The Nose and Paranasal Sinuses

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[edit] The Nose and Paranasal Sinuses

Samuel A. Mickelson

Michael S. Benninger

The nose and paranasal sinuses provide for the diverse functions of respiration, conditioning and purifying inspired air, and olfaction. Although healthy individuals are not necessarily conscious of these functions, they may be significant sources of discomfort and lifestyle interruption when dysfunctional. In fact, nasal sinus–related disorders are the most common reason that patients now visit physicians in the United States. This chapter concerns the more common disorders affecting these sites and suggests approaches to management of patients with nasal and sinus disorders.

[edit] MEDICAL HISTORY

[edit] Symptoms and Their Significance

Many disorders affecting the nose and paranasal sinuses can be diagnosed by history and physical examination alone. Most laboratory testing is confirmatory only. It is important to obtain a thorough history and have an understanding of the various symptoms and their significance. The major symptoms related to the nose are nasal obstruction (congestion), drainage, facial pain or headache, epistaxis, and change in smell or taste.

[edit] Nasal Obstruction

Nasal obstruction (congestion or stuffy nose) can be caused by a deflected nasal septum, enlargement of turbinates, or polyps or mass lesions within the nose. Nasal obstruction is the most common symptom, since turbinate hypertrophy can result from many disorders. It is important to assess whether the nasal obstruction is unilateral, bilateral, or alternating in sides and determine if it is constant or intermittent. If unilateral, a fixed anatomic problem such as a deviated septum, polyp, or mass lesion is likely. Any intermittent or alternating obstruction must relate to variations in the turbinate size. When bilateral, the obstruction is due to a bilateral process such as polyps or allergy, or from a complex deflection of the septum.

[edit] Nasal Drainage and Postnasal Drip

Drainage from the nose is one of the most helpful symptoms in determining the nature of the disorder. It is important to determine if rhinorrhea is unilateral or bilateral, clear or discolored, and watery, mucoid, or tenacious. Unilateral drainage represents a localized process such as unilateral sinusitis or cerebrospinal fluid (CSF) leak, whereas bilateral drainage is due to a more systemic or general process. Clear drainage suggests a diagnosis of vasomotor, nonallergic, or allergic rhinitis, whereas thick and discolored (yellow, green, or brown) drainage suggests bacterial or viral infection. The sensation of postnasal drainage is influenced more by the thickness of the drainage than the quantity. Though many patients complain that swallowing large amounts of drainage causes nausea, it is unclear if they are causally related. A sense of mucus in the throat, hoarseness, and chronic throat clearing are rarely, if ever, caused by sinus drainage since the normal swallowing mechanism clears the mucus without laryngeal contact. The exceptions are during an allergic or viral episode where both nasal sinus and laryngeal inflammation occur simultaneously.

[edit] Facial Pain and Headache

Facial pain and headache are not useful symptoms in differentiating disorders because of the multiple different disorders that can cause pain. These include many of the nasal and sinus disorders, tension headache, migraine headache, myofacial pain syndrome, temporomandibular joint syndrome, tic douloureux, and dental caries. Pain overlying the sinuses is not necessarily due to pathology in the underlying sinus. When pain is related to nasal or sinus pathology, it is usually due to ostial obstruction or mucous membrane contact with referred pain to other areas of the face. Severe facial pain associated with swelling over the sinuses and purulent drainage is generally related to sinusitis. Many patients with allergic or nonallergic rhinitis complain of intermittent facial pressure or headache associated with changes in the weather, humidity, or other environmental factors. Malignant tumors are to be considered in patients with persistent unilateral facial pain without purulent rhinorrhea.

[edit] Epistaxis

Epistaxis is a nonspecific symptom that may accompany almost any pathology in the nose, nasopharynx, or paranasal sinuses. The most common cause of bleeding is breaks in the prominent capillary vessels along the anterior septum (Kiesselbach's plexus or Little's area). This occurs frequently with local trauma such as frequent nose blowing, sneezing, or digitally caused trauma. Once bleeding occurs, it may spontaneously recur if the scab becomes dislodged. Patients with a septal deviation may bleed along the deflected portion of the septum, which becomes dry and excoriated. Blood mixed with purulent drainage generally suggests acute sinusitis. Blood will exit anteriorly if the head is leaned forward and posteriorly if the head is straight or leaned backward. Tumors are rare causes of nasal bleeding.

[edit] Changes in Olfaction

Anosmia is the complete loss of olfaction, and hyposmia is a decrease in the sense of smell. Parosmia and dysosmia are conditions resulting in an altered sense of smell. Cacosmia, the sensation of unpleasant smell, can occur with acute sinusitis, when recovering from anosmia after influenza or head trauma, or with the use of tetracycline or streptomycin. Phantosmia is the hallucination of smells and can be seen in schizophrenia and temporal lobe seizures.

