 Inflammation of the nasal mucosa

 May predispose to sinusitis

 Rhinitis v/s sinusitis

 ‘Sinus problem’ usually over diagnosed

 Clinically and by investigations try to differentiate

 Infective rhinitis  Special forms
 Acute › Atrophic
 Chronic rhinitis
Non-specific › Rhinitis sicca
Specific › Rhinitis
 Reactive rhinitis medicamentosa
 Allergic rhinitis › Rhinitis
 Vasomotor rhinitis caseosa
 Acute inflammation of the nasal mucosa
usually viral with or without secondary
bacterial infection
 Syn: Coryza or ‘Common cold’ or ‘Flu’
 Common organisms
› Rhino, influenza, adeno, echo, etc.
 Various viruses and various strains
 Difficult to prevent by immunization
 Air-borne ‘drop-let’ infection
 Common during change of season or weather
 Generalized mucosal congestion and
hypersecretion
 Systemic: Acute fever, myalgia, malaise, lethargy, head
ache, etc.

 Local
 Initially irritation, tickling or dry sensation in the nose
—sneezing
 Watery nasal discharge—becomes thicker and scanty
in 2-3 days—mucopurulent if secondarily infected
 Stuffy feeling/ nasal obstruction
 Blocked sensation in the ears +/-
 Resolution usually within a week
 Fever (around 102ºF), toxic look

 Generalized congestion and edematous mucosa

 Mucoid- mucopurulent nasal discharge

between the turbinates and in the floor

 Nasal obstruction
 Pharyngeal/ laryngeal mucosal congestion+/-
 ET dysfunction +/-
 Rest and avoid mixing with others
 Analgesics like paracetamol, numesulide- relieves
pain and fever
 Nasal decongestants
 Tapid sponging
 Gargles (saline/ topical analgesic) or lozenges
 Steam inhalation
 Antibiotics if delayed resolution
 Avoid contact with infected persons
 Well ventilated room
 Vitamin C and B-complex
 Good nutrition
 Chronic inflammation of the nasal mucosa due
to non-specific bacteriae like streptococcous/
staphylococcus/ etc., usually secondary to other
causes of rhinitis

 Types

› Chronic hyperemic rhinitis

› Chronic hypertrophic rhinitis
 Anterior nasal discharge
› Mucoid—mucopurulent

 Nasal stuffiness/ obstruction

 Irritation/ itching nose

 Headaches rare but can occur due to

› Meatal obstruction—vacuum in the sinuses
› Secondary sinusitis
› Contact neuralgia

 Hyposmia/ anosmia: rare

 Nasal mucosa is hyperemic and edematous
(Chronic hyperemic rhinitis)
 Hypertrophy of the turbinates (Chronic
hypertropic rhinitis)- decongest the nose to
examine better
 Mucoid or mucopurulent discharge/ strands seen
in the floor of the nasal cavity or between the
turbinates and the septum
 Signs of DNS/ allergic rhinitis/ secondary chronic
sinusitis +/-
 Signs in the ear/ throat if affected
Objectives

 Identify the predisposing cause like allergy,

vasomotor rhinitis, drug-induced rhinitis,
anatomical variations in the nasal cavity etc.

 Rule out secondary sinus/ ear/ throat

involvement
 Diagnostic nasal endoscopy (DNE)

 Radiological- if secondary sinusitis is

suspected
› X-ray PNS/ CT scan of the PNS

 Audiological if ET dysfunction/ otitis media

is suspected

 Allergic skin tests if nasal allergy is

suspected
 Treat the cause and the result

 Nasal decongestants- topical/ systemic

 Antihistamines

 Broad spectrum antibiotics

 Steam inhalation

 Nasal douching

 Steroidal nasal spray

 Turbinate reducing procedures

› Sub-mucosal diathermy (SMD)

› Bipolar cauterization of the turbinates
› Cryo therapy
› Partial turbinectomy
› Out-fracture of the turbinates
› Laser turbinoplasty

 Septoplasty if DNS+
 Sinus surgeries if chronic sinusitis+
 Surgical treatment of polyps if they are present
 Syn: Simple mucosal polyp

 Multiple: Polyposis/ Polypi

“ Defined as odematous, prolapsed mucosa of the paranasal
sinus/ nasal cavity,

 usually appearing as a round, pedunculated, fleshy,

 ‘grape-like’ mass which is greyish/bluish white

 translucent in colour with smooth glistening surface

 and is soft, mobile, insensitive and does not bleed on touch”.

