Nose and paranasal sinuses Lateral wall of nasal cavity Paranasal sinuses Anatomical variations causing dysfunction of ostiomeatal complex Upper third nasal cavity blood supply from a. carotis interna- a. ophthalmica-a. ethmoidalis anterior a posterior . A. carotis externa - a. maxillaris - a. palatina descendens - a. palatina maior- a. nasopalatina. Locus Kiesselbachi (plexus) Nasopharyngeal Woodrof plexus 1-Locus Kiesselbachi 2-a.maxillairs 3-a.sphenopalatina 4-a.ophthalmica 5-a.ethmoidalis ant. et post. Posterior end inferior nasal cavity a. carotis externa via a. maxillaris and a. sphenopalatina - a.a. nasales posterores lat. et septi. Venous sinusoids (cavernous venous plexus) Localised between capilars and venules – surrounded by smooth muscles, which causis their vasodilatation and vasoconstriction … 1.Arteriolovenózní zkrat 2.subepiteliální kapilární síť 3. kapiláry kolem žlázek 4. periostální kapiláry 5. kavernózní žilní pleteň Fibres of smooth muscles of arteriols and venous plexus supplied by autonomes nervoous system. Parasympatic stimulation – vasodilatation, filling of venous plexus with blood – congestion a discharge. Sympatic stimulation – vasoconstriction, leading to empty venous plexus with blood – not blocked nose and lower discharge. Mucous membrane of the nose: multirow cylindric epithelium with cilias „Mucociliar escalator“ Microbs on mucose membrane Evaluation of nose and paranasal sinuses l aspection, palpation l rhinoscopy l diaphanoscopy l ultrasound l radiology (X-ray examination) l lavage of the sinuses l sinoscopy Evaluation of nose function l Mucociliar transport – sacharin test l Smell – olfaktometry – Smell=vanilka, kafr, dehet – Smell + n. V =ocet, čpavek, mentol – Smell and taste – éter, chloroform l Patency – Glatzell desk – Rinomanometrie Smell disorder: – Kvantitative – perifery, central – Kvalitative – parosmie, kakosmie Endoscopy Physiologic endoskopic view DS – inferior turbinate SS - middle turbinate P - septum Computed tomography Definition of rhinitis Inflammation of nasal mucosa membrane, characterized by at least two of following symptoms: l Congestion of nasal mucosa membrane (impaired nasal patency) l Discharge from the nose l Sneezing l Itching in the nose Symptoms should last at least 1 hour daily. Until 12 weeks – in acute rhinitis, longer than 12 weeks in chronic rhinitis.. Lund J., et al. Report About International Consensus regarding diagnosis and treatment of rhinitis, Allergy,1994; 49, Supl.19:34 s European Position Paper on Rhinosinusitis and Nasal Polyps (EP3 OS). Rhinology , Supplement 18, 2006, 88 s. Rhinosinusitis chronica Inflammation of nasal mucosa membrane, characterized by : • nasal obstruction • pain, pressure in face or • water discharge from the nose, postnasal drip or • smell disorder Symptoms should last at least 12 weeks in chronic rhinitis. European Position Paper on Rhinosinusitis and Nasal Polyps (EP3 OS). Rhinology , Supplement 18, 2006, 88 s. Classification of rhinitis 1. Alergic – Intermitent – Persistant 2. Infectious – acute – chronic l specific l nonspecific 3. Other l Vasomotor ( professional, hormonal, drug inducated, irritant, Alimentáry, psychogenic, NARES (non allergic rhinitis with eosinofilia syndrome) l Atrophic l Idiopathic Epidemiologie chronické rýmy l alergická a chronická nealergická rýma patří k civilizačním chorobám l postihuje asi 25 % populace l výskyt je vyšší u obyvatel měst l okolo 50 % chronické neinfekční rýmy tvoří alergická rýma Degree - mild - moderate - sever Visual analog scale (VAS) Without symptoms 10 cm Most intensive symptoms Allergic rhinitis Persistens Intermitens Degree - mild - moderate - sever Allergic rhinitis- diagnosis l Proof of IgE – mediated mechanism l Symptoms as a result of immune reaction mediated by spicific. IgE antibodies l Cellular inflammatione of mucose membrane (T-lymfocyty, eozinofily) l Cause of production of IgE antibodies atopic genetic predisposition (HLA