Anosmia or hyposmia can occur in any condition that affects nasal air flow to the region of the cribriform plate bilaterally. Therefore an alteration in smell thresholds is common in patients with nasal polyps or severe chronic sinusitis, whereas unilateral anosmia usually goes unnoticed. Anosmia without nasal obstruction is most frequently caused by viral upper respiratory tract infections or severe head trauma. Certain industrial chemicals, such as formaldehyde, can also lead to anosmia. Lead poisoning, vitamin A deficiency, tobacco use, and radiation therapy have been associated with hyposmia or anosmia. Hyposmia occurring in hypogonadal females or during pregnancy is relieved with hormonal treatments or the completion of pregnancy. Rarely, an anterior cranial fossa meningioma can cause slowly progressive anosmia. Other rare causes of anosmia include diabetes, hypothyroidism, pernicious anemia, and amphetamine toxicity.

Congenital or genetic causes of anosmia include Turner syndrome, pseudohypoparathyroidism, and congenital hypogonadotrophic eunuchoidism. A decreased sense of smell frequently occurs with increasing age (presbyosmia).

In patients with anosmia but a normal nasal examination, a thorough history and directed laboratory and radiologic tests usually determine the etiology. Treatment of the loss of olfaction should be directed at the cause. Postviral anosmia often spontaneously resolves. Use of oral zinc supplements has recently been advocated for persistent anosmia but benefit has not been proved. Patient counseling is of utmost importance with regard to use of smoke detectors in the home, avoidance of excessive perfumes or colognes, control of bodily odors, and attention to expiration dates on food products.

[edit] Allergic Symptoms

Characteristic symptoms of seasonal allergic rhinitis include sneezing, nasal or ocular pruritus, bilateral clear watery or mucoid nasal drainage, and nasal congestion. Patients also complain of pruritus of the upper palate and ears, and dry, scratchy and erythematous conjunctiva. These symptoms are associated with elevations of specific pollen counts. Springtime allergies typically relate to tree pollens, midsummer symptoms to grasses, and fall symptoms to weed pollens.

Dust and mold perennial allergies are less distinct because nasal congestion and clear drainage frequently occur without sneezing and pruritus. Patients with dust or mite allergies are more symptomatic in the morning and with exposure to upholstered furniture, mattresses, pillows, and carpeting. Mold allergies vary significantly through the year depending on the particular mold sensitivities.

[edit] Tobacco, Medications, and Chemical Exposures

Tobacco smoke is an irritant causing congestion of the turbinates, destruction of cilia, and alteration in the mucus-secreting cells of the nasal mucosa. Smokers have increased symptoms of nasal congestion and thick postnasal drainage and may be predisposed to sinusitis.

A variety of medications can also affect the nose. After just a few days of using topical phenylephrine or oxymetazoline, there is rebound swelling of the turbinates (rhinitis medicamentosa) in which the nose becomes chronically congested. Treatment is the discontinuation of the offending agents. Diuretics cause thicker and more tenacious secretions. Turbinate hypertrophy is caused by many drugs, including β-blockers, reserpine, and exogenous estrogens. Although most medication effects are temporary, long-term use of these drugs can have irreversible effects on the nose.

Many chemicals used in industry cause mucosal edema and increased mucoid secretion from the turbinates. Use of intranasal cocaine can cause large septal perforations with resultant bleeding and crusting from the edges. Wood dust and asbestos exposure can also have irritant effects on the nose with secondary congestion of the turbinates.

[edit] Systemic Disorders and Their Effects

Systemic conditions can affect the nose either directly or indirectly. Rhinitis of pregnancy due to elevated estrogen levels causes turbinate engorgement and resolves at the end of pregnancy. When severe it can be treated with an oral decongestant.

Sarcoidosis and Wegener's granulomatosis can affect the nose and are covered in more detail later.

[edit] EXAMINATION AND DIAGNOSTIC STUDIES

[edit] Physical Examination

The nasal examination is important in the diagnostic work-up of any nasal or sinus disorder because most pathologic conditions can be visualized without special studies (Fig. 179-1). Otolaryngologists typically examine the nose before and after use of a topical decongestant to allow a better view of the nasal cavity. Anterior rhinoscopy with a nasal speculum and headlight allows delineation of the septum, the inferior and middle turbinates, and portions of the nasopharynx and may allow a limited view into the middle meatus. Posterior rhinoscopy with a tongue blade, nasopharyngeal mirror, and headlight allow examination of the posterior choana, nasopharynx, eustachian tubes, and posterior edges of the septum and inferior turbinates. Although examination of the anterior nares with an otoscope is easy, the view is limited to the first 2 or 3 cm of the nose. If this technique is to be used, the nose should at least be decongested first with a topical decongestant.

Figure 179-1 Algorithm describing the treatment of a patient with rhinorrhea.