Exception: Infected polyp appears red in colour

 Useful in evaluation of nasal mass

 Probe used for examining:

› Consistency

› Mobility

› Site of origin

› Sensitivity to touch

› Bleeding on touch (friability)

 Simple mucosal polyp (POLYP)

 Polypoidal middle turbinate (rarely IT)

 Thick mucous

 Granulomatous polyp: Ex: Rhinosporidiosis

 Neoplastic polyp
› JNA, Inverted papilloma, Olfactory neuroblastoma, SQ cell ca., Acc.
Salivary tumors etc.

 In children:
› Meningocoele/ meningo-encephalocoele
› Nasal glioma/ dermoids
› Rhinolith/ FB
 End product of prolonged odema
 Submucosa especially around MM is lax
and is easily water logged
 Increase vascular permeability fluid
retention (odema) prolapse of mucosa.
 Allergy ‘Multifactorial ’

 Infection

 Vasomotor response

 Bernoulli’s phenomenon

› Velocity of airflow increases at stenotic sites-produces

suction effect on mucosa due to negative pressure
created.
› Repeated blowing/hawking causes?
 Defective polysaccharide metabolism

› Water retention

 Polypeptide theory:

› Contact sites-release of P factor-vasodilator

 Endocrine?
 Surface:
› Odematous mucosa
› Respiratory epithelium/ squamous metaplasia at
exposed site
 Submucosa:
› Loose areolar tissue- ‘water logged’
› Eosinophilic infilterate with plasma cells and
lymphocytes
› Scanty blood supply
 Ethmoidal polyposis

 Antrochoanal polyp

 Frontal polyp

 Sphenoidal polyp

 Nasal polyp

 Choanal polyp
 Infection  Allergy

 Anatomical
obstruction in MM?

 Accessory ostium

 Exact cause?
 Arises from maxillary
 Arises from ethmoid
antrum sinuses

 Antral
 Bilateral due to allergy
Antronasal
Antrochoanal
 Multiple due to
multiple ethmoid air
cells (8-20)
 Usually unilateral and
solitary
 Children  Middle aged
 Unilateral nasal  Exception: in cystic
obstruction ‘Valvular’ fibrosis/ mucovisidosis
 Bilateral if opposite occurs in children
choana is blocked in  Allergy symptoms+
nasopharynx  Bilateral nasal
 Unilateral nasal obstruction/discharge
discharge-mucoid/  Anosmia
mucopurulent  Asthma/ aspirin
 No allergy symptoms intolerence
 Solitary and unilateral
 Seen more postnasally
than anteriorly
 Reasons:
› Accesory ostium is
posteriorly situated
› Ostium directed backwards
› Obliquity of posterior part
of IT-polyp slides
› Negative pr. created during
swallowing, etc.
 External: ‘Frog-face’
deformity +/-
(intercanthal widening)
 Multiple and bilateral
 Seen more anteriorly
 Reason: Multiple cells-
polyp from anterior cells
slide towards nostrils
 General mucosal changes
of nasal allergy
Polypi seen on nasopharyngoscopy
JNA may be mistaken for an antrochoanal polyp!
1. DNE: Unilateral and solitary Bilateral and multiple
from accessory maxillary
ostium
2. X-ray/ Unilateral max. opacity Bilateral ethmoid hazy
CT scan Uni/bilateral max. opacity

3. Allergy Negative Positive

tests:
4. Biopsy: If other causes of nasal mass suspected.
DNE
CT showing bilateral extensive sphenoethmoid disease
  Always with or without
 Usually not effective
surgery
 Polypi ‘melt’ with steroids
 Antibiotics, steroids  Systemic/topical steroids
 Sodium chromoglycate
 Antihistamines
 Antibiotics
 Decongestants
 Douches
 Medicated steam inhalation
 Intranasal AVULSION  Intranasal AVULSION
polypectomy polypectomy
 Endoscopic  Intranasal
polypectomy with ethmoidectomy
MMA  Endoscopic
 Caldwel-Luc operation ethmoidectomy (ESS)
if >18 years  Transantral
(Especially if recurrent) ethmoidectomy
 External
ethmoidectomy
 Good if completely  Tends to recur
excised  Reasons:
› Allergy is the cause
› Incomplete removal
 Poor accessibility
 Poor visualization
 Multiple cells
 Bleeding
 VITAL STRUCTURES
 Near total excision:

› Shrink polypi with ‘steroids’, prior surgery

› Antibiotics coverage to control secondary infection

› GA and good decongestion during surgery

› Endoscopic sinus surgery

› Image guided endoscopic surgery

 Control of nasal allergy

› May need long term steroid and sodium

chromoglycate nasal spray and antihistamines

› Immunotherapy
Image guided endoscopic surgery

Surgeon is near the orbit

Functional endoscopic sinus surgery is a minimally invasive technique
used to restore sinus ventilation and normal function.

