lateral nasal wall, aspiration, lavage, or the introduction of drugs may be
carried out through the needle. A thin polyethelen tube can be inserted into the
sinus and sinus is washed 1, 2, 3 times a day by the antiseptic until clear.
Principle of lavage via middle meatus
Local anesthesia of the middle meatus is induced. The ostium of the maxillary
antrum is sought, and a blunt curved cannula is introduced through it.
Aspiration, lavage, and introduction of drugs can be carried out through the
cannula. This manipulation carried out daily.
2. Introduction of antibiotics, corticosteroids and ferments into the sinus
daily. Antibiotics are used according to the result of bacteriological analysis.
3. Systemic antibiotics.
4. Decongestant nasal drops.
5. Antihistamine drugs in tablets.
6. Calcii gluconas.
7. Physiotherapy.
If the complications take places and their conservative treatment has not
effects radical antrostomy should be carry out.
Chronic maxillitis
1. Lavage of the sinus.
2. Introduction of the antibiotics, corticosteroids and ferments into the sinus.
3. Decongestant nasal drops.
4. Antibiotics are given systemically.
5. Antihistamine drugs in tablets.
6. Calcii gluconas.
7. Physiotherapy.
Surgical treatment:
1. Endoscopic enlargement of the sinus ostium.
2. Endoscopic antrotomy and removal of the pathological mucosa, polyps, cysts.
3. Radical antrostomy.
4. Intranasal antrostomy.
Frontal sinus
Acute frontitis
1. Lavage of the sinus.
Puncture can be carried out using a fine drill or special trocar under local
anesthesia. Puncture is carried out through the anterior wall. A thin
polyethelene tube is inserted and daily lavage is carried out.
2. Introduction of the antibiotics, corticosteroids, ferments into the sinus.
3. Systemic antibiotics.
4. Decongestant nasal drops.
5. Antihistamine drugs.
6. Calcii gluconas.
7. Physiotherapy.
Chronic frontitis
Conservative treatment is the same as in the case of acute frontitis.
Surgical treatment:
1. Endoscopic enlargement of the sinus ostium.
2. Radical operation on the frontal sinus.
Ethmoidal sinus
1. Intramuscular introduction of antibiotics.
2. Decongestant nasal drops.
3. Antihistamine drugs.
4. Calcii gluconas.
5. Endoscopic intranasal ethmoidotomy.
6. Radical ethmoidotomy.
Sphenoid sinus
1. Antibiotics.
2. Nasal drops.
3. Antihistamine drugs.
4. Calcii gluconas.
5. Endoscopic intranasal sphenoidotomy.
6. Radical sphenoidotomy.
Operations for maxillary sinusitis
Intranasal antrostomy. The principal indication for this operation is in the
treatment of recurrent, acute sinusitis, but it is also recommended for chronic
sinusitis of recent origin and is particularly effective in children. It creates
a large dependent opening in the medial wall of the antrum so that stasis of
mucoid secretions does not occur within the sinus. A flap is raised under the
anterior end of the inferior turbinate and the antronasal wall is breached and
cleanly punched out as far inferiorly as the floor of the nose. The flap of
mucosa is then turned into the sinus to lessen the chance of subsequent closure.
Radical antrostomy. This is sometimes referred to as the Caldwell-Luc operation
and is the procedure of choice when conservative measures have failed, and when
it is considered that the pathological changes within the sinus have reached an
irreversible state. A sublabial incision is made over the canine fossa, and an
area of bone removed to gain sufficient access to the antrum. All diseased
mucosa is removed, and a large intranasal antrostomy is fashioned. The sublabial
incision is closed with absorbable sutures, and the sinus is washed out through
the intranasal antrostomy postoperatively and prior to discharge from hospital.
Cysts of the maxillary sinus
Cysts of the maxillary sinus are usually of dental origin and are called dental
cysts. If the cyst contains a tooth it is termed a dentigerous cyst. The cause
of a dental cyst lies in the periodontium or periosteum of a diseased upper
premolar or molar tooth. The cyst enters the antrum through its floor and
gradually enlarges until it may distend the sinus cavity by pressure on its
walls. Dental cysts may occur at any age.