Flexible and rigid nasal endoscopes have recently been reintroduced for use in the nose in the office setting. The procedure is done after application of a topical decongestant and anesthetic agent. Nasal endoscopy is a sensitive way to evaluate the nose for gross or subtle changes associated with sinusitis. The scope can frequently identify small polyps, erythema, and purulent drainage coming from sinus ostia that would not be visible by routine anterior or posterior rhinoscopy. The maxillary sinuses can also be examined with the endoscope via a sinus puncture, which can assist in the diagnosis of sinus malignancies. Due to the high cost of the instrumentation, nasal endoscopy should not be used for the routine examination of the nose.

Transillumination is a simple technique whereby a bright light (in a darkened room) is applied to the frontal or maxillary sinuses. Transillumination occurs in a sinus with normal or slightly thickened mucosa, whereas the light does not transmit in an opacified or fluid-filled sinus. Transillumination can be used instead of a radiograph before treating acute sinusitis.

[edit] Laboratory Studies

Nasal and nasopharyngeal cultures are generally not useful because pathologic bacteria (Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis) are present in both normal and sinusitis patients. Cultures from a sinus tap or from an endoscopic-guided culture through the sinus ostia are more precise.

Nasal smears are simple and inexpensive studies that can help differentiate sinusitis from allergic or nonallergic rhinitis by determining the type of white blood cells present. A predominance of eosinophils suggests allergic rhinitis, whereas predominance of leukocytes suggests an infection.

Serum immunoglobulin (Ig) levels can be helpful in the diagnosis of allergic rhinitis (elevated IgE level). Immunoglobulin G (IgG) subclass studies are performed when an immune deficiency is suspected as a cause for persistent sinusitis. The patient's immunologic response to a pneumococcal vaccine can confirm or eliminate a functional immune deficiency. A complete blood count is useful to help differentiate bacterial sinusitis (elevated neutrophil count) from viral rhinitis (elevated lymphocyte count).

[edit] Radiographic Tests

Routine sinus films are useful to help confirm a suspicion of sinusitis and to follow disease resolution following a course of treatment. They are sensitive for air-fluid levels (Fig. 179-2) in the maxillary or frontal sinuses and for moderate to severe mucosal thickening or complete opacification in the maxillary sinuses (Fig. 179-3). However, their ability to identify mild ethmoid, sphenoid, maxillary, or frontal mucosal thickening is severely limited.

Figure 179-2 Waters' view of maxillary sinus with air-fluid level.

Figure 179-3 Waters' view of maxillary sinus with mucosal thickening.

Computed tomography (CT) is the most useful of all radiographic studies for the paranasal sinuses. Axial and coronal views give detailed information about the osseous and soft tissues of the nose and paranasal sinuses, as well as the region of the osteomeatal complex. While some centers perform screening CT scans at a fee comparable to routine sinus films, they should rarely be ordered by primary care physicians, since their major roles are in assessing patients refractory to medical therapy, evaluating the extent of disease, and preoperative planning.

Magnetic resonance imaging (MRI) is very accurate in determining the extent of sinusitis and tumors. However, at this time, cost and availability preclude it from use in the routine management of sinus disease.

[edit] Allergy Testing

Allergy testing is useful in patients who have significant symptoms related to seasonal or perennial allergic rhinitis. Radioallergosorbent test (RAST) is a serum test that determines the amount of IgG-mediated immunoglobulin against a specific allergen or allergen group. Prick or scratch skin testing measures the clinical responses to inoculation with various allergens and is mediated by release of histamine and other chemicals. Intradermal testing is more sensitive than prick tests, yet poses a higher risk of anaphylaxis and is performed if prick testing is negative or not diagnostic.

[edit] EVALUATION OF COMMON DISORDERS

[edit] The Common Cold

The common cold is an acute viral rhinosinusitis with inflammation of all mucosa of the nose and paranasal sinuses. Generalized symptoms include malaise, fatigue, low-grade fever, chills, and sore throat. The nasal symptoms include nasal obstruction, anterior and posterior clear rhinorrhea, diffuse pressure over the paranasal sinuses, and occasionally plugged ears associated with eustachian tube dysfunction. On the second or third day of infection an increase of neutrophils in the nasal secretions may cause the drainage to be more discolored, but within 1 to 2 days the drainage becomes clear again. The white blood cell count may be slightly elevated, with a predominance of lymphocytes or atypical lymphocytes. Sinus radiographs are normal or show mild mucosal thickening.

[edit] Management

Management is supportive with antipyretics, analgesics, and oral decongestants; hydration and saline nasal sprays aid in mucus clearance. Although a topical decongestant is helpful for the symptoms, one needs to be cautious about the potential for rebound effects from excessive use. Symptoms usually resolve in 5 to 8 days without other treatment.