Functional endoscopic sinus surgery (FESS) is a minimally invasive

technique in which sinus air cells and sinus ostia are opened under direct
visualization.
The goal of this procedure is to restore sinus ventilation and to return the
mucociliary drainage of the sinuses to normal function.
The procedure can be performed under general or local anesthesia on an
outpatient basis, and patients usually experience minimal discomfort.

CT PNS before FESS is mandatory

To identify the patient's ethmoid anatomy and its relationship to the skull
base and orbit.
CT scanning identifies the anatomic relationships of the key structures
(orbital contents, optic nerve and carotid artery) to the diseased areas, a
process that is vital for surgical planning.
CT also defines the extent of disease in any individual sinus, as well as
any underlying anatomic abnormalities that may predispose a patient to
sinusitis.

Diagnostic Nasal Endoscopy (DNE) is a must before FESS

 Messerklinger is the first person to develop and
establish a systematic endoscopic diagnostic
approach to the lateral wall of nose.

 This technique focused on changes in the lateral

wall of the nose and identified and isolated these
changes with aid of the rigid endoscope and
tomography of the sinuses.

 This inturn resulted in an endoscopic surgical

technique.
1.polyposis.
12.Estuchian tube
2.Obstructed nasal respiration.
problems.
3.Rec &chronic sinusitis
13.Postnasal drip.
4.Epiphora .
14.As adjuvant therapy
5.Anosmia .
in allergies.
6.Chronic headache.
13.Recurrent
7.Mucocele of PNS.
pharyngitis.
8.Retension cyst.
14.sinubronchial
9.Mycoses (noninvasive).
syndrome.
10.Orbital complications of
15. Some phonation
acute sinusitis.
disturbances.
11.Septal spurs.
1.Extensive invasive processes in the area of the
paranasal sinuses or the skull base.

2.Extensive bony changes such as broadly based

osteoma.

3.In orbital extension of an acute sinusitis with indication

of an incipient central complication (e.g.,
meningitis ,subperiosteal or epidural abcess, or
cavernous sinus thrombosis)

4.Osteitis or osteomyelitis of the frontal bone with

sequestration.
 Bleeding .  Synechiae.

 CSF leak.  Epiphora .

 Blindness.  Toothache.

 Diplopia.  Closure of
antrostomy.
 Subcutaneous and
orbital emphysema.
 FESS can be done under LA in adults and cooperative patients
But in children and apprehensive pts, GA should be given.
.
 After sedation local mucosal spray with 4% xylocaine with
adrenaline and packing of nose with xylocaine lotion, a
thorough endoscopic examination of the nasal cavity should be
done using ‘0’degree and ’30’ degree endoscopes.
.
 Firstly endoscope is passed between the nasal septum and
inferior turbinate examining the whole area upto choanae,
visualizing both ET openings and the nasopharynx .
 secondly, endoscope is passed along the middle meatus to
examine for any pathology
 And then third pass between middle turbinate and septum upto
anterior wall of sphenoid sinus and its osteum.
 The lateral wall is infiltrated with 2% xylocaine with adrenaline at
various points on uncinate process upto posterior end. In case of
canine fossa puncture a sublabial injection is done.
 Using ‘o’ degree telescope , an incision is made with sickle knife
on the uncinate process from the level of middle turbinate
downwards along the curve of the UP till just above the inferior
turbinate.
 The UP is grasped with firmly with blekesley’s forceps and
removed with a twisting movement, exposing the infundibulum,
known as infundibulotomy.
TECHNIQUE

 After removing ant cells the opening of frontonasal duct is seen

which is cleared by removing the diseased mucosa surrounding
it.
 Posterior ethmoid cells and the sphenoid sinus shold be opened
only if the CTscan shows any disease in this area.
 The posterior ethmoidal cells are reached by gently perforating
the basal lamella with tip of blakesly forceps and the cells are
removed upto the anterior wall of sphenoid.
 The sphenoid sinus anterior wall is perforated and the ostium is
widened.
 The rationale behind
FESS is that localized
pathology in the
osteomeatal complex
blocks the ostia and
leads to inflammation
in the dependent
sinuses.

The surgical
interventions of the
procedure are designed
to remove the
osteomeatal blockage
and restore normal
sinus ventilation and
mucociliary function.