The cyst may be entirely painless, giving rise to no symptoms and being
discovered accidentally. Infection within the cyst causes toothache, headache
and pain in the infra-orbital region. Similarly, distension of the sinus
produces local pain.
CLINICAL FEATURES. Clinical examination may be negative if the cyst is small.
When the antrum becomes enlarged there may be a fullness of the inferior meatus
or even of the hard palate, and palpation of the gingivolabial fold gives a
sensation of crackling elasticity. Radiography will show a spherical dense area
in the floor of the maxillary sinus if the cyst is small. When the cyst fills
the antrum there is a homogeneous opacity, and if it contains a tooth this will
be seen on radiography. Radiography with contrast and CT-scan are effective.
TREATMENT. Proof puncture of the affected antrum will produce clear greenish or
amber-coloured fluid which may issue through the cannula when the trocar is
withdrawn. The rest of the contents may be aspirated into a syringe through a
blunt-pointed needle inserted through the cannula. This in itself may cure the
condition if dental attention is given to the unhealthy tooth. If the cyst is
large or infected, or if it should contain a tooth, a endoscopic antrotomy is
performed and the entire cyst removed.
COMPLICATIONS OF SINUSITIS
Orbital Cellulitis and Orbital Abscess
Orbital complications are commonest. The ethmoidal sinuses are separated from
the orbit by only a very thin plate of bone, the lamina papyracea, and orbital
complications are thus associated more with infection of the ethmoidal cells
than with other sinuses. As acute upper respiratory tract infections are
particularly common in childhood, and as the ethmoidal sinuses are present at
birth and expand fairly rapidly, orbital cellulitis and abscess occur
particularly in older children.
Orbital cellulitis arises from a blood-borne spread of infection.
Thrombophlebitis occurs in the vessels of the mucosa and bone of the inflamed
sinus, and infection extends to the loose tissues of the orbit giving rise to a
cellulitis which spreads rapidly.
An orbital abscess usually arises from direct spread and is a subperiosteal
abscess lying between the lamina papyracea and the orbital periosteum (on
occasion it can be due to localized abscess formation in a patient whose orbital
cellulitis is not controlled. The infecting organisms are staphylococcus,
streptococcus - including the anaerobic type pneumococcus and Haemophilus
influenzae.
CLINICAL FEATURES. Initially there are, of course, symptoms of acute sinusitis.
In orbital cellulitis these are followed by venous congestion and swelling of
the eyelids, particularly the upper one, and the eye is soon closed. There is
infection of the conjunctiva, and in severe cases chemosis develops. There may
be mild proptosis, but eye movements should remain full.
In orbital abscess there is swelling of the eyelids with outward displacement of
the globe, limitation of eye movements, and pain is felt particularly on
attempted medial movement of the eyeball. If the abscess is situated
posteriorly, coming from the posterior ethmoidal cells, the optic nerve and
ophthalmic artery are particularly at risk from pressure effects, and a close
watch should be kept on visual acuity, visual field and signs of pallor of the
optic disc.
Examination of the nose will show signs of an acute bacterial infection with a
swollen inflamed airway and mucopus in the middle meatus and postnasally.
Radiography will reveal opaque ethmoidal cells, and there may be a fluid level.
There is commonly a unilateral pansinusitis affecting the maxillary, sphenoidal
and frontal sinuses as well.
TREATMENT. Orbital cellulitis is treated medically with systemic antibiotics.
Decongestants will aid sinus drainage. In the case of abscess formation, if the
patient is seen early and appropriate antibiotics have not been given, a similar
regime is appropriate. If there is no obvious improvement within 24 hours, the
abscess should be drained externally through an incision in the supramedial
quadrant of the orbit, and a drainage tube inserted for several days.