[edit] Epistaxis

The etiologies of epistaxis include both local and systemic factors. Local causes are most common in children and are usually associated with nose picking, excessive blowing, sneezing, or rubbing. Bleeding frequently occurs with the common cold, acute sinusitis, or allergic rhinitis. Recurrent bleeding may occur if a scab forms at the bleeding site and becomes dislodged. Although tumors are rare causes of epistaxis, they should be included in the differential diagnosis, especially with profuse bleeding in adolescent males (juvenile nasopharyngeal angiofibroma) or in adults without other known etiologies. In adults, bleeding tends to be more profuse and may be from the posterior nasal cavity. Systemic causes of epistaxis include acquired coagulopathies, hereditary blood dyscrasias, and the use of aspirin, coumadin, or heparin. Patients with hypertension are not more likely to have a nosebleed, although elevated blood pressure can result in more profuse bleeding and makes it more difficult to control. Antihypertensive agents should be administered to hypertensive patients with epistaxis.

The most common site of bleeding is from Kiesselbach's plexus (Fig. 179-4) on the anterior septum. Posterior epistaxis is less common but can be a serious problem in adults. A posterior bleed is defined as bleeding far enough posterior that the site of bleeding cannot be seen by anterior rhinoscopy.

Figure 179-4 Kiesselbach's plexus on the anterior septum derives blood supply from the superior labial, descending palatine, and sphenopalatine arteries.

Evaluation of epistaxis is primarily by physical examination. Anterior rhinoscopy with a nasal speculum and Fraser suction (to remove clots and fresh blood) are usually sufficient to identify the site of bleeding. Areas with prominent vessels or scabs should be examined with caution because manipulation may start up active bleeding. Sinus radiographs should be done only when tumors are suspected as the cause of bleeding. When a severe posterior bleed cannot be controlled by packing, carotid artery angiography may help to delineate the source of bleeding.

The management of epistaxis depends on the site of bleeding, the severity, and the etiology. Patients with coagulopathies should have the nose packed with dissolvable packing materials (Oxycel cotton or Gelfoam), since any localized trauma such as pack removal will cause bleeding from multiple sites in addition to the original site. Attempts should be made to correct the coagulopathy.

Conservative measures can be helpful in all patients. These include improving the humidity of inspired air, moisturizing the nose with saline sprays 6 to 10 times a day, and applying antibiotic ointments to reduce scabbing and speed healing of the excoriated areas. Long-term care with an unscented water-base lotion twice a day along with saline sprays usually prevents recurrences.

Recurrent bleeding along the anterior septum is best treated conservatively. When these measures fail, application of silver nitrate or electrocautery can be helpful. This should be performed after application of a topical decongestant and anesthetic agent (4% cocaine or 1% tetracaine). Silver nitrate cautery should be performed from the periphery toward the site of bleeding. When done in the opposite direction, there is a risk of precipitating active bleeding that may be difficult to control. A cotton-tip applicator helps remove excessive silver nitrate from the rest of the nose.

Active bleeding from the anterior nasal cavity is best treated with an anterior nasal pack left in place for 2 to 5 days. Vaseline gauze packing impregnated with an antibiotic ointment can be layered in the nose to apply pressure to the bleeding site. Other packing materials include commercially available balloons and Merosel sponge packs. Oral antibiotics should be given to help prevent excessive bacterial growth in the packing and subsequent bacterial sinusitis. A posterior pack is indicated for more posterior bleeding that fails to respond to anterior packing. Posterior packs may be fashioned from gauze materials, Foley catheters, or commercially available balloon packs. Patients with posterior packs are usually admitted to the hospital and given supplemental oxygen, since significant hypoxemia can occur.

Alternative methods of controlling severe posterior bleeds include arterial ligation of the internal maxillary or ethmoidal vessels and occasionally even ligation of the external carotid artery. Arteriography with embolization has also been used for posterior bleeds. Posterior bleeding may be severe enough to require ICU monitoring and multiple transfusions to maintain normal hemodynamics.

[edit] Trauma

Due to their position on the face, the nasal bones are the most frequently fractured bones of the facial skeleton. There is frequently epistaxis associated with fractures from intranasal mucosal tears. Most nasal fractures can be diagnosed by palpation of the bony nasal skeleton finding pinpoint tenderness along with displacement of the nasal bones. Nondisplaced and small fractures at the tip of the nasal bones are more difficult to palpate. Lateral radiographs can confirm a displaced fracture but should be used with caution, since normal suture lines can look like nondisplaced fractures.

Initial management is supportive with head elevation and cold compresses to diminish swelling. Epistaxis usually stops spontaneously or with a topical decongestant spray. Nondisplaced fractures require no active treatment. Nasal fractures are repaired for either functional (nasal obstruction) or cosmetic reasons. Reduction of the nasal fracture is generally done 4 to 8 days after injury. This allows the soft tissue swelling to diminish, allowing for a better reduction of the displaced nasal bones. A comparison to the preinjury state in a recent photograph helps assess the need for reduction. Although management of the fracture is not emergent, it is important to examine and palpate the nasal septum at the time of the initial evaluation to be sure there is no widening and softening that would be suggestive of a septal hematoma. Untreated septal hematomas cause disruption of the blood supply to the septum and can lead to a subsequent saddle nose deformity. When a septal hematoma is suspected, an emergency consultation with an otolaryngologist is in order. All other fractures may be assessed 3 to 4 days after injury, allowing for a better assessment of subtle deformities. Nondisplaced fractures do not require further evaluation.

