MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Nose and paranasal sinuses II. Ass.prof. Pavel Smilek, MD, Ph.D. ENT Clinic of Masaryk university, Brno Faculty St. Ann Hospital Head: Ass.prof. Gál Břetislav, MD, Ph.D. Pekařská 53, Brno , 656 91 Olfactory organ – applied physiology ▪ Gustatory olfaction – sensory impressions caused by food (aroma, bouquet) search and food intake. Perception of impulses from external environment are mediated with smell, trigeminal nerve and taste chemosenzoric perception ▪ Protective function – warning against poisenous foods and toxic substance ▪ Social communication (psychology, occupation…) ▪ Symptom of some psychiatric disorders Applied anatomy of olfactory sense peripheral and central part 1) peripheral part: olfactory mucosa (regio olfactoria) fila olfactoria localised: c. nasi superior, cranial part of c. nasi media and septum olfactory mucosa: smell, supporting and basal cells fila olfactoria: fibres of the olfactory nerv connected with axons of olfactory cells, go through lamina cribriformis into bulbus olfactorius 2) central part: bulbus olfaktorius - connection and smell stimulus processing olfactory cortex primary olfactory cortex (piriformní kortex, amygdala) - secondary olfactory cortex (parahippocampus and limbic systém) Applied anatomy of olfactory sense Diagnosis of olfactory disorder ▪ History of disease injuries, surgery of nose and paranasal sinuses, surgery of brain, inflammations, toxic influences, medication, neurodegenerativ, psychiatric and metabolic disorder. ▪ ENT investigatios rhinoscopy, rhinoendoscopy ▪ Subjective methods of evaluation of smell ▪ Objective methods of evaluation of smell - EEG with olfactory evoked potentials, elektroolfactogram and functional magnetic resonance (research) ▪ Imagination evaluations CT, MR Evaluation of smell: subjective methods ▪ Sniffin´ stick test – threshold (the lowest concentration) and supratreshold tests (discrimination of odours) ▪ test of odoured marker (pen)s - screening supra- threshhold evaluation 1.part – name the odour (points) 2.part – identification of odour Olfactory disorder Quantitative disorders: partial loss of smell – hyposmia to anosmia Qualitative disorders : change of perception of disorder • parosmia – distorted perception of odour • specific anosmia – inability of perception of some odours • fantosmia - perception of some odours even in their absence • kakosmia – unpleasant perception of odours (graviditas, mb. Parkinson) Olfactory disorder Time viewpoint: acute, chronic a fluctuate Etiopathogenetic viewpoint: conductive – peripheral odour cannot influence olfactory epithelium, sensorineural - central disorder of olfactory perception ▪ conductive disorder – one-, or both sided 1. mechanical obstruction of nasal cavity (septal deviation, rhinitis, nasal polyposis, tumors of nose and paranasal sinuses) 2. pathologic changes outside nasal cavity (choanal atresia, adenoids , tumors of epipharynx, pts after total laryngectomy) ▪ sensorineural disorders 1. disorders in olfactory epithelium (viral damage, inhalation of toxic odours, rhinitis atrophica, A avitaminosis) 2. disorders in central parts – in olfactory pathway, olfactory cortex (congenital diseases, injury, diabetes mellitus, tumors etc.) Olfactory disorder Congenital diseases congenital Choanal atresia Cystic fibrosis Primary ciliary dyskinesis ASA syndrome Meningocele, meningoencefalocele other Septal deformities Inflammatory diseases Infectious Viral Bacterial Mycotic Non-infectious Alergy Non-alergic – nosal polyposis, medicamentous rhinitis Tumors Benign Papilloma, inverted papilloma Juvenil angiofibroma, hamartoma Malignant Epithelial – spinocellular cancer, adeno-cancer, melanoma Mezenchymal – plazmocytoma, chondroma, chondrosacoma Neuroectodermal – olfactory neuroblastoma Injuries Injuries of face skeleton Injuries of middle etage Injuries of superior etage Injuries of base of the skull Frontobasal injuries Therapy of olfactory disorder conductive disorder ▪ Conservative treatment: corticosteroids systemically and locally, olfactory training and improving nasal ventilation ▪ Surgery: chronic rhinosinusitis with nasal polyposis not reacting on conservative treatment– FESS, removal of nasal obstruction in tumors and anatomical deformities