Mucocele Extraction

Erythematous Edematous Turbinates

Fig. 3.54a-c Acute rhinitis. In the common cold, the nasal mucous membrane is edematous, so the inferior turbinate abuts against the septum to result in obstruction and an excess of mucous which causes the running nose.

A similar appearance is seen in nasal allergy, either "seasonal hay fever" or perennial allergy, but the edematous turbinate mucous membrane appears gray (c) rather than red (b). A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal sprays for nasal allergy reduce the obstruction, rhinorrhea, and sneezing that characterize both seasonal and perennial nasal allergy. Skin tests to detect specific allergens are of use with grass pollen and house dust allergy related to the house dust mite.

Nasal sprays, along with allergen avoidance where possible, and oral antihistamines without sedative side effects are the first lines of treatment for nasal allergy. This management of nasal allergy is preferable to desensitization, as there is an increased awareness and concern regarding anaphylactic shock.

Fig. 3.54a-c Acute rhinitis. In the common cold, the nasal mucous membrane is edematous, so the inferior turbinate abuts against the septum to result in obstruction and an excess of mucous which causes the running nose.

A similar appearance is seen in nasal allergy, either "seasonal hay fever" or perennial allergy, but the edematous turbinate mucous membrane appears gray (c) rather than red (b). A persistent purulent nasal discharge usually means that there is a sinusitis. Corticosteroid nasal sprays for nasal allergy reduce the obstruction, rhinorrhea, and sneezing that characterize both seasonal and perennial nasal allergy. Skin tests to detect specific allergens are of use with grass pollen and house dust allergy related to the house dust mite.

Nasal sprays, along with allergen avoidance where possible, and oral antihistamines without sedative side effects are the first lines of treatment for nasal allergy. This management of nasal allergy is preferable to desensitization, as there is an increased awareness and concern regarding anaphylactic shock.

Fig. 3.55 Chronic rhinitis. The turbinate mucous membrane frequently reacts to irritants, whether tobacco, excessive use of vasoconstrictor drops, or atmospheric irritants, by enlarging. Thickened red inferior turbinates are seen adjacent to the septum, limiting the airway. Nasal obstruction, either intermittent or persistent, with a postnasal discharge of mucus ("postnasal drip") are the symptoms of chronic rhinitis. This is the condition most frequently labeled by the patient as "catarrh" or "sinus trouble."

If the changes due to chronic rhinitis are irreversible, i.e., the nasal obstruction persists when the irritants are removed, it is probable that minor surgery to reduce the turbinates in size will be necessary.

A nasal corticosteroid spray and nonsedating oral antihistamines help, but vasoconstrictor drops have no place in the treatment of chronic rhinitis and their constant use is a cause of rhinitis medicamentosa.

Rhinitis frequently coexists with asthma (the upper and lower respiratory tract sharing a common epithelium), and about 30% of those with rhinitis have asthma.

Fig. 3.56 Wegener's granuloma. An endoscopic view of the granulomatous tissue seen on nasal endoscopy. Wegener's granuloma is a rare autoimmune inflammatory disease which often presents with nasal symptoms of obstruction, crusting, and epistaxis. Damage to the septum may lead to a saddle deformity (Fig. 3.21-3.23).

The granulomas may be limited to the nose, but the respiratory tract may be involved along with a generalized vasculitis and glomerulonephritis. The condition is characterized by periods of remission, and treatment with oral steroids and cytotoxic drugs has dramatically improved the prognosis of a previously fatal condition.

(About 80% of asthmatics have rhinitis.)

In most inflammatory conditions of the nasal mucous membrane, there is an excess of mucus. An atrophy of the mucosa and mucous glands with fetid crusting of wide nasal fossae, however, is seen with atrophic rhinitis. This is uncommon and idiopathic. It may be an isolated nasal condition, part of Wegener's granuloma, or disseminated lupus erythematosus. There is also a phase of atrophic nasal crusting in rhinoscleroma.

Nasal surgery in which there is excessive resection of nasal tissue and mucosa also predisposes to atrophic crusting.

