Rhinology

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esmond
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165032
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Rhinology
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2015-06-25 10:16:38
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Rhinology
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FRCS Rhinology
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  1. English national comparative audit of surgery for nasal polyposis and chronic rhinosinusitis
    • At 5 years
    • revision surgery 20% for polyps 15% CRS
    • revision surgery polyps no sig nif difference +/-sinus surgery
    • significant after multivariate logistic regression
    • mean SNOT 22 score 28, sim to 3/12 & year - better polyps than CRS

    SNOT 22 = 22 questions(symptoms) 0-5
  2. Intraorbital haematoma

    Iatrogenic pneumocephalus
    Mild Delayed onset - iv dex, timolol 0.5%drops.acetazolamide 500mg, , mannitol 20% 2mg/kg over 20 min

    Otherwise Lateral canthotomy, inferior cantholysis +/- endoscopic or external decompression


    Iatrogenic pneumocephalus - 100% oxygen, avoid asisted ventilation, if under tension needle aspiration and ventriculostomy
  3. CT scan check list
    • Uncinate
    • Lamaina papreacea
    • Ethmoid roof
    • Cribiform plate
    • Posterior ethmoids
    • Middle turbinate / middle meatus
    • Sphenoid sinus
    • Frontal recess
  4. Inverted papilloma
    • Proliferation of reserve cells in Schneiderian mucosa
    • Increased males
    • Association with HPV 6 & 11 & EBV
    • 10% malignant association -7% synchronous 4% metanchronous, mostly scc, also transitional, adeno,verroucous
    • HPV 16,18 high risk malignancy, 6,11 low risk
    • Follow up minimum 5 years
    • Original classification - fungiform, cylindrical and inverted
    • WHO classifcation - exophytic, columnar and inverted
    • Recurrence rates 20%
    • Smoking is, however, higher in patients who have IP associated with malignancy
    • Histological features that are associated with an increased risk of malignant transformation include: the presence of bilateral lesions, a predominance of mature squamous epithelium, severe hyperkeratosis, an increased mitotic index (>2 mitoses per high powered field) and an absence of inflammatory polyps, low numbers of neutrophils, and the presence of plasma cells

    • Krouse (2000)
    • T1 Confined to the nasal cavity
    • T2 Osteomeatal complex, ethmoid, medial maxilla +/- nasal involvment
    • T3 Any wall of maxilla (exc medial), frontal, sphenoid +/- T2 criteria
    • T4 extra sinus involvement or malignancy

    Also Cannady staging Gp A-C
  5. Juvenile nasopharyngeal angiofibroma
    • Exclusive adolescent males , genetic testing females
    • Association with Gardners syndrome
    • Not capsulated so easy to leave recurrence
    • Origin vidian canal/pterygoid plate therefore drill this area at end
    • Invasion of sphenoid = predictor for recurrence
    • Assoc Familial adenomatous polyposis
    • Fisch classification
    • 1 Nasal cavity
    • 2 Extends into pterygomaxillary fossa or sinuses with boney destruction
    • 3.Invades infratemoral fossa,orbit,parasellar area
    • 4.Extends into cavernous sinus, optic chiasma, pituitary fossa

    • Radkowski
    • 1a Limited nose/PNS
    • 1b Extension 1+sinus
    • 2a  Minimal extension pterygopalatine fossa
    • 2b Fully occuies PMF +/- orbital erosion
    • 2c posterior pterygoid plate
    • 3a skull base erosion minimal intracranial extension
    • 3b skull base erosion extensive intracranial extension

    • Preop embolisation
    • Some evidnce for preop antiandrogen flutamide
    • Stage 1 and 2 endoscopic treatment
    • Open approaches incl midfacial degloving, lateral rhinotomy, maxilllary swing, preauricular infratemporal fossa approach

