Ear, Nose & Throat 
For Dental Students 

SGS 422 
 
 Diseases of the mouth and pharynx.

CONGENITAL

i. Fordyce spots:
Small elevated yellowish spots found on the lips & buccal mucosa. They are due to sebaceous
glands in the oral mucosa & are apparent in early adult life. Present in about 60% of
population.

Congenital anomalies of teeth:

1) Total anodontia: rare sometimes associated with ectodermal dysplasia & is due to lack of
development of the dental lamina.
2) Partial anodontia: more common.
3) Supernumerrary teeth: due to an accessory bud from the dental lamina.
4) Real occlusion of the teeth: may be due to local causes e.g.
· Premature loss of deciduous teeth.
· Supernumerrary teeth.
· Absence of one or more teeth.
· Disparity in size between the teeth & jaws.
· Mal relationship between the two jaws...
ii. Congenital malformation of the tongue:
1) Bifid tongue: due to failure of fusion of the lateral tubercles of the mandibular arch.
2) Macroglosssia: may occur in cretinism, mongolism, acromegaly, lymphangioma.
Treatment: excision of a wedge shaped portion of tongue.
3) Microglossia or aglossia:
4) Ankyloglossia (tongue tie): short frenum linguae attached to tip of tongue. Treatment: free
the tongue by surgical division of the tie.
5) Median rhomboid glossitis: smooth oval patch on the dorsum of tongue anterior to vallate
papillae due to persistence of tuberculum impar.
 6) Furrowed tongue: congenital fissuring of tongue.
7) Lingual thyroid.
8) Accessory thyroid tissue.
9) Thyroglossal cysts.
iii. Perforation of anterior facial pillars: bilateral & symmetrical
iv. Bifid uvula: A very minor degree of cleft palate.
v. Stenosis of the pharynx: Involves mainly the nasopharynx.
vi. Bronchial cysts & fistulae:

Injuries

¨ Lacerations & penetrating wounds:

· Lacerations: due to trauma by foreign body. Antibiotics are prescribed to avoid secondary
infection. Tonsillectomy may be complicated by a hole in one faucial pillar.
· Penetrating wounds: Stabs, missiles, etc--- They are usually fatal due to associated
damage of internal structures.
¨ Caustic burns: self inflicted. The resultant stricture is non fatal. It usually involves the
esophagus.
¨ Foreign body: less common than in the esophagus.
· Smooth rounded objects.
· Sharp irregular Foreign body: For e.g. small fish bones.
· Treatment: a) per oral removal by forceps.
B) Endoscopy: for Foreign body in pyriform fosse & valecullae.
 The oropharynx

Diseases of the tonsils

¨ Acute tonsillitis:
Acute inflammation of the tonsils.

· Aetiology:
- Age: childhood 5-6 y (adolescence & early adulthood) rare in infancy & above 50y.
- Bacterial cause: usually due to streptococcus. Hemolytecus, other pyogenic organisms
may be present. In many cases virus infection may be responsible. It's transmitted by
droplet infection. It may occur in epidemic forms especially in schools & camps.
· Pathology:
(i) Acute catarrhal or superficial tonsillitis:

A part of general pharyngitis. It is usually concurrent with upper respiratory tract

infection. There is little or no swellings of the tonsils, the surface merely appears inflamed
in continuity with the rest of the pharyngeal mucosa.

(ii) True acute tonsillitis:

1- Acute parenchymatous tonsillitis: marked generalized redness & swelling.

2- Acute follicular tonsillitis: Yellowish exudates in the crypts leading to characteristic

spotted appearance.

3- Acute membranous tonsillitis: in which the exudation from the crypts may coalesce to
form a non adherent membrane.

¨ Clinic Picture:
A) Symptoms:

1) Sore throat & dysphagia of rapid onset.

2) Fever, malaise & constipation.

3) Earache.
 B) Signs:

1) The tongue is coated with fetor of the breath.

2) Oropharynx is congested. Pathological changes in the tonsil

3) Cervical Lymph nodes: enlarged & tender especially the tonsillar gland just below the
angle of the mandible.

¨ Complications: the most important are:

1) Peritonsillar abscess.

2) Para pharyngeal & retropharyngeal abscess.

3) Otitis media.

4) Laryngeal edema.

5) Rheumatic fever & acute nephritis.

6) Chronic tonsillitis.

7) Septicemia.

¨ Symptoms and Signs: see diphtheria

Scarlet fever: marked injection of the whole pharynx. Tongue has a strawberry appearance;
the skin is hot & soon develops punctate erythema.

¨ Treatment:
1) General: rest in bed, warm fluid diet.

- Antibiotics & analgesics.

2) Local: - warm gargles.

- Hot applications for the cervical glands.

¨ Chronic tonsillitis: (non-specific):

Chronic inflammation of the tonsils.
¨ Aetiology:
Repeated attacks of acute tonsillitis.

¨ Pathology:
1) Chronic parenchymatous tonsillitis: more in children between 4-14y. There’s chronic
inflammatory hypertrophy usually associated with enlargement of nasopharyngeal tonsils.

2) Chronic follicular tonsillitis: more in adults.

Chronic fibroid tonsillitis: small fibrotic tonsils, harmless in appearance.

¨ C/P:
A) Symptoms:

1) History of repeated attack.

2) Sense of irritation in the throat.

3) Fetor & bad taste.

4) Interference with swallowing or breathings (if large).

5) Symptoms of septic focus: focal sepsis is a complication of toxemia or bacteraemia

induced by a chronic latent infection (e.g. septic teeth, tonsillitis, sinusitis, appendicitis,
cholecystitis, periosteitis & salipingitis)

The tonsil acting as a septic focus may lead to nephritis, carditis, Rheumatic fever, iritis,
optic atrophy, skin eczema, psoriasis, rheumatoid arthritis, myositis & chronic toxemia
(anemia, poor appetite, fatigue).

B) Signs:

1) Inequality of the size of the tonsils.

2) Congestion of the anterior pillars.

3) Chronic intratonsillar abscess, cyst, calcification or scarring.

4) Pus oozing from the crypts on pressure.

 5) enlarged cervical (tonsillar) glands.

¨ D.D:
1) Cancer tonsil

Treatment:

When the symptoms are persistent tonsillectomy is indicated.

