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Sinking of what part of embryonic face results in olfactory pit?
olfactory or nasal placode
what separates the nasal and oral cavity in embryo?
bucconasal membrane which thins later and form primitive choannae.
Name the parts of maxillary bone
- Frontal process
- zygomatic process
- alveolar process
- palatine process
- floor of the orbit
Which paranasal sinus appears first?in what age it reaches to final size?
- Maxillary (7 to 10 weeks)
- final size: 17-18 years
When is the time for ethmoid sinus to appear?
9-10 weeks of gestation
How the ethmoid aircells and nasal turbinates are formed in emryogenesis period?
- 9-10 weeks of gestation, 6-7 folds appear on the lateral nasal wall:
- Nasoturbinal makes aggar nasi and uncinate process.
- Ethmoturbinals make aircells, middle, superior and supreme turbinates.
- Maxilloturbinal makes inferior turbinate
When is sphenoid sinus first appearance?
3rd intrauterine month as an invagination from sphenoethmoidal recess.
When is the frontal sinus first appearance?
- 4th month of foetal age from frontal recess.
- It is the last to complete in adulthood.
Blood supply of nasal septum?
- Anterior ethmoid
- posterior ethmoid
- greater palatine
- superior labial
What are anterior and posterior fontanelles of nasal lateral wall? Their significance?
Parts of maxillary hiatus which are covered by only mucous membrane in front and behind ethmoid bulla. may contain maxillary accessory ostia.( mostly in the posterior one) and are considered to be due to infection ( like TM perforation)
Variation of uncinate process attachment?
- Lamina papiracea
- Skull base
- Middle turbinate
What is the lining of the maxillary sinus?
Cilliated collumnar epithelium with goblet cells
What is the benefit of nasal airway resistance?
Adults breathe preferentially from their nose, and positive pressure in the nose during expiration keeps the alveoli patent.
What is the cause and length of the cyclic changes of nasal pressure?
- vascular activity
- 4 to 12 hours
Composition of nasal mucus?
- Water and ions
- Glycoproteins (80% of dry weight)
- Enzymes circulatory proteins (complenet, CRP)
- cells (WBC, EOS, ..)
structure of nasal cillia?
- 9 outer pairs of microtubules around 1 inner pair. outer pairs have Dynein arms which has ATPase (lost in Kartagener's syn), 200 for each cell.
- Beat frequency 7-16Hz
What interferes with nasal cilliary function?
- Hypo/Hypertonic solutions
- URTI (destroys epithelium)
What is the action of Menthol in nose?
It stimulates the cold receptors in the nose, causing apparent increase in airflow.
What are the effects of thyroid disturbance on nose?
- Hyperthyroidism: rhinitis
- Hypothyroidism: nasal blockage (deposition of mucopolysaccarides)
Keros classification for ethmoid roof?
- 1) 1-3mm
- 2) 4-7mm
- 3) 8-16mm
What is the definition and Pathophysiology of Young's syndrome?
- A genetic disease causing Bronchiestasis, nasal polyps, rhinosinusitis, Azoospermia.
- It is due to thick viscous mucus in nasal, pulmonary and epididimal spaces.
Definition of rhinolalia aperta?
A nasal quality of the voice from some disease or defect of the nasal passages.
Describe Osler weber rendu syndrome
- Osler-Weber-Rendu syndrome, also known as hereditary hemorrhagic telangiectasia (HHT), is an autosomal dominant disorder typically identified by the triad of telangiectasia, recurrent epistaxis, and a positive family history for the disorder. Mostly in whites, m=f.
- The main areas of involvement: nasal mucosa, skin, the GI tract.
- Treatment: dermoplasty
What is Esthesioneuroblastoma?
- Esthesioneuroblastoma (ENB), also known as olfactory neuroblastoma, is a rare neoplasm originating from olfactory epithelium.
- No sex discrimination.
- Bimodal peak of occurrence in the third and sixth decades of life.
Classification of Fungal rhinosinusitis (FRS)?
- Non-Invasive FRS
- --Fungal Ball(FB)
- --Allergic Fungal Rhinosinusitis(AFRS)
- --Mixed FB/AFRS
- Invasive FRS
- --Acute Invasive Fungal Rhinosinusitis(AIFRS)
- --Chronic Invasive Fungal Rhinosinusitis(CIFRS)
- --Chronic Granulomatous Fungal Rhinosinusitis(CGFRS)
What is the usual age, sex, and the paranasal sinus involved in Fungal ball?
