NATOMYOFEAR e a u :i "0 SP Baseline eStimulus v :i SP Baseline Fig.4.9Electrocochleography.(A)Normalear.(8)Ear withMeniere'sdisease.Voltageof summatingpotential (SP)iscomparedwiththatofactionpotential(AP) . NormallySPis30%ofAP.Thisratioisenhancedin Meniere'sdisease. I-III2.0ms o (1.0ms/ div) Fig.4.108rainstemauditory evokedpotentials. (a)Amplitudeof awaveismeasuredinmicrovolts(fLV) frompeak of awavetothepeak of nexttrough. (b)Absolutepeak latency isthe durationinmilliseconds (ms)fromthe start of clicktoappearanceof awave. (c)Interpeak latency or intervalisthe durationinmillisec-ondsbetweenpeaksof twowaves,e.g.,wavesI-IIIor I-V or IIIand V,andit iscompared withnormative data. (1-111,2.0ms;III-V,2.0ms;I-V,4.0 ms). (d)Interauralpeaklatencyisthedifferenceinmillisec-ondsof aparticular wavebetweentwoears.Thisisuse-fulinunilateraleardisease,e.g.,acousticneuroma (interauralwave Vlatencies). Thefirst,thirdandfifthwavesaremost stableand areusedin measurements. The waves are studied for absolutelatency',inter-wavelatenc),(usuallybetween waveI andV)andtheamplitude(Fig.4.10). s I. 1-or The exact anatomic site of neural generators for various wavesis disputedbut thelatest studiesindicatethe follow-ing sites: WaveI WaveII WaveIII Wave IV WaveV WavesVIandVII Distalpart of CNVlll ProximalpartofCNVIIInear thebrainstem Cochlear nucleus Superior olivarycomplex Laterallemniscus Inferior collicu Ius As anaidememor ieremember thepneumonic EECOLI (eight,eight,cochlearnucleus,olivarycompl ex,lateral lemniscus,inferiorcolliculus)compareECOLI-MAin pathways of hearing. ABRisused: (i)As a screening procedureforinfants. (ii)Todeterminethethresholdofhearingininfants; alsoinchildrenandadultswhodonotcooperate andinmalingerers. (iii)Todiagnoseretrocochlearpathologyparticularly acous ticneuroma. (iv)Todiagnosebrainstempathology,e.g.multiple scle-rosis orpontinetumours. (vi)Tomoni torCNVIIIintraoperativel yinsurgeryof acousticneuromastopreservethefunctionof cochlear nerve. 5.OtoacousticEmissions(OAEs) They arelowintensity sounds produced by outer hair cells of a normal cochlea and can beelicitedbya very sensitive microphoneplacedintheexternalearcanalandan analysisbyacomputer.Soundproducedbyouterhair cellstravelsinareversedirection:outerhaircells-> basil armembrane->perilymph->oralwindow->ossi-cles->tympanicmembrane->ea rcanal.OAEsare presentwhenouter hair cellsarehealthy andareabsent whentheyaredamagedandthushelptotestthefunc-tionof cochlea.Theydonotdisappearineighthnerve pathologyascochlear haircellsarenormal. Types of OAEs:BroadlyOAEs are of twotypes:spon-taneousorevoked.Thelatteraree licitedbyasound stimulus. ASSESSMENTOFHEARING Spontaneous OAEs:Theyarepresentinhealthynor-malhearingpersonswherehearinglossdoesnotexceed 30 dB.Theymaybeabsentin 50%of normalpersons. Evoked OAEs:Theyare further di videdinto twotypes depending onthe soundsti mulususedtoelicit them. (a)Transient evoked OAEs (TEOAEs).Evoked byclicks. Aseriesof clickstimuliarepresentedat80- 85dB SPL andresponserecorded. (b)Distortion product OAEs(DPOAEs)Twotones are Simult aneousl ypresentedtothe cochleatoproduce distortionproducts.Theyhavebeenusedtotest hearingin therange of 1000-8000 Hz. Uses 1.OAEsareusedasascreeningtestofhearingin neonatesandtotesthearinginuncooperativeor menta llychall engedindividualsaftersedati on. Sedation doesnotinterferewith OAEs. 2.Theyhelp to distinguish cochlear fr omretrocochlear hearingloss.OAEsareabsentincochlearlesions, e.g.ototox icsensor ineuralhearingloss.They detect ototoxiceffectsearlierthanpure-tone audiometry. 