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OT26 Otolaryngology
Epistaxis Toronto Notes 2019 Chronic Rhinosinusitis
Definition
• inflammationofthemucosaofparanasalsinusesandnasalpassages>8-12wk
• diagnosisrequires≥2majorsymptomsfor>8-12wkand≥1objectivefindingofinflammationofthe
paranasal sinuses (CT/endoscopy)
Etiology
• unclearetiologybutthefollowingmaycontributeorpredispose ■ inadequate treatment of acute rhinosinusitis
■ bacterial colonization/biofilms
◆ S. aureus, Enterobacteriaceae, Pseudomonas, S. pneumoniae, H. influenzae, β-hemolytic Streptococci
■ fungal infection (e.g. Aspergillus, Zygomycetes, Candida)
■ anatomic abnormality (e.g. lost ostia patency, deviated septum – predisposing factors) ■ allergy/allergic rhinitis
■ ciliary disorder (e.g. cystic fibrosis, Kartagener syndrome)
■ chronic inflammatory disorder (e.g. GPA)
■ untreated dental disease
Clinical Features (similar to acute, but less severe) - at least 2 of CPODS for >8-12 wk • facial Congestion/fullness
• facial Pain/Pressure
• chronicnasalObstruction
• purulentanterior/posteriornasalDischarge
• hyposmia/anosmia(Smell)
• others:halitosis,chroniccough,maxillarydentalpain
Management
• identifyandaddresscontributingorpredisposingfactors
• obtainCTorperformendoscopy
• ifpolypspresent:INCS,oralsteroids±antibiotics(ifsignsofinfection),refertootolaryngologist/H&N
surgeon
• ifpolypsabsent:INCS,antibiotics,salineirrigation,oralsteroids(severecases) • antibiotics for 3-6 wk
■ amoxillin-clavulanic acid, fluoroquinolone (moxifloxacin), macrolide (clarithromycin), clindamycin (metronidazole)
• surgeryifmedicaltherapyfailsorfungalsinusitis:FESS,balloonsinoplasty
Complications
• sameasacutesinusitis,mucocele
Epistaxis
Blood Supply to the Nasal Septum (see Figure 4, OT3) 1. Superior posterior septum
■ internalcarotid→ophthalmic→anterior/posteriorethmoidal 2. Posterior septum
■ externalcarotid→internalmaxillary→sphenopalatine→nasopalatine 3. Lower anterior septum
■ external carotid → facial artery → superior labial artery → nasal branch
■ external carotid → internal maxillary → descending palatine → greater palatine
• thesearteriesallanastomosetoformKiesselbach’splexus,locatedatLittle’sarea(anterior-inferior
portion of the cartilaginous septum)
• bleedingfromabovemiddleturbinateisinternalcarotid,frombelowisexternalcarotid
Allergic fungal rhinosinusitis is a chronic sinusitis affecting mostly young, immunocompetent, atopic individuals
Treatment options include FESS
± intranasal topical steroids, antifungals, and immunotherapy
FESS = Functional Endoscopic Sinus Surgery
Opening of the entire osteomeatal complex in order to facilitate drainage while sparing the sinus mucosa
90% of nose bleeds occur in Little’s area