More in female adults, and Maxillary then Sphenoid.
What are the specification of mucin in allergic fungal rhinosinusitis?
The eosinophilic mucinous material admixed with eosinophils, acute inflammatory cells, eosinophilic debris and Charcot-Leyden crystals, sparse fungi or positive fungal cultures.
Bent-Kuhn Criteria for Allergic fungal rhinosinusitis?
- Type I (IgE-mediated) hypersensitivity to fungi.
- Nasal polyposis.
- Characteristic radiographic findings.
- Eosinophilic mucin without fungal invasion into sinus tissue.
- Positive fungal stain of sinus contents removed at the time of surgery.
Main treatment plan for Fungal allergic rhinitis?
- removal of all the mucin
- oral steroid (prednisolone)
- No need topical/ systemic antifungal therapy
Definition of Acute invasive fungal rhinosinusitis?
Invasion of fungal forms into submucosal with frequent angioinvasion and necrosis in a patient with symptoms of less than one-month duration.
Definition of Chronic invasive fungal rhinosinusitis?
Chronic inflammation and fibrosis in patient with long-standing symptoms(>3 month duration)
Definition of Chronic granulomatous fungal rhinosinusitis?
Invasion of fungal forms into submucosal often with surrounding chronic inflammation, fibrosis and granuloma production in patient with long-standing symptom(>3 month duration)
What is management plan for Allergic fungal rhinosinusitis?
- Prednisolone 10 – 20mg/day for 2 weeks.
- Same dose on alternative days for another 2 weeks or more.
How to administer Amphotricine B in fungal rhinosinusitis?
50mg lyophilized powder, Reconstituted with 10ml Dextrose solution & further diluted with 490ml 5% dextrose solution given over 4 – 6 hrs.
Dose of Amphotricine B in Fungal rhinosinusitis ?
- Fulminant invasive: 1.25-2.0mg/kg/day,total dose: 2.0 – 2.5g.
- Chronic invasive: 0.5 –1.0mg/kg/day total dose: 1.0-2.0g.
- Less severe forms: 0.5 – 0.75mg/kg/day EOD dose
Doses of lipid forms of Amphotricine B?
- AmB lipid complex: 5mg/kg/day
- AmB colloidal dispersion: 3-5mg/kg/day
- Liposomal AmB: 1-5mg/kg/day
Common side effects of Amphotricine B?
Rigors, chills , fever, Nausea, vomiting, Aches & pains, Thrombophlebitis, Normocytic normochromic anaemia, Nephrotoxicity
Dose of Itraconazole?
- Orally: 100mg – 400mg daily
- IV: 200mg b.d. for two days followed by 200mg/day
Samter's triad? What is its treatment?
- Aspirin triad: aspirin intolerance, nasal polyps, Asthma.
- Treatment: low dose aspirin for desensitizing.
Definition of mucocoele?
A mucocoele is an epithelial-lined, mucus-containing sac completely filling the sinus and capable of expansion. This is in contradistinction to a blocked sinus cavity which simply contains mucus.
where is the most common site for mucocoele?
The fronto-ethmoidal region IS by far the most commonly affected overall and the maxillary sinus the least, but a proportion of sphenoidal mucocoeles present to neurosurgeons and the number is therefore probably more common.
The cause and main theories of pathogenesis of mucocoele?
- Mucocoeles are thought to arise as a consequence of obstruction plus inflammation. Three main theories of pathogenesis are found in the literature:
- 1. pressure erosion;
- 2. cystic degeneration of glandular tissue;
- 3. active bone resorption and regeneration.
What is one of the possible symptoms of maxillary mucocoele?
nasal obstruction due to expansion of the lesion into nasal cavity
surgical treatment options for frontal sinus mucocoele?
- Combined endoscopic and external approach
- Lynch-Howarth fronthoethmoidectomy
- Osteoplastic flap
Chandler classification of Orbital complications of rhinosinusitis?
- Preseptal cellulitis
- Postseptal cellulitis or orbital cellulitis without abscess Subperiosteal abscess
- Orbital or intra periosteal abscess
- Cavernous sinus thrombosis
What are the main complications of rhinosinusitis?
