Disorders of the nose and paranasal sinuses

László Tóth M.D. Ph.D

Associate Professor

University of Debrecen
Faculty of Medicine
Department of Otorhinolaryngology and Head and Neck Surgery
Debrecen
Hungary
What are the functions of the nose?

Breathing,
Moistening,
Warming
Filtering incoming air, (nose hair cleans the air
to expel dust from the body by sneezing)
 Modifying Voice Vibrations
 Smelling
 Ostiomeatal complex

The OMC is bounded

medially by the middle turbinate,
posteriorly and superiorly by the basal lamella, and
laterally by the lamina papyracea.
inferiorly and anteriorly the OMC is open.

This anatomic region therefore includes:

the anterior ethmoid sinus, ethmoid bulla,
frontal recess,
uncinate process,
infundibulum,
hiatus semilunaris, and
middle meatus
 Obstructing nasal breathing
disorders

Allergic rhinitis
Inflammation - rhinitis, rhinosinusitis – viral, bacterial, fungal
Septal deviation
Choncha bullosa
Hypertrophy chonhae
Polyposis nasi
Mucocele
Tumor
Foreign body

Choana atresia
Adenoid vegetation
 Diagnosis

Anamnesis
Physical examination (anterior rhinoscopy, posterior rhinoscopy)
Rigid or flexible nase endoscopy
Imaging methods – X-ray – sinusitis, fracture, tumor, foreign body
CT
MRI
Ultrasound

Nuclear medicine methods – PET

SPECT
Hybrid methods PET/CT
SPECT/CT
Microbiological method
Functional examination – Rhinomanometry
Acoustic rhinometry
Allergy skin test – intra and subcutan provocation skin tests
Cytology and Histopathology
 Endoscopy of the nose

 Current state
 The nasopharynx is to be inspected with an evaluation of
septum nasi,
lower turbinate,
choanae
nasopharyx
edge of the middle concha
rostrum sphenoidale,
middle and upper concha
drainage from the sinuses
possible accessory ostia from the maxillary sinus and sphenoid sinus
view of the osteomeatal complex
ethmoidal bulla and the access to the frontal sinus.
 Imaging methods – X-ray

X-ray

Normal

Semi-axial (Water’s
(Occipitomental X-ray)
(Sinusitis, fracture,
foreign body

Frontal view (Caldwell)

Lateral view Plain X ray of skull allowing the evaluation of the adenoid volume in
relation to the nasopharyngeal airway passage.
Fracture,
foreign body
 Imaging methods – CT

Today the most useful method is CT.

Two general planes to consider the paranasal sinuses:

the coronal and axial sinus CT

The signs of ethmoiditis: the ethmoid cells are covered.

Concha bullosa: the middle turbinate are duplicated.

This may be the reason for obstruction in the nose.

The FESS it is obligatory to make a skull CT.

 Imaging methods – MRI

 Normal Tumor
(Invert
papilloma
Sinusitis

Rhinitis allergica Tumor

(carcinoma)

Cisternal fluid leak

 Imaging methods –Nuclear medicine methods - Hybrids
PET,PET/CT – Scintigraphy,SPECT/CT

Nuclear medicine methods:

Scintigraphy

SPECT

SPECT/CT

PET/CT PET/CT demonstrated 18F-fluorodesoxy glucose (FDG) accumulation

in tumors
Objective evaluation of the nasal airway

Nasal peak flowmetry

Acoustic rhinometry (AR)

Rhinomanometry (RM)
 Peak nasal inspiratory or
exspiratory flow (PNIF, PNEF)


Nasal peak flow :
physiologic measure of the air flow through both nasal cavities
during forced inspiration and/or expiration
expressed in liter per minute

mucus being blown into

the peak flow meter

(subjective discomfort during

maximal expiration in patients
with mucosal disease)
 Nasal Peak Flow

Advantages
- economic
cheap and portable equipment
- assistance not required after short training session (5 minutes)
- rapid and easy to use
- good correlation with subjective feeling of nasal obstruction
Disadvantages
- influence of lower airway function
- cooperation of patient required
- no unilateral measurement possible
- impossible in patients with alar collapse during inspiration
Objective measurements in the nose
Objective measurements in the nose

Rhinomanometry
• 75, 150, 300 kpascal

• Nasal air-flow
• Nasal pressure
• Nasal airway resistance NAR
(NAR was calculated from rhinomanometric
measurements of nasal airflow and
transnasal pressure)
• Rhinomanometry anterior
• Rhinomanometry posterior

• Rhinomanometry measures
unilateral airflow.
• Both nasal passages may be
measured separately
 Rhinomanometry

Normal curves Allergic rhinitis curves

In anterior rhinomanometry, the pressure-sensing tube is placed in one nostril

and data represent unilateral pressure and flow measures.
 Acoustic rhinometry

 non-physiologic measure of nasal patency

 measuring echoes of sound impulses sent into one nostril

information on the nasal luminal anatomic structures

nasal volume over a standard distance into the nostril
minimal cross-sectional area within the nasal cavity.