sensorineural disorders cannot be treated, diagnosis could reveal life threatening diseases which could be treated Epistaxis (symptom!) Local causes • vascular, microtrauma of plexus Kiesselbachi • rhinitis ant. Sicca • eenvironmental influences • trauma of the nose • fforeign bodies • bleeding septal polyp (granuloma teleangiectatica or hemangioma) • tumors of the nose • tumors of epipharynx and paranasal sinuses § !!! • idiopathic epistaxis - mild, recurrent epistaxis in young adult General causes • Hypertension • infection (flu, measles, typhus et al.) • diseases of blood and hemocoagulation • kidney/hepatic failure • endocrine causes (pheochromocytoma, menstruation) • hereditary hemorrhagic telangiectasia (morbus Rendu-Osler) 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 Woodruf‘s plexus (plexus a. sphenopalatina) 1-Locus Kiesselbachi 2-a.maxillairs 3-a.sphenopalatina 4-a.ophthalmica 5-a.ethmoidalis ant. et post. Posterior and inferior nasal cavity a. carotis externa via a. maxillaris and a. sphenopalatina - a.a. nasales posterores lat. et septi. Blood supply Woodruf’s plexus („posterior epistaxis“) Woodruf’s plexus is a vascular network located on the posterior lateral wall of the inferior meatus of the nasal cavity and it is responsible for posterior epistaxis. Vascular supply of the nasal cavity. Arteries described as contributors to Woodruf’s plexus exemplifed on the grid on the side of the figure, mainly sphenopalatine artery. Woodruf’s plexus – venous vascular network as described by anatomical dissection studies Morosanu, CO, Craig Humphreys C., et al.: Woodruf’s plexus—arterial or venous? Surgical and Radiologic Anatomy (2022) 44:169–181 Epistaxis – first diagnostic steps ▪ take accurate history of disease ▪ try to find the origin of bleeding ▪ examine blood pressure ▪ evaluate hemo-coagulation Another possibilities: ▪ X-ray examination ▪ general internal examination Epistaxis – local treatment • preserve a calm atmosphere • the patient should sit with the upper part of the body tilted forward • cold compresses to the nape of the neck and dorsum of the nose • mild pressure is applied to both nasal alae for several minutes • cautery: chromic acid, electrocautery, laser • nasal packing • Vascular ligation maxillary artery in the pterygopalatine fossa, the anterior and posterior ethmoidal arteries • Selective arterial embolisation Absorbable materials for nasal packing/tamponade • Gelatin (Gelaspon, Gelfoam) • Gelatin with thrombin (FloSeal) • Hyaluronic acid (Merogel) • Carboxymethylcellulose (Sinu-knit) • Polyurethane (Nasopore) • Fibrin glue (Evicel) Non-absorbable materials for nasal tamponade • Gauze with Vaseline • Balloon tamponades • Polyvinyl alcohol (PVA) - Merocel, Rhinocell)Viscose and cellulose (Rapid Rhino) • Pork belly (Ian Humprey - October 2014 -Nobel Prize; 4 year old girl with Glanzman's thrombasthenia) Anterior nasal packing topical anesthesia, strips of ointment-satured gauze are introduced in layers from above downward into the nasal cavity. floor (etage) continuing Pneumatic nasal packing Posterior nasal packing a gauze pack with a stay suture is used to close off the choana and is fixed in the nasopharynx to prevent the escape of blood from the nose into the nasopharynx, anterior packing is then performed. Technique - a Foley catheter is passed into the nasopharynx down the side of the nose.... Posterior nasal packing cont. Vascular ligation a. 1. Ligation a. maxillaris. 2. Ligation a. car. ext. b. Ligation a. ethmoidalis post. c. Ligation a. maxillaris ve fossa pterygopalatina Epistaxis - general therapeutic management according to causes • supply of the blood, frozen plasma • hem styptics (Dicynone, …) • treatment of hypertension • substitution of missing hemo-coagulation factors Endoscopic electrocautery sphenopalatinal artery Classification of splanchnocranial fractures 1.) upper face (frontal sinuses, frontobasal fractures) 2.) middle facial stage a.) lateral fractures - injuries of the zygomatico-maxillary complex b.) central fractures - fractures of the nasal bones, naso-maxillary complex, maxilla, blowout fracture of the orbit, breakage of the alveolar processes and LeFort type fractures: LeFort I (subzygomatic inferior) LeFort II (subzygomatic superior) LeFort III (suprazygomatic) 3.) lower facial region a.) Fractures of the mandible b.) luxation of the temporomandibular joint a) fractures of the Middle third of the Face, horizontal 1) LeFort I inferior subzygomatic 2) LeFort II superior subzygomatic 3) LeFort III suprazygomatic fracture b) lateral fractures of the Zygoma and the Bony Orbit c) blow out fracture Trauma of the Face - middle facial stage - central - lateral Injury of nose cause - accident, industrial and sports injuries incidence - growing serious consequences – blocked nose, lesion of voice, smell, appearance Injury of anterior skull base Soft tissue injuries Bone injuries Open Combined Soft tissue injuries Bone injuries Closed Nose injuries Symptoms • Visible deformity • Oedema, hematoma, • Crepitation of the fragments on lateral pressure on the nose • Sub skin emphysema injury of mucosa membrane • Bleeding • Liquorhea – intracranial communication • Blocked nose, rhinolalia clausa a anosmia • Shock Diagnosis depends on the severity of the course • History • Inspection, palpation and documentation (legal reasons !) • Rhinoendoscopy • Radiography, CT • Evaluation of smell Treatment • Shock prevention • securing the airway (oro- or nasotracheal intubation - especially during the subsequent surgery in the oral cavity), if intubation is not possible, coniotomy with later transfer to tracheostomy is indicated (for anaesthesia during the subsequent surgery, especially in polytraumatised patients where long-term ventilatory support can be assumed) • to stop bleeding (compression, ligature) • open wounds must be treated according to the principles of plastic surgery (disinfection of the wound area, removal of foreign bodies, excision of necrotic masses, wound adaptation in layers, suture with single (removed after 3-4 days) or continuous suture (removed after 7 days), in wounds with loss of soft tissue, skin grafts) • Tetanus prevention • Transport • Antibiotic treatment Treatment cont. for fractures, procedures under local or general anaesthesia: • non-bloody or bloody repositioning • fixation of the fracture, if necessary (sling dressing, cast, Sauer splints, intermaxillary fixation) • most maxillofacial trauma requires delayed surgery (3-10 days, resolution of swelling and hematomas) Reposition of the nasal bones Reposition and fixation of fractured nasal bones Frontobasal fracture – young man, injury from cracked tyre 1) LeFort I inferior subzygomatic fracture 2) LeFort II superior subzygomatic fracture 3) LeFort III suprazygomatic fracture Injuries of paranasal sinuses Surgery is necessary if: 1) liquorhea 2) injured sinus is inflamed 3) inflammation after injury 4) foreign body in wound 5) complicated fractures with displaced fragments 6) endocranial complications Tumors of nose and paranasal sinuses see „Oncology day 8“ MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Diseases of the orbit a) inflammations, tumours, injuries b) surgical procedures Inflammation of the orbit 85% of infections of sinogenic origin, mostly from ethmoid sinuses Diagnostics ▪ Clinical examination: eyelid, eyeball (mobility, visus), rhinoendoscopic examination to exclude pathology in the area of the ostiomeatal unit. ▪ Imaging methods: CT of the orbits and paranasal sinuses with contrast or MRI with contrast to better visualize the inflammatory seepage and possible abscess. Therapy Medical - (preseptal cellulitis, incipient orbito-cellulitis) - beta-lactam PNCs, cephalosporins IIIrd generation. Anemisation of the nasal cavity and anti-edema therapy (corticosteroids contraindicated). Surgical - if symptoms worsen despite 24-hour ATB therapy or if condition does not visibly improve within 48 hours. In abscess drainage from external or endoscopic approach. This includes treatment of the primary inflammatory focus in the paranasal sinuses. Inflammations of the orbit - division Swelling and redness of the eyelids Position and mobility of eyeball Conjunctival chemosis Vision Meningism, fotofoby, sepsis Preseptal celulitis yes normal no normal no Orbital celulitis yes exopthalmos, impaired mobility yes normal no Subperiostal abscess yes dislocation laterocaudal, mobility normal yes normal no Orbital abscess yes exopthalmus, impaired mobility yes impaired no Thrombosis of the cavernous sinus