antigens of atopic patient) Part of „home dust“ - Dermatophagoides pteronyssinus in electron microscop) Rhinitis allergica - treatment Management of Allergic Rhinitis and its Impact on Asthma. Based on: Bousquet J. ARIA workshop report. J Allergy Clin Immunol 2001; 108 (5): 147-333. Comparison of local decongestant Remedy Time of onset (min.) Duration of action(hod.) Undesirble side effects Efedrin 10 3-4 +++ Fenylefrin 15 1-2 +++ Nafazolin 15 2-6 ++ Xylometazolin 20 10-11 ++ Oxymetazolin 20 10-12 ++ Tramazolin 5 11-12 + Rhinitis vasomotorica l Disorder of mucos membrane without structural backround, not infectious, autoimune neither allergic in traditional sense. l The same symptomatology as persistans allergic rhinitis. l Cause- faktors of none-imune character. (Charles W. Cummings, et al. Otolaryngology— Head & Neck Surgery,, Mosby) Rhinitis vasomotorica • Neurovascular reaction on various stimulus: mechanical, chemical, psychic stress. • Manifestation of sympathic-parasympathic neurovascular disbalance Symptoms of vasomotor rhinitis • „blocked nose“ • Watery discharge - rhinorrhea – • Výtěr z nosu s velkým množstvím eozinofilů typický pro alergii nebo NARES – Žlutý hnisavý – bakteriální infekce (neutrofily) – Krvavý nebo krustózní a ulcerace typické pro bakteriální infekci, nádor nebo granulomatózu l Itching in nose, sneezing l Smell disorder l Feeling of dryness in nose l Eye symptoms l Headache l General symptoms Anterior rhinoscopy l Alergic and vasomotor rhinitis livid or pale, diffus swollen mucose l Irritation or abuse nebo of nasal spray– red mucose l sinusitis red mucose with pus Rhinitis vasomotorica – diagnosis l X-ray evaluation is normal l Higher amount of inflammatory mediators and cells – Histamins, leukotriens, prostaglandins, neuropeptids aj. l Negative skin allergen tests l In nasal secretion not present eosinofils l Positive answer on histamin skin test Rhinitis vasomotorica - causes 1. Rinitida drug inducted a. Antihypertensiva b. Nadužívání nosních kapek/sprejů c. Kokain d. Hormony 2. Pregnancy and ‘‘premenstrual rhinitis’’ 3. Hypothyroidismus 4. Emotional causes 5. Temperature changes 6. Rhinitis from iritation and external influences 7. Rinitida z chuťových podnětů 8. Konečná fáze vaskulární atonie u chronické alergické nebo zánětlivé rinitidy 9. Rinitida from position 10. Paradoxní nosní obstrukce a nosní cyklus 11. Rinitida neventilovaného nosu (laryngektomie, choanální atrézie, adenoidní hyperplázie) 12. Kompenzatorní hypertrofická rhinitis 13. Eosinophilic and basophilic nonallergic rinitida 14. Ostatní systémové příčiny: syndrom vena cava sup., Hornerův syndrom, cirrhosis, uremia 15. Idiopathická rinitida Rhinitis drug inducted • Antihypertensiv drugs - Reserpin, Hydralazin, Guanethidin, Methyldopa, Prazosin, Betablokátory, Propranolol, Nadolol • Antidepressiv drugs a antipsychotika -Thioridazin, Chlordiazepoxid and Amitriptyline, Perfenazin • Hormons - Ovariální hormony, orální kontraceptiva • Abuse of nasal decongestants – i když jde o dekongestiva - rebound fenomén vasodilatace kongesce. Prodloužení užití topický vazokonstriktorů vede ke ztrátě cévního tonu. Dekongesční nosní kapky a spreje by neměly být používány déle jak 3 po sobě následující dny. (rhinitis medicamentosa = rebound rhinitis) • Kokain - vasokonstriktor Pregnancy and ‘‘premenstrual rhinitis’’ • Higher level of endogenous progesterone –congestion not only in uterus but also in the nose • From the some reason – immediately before menstruation Psychogenic and emotional reasons • Anxiety, hostility, feeling of frustration a anger – it could disturb autonomic neurovascular balance – nasal congestion and watery discharge • migraine - dysfunctio in carotic system Rhinosinusitis -Diagnosis History family, external factors ENT clinical investigation Rinoscopy, endoskopy, X-ray, ultrasound Semiaxial rtg, CT of paranasal sinuses Alergologic tests Skin test, serology - IgE, Cultivation Bacteriology