- Intracranial (meningitis, abscess)
- Bony (Pott's puffy tumour)
- Chronic (Mucocoele,pyocoele)
prevalence in population?
Mean age of onset?
Main causes of nasal polyposis?
- Nonallergic rhinitis with asthma and aspirin intolerance.
- Allergic fungal rhinosinusitis (90% of patients).
- Cystic fibrosis (40% patients, polyps in children).
- Kartagener's syn ( 40% of patients).
- Young's syn.
- Churg-strauss syn.
Where is the commonest site of nasal polyposis? What are theories about it?
- osteomeatal complex
- 1) touching that mucosa releases the proinflammatory citokines
- 2) influence of special airflow and pressure in upper part of nose (narrow passage causes faster arflow and reduced pressure which sucks the fluid toward the mucosa)
- 3) Damage of thin regulatory nerve ending of the area by cytotoxic proteins of eosinophils causes abnormal vascular permeability and tissue edema.
What is Surface epilthelium of nasal polyp?
The major part of the polyp surface is covered by a ciliated pseudostratified epithelium, but, in addition, transitional and squamous epithelia are found, especiallyin anterior polyps, influenced by the inhaled aircurrents.
Lund-McKay Endoscopic staging of nasal polyps?
- 0)No polyps
- 1) Restricted to middle meatus
- 2) Below middle turbinate
- 3) Massive polyposi
Indications for septoplasty:
Nasal obstruction, crusting, rhinorrhoea, post-nasal discharge, recurrent sinus pressure or pain, epistaxis, headache, snoring and sleep apnoea.
Principal symptoms in septal perforation?
crusting, epistaxis, whistling, dryness, emptiness in nose, and general discomfort
Clinical types of epistaxis?
- --Childhood < 16 years
- --Adult >16 years
- --Anterior (Bleeding point anterior to piriform aperture)
- --Posterior (Bleeding point posterior to piriform aperture)
Why consumption of alcohol can cause epistaxis?
Due to prolonged bleeding time in presence of normal platelets count.
Where and what is woodruff's plexus?
- posterior to middle turbinate, spot for epistaxis in adult due to athersclerosis of feeding arteries.
Classes of nasal fracture?
- 1) low-moderate degrees of force causing depressed nose and Chevallet fracture in septal cartilage.
- 2) greater force: causing deviation and Jarjarvay fracture in septal cartilage.
- 3) naso-orbito-ethmoid: classic pig-like nose and telecanthus
Stranc- Robertson's classification for nasal bone #?
- -Plane I: nasal spine
- -Plane II: Maxillary process
- -Plane III: orbital-ethmoidal
Markowitz classification of naso-orbito-ethmoid #?
- A: solid central segment which medical canthus is attached to.
- B: More comminuted but still has a central segment for medial canthus.
- C: No solid bone for medial canthus to attach to.
Types of Septal cartilaginous fracture in nasal trauma?
- Lateral fracture: Jarjaway
- Frontal fracture: Chevallet
Types of Lefort fracture?
- Le Fort 1: runs above the floor ofthe nasal cavity, through the nasal septum,maxillary sinuses and inferior parts of the medialand lateral pterygoid plates.
- Le Fort 2: This is a fracture which runs from the floor of the maxillary sinuses superiorly to the infraorbital margin and through the zygomaticomaxillary suture. Within the orbit it passes across the lacrimal bone to the nasion. The infraorbital nerve is often damaged by involvement in this fracture.
- Le Fort 3: This represents a disconnection of the facial skeleton from the cranial base. The fracture traverses the medial wall of the orbit to the superior orbital fissure and exits across the greater wing of the sphenoid and zygomatic bone to the zygomaticofrontal suture. Posteriorly, the fracture line runs inferior to the optic foramen, across the lesser wing of the sphenoid to the pterygomaxillary fissure and sphenopalatine foramen. The arch of the zygoma is also broken.
Signs of orbital fracture?
- enophthalmos and hypoglobus (depressed pupillary level). Enophthalmos is most apparent when the contralateral eye is normal.
- Other signs include supratarsal hollowing, hooding of the eye, narrowing of the palpebral fissure width and an infraorbital nerve deficit.