· Chronic enlargement of lingual tonsil:

It is more common in adults. It is usually a delayed result of tonsillectomy. In the former
it may follow whooping cough. It leads to persistent irritation & cough.

· Treatment: astringents lozenges & paints. In persistent cases excision. Cryosurgery and
laser are more suitable in this respect.
· Tonsilloliths:
Chronic infection is the usual cause. It may result in calcification of follicular cysts. They
may simulate carcinoma or elongated styloid process on examination.

· Treatment: Tonsillectomy or simple removal of the calculus under local analgesia.

· Intratonsillar abscess: usually due to infection around a tonsillolith.
· Asymptomatic T.B infection of the tonsil:
The tonsils may appear pale & bulky (more than usual). Large painless cervical glands
are common & typical. Adenoids are often similarly infected.

Treatment: tonsillectomy in the quiescent period.

· Peritonsillar abscess:
It's an abscess in the Peritonsillar space between the capsule of the tonsil & its muscular
bed (superior constrictor).

- Aetiology: It's usually related to the upper pole of the tonsil as infection passes
mainly through the crypta magna during an attack of acute tonsillitis. It's usually
unilateral.
- C/P:
 Symptoms of acute tonsillitis become worse with the development of:

1- Severe dysphagia: the patient is unable to swallow even his saliva.

2- Pain: throbbing, referred to the ear on the side of the abscess.
3- Trismus, torticollis.
4- Pyrexia, headache, malaise, & fetor oris.
- Signs:
1- Swelling of the soft palate above & lateral to the inflamed tonsil pitting edema
on probing indicates pus formation.
2- The adjacent tonsil is pushed downwards & medially.
3- The usual is edematous & is pushed to the other side. Its tip pointing to the
same side.
4- Enlarged tender cervical glands.
- Complication:
1- Spread of infection laterally outside the pharynx (parapharyngeal abscess).
2- Spread of infection downwards to the larynx (laryngeal edema)
3- Septicemia.
- Treatment:
1- Conservative: in early cases of peritonsillits before suppuration.
1) Antibiotics.
2) Analgesics.
3) Resting in bed, fluids & purgation.
2- Surgical:
1) Incision & drainage: if pus is formed (throbbing pain, pitting edema &
pus on aspiration). No anesthesia. It's done in one of the following
sites while the patient is sitting.
2) 1/2 cm lateral to the meeting of 2 lines, a vertical line from the
attachment of the anterior pillar to the base of the tongue & a
horizontal line along the base of the uvula.
3) Midway of a line between the base of the uvula & the last upper molar
tooth.
4) The most pointing point.
 5) Through the crypta magna.
3- Tonsillectomy: after one month. Few surgeons remove the tonsil in the
presence of the abscess (abscess-tonsillectomy).
· Para pharyngeal abscess:
Abcess in the parapharyngeal space.

Infection spreads from the tonsils, tonsillar fosse & from the lower molar tooth & its
surroundings gums & bone. This may occur after tonsillectomy or injury of the pharyngeal wall.

The abscess may occur at any age but is more frequent in adolescents & adults.

- C/P:
1- Painful throat.
2- Trismus.
3- Pyrexia.
4- Swelling of the neck.
5- Pharyngeal wall & tonsil are pushed medially.
It is characterized by Bic's triad: This includes

a) Parotid swelling.
b) Swelling related to the tonsil pushing it medially.
c) Trismus.
- Complications:
The abscess forms in the deep substance of the neck between the pharyngeal wall
(superior constrictor muscle) & the investing layer of the deep cervical fascia, in
close proximity to the jugular & carotid vessels.

1- Acute edema of the larynx.

2- Thrombophlebitis of I.J.V., septicemia, pyaemia & even rupture.
3- Direct spread. To the superior of part of the neck: swelling behind
sternomastoid. To the mediastinum : mediastinitis
- Treatment:
1- Antibiotics.
 2- Incision of the abscess. Through the pharynx or external drainage depending
upon the point of maximum swelling.
· Retropharyngeal abscess:
It occurs between the buccopharyngeal & prevertebral fascia.

1- Acute retropharyngeal abscess:

It's due to suppuration of the retropharyngeal lymph nodes of Henle present in each
side of the midline. The glands of both sides are separated by a tough median
partition due to midline attachment of buccopharyngeal with prevertebral fascia & so
the retropharyngeal lymph gland of Henle lies in the lateral space of Gilette.

- Aetiology:
1) Infection in the adenoids or tonsils.
2) Injury by foreign body.
3) Neoplasms.
4) Rarely from Acute suppurative otitis media through the Eustachian
tube either along the tissues or by the formation of an abscess below
the petro us bone. These glands tend to atrophy about the fifth years of
life & so the condition occurs only in infants and young children.
- Symptoms:
1) Fever and toxemia.
2) Difficulty in swallowing & suckling due to obstruction of the opening of the
high & obliquely placed infant's larynx.
3) Stridor: difficult noisy breathing.
4) Torticollis: sometimes.
- Signs:
1) Swelling in the posterior pharyngeal wall limited to one side.
2) Edema of the larynx.
3) Enlarged tender cervical glands. Spontaneous rupture of the abscess
may occur --- sudden death from aspiration.
- Treatment:
1) Antibiotics.
 2) Incision of the abscess form inside with the head low & using suction
to avoid inhalation of pus into the larynx.
3) Tracheotomy: in stridor.
2- Chronic retropharyngeal abscess:
Aetiology:

Usually caused by T.B infection.

Types:

1) A cold abscess behind the prevertebral fascia due to T.B. of the cervical
vertebrae. It usually occurs in later age. It forms a swelling in the post
pharyngeal wall in the midline.
2) T.B. infection of the retropharyngeal lymph gland due to spread of infection
from the deep cervical gland. The abscess lies laterally in the space of Gilette.
- Clinical picture:
Seen in older children, adolescents & adults.