Cytology Inflammatory cellulisation Evaluation of mucociliar transport mukociliar clearance Nose patency Rinomanometry Evaluation of smell Sniffing` s test, odour parfumed test Morphologic causes of nosal obstruction crista septi nasi papilloma invertens Intranasal foreign boddies Inflammations Acute rhinosinusitis Mycotic sinusitis Nosal polyps Antrochoanal polyp Therapy of rhinitis History of disease ENT investigation Rtg, CT alergology cultivation, cytology Nasal patency Evaluation of smell Allergy Infection - acute - chronic Other - Nares, - hormonal, - idiopatic - Wegener` s granulomatosis - tumors aj... Alergen evoidance antihistaminics topical steroids Allergology reevaluation consider imunotherapy Otolaryngology sugery antibiotics decongestans corticoids? Anatomical changes (septum, conchae…) topical steroids local anticholinergics Surgical therapy of chronic rhinosinusitis lMedicamentous, conservative – topical steroids lSurgery – „classical“ rhino-surgery – Functional endonasal sinus surgery (FESS) „Classical“ rhino-surgery l Approach through healthy tissue l All mucose is removed l Mostly non-physiologic comunication into the nose Maxillar sinus – sec. Caldwell-Luc Ethmoidal labyrint – sec. Moure Frontal sinus– sec. Jansen-Ritter Caldwell-Luc George Walter Caldwell 1866-1946 Henri Luc 1855-1925 1889 1893 Classic rinosurgery l Too high radicality l many iatrogenn complicatoins (swelling, pain, inervation disorder) Caldwell-Luc external ethmoid- ectomy „classical“ rhino-surgery - indication l Repeated FESS lege artis failed l some atypical forms of sinusitis - mycotic sinusitis (aspergilom) l Inflammatory complications of sinusitis l Tumors of paranas. sinuses l Some injuries l Immunocopmpromised persons, congenital diseases Functional endonasal sinus surgery (FESS) Basic considerations l Pathologically changed musose is able to restitution and should be preserved as more as possible l For restitution it is necessary to create ventilation and drainage l Epicentrum of rhinogenn sinusitis is in ehtmoidal labyrint Pathogenesis of chronic rhinosinusitis – „circulus vitiosus“ Disorder of gas exchange Blocked ostium Impaired ventilation and drainage Stagnation of secretion Disorder of mukociliar transportation Isthmus surgery D paranas. sinus connected with nasal cavity N. 1. – normal situation 2. – closed ostium 3. – weidened ostium 4. – heald ostium with renewal communication D-N. Functional endonasal sinus surgery (FESS) Indications, limits of FESS l Only some surgeries are treating the cause – some cjhronica infectiois inflamm., cysts and various structural changes disabling změn ventilation (deviatio of nasal septum, hyperpneumatised middle nasal concha et al.) l Nasalization and enabling concervative treatment - symptomatic surgery as a part of complex treatment Indication of FESS l History of disease l Imaginating methods (CT) l Rhinoendoskopy Surgery l Structural changes in nasal cavity (deviace přepážky nosní, concha bullosa) l One sinus (supraturbinal antrostomy, sphenoidotomy, frontal sinotomy, ethmoidektomy) l Pansinus surgery („ Wigand complet“) Surgery of nasal septum – endoscopic resection (cristae, spins) Resectio concha bullosa Concha bullosa Stav po resekci CT – c.b. Maxillary sinoskopy Mucosal cyst in antrum Supraturbinal antrostomy Indication - chronic inflamm.chaneges of maxillary sinus caused by blocked OMU Supraturbinal antrostomy n renewal of communication between nose and maxillary sinus n usually part of extent surgery Pansinus surgery Indication : chronic inflammations with polyposis Aim : nasalisation of big paranas. sinuses Co.i.. S. Pansinus surgery - CT Complications l „Small“ § bleeding § hematoma,emphysema of eye lids § headache l „Big“ § retrobulb. hematoma - 2 § meningitis - 1 § liquorea - 4 § Bleeding from ACI § death Complications II Likvorea + pneumoencephalus CAS – computer assisted surgery Navigation system (Medtronic, Scopis – magnetic navigation)