    • MRI 72 hrs post op then 6/12 for 3 years
    • Radiotherapy for unresectable tumours
  6. Hereditory haemorrhagic telengectasia
    (Osler-Weber-Rendu disease)
    • Autosomal dominant - onset 4th decade, ave age epistaxsis 12
    • lesions may be minimal and because 10% of patients have no episodes of bleeding
    • Mucocutaneous telengectasia & AV malformantions
    • abnormal vascular architecture at discrete sites
    • Curaçao criteria - epistaxsis, telengectasia, Visceral lesions, 1st degree relative. Definte = 3, possible/suspected = 2, unlikely <2
    • Genes Endoglin (ELK) & ALK-1
    • Types based on genetic anomaly - 1 - 3 +  HHT-juvenile polyposis overlap syndrome
    • Investigations
    • FBC/Coag
    • Urinalysis
    • Faecal occult blood
    • Imaging CT/MR/echo - Head/Lungs/Liver/heart
    • Lung screening with oximetry and CXR
    • Treatment - tranexamic acid,oestrogen therapy,cautery, septoplasty, septodermoplasty, KTP laser,Avastin (bevacizumab) – injection (antiVEGF),  Youngs, embolisation
    • Nottingham - bipolar, tranexamic acid, nasal occlusion splint
    • International guidelines - humidification, endonasal coagulation, MR screening cerebral avm,transthoracic contrast echocardiography as the initial screening test for Pulmonary AVMs(confirm with CT).Directed endoscopic evaluation should be undertaken in patients with anemia disproportionate to epistaxis. The expert panel advises against gastrointestinal endoscopic investigations in patients with HHT and no evidence of anemia.oral iron for anaemia, Tranexamic acid is usually started at 500 mg orally every 8-12 hours and increased to 1-1.5 grams orally every 8-12 hours.abnormal liver enzymes and/or a clinical picture suggestive of complications of liver VMs - liver US or CT, US if to clarify dx,
  7. Open sinus surgery approach
    • Cal De-Luc 
    • Midfacial degloving
    • - bilateral sublabial incision. intercartilaginous incision continued into transfixion incision, elevated upto orbit, beware infraorbital nerves
    • - limits posteriorly the posteriorwall of the sphenoid sinus, pterygoid muscles andplates, superiorly the roof of the ethmoids and Cribriform plate and laterally the coronoid process ofthe mandible. - can access nasopharynx  with resection lat nasal cavity wall
    • External fronto-ethmoidectomy - lynch-howarth incision, access ethmoids and frontal sinus
    • Lateral rhinotomy 
    • - access lateral nasal wall for medial maxillectomy
    • Weber-Ferguson incision
    • - for total maxillectomy
    • Craniofacial resection
    • -resect ethmoid roof/cribiform plate
    • -bicoroanal/transfacial approach or extended lateral thinotomy onto forehead
  8. Endoscopic sinus surgery skull base limits
    • Falx
    • Dura penetrated into frontal lobe
    • Intracranial sinus
    • Lateral to mid point orbit

    Then do craniofacial
  9. Sinaonasal malignancies
    • Olfactory neuroblastomas need radiotherapy
    • Adenocarcinoma radioresisant

    Preserve orbit if periosteum not breached
  10. Orbital cellulitis Chandler classification
    • I Preseptal
    • II Orbit cellulitis
    • III Subperiosteal abscess - strep,s.aureus,HInf
    • IV Orbital abscess
    • V Cavernous sinus thrombosis Staphylococcus aureus

    Septum=extension of the pericranium extending into tarsal plate
  11. Benign nasal tumours(main)
    • Epithelial
    • -Papilloma - inverted, cylindrical,everted
    • Fibroosseous
    • -Osteoma 3% scans,norm asymptomatic, levae unless causing problem
    • -Ossifying fibroma well circumscibed, cont growing, mainly mandible also sinus, remove
    • -Fibrous dysplasia =disorder,normal bone replaced with fibrous tussue & immature woven bone, 1st & 2nd decade, regress as reach skeletal maturity,treat conservatively
    • -Osteoblastoma - painful <30yrs v rare
    • Vascular
    • -Haemangiomas
    • -Haemangipericytomas from extracapillary cells(pericytes), up to 50% recurrence, mortality from bleeding
    • -Angiofibroma - nasal and angiofibroma
    • Minor salivary gland tumours
    • Mesnchymal tumours
    • Neuroectodermal
    • Muscle origin tumours
  12. Granulomatous diseases
    • Definition = transformed macrophages surrounded by lyphocytes
    • Causes
    • -Autoimmune(Wegeners,Relapsing polychondritis,  Churg Strauss)
      -Idiopathic(Sarcoid)
      -neoplastic
    • - infectious(rhinoscleroma,syphylis,tb,rhinosporidosis)
    • - congenital(immune related)
  13. CT Sinus Analysis
    • Pathology and then danger areas
    • Frontal sinus / agger nasi cells
    • Cribiform plate/skull base
    • Anterior ethmoid
    • Lamina papreacea
    • Middle meatus - uncinate/cocha/haller
    • Sphenoid/optic nerve/carotid
    • Septum

