can be used in ventilator  May get blocked- has to be removed  Metal tubes  2 tubes - inner and outer tubes  Advantage - can be used for long period and has and less chance of blockade (if inner tube is blocked, it can be removed and patient breathes through the outer tube) Metallic tube Non metallic tube It has set of outer tube, inner tube and introducer Outer tube is fastened to neck with ribbon strap Inner tube is slipped into outer tube and fused to it by locking device Made of silastic Consists of single tube Advantage Main advantage of metal tube is that , if crusts or mucous plug blocks the inner tube and patient has difficulty in breathing, inner tube can be removed while outer tube remains in trachea and maintains patency of airway allowing the patient to breathe Advantage : Have inflatable cuff and can be connected to ventilator Disadvantage Do not have cuff and cannot produce an airtight seal needed for ventilator If lower end of metal tube do not fit properly, it can cause injury and even erosion of tracheal wall Disadvantage Inflatable cuff itself can cause excess cuff pressure leading to subglottic stenosis if used more than 2-3 weeks Has single tube, so that tube can get blocked due to mucous plug or crust leading to respiratory obstruction Nursing Care of Tracheostomy  Meticulous postoperative care of tracheostomy is necessary to avoid complication  Bed should be close to nursing station  Bedside items - suction machine with sterile suction catheters, 1 extra tracheostomy tube, paper and pen for the patient to communicate  Suction: regular tracheal suction after putting 1-2 ml of sterile saline into trachea to prevent crusting  Humidification : regular humidification( done by inhalation of steam or alternately by electric humidification unit ; nebulizer)  Chest physiotherapy: regular chest physiotherapy  First change of tube The first change of tracheostomy tube is done after 72 hours of surgery . after 72 hours a tract usually form and remains patent . if removed earlier than there is likelihood of soft tissue around tracheostomy collapsing and obstructing the airway Subsequent change of tube  When a metal tube is used –inner tube is removed, cleaned and reinserted without disturbing outer tube, 2 times a day  Outer tube is similarly removed and cleaned and reinserted once a day  When single lumen silastic tube is used – this tube should be removed cleaned and reinserted everyday Deflation of cuffed tube  When a cuffed silastic tube is used, cuff should be deflated every 2 hours for a few seconds or min in order to prevent tracheal injuries- necrosis and subglottic stenosis Principles of Decanulation  Tube size reduced before decanulation  Tube is corked off for increasing periods  Self-ventilating for at least one full night  No further need for tracheal suction  Remove the tube; plug the tracheostomy site

Foreign Body Oesophagus and Differential Diagnosis of Dysphagia: Foreign Body Oesophagus:  One of the commonest emergencies  Most of the time : accidental  Due to negligence  Various objects  If not tackle on time, severe complications  Life threatening. Types of foreign body:  Depends upon age group;  Paediatric : coins, battery, parts of toys  Adult : fish bones, meat bones  Old age: dentures, meat bolus Site of impaction:  Pyriform sinus  Cricopharyngeal junction = 15 cm  Arch of aorta= 23 cm  Left main bronchus= 27 cm Clinical features:  Symptoms : painful swallowing (odynophagia) : Associated symptoms  Signs : tenderness over neck : excessive salivation I/L : pooling of saliva in pyriform sinus Diagnosis:  X-ray soft tissues neck lateral view: : radio-opaque object : increased soft tissues density, prevertebral space  X-ray chest Lateral view:  Ba- swallow  Flexible upper GI-endoscopy  Rigid endoscopy Treatment:  Fresh: rigid oesophagoscopy and removal of foreign body under GA + antibiotic therapy  With infection: IV-Antibiotic therapy for 72 hrs followed by rigid oesophagoscopy  With impaction: thoracotomy and removal of foreign body. Complications:  Trauma : lip------- cardiac sphincter  Perforation of oesophageal wall  Mediastinitis  Haemorrhage  Haemo-pneumothorax  Dislocation of A-O joint. Contraindications:  Severe trismus  Acute oropharyngitis  Acute corrosive burn  Severe cervical spondylosis  Fracture of cervical spine  Secondaries in cervical spine  Aortic aneurism  Vascular tumour Causes of Dysphagia: 1. Congenital: stricture, atresia, web 2. F.B oesophagus 3. Neoplastic : in the lumen: pharynx, oesophagus : outside the wall: thyroid, larynx, bronchus, neck nodes 1. Paralytic: head injury, # base of skull, CVA, encephalitis, myasthenia , LMND, PBP