3.OAEsarealsousefultodiagnoseretrocochlear pathology,especiallyauditoryneuropathy.Auditory neuropathyisaneurologicdisorderofCNVIII. Audiometric tests,e.g.SNHL for pure tones,impaired speech discrimination score, absent or abnormal audi-torybrainstemresponse,showaretrocochleartype of lesionbut OAEs arenormal. OAEsareabsentin50%ofnormalindividuals, les ionsof cochlea,middleear disorders(assoundtrave l-linginreversedirection cannotbepi ckedup)andwhen hearinglossexceeds30 dB. 6.Central Auditory Tests Thesetestsaredesi gnedtofinddefectsinthecentra l aud itory pathwaysandthe temporal cortex.Several tests withtestsignal deliveredtooneear(monotic)orboth ears(dichotic)havebeenused,butcurrentlythe "Staggeredspondaicwords"testiswidelyemployed. Central audi torytestsarenotusedroutinely. 7.HearingAssessment inInfantsand Children(seepage116) 29 30 HEARINGLOSS CLASSIFICATION Heanng Cor,duehve Orgnnk Sensonneural Sen50ry (cochlear) Peripheral (Vllllhnerve) Neural I Non-orgon lc. Central (Cent reloudrfory pafhways) CONDUCTIVEHEARINGLOSSAND ITSMANAGEMENT Any diseaserrocesswhichinrerfcrcswith(he ri on of sound[0 reach cudllea CalJs e Scondu rJ rx" Fig. 5. 1(A)Audi ogram of right ear showingco nductive hea ringloss wi th A-B gap.(B) Symbol sused inoudiogram cha rting. 5.Audiometry shows bone cond uc tio nbenn lhanair conduc tiunwithair, hont'gap. Grea tertilL'gap, mOTeistheconduclivcloss(Pig.S. I ). 6.Lossis notmorethan60 dR. 7.Speech discriminationis good. Aetiology Thecausemayhecongeniml(Table5.1)oracquired (Tabl e1.2). AverageHearing LossSeeninDiHerent Lesions of Conductive Apparatus I .Completeohstructionof ear canal : 30 dI3 2.Pelforar ioJ)oftympanicmembrane:(I tvariesand isdirec tlypropo rtionalLOthe:i heofpt'Tfo rdl1nn) 10-40 dB 3.OssicularinrerruptionwithinTact drum:54 dB 4.Ossicularinrerrupt ionwithperforat iun: 38 dB 5.Closureof ovalwindow: 60 dB Table5.1Congenitalco usesofconduC1iv8hearinl) Iloss Meotalatresia Fixati onofstapesfootpla te Fixationofma ll eushead Ossicul ardi scontinuity Congeni taldlOles.teatoma Table 5.2causes of conduC1ivehearingloss ExternalearAny obstructioninthe eor canol,e.g.wax, foreignbody,furuncle,a cuteinfl ommatory swelling,beni gnormalignanttumouror atresiaofcona l. Midd leeor(a ) (b) (e) (dl (el (t) Pertomtionottymponicmembrane, traumat icorinfecti ve Fluidinthemiddleea r,e.g.acute otitismedia,serousotitis rnediaor hoemotymponum Mass inmiddle ear,e. g. benignor ma li gnanttumour Disruptionofossides,e,g.traumato ossicular chain,chronic suppurative otifs media,cholesteatoma f: xotionof ossides,e.g. otoscl erosis, tympanosclerosis,adhesiveotiti s media Eustachiantubebl ockage,e.g,retracted tympanicme mbra ne,serous otitis media . a ,d - -Nocc heret ha t ossicuL'lfinre rrup[lonwi thm r.