1) Slight dysphagia.
2) Cold abscess; median or lateral.
3) Enlarged painless cervical glands.
- Treatment:
a) Incision from outside a long the posterior border of sternomastoid.
b) Spinal cold abscess is treated appropriately. Large cervical glands may need
dissection at a later stage.
c) Anti T.B treatment

d) Ludwig's angina:
It's a diffuse cellulitis of the floor of the mouth & neck. It may occur after extraction of
an abscessed tooth. It has been observed associated with acute parotitis & occasionally
during specific fevers. The infection spreads from a molar tooth socket to sub mental &
submandibular spaces.

a. Organism: streptococci, staphylococci, pneumococcal.

 b. C/P:
a. Severe illness-high fever.
b. Brownish swelling in the floor of the mouth, submandibular &
suprahyoid regions. Skin red & edematous.
c. Pain & discomfort in the neck. Painful swallowing.
d. Trismus may be present.
e. Tongue swelling & tender.
f. Dyspnea.
c. Treatment:
a. Free incision in the midline (chin-thyroid) and may be lateral incisions
in addition.
b. Broad spectrum antibiotics.
· Tumors of oropharynx:
Benign tumors:

i. Papilloma:
Arise on the soft palate or anterior faucial pillars & form soft mobile
warty growths. They are usually small & discovered accidentally. They are easily
removed under topical anesthesia by scissors or snares.

ii. Adenoma:
Rare salivary gland tumor, & should be regarded as potentially malignant. It
arises in the mucous membrane of the glands of the soft palate. Painless & diagnosed
late.

iii. Benign Connective tissue tumors:

Rare e.g. lipoma, fibroma.

iv. Neurilemmoma:
It lies in the lateral part behind the tonsil. It's an encapsulated tumor arising from
the sheath of the Vagus or other cranial nerves. Unilateral Horner's syndrome may be
associated with the tumor. It shells out easily.

v. Haemangiomatous malformation:
 In the palate, tonsil, posterior & lateral wall of oropharynx

Treatment:

Diathermy coagulation with ligature of E.C.A. Also cautery or injection of

sclerosing materials.

c. Malignant tumors:
i. squamous cell carcinoma:
Undifferentiated form in the elderly. A less differentiated type is seen in
younger patient & usually arises in the tonsillo-lingual sulcus. Other sites:

- Tonsil itself.
- Palate & uvula.
- Lower part of posterior wall of oropharynx.
- T.N.M. classification:
T1: tumors less than 1 cm in diameters.

T2: tumors between 2cm & 4cm in diameter.

T3: tumors more than 4cm in diameter.

T4: massive tumors.

Intraepithelial carcinoma (carcinoma in situ or boune's disc) may proceed to

malignant changes especially in the palate.

- C/P:
- Early:
1) Persistent mild sore throat.
2) Slight dysphagia
- Late:
1) Ear ache.
2) Enlarged cervical glands.
3) Salivation.
4) Bleeding from the mouth
 There may be local infiltration of the tongue, hard & soft palates, alveolus &
mandible. The tumor is usually ulcerated & infiltration into the tongue causes it to
be partly immobilized & pulled towards the side of the lesion when protruded.

- Investigations:
1) Biopsy.
2) Chest radiographs.
3) Blood exam.
- Treatment:
1) External irradiation: to the whole tumor & lymphatic fields.
2) Monoblock removal: wide removal of the tumor & cervical glands in block. A
portion of the mandible, tongue, cheek, tonsil & palate is included in the
excision (commando operation). 5-y cure rate 30%.
3) Intra-arterial injection of cytotoxic agent: for palliation & to relieve pain.
ii. Polygonal cell carcinoma: "lympho-epithelioma:
In young patients – affects tonsil, base of tongue & valecullae. Bulky non ulcerating
tumor. A lingual thyroid can always be excluded by a radio-isotope scan.

iii. Adenocarcinoma:
Mixed salivary gland tumors. It presents usually in the palate & faucial regions as a
smooth encapsulated swellings which can be shelled out. Sometimes it is an extension
from a parotid tumor. This necessitates an external approach.

iv. Sarcoma:
Lymphosarcoma & Rhabdomyosarcoma. They occur usually in young adults &
children. There is unilateral enlargement of tonsil without ulceration & may simulate a
quinsy. Lymph gland involvement occurs sooner or later.

- Treatment.:

External irradiation. Removal of the tonsil may be needed for biopsy. Irradiation
gives a very good response.
 1

ACUTE SINUSITIS

It's acute infection of one or more of the paranasal sinuses by pyogenic organisms. It's
most common in the maxillary sinus, then the ethmoids, frontal and sphenoid.

Aetiology:

I. Exciting causes:

1. Nasal:
Infection reaches the sinus through the ostium:

a. Acute rhinitis: due to common cold, influenza or exanthemata (measles whooping

cough…). This is the commonest cause of acute sinusitis.
b. T.B.
c. Nasal packing.
d. Swimming and diving.
2. Dental:
a. Dental infection: the antrum can be affected in two ways:
§ Chronic dental infection can cause localized areas of granulations in the sinus mucosa
where it lines the alveolar recesses of the antrum.
§ Bacteria may spread directly from an apical granuloma or periodontal pocket or they
may be carried to the antrum by lymphatics.
b. Dental extraction of 2nd premolar or 1st molar with a fistula reaching the antrum.
3. Trauma:
a. Compound fracture of one of the sinuses.
b. Contusion of the sinuses: Blow to the check or forehead with extravasation of blood into
the sinus cavity.
c. Barotrauma.
4. General disease.
II. Predisposing Factors:

1. Poor general environment.

2. Lowered resistance.
 2

3. Undue exposure.
4. Obstruction:
Any nasal disease obstructing the ostium of the sinus e.g. DS, allergy polypi, large middle
turbinate and tumors.

III. Association with Chest Conditions:

a. Bronchiectasis:
b. Cystic fibrosis:
* Organisms:
i. Bacteria: pneumococci, Streptococci, Staphylococci, haemophilus influenzae, E. coli
Micrococcus catarahalis, bacillus pyeogenes and Bacillus Friedlander.
ii. Virus: Rhinovirus, para-influenza I and II.
iii. Specific infections: fungi, $, TB and leprosy.

* Pathology:

There's thickening of the connective tissue in chronic sinusitis. In acute sinusitis there is
swelling of the mucus membrane with invasion by many PLNL. Later on the epithelium looses
its cilia.

The vessels are engorged and the submucosa becomes oedematous. Swelling of the
mucosa leads to blockage of the ostium.