    CLOSED=danger areas

    • Carotid - optic carotid recess
    • Lamina papreacea
    • Optic nerve
    • Skull base
    • Ethmoid arteries - Kennedys nipple
    • Dehiscence


    • Holes sphenoid sinus wall -  optic nerve, V2 , vidian nerve
    • Horizontal septa sphenoid=Onodi cell
  14. Frontal Sinus Approach
    • Ethmoidectomy and endoscopic  frontal sunusotomy(Draf 1)
    • Endoscopic frontal sinuplasty (Draf 2a & b)
    • Endoscopic modified Lofrop (Draf 3)
    • External sinustotomy +/- endoscopic
    • Frontal sinus obliterisation - remove mucosa, use fat
    • Riedels procedure - removal frontal/inferior wall with obliteration of sinus & preservation of supraorbital rim
    • Cranialisation
  15. Frontal cells
    • Ager nasi cells
    • Frontoethmoidal Kuhn cells
    • - K1 single cell above Agger
    • - K2 2+cells above Ager
    • - K3 cells encroaching into Frontal sinus
    • -K4 cells entirely in Frontal sinus or occupying >50% height sinus
    • Suprabulla cells
    • Supraorbital cells
  16. Cavernous sinus thrombosis
    • Mortality 20%
    • Visual loss 50%
    • Microbiology S aureus
    • MRV CT with contrast
    • Rx abx, Surgical treatment sinusitis
    • No good evidence for Anticoagulation
    • Steven et al no conclusive evidence in reduction in mortality but reduction in morbidity with a significantly higher percentage of patients neurologically normal
  17. Facial flaps
    • Langer lines - not visable, coincide with skin creases, determined by the orientation of collagen and elastin
    • Borges lines - Relaxed Skin Tension Lines, perpendicular to the action of the underlying mimetic muscles
    • Kraissl’s skin crease lines

    Concave areas heal better by secondary intention cw convex

    vascular supply to the skin is based on a dermal and asubdermal plexus fed by perforators

    • Flaps
    • ● Random - Advancement, rotation, transposition, 3:1 rule
    • ● Axial
    • ● Free

    Creep occurs when skin exhibits an additional lengthening beyond its initial stretch, when constant tension is placed for 5 to 15 minutes

    Stress relaxation occurs over a longer period of time and can be explained by increased cellularity in the skin and a permanent stretching of the skin architecture.
  18. Facial sub units
  19. Facial reconsrtuction options
    • Eliptical incision - 3:1 rule, </= 1.5cm
    • A-T closure where lesion adj to key areas
    • V-Y closure long axis orietated with RSTL
    • Banner flap/single lobed flap
    • Rhomboid flap sides of equal length, with 2 opposing 60° angles and 2 opposing 120° angles, short diagonal rotated along RSTL, 4 possible flaps are possible along the 2 short diagonals and the f lap of choice is that which will transpose easiest and cause the least distortion.
    • Burow’s triangles increases the reach of flaps, minimises distortion andallows the transfer of a defect from one site to another.Dufourmental and Note type f lap modifications
    • Esser’s bilobed flap - primary f lap repairs the surgical defect and the secondary f lap fills the donor site, original description had each component rotate through an arc of 90 degrees
    • Zitelli’s modification of bilobed flap - reduces the arc of rotation andwith the addition of a Burow’s triangle at the tip reduces the standing cone,difficult to adjust the flap to accommodate RSTLs or to follow skin creases,best used for reconstructions of the nose when the f laps aresmall or where RSTLs are less significant,donor f laps are typically 2/3 the sizeof each resultant defect
  20. Facial defects
    • Forehead- small elipse, large advancement
    • Temple - rhomboid, facial nerve superficial 2cm from lat eyebrow, beware lat canthal region
    • Cheek - elipses,rhomboid,banner flaps.between the zygomaticus muscle and the orbicularis oris muscles the branches of the buccal division are relatively exposed, Larger defects require the distribution and transfer oftension over a wider area and a Mustarde type f lap
    • Nose - Banner flaps for the naso-facial groove and alae subunit, Bilobed flaps For the lateral and dorsal subunit, Rieger and modifications(adv flap), forehead flap
  21. Forehead flap
    sup trochlear artery- 3mm lat/med inner canthus,10-16 mm from the midline, and it pierces the frontalismuscle about 15mm above the supraorbital rim))separation between artery and vein at the brow can be up to 15mm so the width of the pedicle should be no less. The flap cantherefore be raised above the level musculo-aponeuroticgalea as a skin only flap, but within 2 cm of the brow, the flap has to be deepened down to the pericranium to include the muscle