Osteomyelitis
Osteomyelitis occurs as a complication of sinusitis where there is diploic bone
in relationship to an acutely infected sinus. It tends to occur in the maxillary
bone in children and in the frontal bone in adults. The spread of infection to
the bone-marrow space is by thrombophlebitis.
CLINICAL FEATURES. The symptoms are minimal in the early stages of the disease.
There is a dull boring pain in the affected bone with a tender puffy swelling
developing slowly over it. There is considerable systemic upset with rigors. An
X-ray will show signs of sinusitis with sclerosis of the affected bone. This
will change to a mottled appearance and finally, if untreated, a sequestrum will
become apparent.
TREATMENT. In the early stages the treatment is medical. Antibiotic
sensitivities should be obtained by culturing pus from the nose. An antibiotic
such as lincomycin which attains high tissue levels in bone is to be
recommended. Lavage of the sinus is carried out. If a sequestrum develops, it
should be removed surgically. This is more likely in osteomyelitis of the
frontal bone in adults, and is an indication for the osteoplastic flap operation
on the frontal sinus.
Intracranial Complications
Intracranial complications of sinus infection can occur by direct spread, by
venous thrombophlebitis or along the perineural tissues of the olfactory nerve.
Direct spread is aided by any breach in the bone separating the sinus from the
intracranial structures. It is encountered in association with congenital
dehiscence of the bone, with previous fractures, and following poorly visualized
surgical procedures like intranasal ethmoidectomy and nasal polypectomy.
Meningitis is the commonest complication and is treated vigorously with systemic
antibiotics. Pneumococcal meningitis has a particularly poor prognosis,
especially in the elderly. Cortical venous thrombosis manifests itself by severe
headaches, rigors, neck stiffness, lowered level of consciousness and epileptic
fits. It should be treated in a similar manner to meningitis.
Cavernous sinus thrombosis is due to spreading thrombophlebitis from the
frontal, ethmoidal and sphenoid sinuses. There is decreased venous return from
the eye, causing swelling of the orbit and congestion of the retinal vessels.
There is a high fever with rigors, severe headache, a reduced conscious level
and cerebral irritation. The III-rd, IV-th, Vl-th and upper division of the Vth
nerve, which lie in the lateral wall of the cavernous sinus, become paralysed,
giving rise to an ophthalmoplegia. As there is free communication between the
two cavernous sinuses, the signs frequently become bilateral. Treatment is with
high doses of systemic antibiotics and heparine. This is a serious condition
which still carries a mortality.
Brain abscesses secondary to sinusitis most commonly occur in the frontal lobe.
Localizing signs are few, and the abscess becomes apparent through signs of
raised intracranial pressure. Treatment is by neurosurgical drainage.
Extradural abscesses are again related to the frontal sinus. When suspected, the
frontal sinus should be explored through an osteoplas-tic flap approach, and
particular attention should be paid to the posterior wall, where there may be a
dehiscence. An extradural abscess can be drained into the frontal sinus, and
hence externally.
A subdural abscess carries the poorest prognosis of all the complications of
acute sinusitis. In its early stages it is very difficult to diagnose, the only
symptoms being general malaise, headache and some neck stiffness. The abscess
may quite suddenly increase in size giving acute raised intracranial pressure.
Treatment is neurosurgical, with drainage through multiple burr holes, or
necessitating the removal of an area of cranium, to achieve adequate drainage.
Nasal polyposis
The polypus is a projection of oedematous mucous membrane composed of loose
fibro-oedematous tissue, the surface of which is covered by ciliated epithelium.
Small blood vessels traverse the surface and are sometimes visible to the naked
eye. There is a variable degree of infiltration of round cells, while with
allergic polypi large numbers of eosinophils are found.
Nasal polypi are caused by a combination of allergy and infection. They are
uncommon in childhood or adolescence, being more frequent in adult life. Those
arising earlier in life have a more obvious allergic aetiology. Nasal polypi are
more common in men than in women.