Acute Maxillary Sinusitis a

Atrophic Rhinitis Cat Scan

Fig. 3.57a, b A CT scan showing total opacity of the left antrum and ethmoids due to infection (arrows). Clearing and a return to a normal CT scan of an infected maxillary and ethmoidal sinuses following intranasal antrostomy (arrow). In this instance the antrostomy (or opening into the maxillary antrum), has been made through the inferior meatus. It is more commonly made through the middle meatus.

Fig. 3.57a, b A CT scan showing total opacity of the left antrum and ethmoids due to infection (arrows). Clearing and a return to a normal CT scan of an infected maxillary and ethmoidal sinuses following intranasal antrostomy (arrow). In this instance the antrostomy (or opening into the maxillary antrum), has been made through the inferior meatus. It is more commonly made through the middle meatus.

Sinusitis With Pus

Fig 3.58a, b Maxillary sinusitis with pus (a, arrow) adjacent to the middle turbinate issuing into the middle meatus, seen with the endoscope (b).

Fig 3.58a, b Maxillary sinusitis with pus (a, arrow) adjacent to the middle turbinate issuing into the middle meatus, seen with the endoscope (b).

Acute Maxillary Sinusitis

This is a common complication of a head cold. If a head cold persists beyond four to five days with continued nasal obstruction, purulent rhinorrhea, and headache, the probable diagnosis is maxillary sinusitis. Apical infection of the teeth related to the antrum or an oroantral fistula following dental extraction also cause maxillary sinusitis, as may trauma with bleeding into the antrum or barotrauma.

Frontal or facial pain may be referred to the upper teeth; nasal obstruction and purulent rhinorrhea are the other symptoms. The antrum is opaque on computed tomography (CT; Fig. 3.57a). There may be tenderness over the sinus, but swelling is rare. Pus is seen issuing from the middle meatus (Fig. 3.58a, arrow).

Acute infection may less commonly affect the ethmoid, frontal, and sphenoid sinuses. Systemic antibiotics, a vasoconstrictor spray, or drops b and inhalations are usually curative for acute sinusitis. A persistent maxillary sinusitis, however, requires surgery.

Although frontal headache, and less commonly pain over the cheek, are characteristic of maxillary sinusitis, very severe pain suggests either a complication of the sinusitis, or a neuralgic cause for the pain. Migrainous neuralgia (cluster headaches) characterized by episodes of frontal pain which increase in severity reaching the level of extremely severe pain, which then regresses. Such a history, without nasal symptoms, suggests a diagnosis of migrainous neuralgia and further investigation is needed.

Fig. 3.59a, b An antral washout may be needed, albeit rarely today, for a persistent maxillary sinusitis. This involves inserting a trocar and cannula under the inferior turbinate, and puncturing the lateral wall of the nose through the maxillary process of the thin inferior turbinate bone, to enter the antrum. Water is irrigated through the cannula, and the pus emerges through the maxillary ostium.

An acutely infected maxillary sinus must not be washed out until medical treatment has controlled the acute phase. Cavernous sinus thrombosis remains a danger. The bad reputation that antral washout has for pain is not justified if a good local anesthetic and gentle technique are used.

Antrum Washout Treatment For Ethmoid Mucocele

Recurrent attacks of acute maxillary sinusitis may require operation. A permanent intranasal opening into the antrum is made either in the middle or inferior meatus (intranasal antrostomy). This operation is also effective for those cases of acute sinusitis that fail to respond to conservative treatment and antral washouts.

Sinusitis Complications Orbital

Fig. 3.61 Orbital cellulitis. Complications of acute sinusitis confined to the antrum are rare. A severe maxillary sinusitis, however, usually involves the ethmoid and frontal sinuses. Infection spreading via the lamina papyracea or floor of the frontal sinus leads to an orbital cellulitis. A CT scan is essential in these cases to define the extent of infection and to exclude frontal lobe involvement.

Fig. 3.60 Dental sinusitis. The apices of the molar teeth may be extremely close to the antral mucosal lining. The upper wisdom tooth apparent on this radiograph (arrow), if infected, would be likely to cause maxillary sinusitis or, if removed, would be clearly at risk for causing an oroantral fistula.