[edit] Acute Sinusitis

Acute sinusitis represents an acute bacterial infection involving the mucosal surfaces of the paranasal sinuses and nasal cavity. It usually occurs after an upper respiratory tract infection. Less common causes include swimming in contaminated water, nasal foreign bodies, and spread from dental infections. Indwelling nasotracheal and nasogastric tubes also predispose to acute sinusitis. When of dental origin, the causative tooth is usually the first or second maxillary molar whose roots extend toward the floor of the maxillary sinus.

Acute sinusitis typically presents with unilateral or bilateral nasal obstruction, purulent rhinorrhea, facial pain, and pressure overlying the paranasal sinuses. There is exacerbation of pain with bending over or straining, and the maxillary teeth may be tender. In contrast to the clear secretions of viral infections, the secretions in acute sinusitis are purulent.

The diagnosis can be made by history, along with a physical examination finding tenderness over the paranasal sinuses, congestion of the turbinates, and purulent drainage in the nose, nasopharynx, or posterior oral pharynx. After decongesting with a topical agent, purulent drainage may be seen in the middle meatus and a nasal endoscope may help in identifying swelling, erythema, and purulence coming out of sinus ostia. Transillumination of the sinuses usually shows a decrease in light transmission of the involved sinus. Radiographic studies are generally needed only to support a questionable history or physical examination. Routine sinus films show mucosal thickening or an air-fluid level in the sinuses. Acute bacterial sinusitis is caused by S. pneumoniae, H. influenzae, and M. catarrhalis.

Acute sinusitis is usually treated empirically without cultures with a 10-to 14-day course of an appropriate antimicrobial agent, saline nasal sprays, oral decongestants, and analgesic agents. Topical decongestants should be used for 2 to 3 days only and then switched to oral agents to prevent potential rebound. Antihistamines should be avoided unless there is also a history of allergic rhinitis. Good first-line agents are amoxicillin, erythromycin plus a sulfonamide, and amoxicillin with clavulanate. Alternatives include cefuroxime, cefprozil, cefpodoxime, doxycycline, and trimethoprim with sulfamethoxazole. Though there is evidence of increasing β-lactamase activity in bacterial pathogens, antibiotics that cover these organisms are generally used as second-line drugs due to their increased cost and potential side effects. When acute sinusitis is from a dental source, the causative tooth should be treated with root canal or drainage of periapical abscess.

Sinus irrigation is indicated when there is severe pain and the maxillary sinus is not draining. The sinus tap obtains a culture and clears the purulent material from the sinus, giving significant symptomatic relief. Surgery is indicated when there is spread of infection to adjacent areas. External ethmoidectomy is used for ethmoiditis with periorbital abscess and frontal sinus trephination for frontal sinusitis with spread to the intracranial cavity. Endoscopic sinus surgery may benefit patients who have sinusitis that recurs more often than three times per year.

The goals of treatment are not only the resolution of symptoms but also the elimination of mucosal thickening that could narrow the ostiomeatal complex and predispose to recurrent or persistent infection. Since sinus radiographs and computed tomography are not routinely performed at the completion of treatment, it would seem prudent to treat the patient for 5 to 7 days after resolution of symptoms. The patient should be referred for otolaryngology evaluation in cases of recurrent infections greater than two to three per year, severe infection that fails to respond to antibiotics, or persistent infection despite a few courses of antibiotics.

[edit] Chronic Sinusitis

Chronic sinusitis represents a persistent low-grade infection involving the paranasal sinuses with persistent mucosal thickening. Pansinusitis or multifocal sinusitis is usually due to nasal polyposis or dysfunction of mucociliary transport (Fig. 179-5), whereas more localized infection is due to ostial obstruction. Patients present with persistent low-grade infection with intermittent acute exacerbations more typical of acute sinusitis. The chronic symptoms are persistent nasal obstruction associated with chronic nasal drainage. The drainage is usually discolored, thick, and copious in the morning, slowly clearing by afternoon. Anosmia is not uncommon, and nasal obstruction is also worse in the morning. Facial pain and sinus headaches may occur daily or only with exacerbations of acute sinusitis.

Figure 179-5 Coronal view of nasal cavity, turbinates, and meati and their association with the paranasal sinuses.

The diagnosis of chronic sinusitis is made by the classic symptoms associated with radiographic findings of mucosal thickening on routine films or sinus CT scans. Allergy testing is helpful, since perennial allergic rhinitis can mimic sinusitis symptoms. Chronic sinusitis is a polymicrobial disease with cultures usually growing multiple pathogens. The most common pathogens are M. catarrhalis, H. influenzae, S. pneumoniae, S. aureus, and a variety of anaerobes.