* Clinical picture:

I. Symptoms:

1. Fever, malaise.
2. Nasal obstruction, hyposmia, nasal tone of voice.
3. Nasal discharge (mucopurlent or purulent). It's fetid in sinusitis caused by dental infection.
4. Pain or headache: increases by bending, straining or coughing. The site of pain depends on
the sinus affected.
 3

A- In maxillary sinusitis:
§ Pain is directly over the sinus.
§ Referred to teeth or ears.
B- In frontal sinusitis:
§ Pain across the forehead.
§ Vacuum headache: Due to obstruction of the frontonasal duct with absorption of air. Pain
is periodic i.e. starts in the morning, becomes severe at mid-day and subsides during the
afternoon.
C- In ethmoidal sinusitis:
§ Pain in the region of the inner canthus.
§ Pain between the eyes.
D- In sphenoidal sinusitis:
§ Pain referred to back of head (occipital).
§ Behind the eye.
I. Signs:

A- External examination:

There may be oedema, flushing and tenderness over the involved sinus. Tenderness over
the frontal sinus must be distinguished from that over the supra-orbital nerve, it is more common
with maxillary sinusitis.

· Nasal mucosa: congested and swollen.

· Swelling of the inferior and middle conchae.
· Pus: its site depends on the sinus involved.
· In maxillary sinusitis: pus in posterior portion of middle meatus.
· In frontal sinusitis: pus in anterior portion of middle meatus.
· In ethmoidal sinusitis: pus in middle portion of middle meatus. Polypi may be present.

* Investigations:

i. Bacteriology: culture and sensitivity for the discharge.

 4

ii. X-ray examination:

Types:

1- Plain X-ray.
2- CT scan: shows thickened mucosa.It is more useful to examine the osseous tissues.
3- MRI: More useful in studying soft tissues.
The appearance will show:

a. Fluid level: More common in maxillary and frontal sinusitis.

b. Opaque sinuses.
c. Thickened mucosal lining.

* Differential diagnosis:

1. Dental neuralgia: teeth tender on precussion.

2. Temporomandibular neuralgia: "Costen's syndrome" it is due to alterations in the bite
producing stresses and strain in the joint.
Treatmen: rest the jaw and correct the bite.

3. Trigeminal neuralgia.
4. Migraine.
5. Temporal arteritis: pain over the course of the temporal artery which is palpable and
tender.
6. Nasopharyngeal tumors.
7. Neoplasms of the sinuses.
* Treatment:

Mainly conservative: Major or even minor surgical procedures should be delayed until
antibiotics have begun their effect.

* Aim:

1. To facilitate drainage.
2. Arrest growth of organism.
 5

3. Relieve pain.
4. Control blood stream infection and prevent complications.
i. General treatment:

1. Rest in bed.
2. Light diet, plenty of fluids.
3. Antibiotics, analgesics, antihistaminics.
ii. Local treatment:

1. Nasal sprays, drops or packs of argyrol ephedrine "decongestant" to improve drainage of the
sinus.
2. Steam inhalation (Tincture Benzoin co) and local heat.
iii. Prophylaxis:

After recovery from the acute phase:

1. Find out any predisposing cause and treat it accordingly e.g. DS, large middle turbinate,
allergy, polypi, etc…
2. Improve resistance by vaccine therapy.
iv. Surgical treatment:

No surgery in acute stage except if medical treatment fails or a complication arises.The

aim is to establish drainage.

· In maxillary sinusitis: Puncture and lavage. Recently endoscopic middle meatal antrostomy
· In frontal sinusitis: External trephine in the floor of the sinus.
· In ethmoidal sinusitis: Suction and proetz displacement. Recently endoscopic ethmoidectomy
 6

CHRONIC SINUSITIS

* Aetiology:

1. Recurrent attacks of acute sinusitis due to persistence of predisposing causes and inadequate
treatment.
2. High virulence of the organism.
3. Low resistance of the patient.
It may be simple non specific Chronic Sinusitis or mixed with vasomotor rhinitis.

* Histopathological changes:

In repeated attacks (chronicity) the venous and lymphatic changes result in edema
,polypoid mucous membrane, polypi, edematous periosteum and rarefaction of bone.

N.B.: It has been shown that the resistance of the maxillary ostium is more in cases of
chronic sinusitis than in normal or acute sinusitis.

* Clinical picture:

A- Symptoms:

i. Nasal symptoms:
1- Nasal obstruction.
2- Nasal discharge: purulent or mucopurulent and may be postnasal.In sinusitis of dental
origin it's extremely foul and profuse and may be associated with epistaxis.
3- Anosmia and cocosmia: the latter especially in dental infections.
4- Hypertrophic rhinitis, atrophy of nasal mucosa, rhinitis caseosa, polypi.
5- Recurrent attacks of coryza.
ii. Nasopharyngeal and pharyngeal symptoms:
1- Post nasal catarrh.
2- Tonsillitis and enlarged cervical LN.
 7

iii. Eye symptoms:

May be due to:

1- Obstruction and infection of nasolacrimal duct and subsequent conjunctival affection.

2- Inflammatory extension, orbital cellulitis and periosteitis ,optic neuritis…
iv. Ear symptoms:
Ear obstruction due to naspharyngitis.

v. Cranial symptoms:
1- Face ache: dull ache over the sinus.
2- Headache: due to obstruction of drainage or exacerbation.
vi. Cutaneous affection:
1- Eczema of nostrils and upper lip.
2- Facial erysipelas.
vii. Respiratory tract symptoms:
1- Unexplained cough.
2- Acute and chronic bronchitis.
3- Asthmatic attacks and bronchiectasis may be due to sinusitis.
viii. Digestive tract symptoms:
Gastric disturbances, nausea…

ix. Constitutional disturbances: "septic focus"

Loss of weight and anemia. Dental infection and tonsillitis cause more troubles.

B- Signs:

1- Inflamed mucous membrane. Pus in the middle, superior meatus or spheno-ethomoidal recess.

2- Examination of the phaynx. There may be post nasal discharge.