AETIOLOGY. Nasal allergy causes oedema due to the release of histamine giving
rise to increased blood-vessel permeability. The oedema results in blockage of
the ostia of the ethmoidal cells, and a secondary bacterial infection
supervenes. As the polypi enlarge they cause poor aeration of the middle meatus
of the nose, and the resulting chronic rhinitis and the underlying allergy lead
to oedema of the middle turbinate and lateral nasal wall. Once the polypi appear
within the nose they enlarge, partly by growing and partly by negative pressure
on nose blowing, causing increased oedema. While they can vary in size, by
enlarging during a cold or an exacerbation of hay fever, once they are visible
on rhinoscopy they will not disappear completely. The vast majority of nasal
polypi arise from the ethmoidal sinuses and they should be regarded as the
end-product of chronic ethmoiditis, while remembering that the sequence of
oedematous blockage of the ostia followed by secondary infection frequently has
an allergic causation. Nasal polypi are almost always multiple and bilateral,
and an individual polypus can exceed the size of a grape.
SYMPTOMS. The principal symptom is nasal obstruction. As polypi are slow-growing
there may be a considerable collection before the patient becomes aware of the
obstruction. At times the patient suddenly becomes conscious of a blockage after
a cold, when infection and nose blowing cause a rapid increase in size. Patients
vary greatly in their tolerance of nasal obstruction, some complaining bitterly
of the blockage by a single polypus while others endure large multiple polypi
for months before seeking advice. Occasionally a pedunculated polypus in the
posterior part of the nasal cavity may swing forwards on expiration to act as a
hall valve and cause blockage. The pressure of large oedematous masses of polypi
can distend the nasal cavities to cause a visible broadening of the external
nose.
On occasions, usually during a cold, a polypus may so enlarge as to appear at
the anterior naris and be seen by the patient. There may be a complaint of
frontal headache, and there is often a loss of sense of smell and taste. Nasal
catarrh is always present, either watery during allergic exacerbations or
mucopurulent during infective episodes.
CLINICAL FEATURES. Anterior rhinoscopy will reveal the smooth, glossy,
bluish-grey swelling which is characteristic of the nasal polypus. When it
reaches the naris, the surface epithelium undergoes a change to the squamous
type from exposure and trauma, and the surface is less glistening and more
pinkish in colour. A polypus may be mistaken for an oedematous enlarged anterior
end of the inferior or middle turbinates by the inexperienced. In cases of doubt
the lesion should be gently probed, when a polypus will be found to be soft,
mobile and relatively insensitive, whereas a turbinate is firmer, has a bony
support and is sensitive.
On posterior rhinoscopy, the polypi can often be seen in the choanae of the
nose, especially if they arise from the posterior ethmoidal or maxillary
sinuses.
Radiography of the nasal sinuses should be carried out. Apart from the expected
cloudiness of the ethmoidal cells, the films may reveal infective changes in the
maxillary sinus which can be conveniently treated at the same time as the polypi
are removed.
TREATMENT. The basis of treatments surgical removal. Medical treatment can only
give temporary relief, because, once the polypi are apparent on rhinoscopy, they
will never disappear completely. Medical measures include short-term use of
nasal decongestant drops, or oral decongestant tablets, and the treatment of
allergy with antihistamines or a steroid spray such as beclomethasone
dipropionate (Beconase).
Recurrences of nasal polypi are common. An attempt should therefore be made to
treat the aetiological cause. If there is radiological evidence of infection of
the maxillary antrum, they should be washed out, and if pus is obtained it
should be sent for bacteriological culture and antibiotic sensitivity, and
polyethylene tubes should be inserted into the antrum so that the nursing staff
can repeat the wash-outs several times a day. An attempt should be made to treat
the underlying allergy. Skin testing frequently shows multiple weakly positive
reactions, and only a minority of patients benefit from hyposensitization. An
injection of steroids, e.g. 80 mg of methylprednisolone acetate, following the
polypectomy is thought to reduce the rate of recurrence. A beclomethasone
dipropionate (Beconase) spray can be used fairly safely on a long-term basis.
Naso-antral (choanal) polypus
The naso-antral polypus arises from the mucous membrane of the maxillary sinus.
