MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Nose and paranasal sinuses Klinika otorinolaryngologie a chirurgie hlavy a krku Fakultní nemocnice u sv. Anny a LF MU v Brně Přednosta: Doc. MUDr. Gál Břetislav, Ph.D. Pekařská 53, Brno , 656 91 Applied physiology ▪ Respiratory organ – ability to increase exchange of breathing gases 8-90 l/min, aerodynamic shape of the nose ▪ Perform both physical and immunologic protection from the environment, „mucociliar escalator“ – from more than 50 % are filtrated particles from 1 to 10ηm ▪ Air-conditioning function – regulation of temperature on 34o C from -10 into +42 oC; moisturing – until 80% relative air humidity ▪ Sensory olfactory organ – sense of smell ▪ Involved in the formation of speech sounds ▪ The nose – major esthetic unit in the center of the nose Applied anatomy ▪ External nose, the nasal skeleton, nasal bone, cartilages ▪ Nasal cavity (cavum nasi proprium) – Vestibulum nasi (the internal nasal valve, „limen nasi“ junction of vestibule and cavum nasi, prominence of the upper lateral cartilage) – Meatus nasi inferior, medius, supperior – Meatus nasi comunis Lateral wall of nasal cavity Paranasal sinuses Ostiomeatal unit (green) 9a ethmoidal infundibulum 9b frontal recess 10 orbital ethmoidal cell (Haller) 11 natural ostium 12 semilunar hiatus 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 and 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.Arteriolovenose short circuit 2.subepithelial capillary plexus 3. capillars sorrounding gland 4. periostal capillars 5. cavernous venous plexus Fibres of smooth muscles of arteriols and venous plexus supplied by autonomes nervoous system. Parasympathetic stimulation – vasodilatation, filling of venous plexus with blood – congestion a discharge. Sympathetic stimulation – vasoconstriction, leading to empty venous plexus with blood – not blocked nose and lower discharge. Transmitter acting in physiology and patophysiology nasal mucose membrane Inervation Neurotransmitter Influence on nasal mucose membrane sympathetic norepinefrin, neuropeptide Y vasoconstriction dekongestion parasympathetic acetylchlorin vasoactive intestinal polypeptid (VIP) Increase of nasal secretion vasodilatation nasal obstruction sensoric (ggl. trigeminale, fibre to seromucinous glands and vessels) P substance vasodilatation nasal mucous membrane swelling increased vessel permeability Epithelium of the nose: respiratory epithelium columnar-ciliated with goblet cells and a layer of mixed glands „Mucociliar escalator“ Evaluation of nose and paranasal sinuses • aspection, palpation • rhino-endoscopy • ultrasound • radiology (X-ray examination), CT, MRI • sinoscopy • lavage of the sinuses • (diaphanoscopy) Evaluation of nose function Mucociliar transport – sacharin test Smell – olfaktometry Patency • Glatzell desk • Rinomanometrie 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 evoced potentials, elektroolfactogram and functional magnetic resonance (research) ▪ Imagination evaluations CT, MR Evaluation of smell: subjective methods ▪ Sniffin´ stick test – threshold (the lowest concentration) and supra-treshold tests (discrimination of odours) ▪ test of odoured marker (pen)s - screening suprathreshhold evaluation 1.part – name the odour (points) 2.part – identification of odour Olfactory disorder Time viewpoint: acute, chronic a fluctuate Etiopathogenetic viewpoint: conductive – peripheral odour cannot influence olfactory epithelium, sensorineural - central diorder of olfactory perception ▪ conductive disorder – one-, bothsided 1. mechanical obstruction of nasal cavity (septal deviation, rhinitis, nosal polyposis, tumors of nose and paranasal sinuses) 2. patologic changes outside nasal cavity (choanal atreisia, adenoids , tumours of epipharynx, pts after total laryngectomy) ▪ sensorineural disorders 1. disorders in olfactory epithelium (viral damage, inhalatiom 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 Quantitative disorders: partial loss of smell – hyposmia to anosmia Qualitative disorders : change of perception of disorder parosmia – distorted perception of odour specific anosmia – unability of perception of some odours fantosmia - perception of some odours even in their abscence kakosmia – upleasant perception of odours (graviditas, mb. Parkinson) Therapy conductive disorder ▪ Conservative treatment: corticosteroids systémově a lokálně, čichový trénink a zlepšování ventilace nosem ▪ Surgery: chronic rhinosinus with nasal polypoisnot reacting on concervative 