Foreign Bodies in Air Passages Foreign Bodies in Tracheobronchial Tree Clinical Features 3 stages a. Initial period of chocking, gagging and wheezing → cyanosis a. Brief period b. Cough out, lodge or down to bronchus b. Asymptopatic interval a. Depend on size and nature of FB b. Various sign Vegetable FB – chemical reaction- tracheobronchitis Non vegetable FB – remain silent for long time a. Later symptoms a. Airway obstruction b. Inflammation  Diagnosis a. History & clinical examination b. Chest X-rays a. Signs of collapse, emphysema c. CT-scan d. Diagonostic bronchoscopy  Treatment a. Antibiotics by IV route b. Anti-inflammatory agents – like steroid c. Heimlich’s manoeuvre. d. Cricothyrotomy and Tracheostomy e. Bronchoscopy and FB removal f. Thoracotomy – impacted FB g. Lobectomy

Tonsillitis Most frequently seen in children but is not uncommon in adults Causative organism 1. Viral most common 2. B-hemolytic streptococcus : most common 3. Streptococcus pneumonae 4. Hemophilus influenza 5. Clinical feature 6. Symptoms 7. Sorethroat 8. Odynophagia 9. Fever 10. Earache (referred otalgia) 11. 12. Sign 13. Congested and enlarged tonsil (bilateral) with or without pus point 14. Enlarged tender jugulodiagastric lymphnode Investigations Clinical diagnosis Tonsillar swab- culture sensitivity Complete blood count Treatment adequate fluid intake for first 2-3 days Oral analgesic 1. Paracetamol 500mg *qid *pc 2. Ibuprofen 400mg *tds *pc 3. Nimesulide 100mg *bd *pc Salt water or betadine gargle Antibiotics Oral penicillin: 1. Amoxycillin 250-500mg *tds for7-12 dys (choice of drugs) 2. Ampicillin 250-50mg *qod for 7-10 dys 3. Erythromycin 250-500mg *qid for 7-10 days 4. Cloxacillin 250-500mg *qid for 7-10 dys 5. Cephalexin 250-500mg*qid for 7-10 dys 6. Ciprofloxacin 250-500mg*bd for 7-10 dys I/M antibiotics 1. Inj. Penicillin 10 lakh I/M 6 hrsly or for 24-48hrs 2. Benzathine penicillin 6-12lakh I/M *od for 10 dys If condition is severe and patient unable to swollen due to pain, patient should be hospitalized and antibiotics should be given intravenously Complication 1. Tonsillitis due to B-hemolytic streptococcus group A can cause 2. rheumatic fever and acute glomerulo nephritis CHRONIC TONSILLITIS Person suffering from recurrent attacks of acute tonsillitis are also referred to as having chronic tonsillitis D/D of ulcer & white patch on tonsil Infection 1. Ac tonsillitis 2. Peritonsillar abscess 3. Candidiasis 4. Infectious mononucleosis 5. TB 6. Diptheria 7. Syphilis Neoplasm Blood disease Tonsillectomy Indications 1. 5 or >5 of acute tonsillitis over a period of 2 years 2. Obstructive sleep apnea syndrome (OSAS) along with adenoidectomy 3. Suspected neoplasm of tonsil There is no evidence of any deleterious long term immunological side effects after tonsillectomy Contraindications 1. Bleeding disorder 2. During acute infection Post operative care following tonsillectomy 1. Nursing care should be directed towards early detection of bleeding and to prevent its aspiration pulse examined every 10 minutes and BP every 30 min in early post operative period: a rising pulse rate and falling BP are signs of bleeding 2. In semiconscious patient noisy breathing and frequent swallowing are indirect sign of bleeding 3. Patient is encouraged to have normal food as soon as possible 4. Chewing and swallowing decreases post operative pain by preventing spasm of pharyngeal muscle