Chronic sinusitis is treated with decongestants and intranasal steroid preparations. Since the cause of infection is ostial obstruction, antibiotics alone frequently do not result in resolution. Antimicrobials of choice for empiric primary treatment include antistaphylococcal penicillin, clindamycin, cephalosporins, and doxycycline. Treatment should be for at least 3 to 4 weeks before surgery is considered. In patients with nasal polyposis, administration of oral or intramuscular steroids can also be helpful in controlling infection. Injection of the polyps with steroids must be done with caution to avoid complications of blindness. Patients with chronic sinusitis and allergic rhinitis should undergo maximal treatment for the allergies to reduce nasal inflammation. Antihistamines should be avoided unless there is an allergic diathesis to avoid thickening of the mucus blanket and slowing of mucociliary transport. Patients with chronic sinusitis should be referred for surgical intervention if symptoms persist despite 1 to 2 months of treatment with intranasal steroids, decongestants, and a trial of antibiotics. Surgery is directed at relieving the obstruction at the sinus ostia.

Chronic infection in the maxillary, anterior ethmoid, and frontal sinuses can be caused by ostiomeatal complex obstruction. Endoscopic sinus surgery can frequently relieve this obstruction, allowing the return of normal function of the sinuses and resolution of the chronic infection (Fig. 179-6). Older surgical options included the nasal antral window, which creates a new opening into the maxillary sinus under the inferior turbinate. This procedure improves aeration of the maxillary sinus but is limited because of a high incidence of closure over time. The Caldwell-Luc procedure involves a sublabial approach to the maxillary sinuses with removal of all mucosa. This procedure is generally reserved for patients with irreversibly damaged, nonfunctioning mucosa. Surgery on the frontal sinuses is indicated for mucoceles or chronic osteomyelitis (Pott's puffy tumor) in which the infectious process has eroded through the anterior or posterior walls of the sinus. Treatment of these patients includes systemic antibiotics plus frontal sinus obliteration with fat following debridement of infected bone and removal of all mucosa. Reconstruction of the patient's frontal nasal duct may have merit when performed with the nasal endoscope.

Figure 179-6 Coronal CT of patient before (left) and after (right) endoscopic anterior ethmoidectomy and enlargement of the maxillary ostium. Maxillary mucosal thickening has resolved following surgery.

[edit] Deviated Septum

Deviation of the nasal septum from the midline occurs either from trauma or from disproportionate growth rates between the facial skeleton and nasal septum. Patients with a deviated septum have chronic unilateral or bilateral nasal obstruction without any other significant symptoms. Although most patients have nasal obstruction on the side of the deflection, some have a worse airway on the opposite side due to compensatory turbinate hypertrophy.

Diagnosis of a deviated septum is made by history and physical examination. Even small anterior cartilaginous deflections tend to cause worse symptoms than posterior deflections. The more common posterior septal spurs rarely cause significant nasal obstruction. Septal deflections may predispose to recurrent sinusitis due to focal ostial edema, increased turbulence of airflow, or bacterial deposition.

Correction of a septal deformity is a minor elective surgical procedure that is performed under local anesthesia with sedation in the ambulatory setting. In patients who have external nasal deformities, a rhinoplasty may be performed in conjunction with septoplasty to improve both the functional and cosmetic problems. Occasionally a functional rhinoplasty is necessary along with the septoplasty to correct a severe septal deflection.

[edit] Turbinate Hypertrophy

The nasal turbinates may enlarge for a variety of reasons, including allergic rhinitis, nonallergic rhinitis, septal deflection, exposure to tobacco smoke, irritants and pollutants, and use of certain drugs (Fig. 179-7). Prescription drugs that cause turbinate hypertrophy include β-blockers, reserpine, and hormones such as estrogen. Frequent cocaine use may cause turbinate congestion similar to the rebound effect associated with overuse of topical decongestants. Compensatory turbinate hypertrophy frequently occurs on the side opposite a septal deviation. Aeration of the middle turbinates (concha bullosa) occurs in 10% of adults and, when large enough, can lead to significant nasal obstruction.

Figure 179-7 View of the lateral nasal wall.

The diagnosis of turbinate dysfunction is based on a history of chronic nasal obstruction associated with examination findings of turbinate hypertrophy. Reexamination after a topical decongestant can help differentiate enlargement due to osseous or soft tissue changes. Patients with turbinate hypertrophy that fails to respond to decongestants, antihistamines, or intranasal steroids may be candidates for surgical reduction. A variety of surgical techniques have been used to reduce turbinate size. Cautery of the inferior turbinates causes scarring in the submucosa and limits edema from allergic and nonallergic rhinitis. Lateral turbinate fracture is commonly performed with septoplasty to displace the turbinates away from the septum. Submucosal resection of the turbinate bone with preservation of the mucosa is useful when the bone is the primary cause of enlargement. Turbinoplasty involves removal of a portion of the turbinate bone and mucosa and leads to a greater reduction than submucous resection. Total resection of the inferior turbinates is rarely performed due to the risk of atrophic rhinitis and ozena (foul smelling mucus accumulating underneath large crusts).