* Investigations:

1. Endoscopic examination: Specificity of the affected sinus.

2. Radiological examination:
Opacity or fluid level.
 8

3. Antral puncture and lavage:

§ Proof puncture.
§ Culture and sensitivity of discharge: usually streptococcal haemolyticum..
* Treatment:

i. Chronic maxillary sinusitis:

A- Conservative:

1. Treat the predisposing occurs e.g. Deviated septum, allergy, polypi, adencoids.
2. Antibioics and antihistaminics.
3. Vaccine therapy and short wave therapy: not encouraging.
B- Minor surgical procedures:

1. Antral puncture and lavage:

It's repeated 3-4 times.If no improvement proceed to intranasal antrostomy. If it shows pure
pus proceed immediately to radical antrum operation.

2. Intranasal antrostomy and if necessary polypectomy, SMR.

3. Endoscopic sinus surgery is now the preferred surgical therapy.
C- Radical measures:

Radical antrosotomy "Cald-Well-Luc operation. It is rarely performed.

ii. Chronic frontal sinusitis:

A- Conservative.

B- Surgical procedures:

1. Endoscopic removal of any obstructing factor:

2. Intranasal frontal op: with creation of a new fronto nasal duct.
C- Radical measures:

External operation done through an incision below medial part of the eye brow. Floor of
the sinus is opened and the diseased mucus membrane removed.
 9

D- Obliterative surgery:

Excision of the anterior wall.

iii. Chronic ethmoidal sinusitis:

A- Conservative:

Displacement (suction and proetz displacement): to displace air from the sinus by suction
and its replacement by fluid (nasal drops).

B- Surgical procedures:

Endoscopic ethmoidectomy or rarely transantral ethmoidectomy.

iv. Chronic sphenoidal sinusitis:

Operations on the sphenoid sinus are usually part of combined operations for
pansinusitis.

* Sinusitis in children:

The maxillary antrum and the ethmoids are the first sinuses to appear. The maxillary
sinus differs from the adult in:

1. Longest in its transverse diameter.

2. Its floor is in the level with the floor of the nose.
3. Its opening is smaller in relation to the size of the antrum and higher.

* Aetiology:

It occurs between 5-8 y:

1. Systemic factors:
a. Allergy.
b. Hypo and a gammaglobulinemia.
c. Endocrine factors.
 10

d. Mucoviscidosis.
e. Hereditary.
2. Environmental factors:
Dietary deficiency-lack of exercise and ventilation.

3. Local causes:
§ Intranatal infection and neonatal infection.
§ Virus infection.
4. Clinical causes:
a. Repeated colds and influenza.
b. Rhinitis of exanthemata.
c. Dental infections.
d. Swimming.
e. Adenoids they act by:
§ Obstruction and stagnation of secretion.
§ Mouth breathing.
§ Scarring of nasopharynx in inadequate removal of Deviated septum..
* Pathology:

Non-suppurative cases are more common than suppurative ones. After 10 years the
condition is similar to that in addicts.

There may be purulent discharge from the nostril but occasionally it remains dry as no
drainage is taking place.

* Specific infections:

1. T.B and $: as a direct extension of nasal disease.

2. fungus infection: due aspergilli Nystatin Actinomycosis.
 11

COMPLICATIONS OF SUPPURATIVE SINUSITIS

Usually result from acute exacerbation on top of chronic sinusitis.

Modes of Spread of Infection:

1. Direct spread: through the bony wall by:

a. Osteitis: in compact bone.
b. Osteomyelitis: in diploic bone.
c. Accidental or surgical trauma.
2. Venous spread by:
a. Septic cavernous sinus thrombosis: advancing and retrograde.
b. Retrograde spread (thrombosis) in minute veins in sinus mucosa: meningitis,sinus
thrombosis and brain infection.
c. Septicaemia and pyaemia.
3. Lymphatic spread:
Perivascular lymphatics transmit the infection through the vascular foramina leading to
subperiosteal abscesses (No direct spread).

4. Spread via perineural space: of olfactory nerve in the subarachnoid space.

I. Cranial complications:

* Osteomyelitis.

* Aetiology:

Usually in young adults (Streptococcal. and Staphylococcal.).

* Pathology:

Usually precipitated by trauma or operation on the anterior wall especially in absence of

systemic antibiotics.
 12

Subperiosteal abscess may form and may end in fistula formation. Separation occurs
later. Thrombosis of the venules crossing the suture lines allows the whole cranial bones to be
affected.

* Clinical Picture:

Dull local pain and headache.

Toxaemia and Intracranial complications are common complications.
* Investigations:

X-ray: necrosis and sequestration (usually after few weeks).

* Treatment:

1. Prophylactic: antibiotic in frontal operation.

2. Early cases:
§ Antibiotics.
§ Drainage of the affected sinus.
3. Chronic cases:
ESS.

II. Intracranial complications:

i. Extradural or subdural abscess.

ii. Meningitis:
Pachy and leptomeningitis.

iii. Sinus thrombosis:

Of the cavernous sinus-longitudinal sinus and frontal cortical veins.

iv. Brain abscess.

v. Orbital complications:
Most common children with ethmoiditis:

§ Orbital cellulitis.
§ Cavernous sinus thrombosis.
 13

§ Optic nerve atrophy.

§ Subperiosteal abscess.
vi. Descending infections:
1- Otitis media.
2- Pharyngitis, laryngitis, bronchitis, laryngotracheitis.
3- Gastrointestinal disturbances.
vii. General:
It acts as a septic focus.
 14

NASAL POLYPI

Types:

i. Simple:
a. Allergic: Usually multiple. Eosinophils and plasma cells are found in large numbers.
b. Inflammatory:
c. Mixed, infective allergic: usually secondary to infection in allergic or vasomotor rhinitis.
ii. Neoplastic:
a. Benign: e.g. bleeding polyposis of septum.
b. Malignant.

Simple Nasal Polypi:

These are pedunculated oedematous nasal mucosa, arising in relation to the middle
meatus where loose areolar tissue is present. They are most often allergic.

* Pathology:

· Site of origin: ethmoidal region.