ACUTE PHARYNGITIS It is clinical condition characterized by inflammation of lining mucosa of pharyngeal wall and subepithelial lymphoid follicles. Predisposing factors 1. Common cold 2. Influenza 3. Measles 4. Scarlet fever 5. Exposure to air pollutants. Smoking 6. Rhinitis Types of pharyngits 1. Bacterial pharyngitis 2. Viral pharyngitis ACUTE BACTERIAL PHARYNGITIS Acute pharyngitis can occur as an isolated condition Sometimes the pharynx is involved together with the tonsils and it is called pharyngotonsillitis causes of acute pharyngitis 1. Viral a. Rhinoviruses b. Influenza c. Parainfluenza d. Measles, chickenpox e. Coxsackie virus f. Herpes simplex g. Infectious mononucleosis h. Cytomegalovirus 2. Bacterial a. Group A, B -memolytic streptococcus b. Diphtheria c. Conococcus 3. Fungal a. Candida albicans b. Chlamydial trichomatis 4. Miscellaneous a. toxoplasmosis Clinical feature Sorethroat: worse on swallowing Fever:+/- Odynophagia but not dysphagia O/E; congested pharyngeal wall Treatment: 1. Bed rest 2. Plenty of fluid 3. Warm saline gargle Analgesics 1. Paracetamol 2. Aspirin 3. Nimesulide 100mg *bd Lignocaine can be used to reduce pain during swallowing Lacal discomfort in the throat Antibiotics a. Group A, B -memolytic streptococcus a. Penicillin v 200,000-250000 units per oral*qid for 10 dys or b. Benzathine penicillin G i. <30kg data-blogger-escaped-body="" data-blogger-escaped-i="" data-blogger-escaped-ii.="" data-blogger-escaped-once="" data-blogger-escaped-units="" data-blogger-escaped-wt="600,000">30kg body wt =120,000 units once IM (12lacks) b. In penicillin sensitive infividuals a. Erythromycin 20-40mg/kg/day in divided oral dose for 10 dys c. Gonococcal pharyngitis a. Penicillin b. Tetracycline Symptomatic treatment Complication Same as acute tonsillitis

Deviated Nasal Septum Fracture Nasal Bone

Anatomy of Nasal Septum

►    Anatomically 3 parts:

1.       Columellar part

2.       Membranous part

3.       Septum proper

DNS

►    Aetiology:

1.       Traumatic

2.       Developmental

3.       Racial

4.       Hereditary

►    May involve the bony or cartilaginous part

►    Classified as:

1.       Spur

2.       Deviation

3.       Dislocation

►    Classification of Deformity of Septum.

►    Spur.  Sharp angulation  at the junction of vomer below with the septal cartilage  and or ethmoid , due to vertical compression force. # in the septal cartilage produces spur.

2.  Deviation : “C” or “S” , can be on vertical or horizontal  zone, may involve cartilage or bone or both.

3. Dislocation :  lower border of septal cartilage is displaced from its medial position ans projects into one of the nostril.Photo

DNS (spur)

►    Sharp projection at the junction of the cartilage and the bony part

DNS ( Deviation)

►    Bulging of the either the quadrilateral cartilage or bone.

►    ‘C’ or ‘S’ shaped.

DNS ( Dislocation)

1. The dislocation of the lower border of the septal cartilage from the maxillary crest. OR
2. Anterior columellar dislocation
3. Rarely posterior dislocation

Clinical features

1. Usually asymptomatic
2. Nasal obstruction
3. Dry nasal cavity
4. Recurrent rhinosinusitis
5. Headache
6. Epistaxis -rarely

Signs

1. Decrease nasal patency on the side of the DNS.
2. On anterior rhinoscopy

-          deviated septum

-          - maybe assoc. compensatory             hypertrophy of the middle or inferior turbinate on the opposite side.