[edit] Nasal Vestibulitis

Nasal vestibulitis is a common problem caused by S. aureus infection around a hair follicle in the nasal vestibule. The infection is associated with excessive nose blowing or picking. Management is directed at limiting digitally induced nasal trauma, application of an antistaphylococcal antibiotic ointment (mupirocin) to help prevent scabbing around hair follicles, and use of an antistaphylococcal oral antibiotic. Patients with diabetes, immune deficiency, or progressive infection despite antibiotics should be placed on intravenous antibiotics due to the potential of spread to the cavernous sinus.

[edit] Nasal Polyposis

Nasal polyps represent an inflammatory disorder of the nose and paranasal sinuses of unknown etiology. They usually originate from sinus mucosa and protrude through the ostia, appearing as gray translucent pedunculated masses above or below the middle turbinate. Although patients with allergic rhinitis have an incidence of nasal polyps similar to that of the general population, those with nasal polyps have a 30% incidence of allergy. The growth and persistence of nasal polyps may be exacerbated by inflammatory reactions and release of histamine and other mediators of inflammation. Solitary nasal polyps may be caused by acute or chronic sinusitis, and diffuse nasal polyposis may cause secondary sinusitis. Antral choanal polyps originate from the maxillary sinus and may fill the nasal cavity and nasopharynx and hang into the oral pharynx.

Symptoms of nasal polyps include nasal obstruction, hyposmia or anosmia, and symptoms associated with secondary infection. The diagnosis is made by anterior rhinoscopy or nasal endoscopy after nasal decongestion. Nasal endoscopy allows detection of smaller polyps that may not be visible without magnification. A biopsy should be taken from unilateral or solitary polyps to rule out a benign or malignant tumor. Isolated asymptomatic polyps or retention cysts occurring in the floor or roof of the maxillary sinuses do not require any treatment or evaluation. These lesions should be biopsied only if symptomatic or suspicious for malignancy.

The management of nasal polyps is directed at the control of symptoms. When secondary sinusitis occurs, broad-spectrum antibiotic therapy is beneficial. When polyps produce nasal obstruction or anosmia, topical steroid sprays may reduce the size of the polyps and improve the airway. Large obstructive polyps may require oral steroids, intramuscular steroid injections, or injection of steroid suspensions into the polyps. When medical management fails to adequately control the symptoms, surgical intervention is warranted.

Nasal polypectomy alone can improve the nasal airway but rarely relieves sinusitis or anosmia, since it fails to open the sinuses, which are the source of polyp growth. Office polypectomy is generally used for diagnosis or for limited or solitary lesions. Sinus surgery with an endoscope or an open approach is used to remove polyps along with enlargement of sinus ostia and removal of the origins of the polyps (Fig. 179-8). This can improve the efficacy of topical steroids and can be beneficial in long-term management of the disorder. Antral choanal polyps are removed by direct visualization of the maxillary sinus through an endoscope or through a Caldwell-Luc approach.

Figure 179-8 Multiple nasal polyps removed from nose and paranasal sinuses.

The triad of nasal polyps, asthma, and aspirin sensitivity (Sampters triad) is a particularly difficult combination to treat. Chronic sinusitis from polyp growth and ostial obstruction may cause exacerbation of the asthma. Although surgical intervention is generally not curative, it can be very beneficial for the nasal symptoms and can be helpful in controlling wheezing in selected patients in whom the sinusitis is an exacerbating factor for the asthma. Asthma has been reported to improve after sinus surgery in 40% to 98% of patients.

[edit] Allergic, Nonallergic, and Vasomotor Rhinitis

Allergic rhinitis typically includes symptoms of intermittent nasal obstruction, clear rhinorrhea or postnasal drainage, frequent sneezing, watery eyes, and pruritus of the nose, eyes, and palate (Fig. 179-9). In North America the seasonal allergies are triggered by tree pollens in the spring, grasses in midsummer, and weeds in the fall (typically August 15 until the first frost). Allergies also occur in response to exposure to animal danders. Dust, mite, and mold allergies produce perennial symptoms, with less pruritus and sneezing than seasonal allergies. Dust or mite allergy is worse in the morning from exposure to upholstered furniture, pillows, and mattresses, which have high mite populations. The diagnosis is confirmed with serologic (RAST), epidermal (prick or scratch), or intradermal skin testing. Nasal smears frequently demonstrate an increase in eosinophils in nasal secretions, and serologic testing shows an increase in IgE levels.

Figure 179-9 Severe pollen allergy as depicted in 1873. (From Augustas Hoppin: Hay fever, plate XIII, Boston, 1873, JS Osgood.)