- A small fracture of the orbital floor can lead to a trap door phenomenon. If the orbital fat or inferior oblique muscle becomes trapped in the fracture configuration, then interference with muscular function results in diplopia on upward gaze.
where Beta2 transferrin can be found?
- aqueous humour (secreted from the ciliary epithelium, a structure supporting the lens)
How to use Flourcein in detecting CSF leak?
0.25 mL of 5 percent fluorescein is mixed with 10 mL of CSF from a routine lumbar puncture, the mixture is introduced via a spinal needle and the patient is placed in the Trendelenberg position for approximately one hour.Then, endoscopic examination is performed, and if positive the fluorescein can be seen coming from the defect. The use of a blue filter on the endoscope light source can increase the ease of detection.
Sarcoidosis in brief:
- systemic granulomatoisis with unknown origin, more in USA and scandinavia, f/m 2/1, more in black (12 times whites), 30-50 years old, involves LRT (lower respiratory tract) more.
- Nasal involvement: stuffiness, obstruction,crusting, blood stained discharge...
- Extrapulmonary sites: Lymph nodes, skin, liver, eye
- Ix: ACE (83%), ESR, CXR, CT, MRI
- Tx: Steroid, Methotrexate, hydroxychloroquine
A condition, characterized by granulomatous inflammation involving the respiratory tract and necrotizing vasculitis affecting small- to medium-sized vessels (e.g.capillaries, venules, arterioles and arteries) with necrotizing glomerulonephritis.
Pathologic hallmark and triad of wegener's ?
- coexistence of vasculitis and granulomas disease.
- It classically involves a triad of lower airway, lung and kidney.
Wegener's granulomatosis clinical symptoms?
- general: malaise, pyrexia, weight losseye: conjunctivitis, proptosis
- ear: AOM, OME
- Face: FN palsy
- nose: septal perforation, crusting, blood stained discharge
- Mouth: gingival lesions
- trachea: crusting, narrowing, stridor
- lungs: lesions seen in CXR
- kidney: segmental glumerulonephritis, casts
- Skin: skin lesions in distal legs, arms
Investigations of WG (Wegener's granulomatosis)?
- ACE (TRO sarcoidosis)
- UFEME (casts)
- biopsy not conclusive, but must be done
- CT, MRI
Treatment of WG (Wegener's granulomatosis)?
- Prednisolone: 60-80mg/d
- Cyclophosphamide: 2m/kg (can cause leukopenia,allopecia)
- Azathioprine: 200mg/d
- Low dose antibiotic (Co-Trimoxazole)?
What is Cholestrol granuloma?
- Granulomatous reaction to cholesterol crystals precipitated in the tissues are presumed to result from haemorrhage and/or trauma.
- The lesion may affect the maxilla or frontal sinuses producing expansion of the bone, cosmetic deformity and displacement of adjacent structures, such as the globe.
What are the main complications of occlusion of nasolacrimal system?
- recurrent dacrocystitis
Prevalence of nasolacrimal obstruction?
- 20% neonates (95% resolve by 1 year)
- 10% in age 40
- 35-40% at age 90
preoperative assessments of nasolacrimal system?
- Syringing and probing
- Massage of sac
- Nasal endoscopic examination
Choices of laser for eDCR?
- KTP/532 (best): can go through felxible fiber, vaporizes bone, good coagulation, no scattering
- Diode lasers
Name 2 Antimitotic agents used on the eDCR incision and osteotomy site to reduce the chance of adhesion/recurrence?
- Mitomycin C (MMC)
- 5 fluorouracil (5FU)
What is Lester-Jones tube?
permanent indwelling ceramic tube in nasolacrimal sac after eDCR as a permanent draining channel.
Etiology of primary atrophic rhinitis?
- H: hereditary
- E: endocrine
- R: Racial
- N: Nutritional
- I: Infections
- A: autoimmune
What is the pathology of atrophic rhinitis?
metaplasia in the nasa epithelium, from ciliated columnar to non keratinized squamous epithelium.
Clinical features of atrophic rhinitis?
- brown/black/green nasal crusting
- Thick purulant discharge and foul smell anosmia
- nasal obstruction
- atrophy of turbinates
Etiology of secondary atrophic rhinitis?