3.     Maybe assoc. wt external nasal deformity.

4.     Investigations:

5.     Clinical diagnosis

Treatment:

•       Always Surgical

“As the septum goes, so goes the nose” Correct the septum first

1.  Treat the chronic sinusitis – Cap. Doxycyclin
2.  Treat the allergy – antihistamine, steroid spray

Treatment

1. Only for symptomatic DNS cases.
2. Surgical modality: Septoplasty OR Submucous resection of the septum (SMR operation)
3. Inferior turbinate reduction if needed. Collumelloplasty if ant. Collumellar dislocation.
4. Septoplasty:
1. Conservative operation where only the deviated part of the septum is removed.
5. SMR:
1. Radical operation where most of the bony and the cartilaginous part is excised leaving only ‘L’ shaped portion of the cartilage, superiorly and anteriorly.

Complications

Immediate:

1. Bleeding
2. Septal hematoma or abscess
3. Fever

Delayed:

1. Septal perforation
2. Nasal deformity
3. Nasal tip collapse
4. Synechiae
5. Depression of bridge
6. Columellar retraction
7. Papery thin septum
8. Parrot beak deformity

Fracture of the nasal bone

1.     After sports injury, RTA, blow etc.

2.     Maybe simple or complex

3.     Simple:

a.     With or without nasal deformity or septal deformity or septal displacement

1. Complex:
1. Assoc. with other facial skeletal fractures (naso-orbitoethmoid fractures)

Fracture nasal bone-clinical features

1. H/O trauma
2. Assoc. pain and swelling around the nose
3. epistaxis                                         
4. Nasal deformity                            
5. nasal obstruction (rule out septal hematoma)
6. Assoc. c/o facial deformity, diplopia, CSF rhinorrhea, proptosis, occlusal deformity
7. Maybe features of head injury, loss of consciousness

Signs:

1. Crooked nose
2. Tender swelling over the nasal bone
3. Epistaxis
4. Septal hematoma
5. DNS
6. Assoc. features of facial swelling, fracture zygoma, maxilla, orbital fracture, skull fracture etc

Fracture nasal bone-management

►    Investigations:

1.       X-ray of the nasal bone-lateral view

2.       CT scan in complex ones

Nasal injury (septal hematoma)

1. Early surgical drainage to prevent cartilage necrosis  and then packing of nose

Nasal bone fracture

1.Assess other facial injury

2. Pack if epistaxis
3. If grossly swollen fracture cant be assessed so wait for one week
4. If no immediate swelling then assess the grade of fracture

Nasal bone fracture (management)

►    Treatment:

1.       Undisplaced fractures- symptomatic treatment

2.       Simple fractures wt minimal displacement - ext. digital manipulation or intranasal fracture reduction in LA or GA. Either before edema develops or after the edema subsides( in 7-10 days). Delayed ones need rhinoplasty

3.       Complex ones – open surgical procedures. May need involvement of other faculties.

NASAL MYIASIS ( Maggots in Nose)

•       Common  in both hot and humid  climate

•       Flies of genus Chrysomyia 

Clinical feature

1. Common in lower socioeconomic pt
2. Predisposing factor:

    Atrophic rhinitis, chronic rhinosinusitis, syphilis, leprosy : provide environment for housefly to lay egg—egg hatch to larvae measuring 1-5 cm which r white in color

Clinical feature

1. First 3-4 days : intense irritation, sneezing, lacrimation
2. Nasal obstruction
3. Foul smelling discharge
4. Thin blood stained discharge , Epistaxsis 
5. Severe pain : in and around nose
6. Cellulitis: redness of skin over nose, face, and eyelid, fistulae  around nose and palate

EXAMINATION:

1. Larvae in nasal cavity
2. s/s of infection

TREATMENT

1. Visible maggots : picked by forceps
2. Liquid paraffin / olive oil or turpentine oil into nasal cavity
3. Antibiotic : if cellulitis/ infection
4. Treatment of cause
5. Isolated with mosquito nets to avoid contact with flies

NASAL CYCLE

1. At given time one side of nose tends to be more blocked than other
2. This alternating pattern is called nasal cycle
3. 4-12 hours
4. Physiological
5. Anxious patient