yes exopthalmus (also both sided), impaired mobility yes impaired yes Inflammations of the orbit Zdroj: převzato z www.slideshare.net Inflammations of the orbit, examples Preseptal orbitocelulitis Adapted from Archiv KOCHHK, FN u sv.Anny v Brně Orbital celulitis Adapted from www.thegeniusprof.com Orbital abscess Adapted from www.drmkotb.com Tumors of the orbit Primary - arising from orbital tissues - lymphangioma, capillary and cavernous haemangioma, glioma, meningeoma, schwannoma, rhabdomyosarcoma Secondary - overgrowth into the orbit from surrounding tissues - orbital promotion of eyelid tumours (basalioma, spinalioma), paranasal sinuses and intracranial tumours, retinoblastoma from the globe Metastasis - neuroblastoma in children, often bilaterally. In adults, most often metastases from breast and lung, also affected in haemoblastoses. Pseudotumors of the orbit non-infectious inflammation that can act like a tumor Histology: signs of chronic inflammation. Clinical picture: heterogeneous - pain on eyeball movement, diplopia, inflammatory changes, conjunctival chemosis, "tumor-like" resistance at the orbital entrance in a completely quiet eye, without elevated inflammatory markers in KO. Diagnosis: MRI of the orbit with contrast (possibly CT orbit with contrast), histological verification. Treatment: corticosteroids, some types respond well to radiation. After repeated recurrences, transition to malignant lymphoma may occur. Injuries (fractures) of the orbit stand-alone unit /or part of extensive facial trauma and intracranial injuries Direct - indirect (hydraulic) Frontobasal - nasomaxillary (nasoorbital) - zygomaticoorbital - hydraulic Clinical picture: swelling, hematoma and emphysema of the eyelids and periorbital landscape, narrowing of the optic fissure, enopthalmus or exopthalmus, dropping of the eyeball, diplopia, sensory disturbance in the innervation area of the infraorbital nerve (2nd branch of the n.V), epistaxis Injuries (fractures) of the orbit Functional eye examination: passive duction test, exopthalmometry (Hertel test), diplopia analysis (Hess screen) Imaging method: CT of paranasal sinuses and orbits in sagittal, axial and coronal projections Treatment: conservative X surgical (ocular and radiographic indications), always ATB Adapted from: www.researchgate.net a archív KOCHHK FN u sv.Anny v Brně Mechanism of the blow-out fracture https://www.researchgate.net/figure/288670499_fig3_Figure-4-Blowout-fracture-from-J-Stelmark-Powerpoint-presentation http://www.internetmedicin.se/page.aspx?id=2011 Blow-out fracture warping of the lower rectus eye muscle (musculus rectus inferior) – consequence – diplopia (double vision) Surgical approaches to the orbit Orbitotomy transorbital X extraorbital (transcranial) Transorbital: - Anterior: transpalpebral or transconjunctival incision for lesions in the orbital entrance, anterior parts of the orbit and peribulbar. Osteotomy is not necessary - Lateral: access through the lateral wall of the orbit - removal of more or less of the lateral part of the orbit, nowadays without lateral canthotomy for tumours retrobulbar and in the lateral half of the orbit both intra- and extraconally (Krönlein, 1874) - Medial: incision in the inner corner of the eye, periorbita and lamina papyracea of ethmoids. In orbital decompression for retrobulbar hematoma and in tumor retrobulbarly and in the medial part of the orbit. Transcranial frontotemporal: - Lowering of the upper orbital wall by transcranial approach, thereby opening the retrobulbar space. There is a possibility of opening the optic canal. Surgical procedures of the orbit cont. Enucleation of the bulb Removal of the eyeball with the adjacent part of the optic nerve for tumour Exenteration of the orbit Complete removal of the contents of the orbit with the periorbita, leaving the bony wall of the orbit. For malignant tumors affecting the soft tissues of the orbit or periorbit. The defect is covered with an autologous musculocutaneous flap on a free vascular pedicle or a removable prosthesis (epithesis). Orbitectomy The most extensive oncological procedure on the orbit involving removal of both the soft tissues of the orbit and the bony shell. It is used for particularly large tumors growing into and destroying the bony orbit.