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 Olfactory disorder Congenital diseases congenital Choanal atresia Cystic fibrosis Primary ciliary dyskinesis ASA syndrome Meningocele, meningoencefalocele Ostatní 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 Endoscopy Physiologic endoskopic view LZ – sulcus lacrimalis U – processus uncinatus SS – middle turbinate P – nasal septum Rhinogram of septum deviation to the right and narrowing of nasal valve Rhinogram normal values after anemisation Rhinogramm with normal values Počítačová tomografie Clinical definition of rhinosinusitis in adults Inflammation of the nose and the paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip). Another symptoms: - ± facial pain/pressure - - ± reduction or loss of smell and either - and - endoscopic signs of: - nasal polyps, and/or - mucopurulent discharge primarily from middle meatus and/or - oedema/mucosal obstruction primarily in middle meatus - and/or - CT changes: - mucosal changes within the ostiomeatal complex - Symptoms should last until 12 weeks in acute rhinosinusitis and at least 12 weeks in chronic rhinosinusitis. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012 (Witske Fokkens, Valeria Lund et al.) Classification of rhinosinusitis 1. Alergic – Intermitent – Persistant 2. Infectious – acute – chronic ▪ specific ▪ nonspecific 3. Other ▪ Vasomotor ( professional, hormonal, drug inducated, irritant, Alimentáry, psychogenic, NARES (non allergic rhinitis with eosinofilia syndrome) ▪ Atrophic ▪ Idiopathic Epidemiology of chronic rhinosinusitis • Allergic and chronic nonallergic rhinosinosinusitis belongs to civilization diseases • Frequency about 25 % population • Incidence is higher in town inhabitants • about 50 % of chronic noninfectious rhinitis is allergic rhinosinusitis Degree - mild - moderate - sever Visual analog scale (VAS) Without symptoms A section 10 cm long Most intensive symptoms nasal polyposis Eosinofilia, IL-5 Chronic rhinosinusitis Allergic rhinitis Persistens Intermitens Degree - mild - moderate - sever Allergic rhinitis • Proof of IgE – mediated mechanism • Symptoms as a result of immune reaction mediated by specific IgE antibodies • Cellular inflammatione of mucose membrane (T-lymfocyty, eozinofils) • Cause of production of IgE antibodies atopic genetic predisposition (HLA antigens of atopic patient) Domestic acarid (Dermatophagoides pteronyssinus, in electron microscope) The most frequent cause of allergy – „domestic dust“ 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 Drug Time to effect (min.) lasting of effect (hod.) Undesirable side affects 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 • Disorder of mucos membrane without structural backround, not infectious, autoimune neither allergic in traditional sense. • The same symptomatology as persistans allergic rhinitis. • Cause- faktors of none-imune character. (Charles W. Cummings, et al. Otolaryngology—Head & Neck Surgery, Mosby) Vasomotor rhinitis • 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 ▪ Itching in nose, sneezing ▪ Smell disorder ▪ Feeling of dryness in nose ▪ Eye symptoms ▪ Headache ▪ General symptoms Anterior rhinoscopy • Alergic and vasomotor rhinitis livid or pale, diffus swollen mucose • Irritation or abuse of nasal spray – red mucose • sinusitis red mucose with pus Vasomotor rhinitis – diagnosis • X-ray evaluation is normal • Higher amount of inflammatory mediators and cells • Histamines, leukotrienes, prostaglandins, neuropeptides aj. • In nasal secretion not present eosinophils • Negative skin allergen tests • Positive answer on histamine skin test Rhinitis vasomotorica - causes 1. Drug provoked rhinitis a. Antihypertensive treatment b. abuse of nasal drops/sprays c. Cocain d. Hormones 2. Pregnancy and ‘‘premenstrual rhinitis’’ 3. Hypothyroidisms 4. Emotional causes 5. Temperature changes 6. Rhinitis from irritation and external influences 7. Rhinitis from olfactory perception 8. End phases of vascular atonia in chronic allergic and infectious rhinitis 9. Rhinitis from position 10. Rhinitis in nasal obstruction and nasal cycle 11. Rhinitis in non-ventilated nose (laryngectomy, choanal atresia, vegetationes adenoideae) 12. Compensatory hypertrophic rhinitis 13. Eosinophilic and basophilic nonallergic rhinitis 14. other systemic reasons: syndrome vena cava sup., Horner´s syndrome, cirrhosis, uremia Drug provoked rhinitis • Antihypertensiv drugs - Reserpin, Hydralazin, Guanethidin, Methyldopa, Prazosin, Beta-blockers, Propranolol, Nadolol • Antidepressiv drugs a