Bacterial flora of patients with atrophic rhinitis?
- coccobacillus fetidus ozaena
- deiphteroid bacilli
- Klebsiella ozaenae
What is rhinitis sicca?
A mild version of atrophic rhinitis
Treatment of atrophic rhinitis?
- nasal douching (Na bicarb, Na Diburate, Na Cl, 1:1:2 in warm water)+ glucose in glycerin 25% solution
- Rifampicin 600mg/OD x 12/52
- Young's op
- Modified Young's op
increasing the size of meningocele-meningomyelocele when baby cries
minor cells of paranasal sinuse?
- agger nasi
- haller's cell
- onody's cell
Anterior bowing of posterior maxillary wall:
Name of sign?
In what disease?
- Holman-Miller sign
- Juvenile Nasophaygeal Angiofibroma (JNA)
Fisch classification fo JNA?
- I: limited to nasopharynx, nasal cavity
- II: invading ptrygomaxillary fossa , paransal sinuses with bony destruction
- III: Invading infratemporal fossa, orbit and parasellar region, lateral to cavernous sinus
- IV: Invading to cavernous sinus, optic chiasma, pituitary fossa
What is Ohngren's line? What does it indicate?
- from medial canthus to angle of mandible
- Maxillary tumours below this line have better prognosis than above it
What is Moure's incision?
- lateral rhinotomy
Name parts of the nasolacrimal aparatus:
- papilla lacrimalis
- vertical segment of canaliculus 2mm 90 degree bend horizontal segment: 8mm
- common canaliculus
- ampula (sinus of Maier)
- Enter to NL sac, through Rosenmuller valve
- fundus 5mm above medial canthus
- sac body 10mm
- valve of krause in midway
- NLD 12mm bony, 5mm membraneous
- Hasner valve
Kuhn's classification of frontal sinus pneumatization?
- 1. Single cell above agger nasi
- 2. more than 2 cells above agger nasi
- 3. Single cell from agger nasi to frontal sinus
- 4. An isolated cell within frontal sinus
What are the most common benign tumors of paranasal sinuses?
- Osteoma (the most common)
- Inverted papilloma (the most commonly operated one)
Inverted papilloma: sex?age?cause?symptoms?histopathology?Investigation of choice?
- 50 HPV 6,11,16,18
- Unilat nasal blockage, watery rhinorrhea
- hyperplastic ribbons of basement membrane that grow endophytically into underlying stroma
- Biopsy, Gadolinium MRI
Krouse clasification of Inverted Papilloma?
- 1. nasal cavity
- 2. ethmoid cavity, medial and superior wall of maxilla
- 3. Inferior and lateral wall of maxilla, frontal and sphenoid sinus
- 4. anything beyond, including malignancy
Stages of Syphillis and its nasal symptoms?
- 1) Around 21 days after exposure: Chancre, regional LMP, malaise, fever.
- 2) 6-10 weeks: systemic disease, with catarrhal rhinitis, crusting, wound on nasal vestibule, mucous patches on pharynx, rash, pyrexia
- 3) Gumma (commonest in nose), with pain, swelling and obstruction of bony septum.
What is "snuffles"?what are the other findings in congenital syphilis?
- Catarrhal rhinitis: Most common lesion of syphilis in infants, which soon becomes purulant, and causes wound on vestibule, upper lip.Gumma, atrophic rhinitis, saddle nose deformity happens in puberty.
- Others: hutchinson;s teeth, moon's molars, corneal opacity, SNHL.
Indications for FESS?
- chronic rhinosinusitis;
- acute recurrent rhinosinusitis;
- nasal polyposis;
- allergic fungal sinusitis and mycetoma;
- repair of cerebrospinal fluid (CSF) leaks;
- orbital and optic nerve decompression;
- repair of blow-out fractures;
- choanal atresia;
- septal and turbinate surgery;
Surgical management options of rhinosinusitis?
- Antral washout
- Inferior meatal antrostomy
- Caldwell-Luc Intranasal ethmoidectomy
- Transantral ethmoidectomy (Jansen Horgan procedure, combination of Caldwell-Luc and access to ethmoids)
Definition of meningocoele?
CSF filled hernial sac, lined and covered by meninges.If it contains brain tissue, is referred to as meningoencephalocoele.
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