· Bilateral multiple pale glistening pedunculated masses (grape-like growths).
· The polyp is covered with ciliated columnar epithelium. The submucosa becomes distended
with fluid. Connective tissue is widely separated .Cellular infiltrate (lymphocytes and
eosinophils).
· Gravity and narrowness of the middle meatus leads to downward distension of the edematous
mucous membrane with polyp formation.
· Metaplasia to transitional and squamous epithelium may occur.
* Clinical picture:

1. Bilateral nasal obstrustion and discharge.

2. Sneezing.
 15

3. Purulent discharge: if there's infection.

4. Expansion of nasal bones.
* Treatment:

1. Steroids or removal under local anaesthesia to relieve obstruction.

2. Antiallergic treatment is continued to prevent recurrence.
3. Ethmoidectomy in recurrent cases.

Antro-Choanal Polyp:

A single unilateral polyp. It arises from the maxillary antrum, comes out through the
ostium and passes backwards to the choana to enter the nasopharynx.

* Clinical picture:

Common in teenagers:

1. Unilateral nasal obstruction and discharge.

2. Snoring and thick speech.
3. Endoscopy: smooth greyish white spherical mass occupying one choana and projecting into
the nasopharynx.
* Treatment:

Endoscopic excision. Middle meatal antrostomy to prevent recurrence.

SEPTAL DEFLECTIONS AND SPURS

The nasal septum lies almost in the mid-line. It's formed of quadrangular cartilage,
perpendicular plate of ethmoid and vomer bones.

Deviated Septum: It means bending of the septum to one or both sides of the mid-line. A septal
spur may be associated (thickening of a part of the septum). It is unusual to see a perfectly
straight septum in normal persons. However, symptoms appear only if the deviation is severe.
 16

* Aetiology: Developmental factors or Traumatic.

* Clinical picture:

1. Nasal obstruction: Unilateral or bilateral obstruction of the ostium of the sinus by a deviated
septum may lead to sinusitis. Nasal discharge.
2. Epistaxis: due to angulation of the vessels on the convex side.
3. Associated external deformity: in traumatic cases.
* Treatment: Submucous resection (SMR).

Hematoma:

Collection of blood beneath mucoperichondrium or mucoperiosteum of septum.

* Aetiology:

Nearly always traumatic:

· Direct blows.
· Following surgery (after Submucous resection).
· Spontaneous during epidemics of influenza.
It leads to bilateral nasal obstruction and red soft swelling on both sides of septum.

* Complication:

1. Septal abscess and necrosis.

2. Permanent thickening.
* Treatment:

1. Aspiration.
2. Incision and drainage and nasal packing.
3. Antibiotics.
Abscess of the Septum:

Usually secondary to haematoma which has become infected or may follow measles
scarlet fever or furunculosis.It leads to
 17

Nasal obstruction

Throbbing pain, headache, tenderness and fever.

* Complications:

1. Necrosis of cartilage, perforation of septum and depression of bridge.

2. Cavernous SinusThrombosis.
* Treatment:

1. Incision and drainage: antibiotics.

2. Plastic repair: later.
Temporomandibular Joint Arthrosis:

Common in young females.

* Clinical Picture:

1. Clicking of the jaw on movement with or without pain.

2. Earache or pain in the side of the face.
3. False conductive deafness.
4. Loss of mobility or stiffness: may be with history of recurring dislocation, gag, blow,
yawning, extraction or filling of a tooth of lower jaw or none. The symptoms are sometimes
related to grinding the teeth at night (bruxism).
5. X-ray: Usually negative signs, unless osteoarthritis has occurred.
* Treatment:

1. Exercises.
2. Bite palate (Night guard): to restore the bite and at night for bruxism.
3. Correction of occlusion to:
§ Restore the vertical dimension and replace missing tooth or correct denture.
§ Allow free sliding movement in mastication.
4. Hydrocortisone injection and treatment of the cause.
5. Condylectomy in cases not responding to treatment
 1
TUMORS OF THE NOSE AND PARANASAL SINUSES

CLASSIFICATION:

i. Benign:

i. Soft tissue:
Epithelial: Papilloma, Adenoma.
ii. Connective tissue:
1- Fibroma.
2- Angioma.
3- Chondroma.
4- Glioma.
iii.Osseous:
b. Primary osseous:
1- Osteoma.
2- Fibro-osseous disorder.
3- Cherubism
4- Cysts
c. Odontogenic:
1- Cysts.
2- Composite odontomes.

ii. Intermediate:

i. Soft tissue:
a. Epithelial:
1- Inverting papilloma.
2- Mixed tumour.
3- Leucoplakia
b. Connective tissue:
1- Chordoma.
2- Teratoma.
3- Haemangio-endothelioma.

ii. Osseous:
 2
a. Primary osseous: Osteoblastoma.
b. Odontogenic: Adamantimma.

iii. Malignant:

i. Soft tissue:
a. Epithelial: Carcinoma (Squamous cell carcinoma, Adenocarcinoma.)
b. Connective tissue:
1- Sarcoma.
2- Melanoma.
3- Malignant lymphoma.
ii. Osseous: Osteosarcoma
iii. Metastatic.

iv. Tumour Like Lesions:

1. Mucocele and pyocoele.

2. Granulomata e.g. Scleroma, TB and Syphillis.
3. Wegner's granulomatosis.
4. Amyloidosis.

i. Benign

They may affect the sinuses, the septum or turbinates.

Clinical picture:

May cause nasal obstruction ,epistaxis….

Treatment:
Excision : Endoscopic excision. You may need tocauterize the base.
Histopathological examination
Local recurrence after excision is common.
May turn malignant.
Angioma:
 3
It is of 3 types:

a. Capillary:
§ Commonest.
§ Commonest site is the septum and leads to epistaxis.
§ Treatment: Excision and cauterize the base.
b. Cavernous: may develop into a cirsoid aneurysm and involve the whole tip of
the nose.
c. Multiple telangiectasia:
§ A familial condition usually associated with telangiectasia of the face, lips,
buccal mucosa "Osler's-Weber-Rendu disease".
§ Treatment: Excision and cauterize the base. Arterial ligation may be
needed. Hormone therapy may be tried.
Glioma:

· It's rather a congenital abnormality consisting of herniation of brain tissue

through a dehiscence in the floor of the anterior cranial fossa.
· It may present as a smooth, rounded, subcutaneous mass, mobile at the
base of the nose.
· It may present as intranasal polyp.

ii. Osseous:

A- Primary osseous:

1. Osteoma:

There are three main types:

A- Compact (hard or ivory) osteoma:

Sessile or pedunculated and may arise from periosteal tissue. Well defined
and may show area of cancellous bone in the centre.