    • Lower lip 
    • • 1/3 or less V or W excision and direct closure
    • 1/3 to 2/3 less Johansson step reconstruction, Abbe,Abbe Estalader,Karapandzic flap
    • • 2/3 +Webster or Bernard flap or Gillies’ fan flap

    • Upper lip
    • peri-alar crescenteric advancementf lap of Webster
    • Abbe flap
  22. FESS complications
    • Haemorrhage 5% - reduced by TIVA, bradycardia, hypotensive anaesthetic
    • Periorbital emphysema - norm settles conservatively
    • Adhesions/cicatrisation
    • Deterioration smell 8% - minimise dissection medial middle turbinate
    • Orbital complications 0.6%
    • Periorbital haematoma 1. Remove packing haematoma 2. Urgent ophthalmology opinion 3. Eye massage, mannitol 1g/kg 20%, systemic steroids, topical timolol(0.5% bd). Lateral canthotomy/cantholysis 5. Haematoma evacuation 6. Artery ligation

    • Skull base injury 0.06%
    • CSF leak intraoperative repair at time, -aspirate stomach to reduce post op nauea/vomiting, deep extubation, avoid positive nasal pressure post op CT. Consider acetazolamide and lumber drain.

    Nasolacrimal duct injury 1% not always symptomatic
  23. Granulomatous diseases nose
    • Aetiology - vascilitic/autoimmune, neoplastic, idiopathic
    • Granuloma = nodular inflammatory tissue characterised by presence of macrophages and lymphocytes

    Infectious TB(extrapulmonary more common HIV+ve), leprosy(mycobacterium leprosae), syphylis,actimycosis, rhinoscleroderma(klebsiella rhinoscleromatis), fungal rhinosporidiosis seebri

    Vasuculitis/autoimmune - Wegeners,Churg Strauss, microscopic polyangitis, SLE, relapsing polychondritis 


    Neoplastic - Natural killer cell malignancy(assoc EBV 95%, 3M:F

    Idiopathic -  Langerhan cell histiocytosis, sarcoid, idiopathic midline destrucive disease, pyogenic granuloma
  24. Facial Pain
    • Sinustis
    • TMJ
    • Dental
    • Vascular
    • - migraine
    • - cluster headache - avoid acohol during attack, pizotifen
    • - Chronic paroxysmal hemicrania- mainly females, indomethacin
    • - temporal arteritis
    • Neuralgic
    • - trigeminal neuralgia
    • - glossopharyngeal neuralgia
    • - post herpetic neuralgia
    • Tension type facial pain
    • Atypical facial pain
  25. Rhinosinusitis classification - by cause or length of symptoms
    • Allergic
    • Infective
    • Other Non allergic non infective
    • - Non-Allergic Rhinitis with eosinophilia Syndrome(Equivalent to intrinsic rhinitis).Requires eosinophils in nasal smear for diagnosis
    • -NENAR- Non-Eosinophilic, Non-Allergic Rhinitis(equivalent to autonomic rhinitis)Parasympathetic stimulation causesrhinorrhea and congestion
    • - Drugs - aspiring, B blockers
    • - Hormone
    • - Food
    • - Job
    • - Emotion
    • - Atrophic
    • - Reflux
    • - Air conditioning/polutants
  26. Modified Khun Cell Classification
    • Agger nasi cell
    • Supraorbital ethmoid cells
    • Fronto-ethmoidal Cells
    • • Type 1 Single frontal recess cell above agger nasi cell
    • • Type 2 Tier of cells in frontal recess above agger nasi cell
    • • Type 3 Single massive cell pneumatizing cephalad into frontal sinus
    • • Type 4 (modified from original classification A cell pneumatizingthrough into the frontal sinus and extending > 50% of thevertical height of the frontal sinus 
    • Frontal bulla cells
    • Supra bulla cellsInterfrontal sinus septal cell (or intersinus septal cell)
  27. Olfactory neuroblastoma
    • Originates olfactory neuroepithelium
    • Variable prognosis