NASAL OBSTRUCTION

UNILATERAL

1. DNS
2. Unilateral rhinosinusitis
3. AC polyp
4. Foreign body
5. Neoplasm: Angiofibroma, Olfactory neuroblastoma, Nasopharyngeal Ca
6. Choanal Atresia

BILATERAL

1. Acute Rhinosinusitis
2. Allergic rhinosinusitis
3. Adenoid enlargement
4. Vasomotor rhinosinusitis
5. DNS
6. Choanal Atresia

HISTORY

1. Onset
2. Duration
3. Unilateral /Bilateral
4. Complete/Incomplete

SHORT DURATION

•       Acute Rhinosinusitis

•       Foreign body

LONGER DURATION:

1.     DNS

2.     Allergic Rhinosinusitis

3.     Vasomotor Rhinosinusitis

4.     Rhinitis due to environmental factor e.g. pollution, fumes     

5.     Adenoid hyperplasia

LATERALITY:

1.     Unilateral: DNS, FB,  AC polyp

2.     Bilateral: Nasal allergy, Septal hematoma, Ethmoid polyp

LATENCY:

1.     Constant: Nasal mass

2.     Intermittent : Allergic Rhinosinusitis

SEVERITY:

1.     Severe: Noticeable enough to prevent routine work of

2.     patient

PROGRESSIVE:

1.     Polyp or Malignancy

FOREIGN BODY NOSE

Common:

1.  Children 2-6 yrs
2.  Adults especially those with mental retardation or psychiatric illness
3. Children habit of  exploring  new object

Common object :

1.Piece of paper

2.     Sponge

3.     Eraser

4.     Beads

5.     Vegetable seed

Inorganic

1.     Plastic or metal;

2.     beads,

3.     eraser and

4.     small parts from toys.

5.     Often asymptomatic and may be discovered incidentally

Organic

a.     Food, wood and sponge

b.     More irritating to the nasal mucosa and thus may produce earlier symptoms

DANGERS

1. Injury from clumsy attempts at removal by unskilled persons.
2. Local spread of infection- sinusitis or meningitis.
3. Inhalation of foreign bodies leading to lung collapse and infection.
4. All foreign bodies harbor the potential for swallowing or airway obstruction if they are displaced posteriorly. 

CLINICAL FEATURE:

1. Unilateral, usually
2. No symptoms: not uncommon initially
3. Nasal obstruction: if large
4. If children: patient are not aware
5. Long term:

a.     Unilateral foul smelling purulent discharge

b.     Sinusitis

c.     Granulation surrounding FB

If a child presents with unilateral, foul-smelling nasal discharge, foreign body must be excluded

TREATMENT

1. Sort of medical emergency: as chance of going further
2. Most FB removed without anaesthesia by FB hook, forceps
3. GA in uncooperative pt
4. If long term may be associated with rhinosinusitis so antibiotics
5. Vasoconstriction if bleeding

RHINOLITH

1. Rare
2. Resemble stone in nasal cavity
3. Small FB , mucous , blood clot—nucleus for concretion & those get coated with calcium & magnesium phosphate--- rhinolith
4. White/ brown or grey in color
5. Irregular surface , hard
6. Brittle and portion may break off while manipulating
7. Radio-opaque
8. May fill up entire nasal cavity: obstruction
9. Unilateral nasal obstruction & foul smelling

    discharge commonly blood stained  

Treatment

1. Removal under GA

Nasal Polyps

Definition:

Polyps – Greek word – Polypous – many footed

  - Oedematous, hypertrophied, Pedunculated mucosa of Nose + Paranasal sinuses

Sites

1. Ethmoidal:

1.  Poor Blood Supply of Ethmoid Sinus
2.  Complex anatomy of Ethmoid Labyrinth

2. Maxillary

     Rare – Sphenoidal and Frontal

    Site of origin – Middle meatus (All the sinus ostium opens)