The measurement is performed in each nasal cavity

separately.
 Acoustic rhinometry

I has send sound of 20 Hz to the nasal cavity.

The size of cross sectional area is tipical of the

disease(disorder)
 Acoustic rhinometry

septal deviation allergic rhinitis nasal polyps

 Acoustic rhinometry

Advantages
- easy to use
- minimal patient cooperation
- information of each nostril separately
Disadvantages
- non-physiological measure of nasal patency
- operator required
- interference with nasal cycle
- weak correlation with subjective nasal congestion
 Nasal cytology

stained by the May-Grunwald Giemsa (MGG)

method

(A) Normal nasal cytology with evident ciliate cells;

(B) allergic rhinitis;
(C) NARES (Non Allergic Rhinitis infiltrated by EoSinophils)
(D) NARMA (NAR infiltrated by Mast cells)
(E) NARNE (NAR infiltrated by NEutrophils)
(F) NARESMA (NAR infiltrated by EoSinophils and MAst cells)
 Obstructing nasal breathing
disorders

Allergic rhinitis
Inflammation - rhinitis, rhinosinusitis – viral, bakterial, fungal
Septal deviation
Choncha bullosa
Hypertrophy chonhae
Polyposis nasi
Mucocele
Tumor
Foreign body

Choana atresia
Adenoid vegetation
 Inflammation in the nose

Definition: Rhinitis is defined as inflammation of the nasal membranes.

Rhinitis allergica: Formed after allergen exposure of the nasal and

sinus mucosa ongoing IgE-mediated inflammation

Allergic rhinitis is one of the most common cause of rhinitis .

Rhinitis symptoms:  sneezing,

nasal congestion,
nasal itching,
rhinorrhea ( and postnasal dripping)
 Allergic rhinitis

Definition: Allergic rhinitis is an IgE mediated inflammation of the nasal

passages, usually associated with watery nasal dyscharge and itching of the
nose and eyes.

Charactaristic symptoms include:

repetitive sneezing rhinorrhea (runny

nose);
post-nasal drip;
nasal congestion;
pruritic (itchy) eyes, ears, nose or throat;
impaired smell
Allergic conjunctivitis
 Pathophysiology

Allergic rhinitis is characterized by a two phase allergic

reaction:

Initial sensitization phase

Clinical phase

early-phase respons

sneezing
itching
leak being responsible for mucosal edema and watery rhinorrhea

late-phase response

nasal congestion
 Diagnosis of the allergic rhinitis

Skin-prick test - sub- and intracutan provocation test

Serum specific IgE determination against allergens
Nasal cytology - nasal eosinophilia (an indicator of eosinophilic
inflammation in allergy)
Nasal examination – rigid or flexible endoscopy (deformity of the septum,
concha bullosa, hypertrophy turbinate, polyps, rhinorrhea, postnasal
discharge,
Rhinomanometry - is the measurement of nasal pressure
flow.(elevated)
 Classification of the allergic rhinitis

The ARIA (Allergic Rhinitis and its Impact on

Asthma) document classifies the AR according to the
frequency (intermittent or persistent) and intensity of
symptoms (mild or moderate)
 Major Indoor Aeroallergens

What triggers indoor allergies?

Common Name Scientific Name(s) Area(s) of High Concentration Source

of Allergen
Dust mite Dermatophagoides Bedding Mite body
pteronyssinus (Der p Upholstered furniture Mite feces
1), Carpeting
Dermatophagoides
farinae (Der f 1)

Cat, dog Felis domesticus (Fel d Bedding Sebaceous glands

1), Upholstered furniture Salivary glands
Canis familiaris (Can f Carpeting
1)
Cockroach Blattella germanica Kitchen Fecal material
(Bla g 1), Secretions
Periplaneta americana Dead cockroach bodies
(Per a 1)
Fungi Alternaria alternata Variable Spores
(Alt a 1),
Cladosporium
herbarium
(Cla h 1),
Aspergillus fumigatus
(Asp f 1)
 Major outdoor allergens

What triggers outdoor allergies?