§ C/P:
1- Symptomless: discovered on X-ray examination.
2- Pain or headache: due to bony pressure.
3- Proptosis: due to expansion of the affected sinus.
 4
4- Empyema or mucocele: may result from obstruction of sinus osteum.
5- It may cause Intracranial pressure symptoms.
6- Nasal obstruction.
7- X-ray: well defined dense bony mass.
§ Treatment: Excision if symptomatizing.
B- Cancellous (spongy) osteoma: common in the maxillary and ethmoid sinus
slowly growing.
C- Osteoid osteoma (multiple exostosis): Rare.

2. Fibro-osseous disorders:

A group of disease affecting the bony framework of the head. The

swelling produced in these conditions consists of irregular spongy subperiosteal
bone with thin cortex and ill defined edge. The lesion may be monostatic or
polyostatic.

* Types:

1. Osteitis fibrosa cystica: hyperparathyroidism (Von Reckling-Hausen's

disease).
2. Osteitis deformans or Paget's disease.
3. Fibrous dysplasia: It may be:
§ Diffuse: involving several of facial and cranial bone.
§ Localized: involving the maxillary and ethmoidal bones and may be
mistaken for fibrous epulis, adamantinoma
§ It's possible that it's due to defective bone growth bone resorption and
fibrous tissue formation.
§ C/P:
1- Deformity: growth is slow and tends to stop after puberty.
2- Headache
3- X- Ray: Ground glass or Cotton wool appearance. It may be cystic or
sclerotic without bone erosion.
§ Treatment:
- Better avoided.
- Partial removal may be done after puberty for cosmetic reasons.
 5

3. Cherubism:

· A familial multilocular cystic disease.

· Occurs in children in the second or third year.
· There iss bilateral symmetrical swelling of the lower and/or upper jaw.
Regression may occur after adolescence. X-ray: radiolucent areas.

4. Cysts (primary osseous-odontogenic):

A- Fissural:
Cysts associated with fusion of embryological elements forming the maxilla

1- Medial group:
§ Median alveolar cyst: between upper central incisors.
§ Median palatal cyst: between the developing palatine processes.
§ Naso-palatine cyst: arises from tissues in the incisive canal and
present either in the palate or nasal floor.
2- Lateral group:
§ Lateral alveolar cysts: at the line of fusion of the palatine process of
the maxilla and premaxilla i.e. between canine and lateral incisor.
§ Naso-alveolar cyst: in the lateral half of the nasal floor anterior to
inferior turbinate.
B- Odontogenic (odontomes):
Cysts of dental origin. They arise from the epithelium that has been
connected with the development of the tooth concerned (paraepethelial
debris of Malassez):

1- Primordial cyst: arise from epithelium of enamel before formation of

dental tissue. They occur in young people commonly in the lower 3rd
molar region.
2- Cysts of eruption: occur in young people and appear over a deciduous or
permanent molar tooth. It appears as a small bluish swelling.
3- Dentigerous (follicular) cyst:
§ Occurs in children.
 6
§ Arises in relation to an unerupted tooth.
§ There is usually a missing tooth.
§ Common in the maxillary premolar or mandibular 3rd molar.
4- Dental (Radicular) cyst:
§ Occurs in addults.
§ Arise in relation to an infected tooth.
§ More common in the maxilla (incisive and premolar).
§ Normal Number of teeth (or the tooth extracted) residual cyst 3 and 4
are lined with squamous epithelium and contains glairy mucoid fluid
with may contain cholesterol.
C- Primary bone cysts:
1- Hemorrhagic bone cyst:
May be due to previous trauma. Intraosseous hematoma stimulates
osteoclastic activity.

2- Cherubism.
3- Solitary bone cyst: Painless expansion of the jaw may be due to mild
trauma.
4- Mucocoele.
D- Dermoid cyst:
Occur at the lines of fusion of the five processes with form the face. They
may fistulate.

E- Retention cysts:
Accumulation of secretion due to obstructed mouth of a gland. They usually
occur in the floor of the nose. Excision: through sublabial incision.

Clinical Picture:

1. Deformity due to expansion of bone.

2. No pain unless infected.
3. Egg-shell crackling: when the bone is thin.
4. X-ray: clear outline in typical positions.
* Treatment:

· Complete removal or marsupializaton.

 7
· If large the bone may be crushed to restore the shape of the alveolus.

ii. Intermediate

i. Soft Tissue:

A- Epithelial:

1. Inverting papilloma:

· Rare and usually occurs in males above 50 y. The commonest site is the
lateral wall of the nasal cavity and/or the antrum and ethmoids. It leads to
unilateral obstruction.
· A gross thickening of the epithelial surface leads to infolding but the
basement membrane remains intact. There can be areas of columnar,
squamous or transitional epithelium. It can turn malignant.

* Treatment:

Wide excision and histological examination. Inadequate removal is

followed by local recurrences, each progressively more destructive.

N.B.: Recurrence suggests malignancy even if there is no evidence of this on

histological examination.

2. Leucoplakia:

· May occur in the nose and oral mucosa but never in the sinuses.
· Hard non-painful grayish blue tumefaction with necrotic smell.
· It may progress to squamous cell carcinoma
· Treatment: excision.

3. Mixed tumour:
 8
· Combining the features of epithelium and Connective tissue growths.
"Pleomorphic adenoma".
· Rounded, painless, submucosal mass, smooth, sessile and rubbery. It grows
slowly and may erode the bone.
· High rate of recurrence. Malignant. transformation is common.

B- Connective tissue:

1. Chordoma:

· It arises from remnants of the embryonic notochord .

· It's most commonly seen in the nasopharynx but may occur in the septum
sphenoid and ethmoid sinus.
· It's a pale pink, soft gelatinous tumour with infiltrates the bone and
surrounding soft tissues.
· Microscopically it consists of groups of polyhydral cells, the larger ones
contain large vacuoles in the cytoplasm. They may coalesce to form large
vacuolated foam cells. The histology is very variable.
· It metastasises rather late by blood stream.
· It's radioresistant so that palliative surgery is of great value (by virtue to its
situation can seldom be eradicated surgically).
2. Teratoma:

Midline tumor , some are incompatible with life.

ii. Osseous:

1. Osteoclastoma: "Benign reparative giant cell granuloma":

· Common in females in the third decade.