Fig. 3.60 Dental sinusitis. The apices of the molar teeth may be extremely close to the antral mucosal lining. The upper wisdom tooth apparent on this radiograph (arrow), if infected, would be likely to cause maxillary sinusitis or, if removed, would be clearly at risk for causing an oroantral fistula.

Orbital Cellulitis Children

Fig. 3.61 Orbital cellulitis. Complications of acute sinusitis confined to the antrum are rare. A severe maxillary sinusitis, however, usually involves the ethmoid and frontal sinuses. Infection spreading via the lamina papyracea or floor of the frontal sinus leads to an orbital cellulitis. A CT scan is essential in these cases to define the extent of infection and to exclude frontal lobe involvement.

Fig. 3.62 An orbital abscess, requiring external drainage, may form. Meningitis or brain abscess may also follow the spread of infection from the roof of the ethmoid, frontal, or sphenoid sinus to the anterior cranial fossa.

Infection associated with a rapidly growing neoplasm, such as a rhabdomyosarcoma, is the differential diagnosis in this case.

Chronic Sinusitis

Chronic sinusitis may develop from incomplete resolution of an acute infection. The onset, however, may be insidious and secondary to nasal obstruction (e.g., due to a deviated septum, nasal polyps, or, in children, to enlarged adenoids. Apical infection of the teeth related to the antra can also cause chronic sinusitis.

Purulent rhinorrhea, nasal obstruction, and headache are the main symptoms of chronic sinusitis. Pus in the middle meatus with radiographic opacity of the sinus are confirmatory of infection. Pus confined to the antrum rarely gives complications, but often there is a spread of infection to the ethmoids and frontal sinuses. It is not common for frontal and ethmoid sinusitis to occur without maxillary sinusitis. Pus in the frontal and ethmoid sinus, as with acute infections, may spread to involve the orbit and brain. Obstruction of the sinus ostium may lead to encysted collection of mucus within the sinus—a mucocele.

Fig. 3.63 A mucocele. The front sinus is commonly affected, and erosion of the roof of the orbit leads to orbital displacement downwards and laterally.

Orbital Mucocele Biopsy For Frontal Mucocele

Fig. 3.64 A mucocele. Proptosis also occurs with mucoceles, and is best confirmed by examination from above (a, arrow). The frontal sinus wall may be eroded both posteriorly and anteriorly. An eroded anterior wall results in a fluctuant swelling on the forehead (b, arrow). In this case, there is also orbital displacement and proptosis.

Fig. 3.65 Lateral displacement of the orbit. This occurs with a mucocele arising in the ethmoid sinus, and is usually accompanied by a swelling of the medial canthus. In this case, the mucocele is infected—a pyocele.

Fig. 3.64 A mucocele. Proptosis also occurs with mucoceles, and is best confirmed by examination from above (a, arrow). The frontal sinus wall may be eroded both posteriorly and anteriorly. An eroded anterior wall results in a fluctuant swelling on the forehead (b, arrow). In this case, there is also orbital displacement and proptosis.

Agger Nasi Radiography

Fig. 3.66a, b Maxillary sinus radiographs. In acute and chronic maxillary sinusitis, a fluid level may be seen on radiography. A tilted view is taken to confirm the presence of fluid (b, arrows). A thickened or rather "straight" mucous membrane may look like a fluid level, as may a bony shadow if the radiograph is wrongly angled.

Fig. 3.66a, b Maxillary sinus radiographs. In acute and chronic maxillary sinusitis, a fluid level may be seen on radiography. A tilted view is taken to confirm the presence of fluid (b, arrows). A thickened or rather "straight" mucous membrane may look like a fluid level, as may a bony shadow if the radiograph is wrongly angled.

Sinus Pyocele

Fig. 3.67 CT scans to show the sinuses. CT scans give a much more detailed picture of the maxillary, ethmoid, frontal, and sphenoid sinuses. They are routine when endoscopic sinus surgery is anticipated, and are also of additional help to the plain sinus radiograph for diagnosis. CT scans, however, involve considerably more radiation to the orbit and are expensive. Opacity of the ethmoid sinuses characteristic of infection is seen (a, arrow). Also seen is an air cell in the middle turbinate (concha bullosa; b, upper arrow) and a right intranasal antrostomy into the maxillary sinus (b, lower arrow).