 Tree pollen

 Grass pollen

Ragweed pollen

Mold spores
 Therapy of the allergic rhinitis

Allergen avoidance - environmental settlement

avoiding pollen
mould eradication

Medication – oral antihistamine (second and modifide generation –

cetirizine-Zyrtec,Loratadine-Claritine,Levocetirizine-Xyzal,
Desloratadine-Aerius,Terfenadine-Telfast,Fexofenadine-Allegra)
or local nasal spray antihistamine(Azolestine-Allergodil) ----
to early phase

- local corticosteroid nasal spray (belcomethasone-Beconase,

budesonide-Rninocort Aqua,Flixonase, momethason furoat-
Nasonex,fluticasone-furoat-Avamys
to late phase
- eye-drops
Immunotherapy – parenteral, oral
Other treatments – diet,acupuncture,acupressure ,herbal teas,salt inhalation,
soft laser, infrared
 Rhinitis - rhinosinusitis


Most common pathogens of the viral and bacterial rhinitis

Viral rhinitis Bacterial rhinitis

Rhino- Haemophilus influenzae 20-30%

Adeno- Sterptococcus pneumoniae 30-40%
Influenza- Streptococcus pyogenes
ECHO- Moraxella catarrhalis 12-20%
RS-
Coxsackie- E. coli 7%
Rheo Pseudomona aeruginosa 15%
Klebsiella pneumoniae
 Non-allergic rhinitis

Vasomotor rhinitis-it is important to recognise any potential

environmental triggers and, if possible, avoid them.

 Atrophic rhinitis -Nasal irrigation is the most common

treatment for atrophic rhinitis

Rhinitis medicamentosa - stop using nasal decongestant

sprays
 Acute rhinosinusitis

Symptoms

Acute sinusitis symptoms often include:

Drainage of a thick, yellow or greenish discharge from the
nose or down the back of the throat
Nasal obstruction or congestion, causing difficulty breathing
through your nose
Pain, tenderness, swelling and pressure around your eyes,
cheeks, nose or forehead
Aching in your upper jaw and teeth
Reduced sense of smell and taste Acute sinusitis can be caused by:
Cough, which may be worse at night
Viral infection. Most cases of acute
Other signs and symptoms sinusitis are caused by the common cold.
can include: Bacterial infection. When an upper
Ear pain respiratory tract infection persists longer
Headache than seven to 10 days, it's more likely to
Sore throat be caused by a bacterial infection than by
Bad breath (halitosis) a viral infection.
Fatigue Fungal infection.
Fever
 Acute rhinosinusitis

Acute sinusitis can be caused by:

Viral, bacterial ,fungal infection

Some health conditions can increase the risk of getting a sinus

infection:

Allergies such as hay fever.

Nasal polyps or tumors.
Deviated nasal septum.
Tooth infection.
Enlarged or infected adenoids in children.
Other medical conditions. (cystic fibrosis, gastroesophageal reflux disease (GERD)
or immune system disorders)
Complications
Asthma flare-ups.
Chronic sinusitis
Meningitis..
Vision problems
Ear infection
 Acute rhinosinusitis

Tests and diagnosis

Physical examination
Nasal endoscopy
Imaging studies
Nasal and sinus cultures

Treatments to relieve symptoms

Allergy testing
Saline nasal spray
Nasal corticosteroids
Decongestans
Over-the-counter pain relievers
Antibiotics (Antibiotics usually aren't needed to treat acute sinusitis)
 Sinusitis

Which sinusitis is the most common?

Ethmoidal sinusitis

Maxillary sinusitis

Frontal sinusitis

Sphenoidal sinusitis
 Chronic rhinosinusitis

Symptoms Definition: chronic rhinosinusitis — when the signs

and symptoms last for more than 12 weeks

Two of the following signs and symptoms must be present for a diagnosis of
chronic sinusitis:

Drainage of a thick, yellow or greenish discharge from the nose

Disharge down the back of the throat (postnasal –drip)
Nasal obstruction or congestion, causing difficulty breathing through the nose
Pain, tenderness and swelling around the eyes, cheeks, nose or forehead
Reduced sense of smell and taste

Other signs and symptoms can include:

Ear pain
Aching in your upper jaw and teeth
Cough, which may be worse at night
Sore throat
Bad breath (halitosis)
Fatigue or irritability
Nausea
 Chronic rhinosinusitis

Theories of pathophysiology of CRS:

 Persistent infection (including biofilms and osteitis)

 Allergy and other immunologic disorders
 Intrinsic factors of the upper airway
 Superantigens
 Colonizing fungi that induce and sustain eosinophilic inflammation
 Metabolic abnormalities such as aspirin sensitivity
 Chronic rhinosinusitis

Causes

Nasal polyps or tumors.

Allergic reactions.
Deviated nasal septum.
Trauma to the face.
Other medical conditions.
Respiratory tract infections.
Allergies such as hay fever.