· Affects chiefly the maxillary and ethmoidal region.

* Pathology:

· Multilobulated hemorrhagic cyst, firm with friable light brown cortex.

· Slowly growing with egg shell crackling sensation on palpation.
 9
· Microscopic picture: Many giant cells, some of them have enormous number
of nuclei in a fibrous matrix. Sometimes called giant cell tumor of bone.
· Some are locally malignant and a rarely gives metastasis.
· X-ray: soap bubble appearance without erosion of bone (osteolytic tumor in
which few bony trabeculae are still recognizable).

* Treatment:

Radical excision.

2. Adamantinoma "ameloblastoma":

· Sometimes called multilocular cyst. However, it may not be cystic.

· It arises from enamel organ (responsible for tooth formation) or epithelial
debris of Malassez.

* Pathology:

· Yellowish cystic tumour of the jaws, it is more common in the mandible than
the maxilla). It affects young adults.
· Both in behavior and structure it resembles basal cell carcinoma
· It is a slowly growing tumor, mono or polycystic. However, it may remain
solid. It invades the bone and causes rarefaction and loosening of teeth.
· Microscopic: basal type cells occur in clumps and enclose a stellate central
reticulum which may be cystic.
· Metastasis may occur very late.

* Clinical Picture:

1. Slow expansion of the jaw.

2. Loosening of teeth.
3. Ulceration.
4. X-ray:
 10
§ Multilocular or unilocular cyst.
§ Honey Comb or soap bubble appearance.
§ Resorption of tooth roots.

* Treatment:

· Radical excision.
· If the mandible is affected grafting will be necessary after incision (rib graft).

iii. Malignant

i. Soft Tissue:

A- Epithelial:

1. Squamous cell carcinoma: commonest all degrees of differentiation may be

found (many are anaplastic). Lymphatic metastasis to upper deep cervical
gland and retropharyngeal gland is uncommon. Haematogenous spread is
rare.
2. Lymphoepithelioma: commoner in the nasopharynx.
3. Adenocarcinoma: Relatively slowly growing.
4. Cylindroma: or Adenoid cystic carcinoma
They are round, encapsulated, firm, localized on the alveolus, hard palate
and antral floor.
They tend to recur locally, invade the base of skull, dura and brain. They
are radioresistant. Lung and distant metastasis are late.

B- Connective tissue:

1. Sarcoma: Rare occur in young age.

2. Melanoma:
3. Malignant lymphoma: "Burkitt tumour"
§ Probably viral. Ebstein-Barr virus was isolated from the tumour.
 11
§ Common in child negroes (4-8 years).
§ Frequent affection of the mandible and maxilla. Relative lack of
involvement of peripheral Lymph nodes.
§ Highly sensitive to cytotoxic drugs (methotrexate orally or
cyclophosphamide IV).
ii. Osseous:

1. Osteosarcoma.
2. Ewing's sarcoma.
iii. Metastatic:

rare e.g. breast, thyroid, prostate.

* Sites:

· More common in the maxillary and ethmoid sinus.

* Clinical picture:

i. Tumors of the maxillary antrum:

The tumour usually starts at one of the walls of the antrum and later
infiltrates and fills the whole antrum.

It frequently causes dental pain and a dentist is consulted but without

relief. However this aids to early diagnosis.

According to the wall first affected the patient presents by:

1. Spread through the medial wall:

§ Unilateral proptosis and foul nasal discharge.
§ Unilateral nasal obstruction.
§ Unilateral epiphora and headache.
2. Spread through the roof:
Proptosis.

3. Spread through the floor:

§ Swelling of the palate.
§ Loosening of teeth.
4. Spread through the anterior wall:
 12
Swelling of check.

5. Spread through the posterior wall:

Pain due to involvement of 2nd division of trigeminal. nerve in the pterygo-
palatine fossa.

6. Anterior rhinoscopy:
May show a mass which is friable ulcerated and bleeds easily on touch.

7. Cervical lymph gland:

Late, the retropharyngeal and then the Upper deep cervical lymph gland

8. Cachexia: Late.
ii. Tumor of ethmoid:

1. Spread medially causing unilateral obstruction and epistaxis and headache.

2. Spread lat swelling in the region of the inner canthus and proptosis.

* Investigations:

1. X-ray: (CT & MRI)

§ Early: opacity and expansion of the walls of the sinus.
§ Late: destruction of bony walls of the sinus.
2. Biopsy:
§ From any associated nasal polyp or cervical gland (not preferred).
§ Cytology: through antral lavage.
§ Through endonasal endoscopic approach. A negative biopsy in
suspicioius cases should be repeated.

* Treatment:

Usually combined surgery and irradiation.

i. Surgical:

· Moure's lateral rhinotomy or craniofacial resection: for the ethmoids.

 13
Recently tumors of the skull base can be approached endoscopically
through the nose.
· Fenestration of the hard palate: for antral tumours. The tumour is removed
then a dental obturator is used to close the perforation. Intracavitary radium
is applied.
· Total excision of the maxilla: with pre or post operative irradiation. If
necessary the eye and orbital contents are removed en block with the
maxilla through Fergusson's operation or Trotter's incision.(Total and radical
maxillectomy)
ii. Radiological:

· Teleradiation (preoperative).
· Deep X-ray (pre or postoperative).
iii. Chemotherapy:

in some cases cytotoxic drugs e.g. endoxan, nitrogen mustard,

methotexate or combination may be used, either locally by intra arterial injection
through the external carotid Artery or systemic. 5 year cure rate 35-50% (even
25-35%).

* Sarcoma:

· Occur in children and young adults.

· Growth more rapid. Pain is severe from the start.
· General condition of the patient is worse.
· Prognosis: bad.

Mucocoele

Cystic expansion of the sinus. More common in the frontal and ethmoids.

Aetiology:

1-Obstruction of the ostium of the sinus and accumulation of mucus.

2- Obstruction of the duct of a mucus gland.

3- Cystic formation of the mucosa undergoing polyposis.

 14
Clinical picture:

1- Swelling: Cystic or bony and shows egg shell crackling.

2- Proptosis:

Treatment: Excision or marsupilization. Recently it is better managed through

endoscopic endonasal approach