Types of Nasal Polyps

1.     Antrochoanal Polyps (Killian’s Polyps)

2.     Ethmoidal Polyps (Nasal Polyps)

3.     Sphenoidal Polyps (Rare)

Etiological Factors

1. Infection:-

Recurrent Infection of PNS 

2. Allergy:-

1. Associated with asthama
2. Allergic symptoms like Sneezing, rhinorrhea  and itching
3. aspirin Hypersensitivity

Age & Sex

1. Any age group above 2 yrs
2. Cystic fibrosis develops earlier (Befroe 10 yrs)
3. Below 2 yrs – Meningocoele and Encephalocoele
4. Sex : Equal – In our context (Male:female = 2:1)

Symptoms

1. Nasal obstruction :

    Unilateral / Bilateral, Mild / Severe

2. Rhinorrhea and sneezing

3. Decrease sense of smell / complete loss

              Decrease sense of taste

4. Pain – Normally Painless

    Over bridge of Nose, forehead and cheek

5. Post Nasal Drip :

    White / Yellow (Severe Eosinophillia)

6. Epistaxis :

    Uncommon, Inverted Papilloma, Malignancy

7. Hypo Nasal Voice

8. Mouth Breathing

Signs

1. Anterior Rhinoscopy

1.  Translucent white bags of polyp
2.  Pinkish – Repeated Trauma, Infection
3.  Polyps may protrude out through the vestibule

Polyp may

•       Flaring of Alae of nose

•        Polyps Hanging in oral cavity

Investigation

1. X-ray
2. PNS OM view – Mucosal Thickening / Opaque antrum – fluid level
3. CT Scan – Nose and Para Nasal Sinuses
4.      - Both coronal and axial section (Osteomeatal complex)

TREATMENT

1. Medical Treatment –

    Minimal Polyps, Extesive polyps – to reduce the size

    “Medical Ethmoidectomy”

Tab. Prednisolone  -  1mg /kg body wt.

Betamethasone Nose Drop – 2 drops bid for 2 weeks

Steroid spray – for 3 months

2. Surgical treatment

A.FESS

B. External Approach

       Ethmoid – External ethmoidectomy (Lynch Howarth)

                      Intra Nasal Ethmoidectomy

                      Horgans Approach

        AC polyp – Caldwel Luc Surgery

                          Intra Nasal Polypectomy

Complications of surgery

Bleeding

- Intra Operative

- Post Operative

-        Damage to Lamina Papyracea

- Black Eye / Subcutanious oedema in infra orbital area.

- Occ. CSF Rhinorrhea

- Late Complication – Synechiae formation

Differentiation between AC polyp and Ethmoidal Polyp

AC	Ethmoidal
Origin- Lateral Wall+ floor of Maxillary Antrum	Ethmoid Lybrinth
Single	Multiple
Goes posteriorly	Comes anteriorly
Etiology: Infection	Allergy
Recurrence: Uncommon	Common
Caldwel Luc Surgery	Ethmoidectomy

SINUSITIS    

Inflammation of the paranasal sinuses.

Aetiology

1. Allergy

 2. Infection

             Acute-Bact.- Strept., Staph., H. influenzae, N. 

                 sp., anaerobes.

                 Viral-Rhinovirus, Inf. Virus,parainfl.

             Chronic – Specific-Fungal-Aspergillus

                  -  Non-specific

3. Structural e.g.. OMC-DNS, HIT

                

Contributing factors

1. Anatomical varience -DNS, Concha bullosa, 

     enlarged ethmoidal  bulla, everted uncinate 

     process,  paradoxical MT.

2. Mucociliary abnormalities

1. Primary-primary ciliary dyskinesia, cystic fibrosis, Young’s syndrome
2. Secondary-allergy, Bacterial infection

3. Immune deficiency .- primary-IgA def.,C4 def.,

                    -Secondary- HIV, Immunocompromised 

                     drugs.

3.     Allergy

Clinical Features

Acute sinusitis

Symptoms

1. Acute  Maxillary sinusitis: Pain over the cheek® frontal  region, teeth, in the morning increased by straining & bending forward

2.  Acute Frontoethmoidal:  Pain about the eye & frontal

3. Acute . Sphenoid: Rare,

                     Pain over retro-orbital® vertex, temple or occiput.