The morbid condition of the antrum is probably catarrhal, and as the swelling
increases a small polypus develops in the region of the accessory ostium of the
sinus. The polypus protrudes into the nasal cavity through the accessory ostium,
which is situated posterior to the normal orifice. It increases in size because
of the oedema within it, and it passes posteriorly towards the choana and enters
the nasopharynx. Here it enlarges to fill the nasopharynx, and as greater growth
occurs the polypus then grows forward through the nasal cavity of the original
side, and thus becomes bilobed. It resembles the ordinary nasal polypus in
structure.
SYMPTOMS. A naso-antral polypus is more commonly found in childhood or
adolescence than in adult life. There is a complaint of unilateral nasal
obstruction which becomes bilateral as the polypus fills the nasopharynx. A
mucoid discharge is noted, again unilaterally at first and later bilaterally.
The voice becomes affected and hyponasality develops. Snoring may be complained
of initially. There is no pain, nor is there earache, but deafness may be
present because of the occlusion of the auditory tubes.
CLINICAL FEATURES. Anterior rhinoscopy in the early stages may reveal no
abnormality, although there may be accumulated mucus on the floor of the nasal
cavity of the obstructed side. It may occasionally be possible to see the
polypus far back in the nasal cavity. When the polypus becomes bilobed it will
be seen with increasing ease. Posterior rhinoscopy is not always easy to perform
in the young, but when it is successful a smooth, greyish-white, spherical mass
will be seen in the choana early on, and later filling the nasopharynx. Once the
nasopharynx is filled the polypus may project below the soft palate, or may be
seen when the palate rises on phonation. It presents as a greyish convex mass on
examining the pharynx. Radiography will show a lack of air entry into the
affected maxillary sinus and cyst in this sinus, while a lateral projection will
demonstrate the polypoid swelling in the nasopharynx.
Treatment is surgical.
Part 7
DISEASES OF THE PHARYNX
Adenoid Hyperplasia
Symptoms. These include nasal obstruction leading to mouth breathing, difficulty
in feeding especially in small children, noisy respiration, snoring, typical
adenoid facies, i.e., dull facial expression, open mouth, dilated and flattened
nasolabial folds, indrawn nasal alae, protruding upper incisor teeth, enlarged
lymph nodes at the angle of the jaw or in the nuchal area, the adenoid habitus,
and rhinolalia clausa.
Obstruction of the nasopharynx may be responsible for:
1. Aural diseases, including obstruction of the eustachian tube, chronic tubal
and middle ear catarrh, serous effusion, recurrent acute otitis media, formation
of adhesions, also progression of chronic otitis media and conductive deafness.
2. Diseases of the nose and paranasal sinuses, including chronic purulent
rhinitis or sinusitis, and even pansinusitis
3. Disorders of the masticatory apparatus, including: maldevelopment of the
upper jaw, i.e., arched or "gothic" palate due to absence of the pressure of the
tongue on the hard palate, and absence of lateral pressure on the upper jaw and
alveolus by the tension of the buccinator muscle and the masticatory muscles
because of the open mouth. Also including anomalies of position of the teeth,
such as incorrect contact and orientation of the mandibular occlusion, and
gingivitis
4. Disorders of the lower respiratory system, i.e., chronic laryngitis,
tracheitis, and bronchitis
5. Other somatic effects, including a flat chest, round shoulders, loss of
appetite, poor general development, and sensitivity to attacks of infection
6. Effects on the intelligence and mental development due to chronic respiratory
obstruction and hypoxia during sleep; increased levels of CO2 in the blood
leading to restless, broken sleep causing tiredness during the day, apathy,
dullness, poor school performance, and "pseudodementia"
Pathogenesis. The disease is caused by above-average hypertrophy of the
lymphoepithelial tissue of the pharyngeal ring which is so immunobiologically
active during childhood. There is probably a hereditary disposition. Endocrine
and constitutional factors and the influence of diet, in particular
carbohydrates, are suggested. There are three degrees of adenoid hyperplasia.
