MEZINÁRODNÍ CENTRUM KLINICKÉHO VÝZKUMU „TVOŘÍME BUDOUCNOST MEDICÍNY“ Nose and paranasal sinuses 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 Applied physiology Function: vital (respiration), social (phonation, smell), protection and climatization of upper airways (reflexes) ▪ 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 naší, „limen nasi“(the internal nasal valve), junction of vestibule and cavum nasi, prominence of the upper lateral cartilage) – Meatus nasi inferior, medius, supperior – Meatus nasi comunis Paranasal sinuses Diverticula of upper airways Lateral wall of nasal cavity 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. Blood supply 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. Epithelium of the nose: respiratory epithelium columnar-ciliated with goblet cells and a layer of mixed glands „Mucociliar escalator“ Examination of the nose and paranasal sinuses Nose function Mucociliar transport – sacharin test Smell – olfaktometry Patency • Glatzell desk • Rinomanometry Morphology • aspection, palpation • rhino-endoscopy • ultrasound • radiology (X-ray examination), CT, MRI • sinoscopy • lavage of the sinuses • (diaphanoscopy) 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 CT 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 2020: 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 AFRS, allergic fungal rhinosinusitis; CCAD, central compartment allergic disease; CRSwNP, chronic rhinosinusitis with nasal polyps; eCRS, eosinophilic CRS. CF, cystic fibrosis; EGPA, eosinophilic granulomatosis with polyangiitis (Churg-Strauss disease); GPA, granulomatosis with polyangiitis (Wegener’s disease); PCD, primary ciliary dyskinesia. 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 Classification of intensity of chronic rhinosinusitis nasal polyposis Eosinofilia, IL-5 Chronic rhinosinusitis Allergic rhinitis (primary CRS endotype dominance type 2) Persistens Intermitens Degree - mild - moderate - sever Allergic rhinitis (primary CRS endotype dominance type 2) • Proof of IgE – mediated mechanism • Symptoms as a result of immune reaction mediated by specific IgE antibodies • Cellular inflammatione of mucose membrane (Tlymfocyty, 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 Morphologic causes of nosal obstruction crista septi nasi papilloma invertens Intranasal foreign boddies Inflammations Acute rhinosinusitis Mycotic sinusitis Nasal 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 external ethmoid-ectomy „classical“ rhino-surgery - indication • Repeated FESS lege artis failed • some atypical forms of sinusitis - mycotic sinusitis (aspergilom) • Inflammatory complications of sinusitis • tumors of paranasal sinuses • Some injuries • Immunocompromised persons, congenital diseases Classic rinosurgery Objections against • Too high radicality • many iatrogennic complications (swelling, pain, innervation disorder) 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 „Ostium Surgery“ (Isthmus chirurgie) 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 of paranasal sinuses • Localization and extent of pathological changes – type and extent of surgery • Guidelines for surgeon – relationship to orbit and endocranium 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)