SIGNS

1. Hyperamic nasal mucosa, mucopus in Middle Meatus ,

2. Tenderness over paranasal sinus

3. Post Nasal drip

4. Redness, swelling of cheek® eyelids

CHRONIC SINUSITIS-

Symptoms

1.   Nasal obstruction
2.   Persistent mucopurulent discharge
3.   Coughing, irritaiton in throat
4.   Facial pain
5.   Hyposmia, cachosmia

Investigations

1. Nasal endoscopy
2. Swabs and antral lavage
3. Radiology- Plain x-rays   * Ct scan
4. Sinoscopy
5. Blood tests- TC,DC, ESR, Immunoglobulins

Treatment

1. Acute

   I. Medical

       a. Antibiotic

a.     Amoxycillin 500mg tds *7-10 days

b.     Azithromycin 500mg *Qid*5-7

c.     Cephalexin 500mg*OD

d.     Erythromycin  500mg qid  *7-10 dys

e.     Cotrimaxazole 960mg bd * 7-10days

f.      Doxycline 100mg bd * 7-10days

g.     Ampicillin 500mg qid * 7-10 days

h.     Cefixime 200-400mg bd *7-10dys

                                               i.     <50kg  8mg/kg

i.      Cefaclor 250-500mg tda (max 4mg/day)

ii>1month 20mg/kg/days*tds

      b. Analgesic

1.     Pcm 500mg qid or

2.     Ibruprofen 600mg tds or

3.     Nimesulide 100mg *BD

      c. Decongestant-systemic/topical

      D. Antihistamine

Antihistaminics

i.            Cetrizone 10mg to 20 mg BD

1.           Child 2-6yrs 2.5mg BD or 5mg OD

2.           >6yrs 10mg OD

ii.           Chlorpherarmine 4mg tds

1.           1-2 yrs  1mg BD

2.           2-5yrs  1mg tds (max=6mg/day)

3.           6-12yrs 2mg tds (max=12mg/day)

iii.          Fexofenadine  60mg BID

1.           >2yrs 0.23mg/kg/day (4-6)hrs

2.           2-6yrs 1mg

3.           6-12yrs 2mg

4.           >12yrs 4mg of 4-6 hrs

   II. Supportive

         Steam inhalation

2. Chronic- same

              - Steroids- topical spray

SURGICAL TREATMENT OF SINUSISTIS

•       Maxillary sinusitis: Antral lavage

                                  Caldwell-luc operation

•       Frontal sinusitis:   Trephining-Acute sinusistis

                        

•       Ethmoid sinusitis:  Intranasal/external/transantral       

                                     ethmoidectomy

  

•     Functional Endoscopic Sinus Surgery

Complications

1. Acute

Local:

•       1.Orbital-preseptal cellulitis, orbital cellulitis

       without  abscess, orbital cellulitis with 

       extraperiosteal abscess,  orbital cellulitis with

       intraperiosteal abscess,  cav. sinus thrombosis

   2. Intracranial              

   3. Bony- osteitis/osteomyelitis    4. Dental

Distant:

      Toxic shock syndrome

2. Chronic- Mucocoele/pyocoele

                   Ottitis media, adenotonsillitis, bronchitis,             

               

Allergic rhinitis

Definition

1. IgE mediated immunological response of nasal mucosa to air borne allergen
2. Characterized by sneezing, itching, watery nasal discharge, nasal obstruction

Aetiopathogenesis

1. IgE mediated hypersensitivity reaction to specific allergen
2. Allergens
1. pollen, grass, weeds- seasonal allergic rhinitis
2. House dust mite, animal hair, dander, perfumes, feathers, smoke, dust, atmospheric pollutant- perennial allergic rhinitis

Types

1. Seasonal allergic rhinitis (Hay Fever)
1. Inhaled allergen- pollen grain
2. Certain season –spring, autumn
2. Perennial allergic rhinitis
1. Occur throughout year
2. Caused by house dust mite etc

Clinical features

1. B/L nasal obstruction
2. Rhinorrhoea
3. Paroxysms of sneezing
4. Hyposmia
5. Post nasal drip
6. Itchiness of nose, eyes, palate
7. Associated  other allergy