Diagnosis. The main symptoms include chronic mouth breathing, snoring, and
proneness to infection. Examination by anterior and posterior rhinoscopy shows
the enlarged adenoid. Palpation may be needed.
Differential diagnosis. This includes choanal atresia, foreign bodies in the
nose, and other causes of nasal obstruction such as nasopharyngeal angiofibroma
and malignant tumors of the nasopharynx, possibly of mesenchymal origin
especially in children. Dental causes should be looked for to explain the
anomalies of position of the teeth and malocclusion.
Treatment. Conservative treatment by change of climate, diet, drugs, and so
forth is not satisfactory.
Operative treatment is by adenoidectomy.
The operation is carried out under local or general anesthesia. A Beckman's ring
adenotome is usually used to remove the adenoid. This instrument separates the
adenoid at its base.
Course and prognosis. The symptoms usually resolve rapidly after removal of the
mechanical obstruction. The child usually returns surprisingly rapidly to normal
physical, psychological, and intellectual health. The prognosis is very good;
recurrence after correctly performed adenoidectomy is unusual. Complications are
mainly postoperative bleeding and aspiration. These are only to be feared if
hemostasis is not achieved at operation or if tissue has been left behind.
Because a pathologic bleeding tendency may easily be overlooked, the following
investigations should be carried out before adenoidectomy:
1. History and family history relative to bleeding and coagulation disorders
should be taken.
2. The bleeding time should be determined.
3. The partial thromboplastin time (PTT) should be determined.
4. The thrombocyte count should be determined.
Tonsillar Hyperplasia.
Symptoms. This is usually combined with hypertrophy of the adenoid. In addition,
there is increased difficulty in swallowing and eating because of obstruction of
the faucial isthmus. Considerable respiratory obstruction may also occur when
only the tonsils are hyperplastic.There are three degree of tonsillar
hyperplasia.
Diagnosis. The local findings are obvious.
Differential diagnosis. This is similar to that for adenoid hypertrophy. It is
important to determine whether the tonsils alone are hypertrophic or whether
there is a coexisting adenoid hypertrophy.
Unilateral hyperplasia of the tonsil in an adult must always lead to suspicion
of malignancy. A rapid hyperplasia of the lymphatic pharyngeal ring points to a
disease of the entire lymphatic system.
Treatment. Tonsillectomy is performed, usually combined with adenoidectomy.
Not every enlargement of the tonsil or adenoid in a child is an indication for
removal. There must be considerable hyperplasia with obvious mechanical
obstruction of the naso- or oropharynx, and the appropriate clinical effects and
disorders must be present.
INFLAMMATIONS OF THE PHARYNX
Diphtheria
Symptoms. There is a mild prodromal illness: the temperature is usually in the
region of 38°C and not more than 39°C. There is slight pain on swallowing and
often a very high pulse rate. The tonsils are moderately reddened and swollen
with a white or grey velvety membrane which becomes confluent, extends beyond
the boundaries of the tonsil to the faucial pillars and the soft palate, and
which is fixed firmly to its base. The membrane can only be wiped off with
difficulty and it then leaves a bleeding surface behind. The jugulodigastric
lymph nodes are very swollen, tender, and often hard. There is a characteristic
smell of acetone on the breath. Sixty percent of cases are localized to the
pharynx including the tonsils, and in 8 % the larynx is involved in addition.
Albuminuria is common.
Microbiology. The infection is due to the diphtheria bacillus, corynebacterium
diphtheriae. The disease is transmitted from man to man by contact, droplets, or
contamination by oral or nasal secretions. The incubation period is 3 to 5 days.
In localized forms, the disease is restricted to the tonsil, the nose, the
larynx, or a wound. The generalized form is progressive and toxic.
Diagnosis. This rests on: (1) bacteriologic smear from the tonsils and pharynx;
Gram staining of a smear from the pseudomembrane provides the result within I h;
(2) culture provides the answer at the earliest after 10 h; (3) isolation of the
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