Risk factors

A nasal passage abnormality (deviated nasal septum or nasal polyps

Aspirin sensitivity
A medical condition, (cystic fibrosis or chronic obstructive
pulmonary disease (COPD)
An immune system disorder
Hay fever or asthma — about 1 in 5 people with chronic sinusitis
have asthma
 Chronic rhinosinusitis

Tests and diagnosis

Nasal endoscopy.
Imaging studies
Nasal and sinus cultures
An allergy test
Treatments and drugs

The goal of treating chronic sinusitis is to:

Reduce sinus inflammation Saline nasal spray

Keep your nasal passages draining Nasal Corticosteroids
Eliminate the underlying cause Decongestants
Reduce the number of sinusitis flare-ups Over-the-counter pain relievers
Aspirin Desensitization treatment
Antibiotics

Surgery - FESS
 Differencial diagnosis


 Rhinosinusitis with polyps

What are the nasal polyps?

soft, painless, noncancerous growths on the lining of the nasal

passages or sinuses.

Polyps result from chronic inflammation due to

asthma,
recurring infection,
allergies,
immune disorders.

Small nasal polyps may not cause symptoms.

Larger growths or groups of nasal polyps can block the nasal passages
lead to breathing problems,
a lost sense of smell
frequent infections.
more common in adults.
Medications can often shrink or eliminate nasal polyps
surgery is sometimes needed to remove polyps.
Even after successful treatment…
…. nasal polyps often return
 Chronic rhinosinusitis with polyps

What are the common symptoms CSwNP?

Common signs and symptoms of chronic sinusitis with nasal

polyps include:

A runny nose
Persistent stuffiness
Postnasal drip
Decreased or absent sense of smell
Loss of sense of taste
Facial pain or headache
Pain in your upper teeth
A sense of pressure over your forehead and face
Snoring
Itching around your eyes
 Diagnosis of the nasal polyps

Polyps may be visible with the aid of a simple lighted instrument.

Anterior or posterior rhinoscopy

Nasal endoscopy
Imaging studies –CT, MRI
Allergy tests

Complications

Obstructive sleep apnea.

Asthma flare-ups..
Sinus infections..
Spread of infection to the eye socket.
Meningitis
 Therapy of the chronic
rhinosinusitis with polyps

Medications

Drug treatments may include:

Nasal corticosteroids.
fluticasone (Avamys), budesonide (Rhinocort) mometasone
(Nasonex), beclomethasone (Beconase).
Oral and injectable corticosteroids.
Other medications. .
antihistamines to treat allergies and antibiotics to treat a chronic or
recurring infection.

Surgery

Polypectomy. Small or isolated polyps can often be completely

removed using a small mechanical suction device
microdebrider — an instrument that cuts and extracts soft tissue.
Endoscopic sinus surgery.

Polyps tend to recur

 Functional Endoscopic Sinus Surgery

Indications for Functional Endoscopic Sinus Surgery

Chronic sinusitis refractory to medical treatment

Recurrent sinusitis
Nasal polyposis
Antrochoanal polyps
Sinus mucoceles
Excision of selected tumors
Cerebrospinal fluid (CSF) leak closure
Orbital decompression (eg, Graves ophthalmopathy)
Optic nerve decompression
Dacryocystorhinostomy (DCR)
Choanal atresia repair
Foreign body removal
Epistaxis control
 Advantages of the endoscopic
sinus surgery

Benefits of Functional Endoscopic Sinus Surgery

It is a safe and minimally invasive procedure
It does not disturb healthy tissue
It is performed in less time with better results
Quick Recovery and return to normal lifestyle.

there is less:
external scarring
removal of normal tissue
bleeding
pain

Benefits of Image Guidance

improves the safety and effectiveness of FESS

better visibility
 Deviated septum

Deviated septum

•Obstruction of one or both nostrils

•Nosebleeds
•Facial pain
•Frequent or recurring sinus infections.
•Noisy breathing during sleep
Complications
Nasal obstruction
Sinus infections
Nosebleeds
Facial pain and headaches
Treatments and drugs

Decongestants
Antihistamines
Nasal steroid sprays

Surgical repair - septoplasty

References:

• Rhinology: Diseases of the Nose, Sinuses ang Skull

BaseDavid W. Kennedy, Peter H. Hwang – Ed: Thieme
2012
• Nasal Physiology and Pathophysiology of Nasal
Disorders T. Metin Önerci – Ed: Springer 2013
• Ear, Nose, and Throat Diseases: With Head and Neck
Surger Hans Behrbohm, Oliver Kaschke – Ed: Thieme
2009
Many thanks for your kind attention !