antipsychotics -Thioridazin, Chlordiazepoxid and Amitriptyline, Perfenazin • Hormones - Ovarial hormones, oral contraceptives • Abuse of nasal decongestants – rebound fenomen rhinitis Prolonged usage of topis vasocontrictors causes loss of vascular tonus. Antidecongestiv nasal drops should by use longer then 3- 5 subsequent days • Cocain - vasoconstrictor 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 Rhinitis from temperature changes • External temperature influence nasal patency : • Warm causes vasodilatation (congestion) • Cold air causes vasoconstriction Rinitis from olfactory sensation • Nose discharge during and after eating and beverages, especially hot and spized • reflex cholinergic discharge evoked by irritation of sensoric receptors on palat, sometimes connected with lacrimation, reddnes and perspire. • treatment - ipratropium bromid nosal spray 0.03% given 10 min before eating. Rinitis from non ventilating nose After laryngectomy/tracheotomy Rhinitis in choanal atresia Diagnosis History Rodinná, faktory zev. prostředí, chemikálie ENT clinical investigation Rinoskopie, endoskopie nosu, nosohltanu a paranazálních dutin X-ray, ultrasound Semiaxiální rtg, CT scany obličej. skeletu Alergologic tests Kožní testy, vyšetření celkových IgE, hodnoty a určení specifických IgE v séru Cultivation Bakteriologické vyšetření Cytology Vyšetření zánětlivé celulizace Evaluation of mucociliar transport Nazální mukociliární clearance (např. sacharinový test) nebo určení frekvence ciliárních kmitů, elektronová mikroskopie Nose patency Rinomanometrie Evaluation of smell Vyšetření čichového prahu 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 ENT evaluation X-ray, CT alergologic tests cultivation, cytology Nasal patency Evaluation of olfactory sensation Alergy - intermittens - persistence Inflammation - acute - chronic „Other“ - Nares, - hormonal - idiopathic - Wegener´s granulomatosis - tumor aj... Avoidance of alergen antihistaminics topical steroids Alergology Consider immunotherapy Otolaryngology surgery antibiotics Decongestivs corticosteroids? Anatomical changes (septum, skořepy…) topical corticosteroids local anticholinergics Therapy of chronic rhinosinusitis • Medikamentous, conservative • Surgery • „classical“ rhino-surgery • Functional endonasal sinus surgery (FESS) „Classical“ rhino-surgery • Approach through healthy tissue • All mucosa membrane is removed • Mostly non-physiologic communication 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 • Too high radicality • many iatrogenn complicatoins (swelling, pain, inervation disorder) Caldwell-Luc external ethmoid- ectomy „classical“ rhino-surgery - indication • Repeated FESS lege artis failed • some atypical forms of sinusitis - mycotic sinusitis (aspergilom) • Inflammatory complications of sinusitis • tumory paranas. sinuses • Some injuries • Immunocopmpromised persons, congenital diseases Functional endonasal sinus surgery (FESS) Basic considerations • Pathologically changed musose is able to restitution and should be preserved as more as possible • For restitution it is necessary to create ventilation and drainage • 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 • Only some surgeries are treating the cause – some chronic infectious inflamm., cysts and various structural changes disabling ventilation (deviatio of nasal septum, hyperpneumatised middle nasal concha et al.) • Nasalization and enabling concervative treatment symptomatic surgery as a part of complex treatment Indication of FESS • History of disease • Imaginating methods (CT) • Rhinoendoskopy CT PND • Localisation and extent of pathological changes –type and extent of surgery • Guidelines for surgeon – relationship to orbit and endokranium axial coronar X-ray Surgery • Structural changes in nasal cavity (deviace přepážky nosní, concha bullosa) • One sinus (supraturbinal antrostomy, sphenoidotomy, frontal sinotomy, ethmoidektomy) • Pansinus surgery („ Wigand complet“) Surgery of nasal septum endoscopic resection (cristae, spins) Concha bullosa resection 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 ostio-meatal-unit Supraturbinal antrostomy • renewal of communication between nose and maxillary sinus • 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 • „Small“ • bleeding • hematoma,emphysema of eye lids • headache • „Big“ • retrobulb. hematoma • meningitis • liquorea • Bleeding from ACI • death Complications II Liquorea + pneumoencephalus CAS – computer assisted surgery Navigation system (Medtronic, Scopis – magnetic navigation)