Fig. 3.67 CT scans to show the sinuses. CT scans give a much more detailed picture of the maxillary, ethmoid, frontal, and sphenoid sinuses. They are routine when endoscopic sinus surgery is anticipated, and are also of additional help to the plain sinus radiograph for diagnosis. CT scans, however, involve considerably more radiation to the orbit and are expensive. Opacity of the ethmoid sinuses characteristic of infection is seen (a, arrow). Also seen is an air cell in the middle turbinate (concha bullosa; b, upper arrow) and a right intranasal antrostomy into the maxillary sinus (b, lower arrow).

Concha Bullosa

Fig. 3.68 Endoscopic sinus surgery. In cases of persistent sinusitis that do not respond to medical treatment, endoscopic sinus surgery is now successful in curing most cases. The improvement of instruments and techniques for nasal and sinus surgery enable biopsies of antral mucosa, excision of nasal cysts and foreign bodies in the antrum, e.g., a misplaced apical dental filling, to be dealt with via the sinus endoscope.

The Caldwell-Luc operation (Fig. 3.68) and radical or "open" surgery for chronic frontal sinus infections are now a rarity.

Fig. 3.68 Endoscopic sinus surgery. In cases of persistent sinusitis that do not respond to medical treatment, endoscopic sinus surgery is now successful in curing most cases. The improvement of instruments and techniques for nasal and sinus surgery enable biopsies of antral mucosa, excision of nasal cysts and foreign bodies in the antrum, e.g., a misplaced apical dental filling, to be dealt with via the sinus endoscope.

The Caldwell-Luc operation (Fig. 3.68) and radical or "open" surgery for chronic frontal sinus infections are now a rarity.

Fig. 3.69 View through the sinus endoscope.

Caldwell Luc Operation Definition

Fig. 3.70 The Caldwell-Luc operation in which the antrum is opened with a sublabial antrostomy, the antral mucous membrane removed, and an intranasal antrostomy is made. The Caldwell-Luc operation, previously commonly carried out, is rare. Antibiotics, endoscopic sinus surgery, and a possible change in the nature of the sinus disease account for this.

Fig. 3.70 The Caldwell-Luc operation in which the antrum is opened with a sublabial antrostomy, the antral mucous membrane removed, and an intranasal antrostomy is made. The Caldwell-Luc operation, previously commonly carried out, is rare. Antibiotics, endoscopic sinus surgery, and a possible change in the nature of the sinus disease account for this.

Nasal polyps are a common cause of nasal obstruction, and may cause anosmia. They are benign and do not present with bleeding. Examination shows a gray pendulous opalescent swelling arising from the ethmoid. A polyp is very different in appearance from the red inferior turbinate adjacent to it.

Polyps may be solitary or multiple, often extending from the nasal vestibule to the posterior choana. They are usually bilateral. Nasal polyps may become extremely large, causing expansion of the nasal bones and alae nasi. A nasal polyp which is ulcerated and bleeds is probably malignant.

Nasal polyps result from a distension of an area of nasal mucous membrane with intercellular fluid. They are due to a hypersensitivity reaction in the mucous membrane, but may also result from sinus infection. Obstruction of the sinuses by polyps, however, may lead to a secondary sinusitis, and a sinus radiograph is a routine investigation.

Small nasal polyps may cause little in the way of symptoms and may be chance findings. Usually, however, polyps extend and enlarge, and present with nasal obstruction. They do regress with corticosteroid nose drops and sprays, but in many instances, surgical removal either under local or general anesthesia is necessary.

Nasal polyps in children or young adults, particularly if recurrent and associated with upper respiratory tract infections, suggest cystic fibrosis. In this condition the mucosal cilia of the respiratory tract are poorly motile (ciliary dyskinesia). (The young adult [Fig. 3.75a] with nasal bone expansion from extensive nasal polypi was found on further investigation to have cystic fibrosis.)