    • 3-90 years, bimodal peaks3rd &6th decade
    • Biopsy may bleed profusely
    • Treatment surgery post op radiotherapy







          • In recent series, the 5-year patient survival rates have varied from 50-80%, with the majority of large studies indicating patient survival rates of higher than 70%. In the 2001 meta-analysis by Dulguerov et al, the average 5-year survival was 45 ± 22% (range, 0-86%).[18]
  28. UPSIT
    University of Pensylvania Smell Inventory Test
    • 4 booklests of 10 scratch and sniff strips
    • 4 possible multiple choice answers
  29. Moffets solution
    • Cocaine (1ml 10%)
    • Bicarbonate (1ml 8.4%)
    • Adrenaline (1ml 1:1000)

    • Side effects:Arthymmias, hypertension, temperature, sweating
    • Why bicarbonate?(pka 8.6 free base cocaine, lypophilic
  30. Lateral canthotomy indications
    • tonometry reading greater than 40 mm Hg
    • marked globe compressibility
    • differenc afferent pupillary defect
  31. melolabial flap
    designed in this reconstructive series functions as a superiorly based random-pattern transposition-advancement flap
  32. Allergic fungal sinusitis
    • Diagnosis by Kuhn criteria
    • Evidence type 1 hypersensitivity reaction
    • Nasal polyposis
    • CT hetereogenous hyperattenuation
    • Eosinophilic mucus without fungal invasion
    • Positive fungal stein

    • Treatment
    • Surgical debridement
    • Post op steroids for months
  33. Frontal sinus mucocoele
    • Classification
    • Type 1 Limited to frontal sinus(+/- orbital extension)
    • Type 2 Frontoethmoidal mucocoele  (+/- orbital extension)
    • Type 3 Erosion of posterior sinus wall
    • A Minimal/no intracranial extension
    • B Major intracranial extension
    • Type 4 Erosion of anterior cranial wall
    • Type 5 Erosion anterior and posterior wall
    • A Minimal or no intracranial extension
    • B Major intracranial extension

    • Treatment=surgical=least destructive procedure to provide adequate drainage
    • Endoscopic
    • Open - osteoplastic flap

    • Proptosis resolves 75% patients, improves remainder
    • Diploplia resolves 67% where present
  34. Sphenopalatine artery ligation
    • Sphenopalatine foramen anatomy
    • Superior border - body of sphenoid
    • Notch of perpendicular plate of palatine bone - anteriorly orbital process and posteriorly sphenoid process
    • Lateral = ptergopalatine space
    • CristaEthmoidalis of the palatine bone, which appears to bepositioned anterior and slightly superior to the neurovascularpedicle
    • neurovascular pedicle are the sphenopalatine artery, veinand the nasal palatine nerve (maxillary division of thetrigeminal).
    • main artery branches to formseptal, inferior turbinate and middle turbinate arteries,which supply the majority of the nasal mucosa

    • Procedure
    • incision is made 8 mm from the posterior end of themiddle turbinate with either a Freer’s elevator or angledblade. The incision is vertical in nature extending fromunder cover of the middle turbinate down, but notbeyond, the superior aspect of the inferior turbinate
    • Typically, the level of the foramen corresponds tothe level of the posterior free edge of the middle turbinate,and in the majority of cases is preceded by the CristaEthmoidalis
    • gentle dissectionis required 360 around the pedicle, for example, with aball ended probe.
  35. SMAS
    • Superficial Muscular Aponeurotic System
    • extends from the Platysma to the Galea Aponeurotica and is continuous with Temporoparietal Fascia and Galea
  36. Facial pain
    • Cluster headaches last upto 1 hour, treat with triptan acutely and pizotifen prophylactically
    • Paroxysmal hemicranias - several episodes a day
    • hemicrania continua - continous with fluctiation
  37. Exposed orbital fat
    • Abx 1 week
    • Dont blow nose 2/52
  38. CT check list
  39. Neuropathic facial pain
    • If cant tolerate amytryptyline try
    • duloxetine start 30 mg nocte then increase 60mg nocte

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