Signs

1. Boggy, bluish edematous turbinates
2. Excessive nasal secretions

Sequelae

1.     Regression

2.     Progression to bronchial asthma, ethmoidal polyp

3.     Recurrent sinusitis

4.     Serous ottitis media

Investigations

1. Nasal smear microscopy- eosinophilia
2. Skin prick test- 10-30% asymptomatic- positive test
3. RAST (radioallerosorbent test)
4. Serum IgE
5. Nasal provocation test
6. Scratch test

Treatment

1. Avoidance of allergens
2. Medication
1. Antihistaminics-

                                                               i.      Cetrizine  10-20mg BD

                                                             ii.       Fexofenadine 120-180mg daily

                                                            iii.       loratadine

2. Topical corticosteroids spray-

                                                               i.      fluticasone,

                                                             ii.      momentasone,

                                                            iii.      budesonide,

                                                            iv.       beclomethasone 200mcgbd or 100mcg 3-4times

3. Mast cell stabilizers- sodium chromoglycate
4. Nasal decongestant-

                                                               i.      oxymetazoline,

                                                             ii.      xylometazoline

5. Oral steriod : for severe symptoms
2. Desensitization
1. Blocking IgG antibody that prevent antigen binding to IgE
2. Effective for seasonal allergy
3. Drawbacks

                                                               i.      Multiple allergy

                                                             ii.      Difficult to identify exact allergen

                                                            iii.      Series of injections

                                                            iv.      Anaphylaxis

                                                             v.      Recurrence

Rhinitis sicca
Crust forming disease in hot,

dry dusty climate
Confined to ant 1/3 of nose
Similar to early mild anterior

AR
C/f discomfort, irritation,

epistaxis & crusting
O/e: dry, whitish glazed mucous

membrane
Septal perforation
T/t: douching, Fe & vit supp,

Atrophic Rhinitis (Ozaena)

1. Chronic nasal disease
2. Progressive atrophy of mucosa and underlying bone of turbinates
3. Presence of viscid secretion → foul odour crust

Aetiology

a.     Primary (unknown cause)

                                               i.     Infection

1.     Klebsiella ozaena

2.     Bacillus mucosus

3.     Coccobacillus foetidus ozaena

4.     Diphtheria bacilli

                                             ii.     Endocrine imbalance 

1.     Female

2.     Puberty

                                           iii.     Heredity

                                            iv.     Racial influence

                                             v.     Nutritional

1.     Iron deficiency

                                            vi.     Autoimmune disease

b.       Secondary

                                                               i.      Chronic sinusitis

                                                             ii.      Excessive surgical destruction

                                                            iii.      Chronic granulomatus disease

1.       Syphilis

2.       Lupus

3.       Leprosy

4.       TB

5.       Rhinoscleroma

                                                            iv.      Radiotherapy

Pathology

1.     Metaplasia – columnar ciliated to squamous epithelium

2.     ↓ in no. & size of alveolar glands .

3.     + endarteritis and periarteritis of terminal arterioles.

4.     Active absorption of bone

•       C/F :

–       Symptoms

1.       Nasal obstruction

2.       Epistaxis

3.       Anosmia (merciful anosmia)

–       Signs

1.       Fetor

2.       Crusts- green, yellow, black

-           detached –bleeding

1.       Roomy cavity

2.       Atrophic laryngopharngitis

Treatment

1.     Conservative

a.     Nasal douching x 2

                                                        i.     280ml –warm water

                                                      ii.     28.4 g sod. bicarbonate

                                                    iii.     28.4 g sod diborate

                                                     iv.     56.7 g sod chloride

b.     25% glucose in glycerin

                                                        i.     Inhibits proteolytic organism

c.     Oestradiol in arachis oil

d.     Kemicetine antiozaena solution

                                                        i.     Chlormphenicol , estradiol, vit D2

e.     Potassium iodide

f.      Autogenous vaccines

g.     Human placental extracts

h.     Rifampicin

2.Surgical

1.Young’s operation

2.     Modified Young’s operation

3.     Submucosal inj of teflon paste

4.     Insertion of fat/ cartilage bone or teflon

5.     Medial displacement of lateral wall.