Nasal polyps tend to recur, and in some instances may be a recurrent life-long problem, for example, those with the well-recognized triad of recurrent nasal polypi, asthma, and aspirin hypersensitivity.

Fig. 3.71 Nasal polyp (arrow). Fig. 3.72 Nasal polyps as seen through the sinus endoscope.

Nasal Polyps Antrochoanal

Fig. 3.73 Nasal polyp extruding through the anterior nares. Large nasal polyps prolapse into the nasal vestibule with the exposed surface losing the opalescent gray color.

Fig. 3.73 Nasal polyp extruding through the anterior nares. Large nasal polyps prolapse into the nasal vestibule with the exposed surface losing the opalescent gray color.

Nasal Vestibule

Fig. 3.71 Nasal polyp (arrow). Fig. 3.72 Nasal polyps as seen through the sinus endoscope.

Fig. 3.74 Extensive nasal polyps may expand into the nasal bones, and the external deformity of the polyps may become gross. Surgical removal of the polyps may suffice in the elderly, in whom this complication is usually seen.

Nasal Polyp Removal
Fig. 3.75 Nasal bone expansion due to extensive nasal polyps in the younger patient (a) also requires rhinoplasty to restore appearance (b).
Tooth Abscess Bone Expansion

Fig. 3.74 Extensive nasal polyps may expand into the nasal bones, and the external deformity of the polyps may become gross. Surgical removal of the polyps may suffice in the elderly, in whom this complication is usually seen.

Oropharyngeal Nasal Polyp
Fig. 3.76 Nasal polyps in the oropharynx. Extensive nasal polyps may extend beyond the soft palate and present in the oropharynx (arrow).

Antrochoanal Polyp

This is a special type of nasal polyp occurring in adolescents and young adults. Unilateral nasal obstruction is caused by a gray single polyp seen in the postnasal space. The maxillary sinus is opaque on radiograph.

Cyst Postnasal Space

Fig. 3.77a Antrochoanal polyp seen with the postnasal mirror. A large antrochoanal polyp may present below the soft palate. A solitary polyp in one choana is almost certainly an antrochoanal polyp, but a vascular polyp that should be remembered as a differential diagnosis is the angiofibroma of male puberty.

Fig. 3.77a Antrochoanal polyp seen with the postnasal mirror. A large antrochoanal polyp may present below the soft palate. A solitary polyp in one choana is almost certainly an antrochoanal polyp, but a vascular polyp that should be remembered as a differential diagnosis is the angiofibroma of male puberty.

Male Puberty

Fig. 3.77b, c The angiofibroma of male puberty is a rare vascular malformation in the postnasal space, which may become extremely large, presenting with nasal obstruction and epistaxis. Treatment is difficult, but surgical removal via a midfa-cial "degloving" approach (b,c) allows access via the midfacial skeleton without facial scars. Some facial fractures and other midfacial tumours can managed via this approach. Very large angiofibroma being removed from the postnasal space.

Antrochoanal Polyp

Fig. 3.78 Antrochoanal polyp. This type of polyp, which arises from the antral mucosa, extrudes through the ostium to fill the posterior nasal fossa and postnasal space. It frequently becomes extremely large and extends below the soft palate. Removal of the polyp from its origin in the antrum through a sublabial antrostomy approach may be necessary (Fig 3.70).

The polyp is dumb-belled in shape with a pedicle connecting the nasal and antral portions. Intranasal removal is followed by recurrence in 50% of cases, but may be necessary in early adolescence if the permanent dentition is endangered by a sublabial antrostomy. (Top arrow: polyp removed from antrum; second arrow: polyp from nasal fossa; third arrow: polyp from postnasal space; bottom arrow: polyp that has extended into oropharynx.)

Sinus Aspiration

Fig. 3.79 Aspiration from the antrum.

This shows straw-colored fluid, and is a reliable diagnostic test for an antrochoanal polyp.

Fig. 3.79 Aspiration from the antrum.

This shows straw-colored fluid, and is a reliable diagnostic test for an antrochoanal polyp.

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