Nonallergic rhinitis has symptoms similar to perennial allergic rhinitis but fails to show responses on allergy skin testing. Vasomotor rhinitis is a form of nonallergic rhinitis with exacerbation of symptoms from changes in temperature and humidity, exposure to hot or cold foods, anxiety, or the ingestion of vasoactive substances in foods or drinks. Nonallergic rhinitis with eosinophilia (NARE) is an entity of chronic rhinitis and nasal eosinophilia without evidence of atopy. Nasal polyps have been found more frequently in patients with NARE than in the general population, but symptoms may be more recalcitrant to medical therapy.

The treatment of allergic and nonallergic rhinitis is directed at the control of symptoms. Allergic rhinitis responds to combined oral decongestant and antihistamine preparations, whereas nonallergic rhinitis is better treated with a decongestant without antihistamine. For tenacious mucus, mucus thinners and expectorants such as guafenesin can be helpful. Both conditions may benefit from intranasal steroid sprays, and allergic rhinitis may also improve with topical cromolyn sodium. Cromolyn is used as a preventive agent only. Traditional antihistamines are useful in the primary treatment of allergic rhinitis. When excessive sedation occurs despite use of a reduced dose (pediatric dosage), the nonsedating antihistamine preparations should be considered.

When medications fail to adequately control allergic rhinitis, hyposensitization can be beneficial in symptom control. While hyposensitization is most effective for seasonal allergic rhinitis, avoidance of causative allergens is important for all patients. Surgical reduction of the turbinates is used only for patients with severe symptoms despite maximal medical therapy.

[edit] MANAGEMENT OF UNCOMMON DISORDERS

[edit] Benign and Malignant Tumors

Benign and malignant tumors are discussed in Chapter 183 .

[edit] Granulomatous Disorders

The granulomatous disorders represent systemic diseases with local manifestations. Referral to an otolaryngologist is indicated for nasal symptoms occurring in any patient with a known systemic granulomatous disease. The most common symptoms are persistent nasal obstruction, crusting and bleeding, and secondary sinusitis. Examination may show small nodular areas involving the nasal mucosa, diffuse thickening of the septal and turbinate mucosa, and septal ulceration, granulation tissue, or perforation. The granulomatous diseases that affect the nose, their presenting symptoms, diagnostic criteria, and treatments are listed in Table 179-1.

Table 179-1 Granulomatous Diseases Affecting the Nose

[edit] Mycotic Infections

Mycotic infections are rare, occurring almost exclusively in patients with diabetes or immunocompromised patients in either an invasive or superficial form. The invasive form is a rapidly progressive and destructive infection that causes necrosis of facial soft tissues and the nose. If not contained, infection spreads to the orbit and intracranial cavity, leading to rapid death. Presenting symptoms are severe facial pain, bloody discharge, fever, and facial swelling. A gray or black nonsensate avascular area of nasal mucosa or facial skin is due to fungal vascular invasion with secondary avascular necrosis. Treatment is with aggressive and repeated debridement of avascular tissue along with systemic antifungal agents. Mucor and Aspergillus are the most common fungi to cause the invasive form.

The superficial form is most likely from aspergillosis but can also be caused by histoplasmosis, blastomycosis, cryptococcosis, rhinosporidiosis, mucormycosis, and sporotrichosis. These infections are most common in hot and humid climates, presenting in an indolent manner or occurring along with chronic bacterial sinusitis due to overgrowth of fungi in retained secretions. Recommended treatment is to surgically open the sinus and remove the infected material. Systemic antifungal treatment is not necessary.

[edit] ADDITIONAL READINGS

• A Axelsson, JE Brorson: The correlation between bacteriologic findings in the nose and maxillary sinus in acute maxillary sinusitis. Laryngoscope 1973; 83:2003.
• MS Benninger: Rhinitis, sinusitis, and their relationship to allergies. Am J Rhinol 1992; 6 (2):37.
• MS Benninger, SA Mickelson, K Yaremchuk: Functional endoscopic sinus surgery: morbidity and early results. Henry Ford Hosp Med J 1990; 38 (1):5.
• GM English: Nasal polypectomy and sinus surgery in patients with asthma and aspirin idiosyncrasy. Laryngoscope 1986; 96:374.
• DNF Fairbanks: Pocket guide to antimicrobial therapy in otolaryngology—head and neck surgery ed 7. Alexandria, VA: American Academy of Otolaryngology—Head & Neck Surgery Foundation; 1993:
• DA Leopold: Physiology of olfaction. ed 2. Cummings CWet al.: 'Otolaryngology—head and neck surgery' 1993; vol 1: St Louis: Mosby; 1993:
• RS Rosnagle, E Yanagisawa, HW Smith: Specific vessel ligation for epistaxis: survey of 60 cases. Laryngoscope 1973; 83:517.
• NS Weiss: Relation of high blood pressure to headache, epistaxis, and selected other symptoms: the United States health examination survey of adults. N Engl J Med 1972; 287 (13):632.