-lC(drum ca usesmorelossthanms icllbrinterruption\!r' lth rate(.ldrum. Management Most cases of conductivehearing lossGl nbe managed by medical or surgical means.Trea tment ofcundlti ons is disCUSSL' dinrespectivesec tions.Brief1y,itc\.of: 1.RemovalofGlOatobstructions,e.g.Impactedwax, foreignbody,osteomaorexosrosis,kerarO(lCmass, benign ormnlign:mr tumours,mearala tres ia. 2.Removaloffluid.Myringotomywit horwirhout grommetinsertion. J.Removalofmassfrommiddleear.Tympanororny andremovalofsmallmiJdleeartumoucsor cholesteatomahch i ndmtact drum. 4.Stapedectomy,asinotoscl eroticfi xa tionof stapes footplate. S.Tympanoplasty.Repa irof oss icl.118r chai norboth. 6.H earing aid.In G1SCS,where sl.1rgeryis no tpossible) refusedor hu,fail ed. Tympanoplasty It is an operation to (I) emdicme diseasein the middle car and ( ii ) to rec.onstnict heming mechanism. It maybe com-bmcdwirhmastOldectomyif diseasesoTYr'". of minnieear reconstructi.ondcpcnJs onr.he d(lm(lge present int heea r. The procedurem(lYbelimitedonlyto repair of tympanicmemhrane(myringoplast),) , orto recon-struc tionof ossicula rchain(ossicuioplaslY) , orboth(l)'m-Reconsffil crivesurgeryofthecarhasheen gready facihcaredby development of opcrating microscope, mi crosurgicalinstrumentsandhi(Kompat ibleimplant materials. Front t he ph)'1'i iologyufhear ing mechanism,the ing principles can beded uced LoreslOrehearing surgicillly: / /'-e Hociw, 'at see :J -, Type I (Myringoplasty) :Ji "', \ I"ypeIi i (Mynngoslaped,upcxy)TypeIV HEAAINGLOSS . (i )Anintacttympanicmemhrane,toprovidelarge hydraulicraliobetweentherympanicme mbrane and stapesf(.:x) tplate. (ii)Ossicularchain ,toconductsoundfromt ympa nic membranero(heovalwindow. ( iii)Two funcCluning windows,one 011thescala veslibuli ([0receJvesoundvibrations)lhe other onthe scalarympani (to act as spur-.Jarly Clffectinghigherfrequencies.Site of lesiontest-_ Indicates cochlear lllvolvement,butlight and electron dOSCOpyhave failedto show dnymurphologic changes hair celis,Possiblythey interfere at enzymatic level. lllglossduerosalicyLHl'sisreversibleafter [he drug Quinine.Ototoxicsymptomsduetoquinineare rtus and sensorineural hearing loss,hoth of which are mbJe. The synlptoms generally appear with prolonged .JJc:ttionbutmayoccurwithsmallerdusesinlhose aresusceptible.Congenital deafnessandI{h leahave been reportedin chllJren whose mothers - ':'eH"erlthis drug duringthe firsttrimester of pregnancy. ..,.tOX LCeffects of quinine arc dueto vasoconstricrlOn in vesselsof thc cochlea andstriavascular is. i .Chloroquin.Effectissimilartothatofquinine pcrm;)LleLlldearnesscan tesult. 6.Cytotoxicdrugs.Nitrogen mustard,cispiatin and ' ")r latincnnGUisecochlear d;)mage.Theyaffcctthe f ' rhng Rhinorrhoea congestion Fig.30.1(A)Structure of IgEantibody.Fcendisattached to themast cellor bloodbasophilwhileFab endisthe anti-genbindingsite.(8)Releaseof mediator substances frommast cellproducingsymptomsof nasalallergy. 157 158 DISEASESOFNOSEANDPARANASALSINUSES ~ Prelarmed Histamine ECF-A NCF-A Heparin Others Histamine ECF-A NCF-A Heparin Prostaglandins Leukatriene PAF Releaseofmediators Antigen ~ NewlysYl1thesised Prostaglandins, e.g.PGD2 Leukatrienes, e.g.SRS-A PAF ThrambaxaneA TNFa: Vasodilatation,bronchospasm Eosinophilchemotacticfactorof anaphylaxis-allractseasinophilstothesiteofreaction. Neutrophilchemotacticfodor-attracts neutraphi Is Enhancesphagocytosis Vasoactiveandbronchaspastic Vasoactiveandbronchaspastic Plateletaggregatingfactor.Histamine and serotoninarereleasedfromplatelets.Causes chemotaxisof neutrophils andeasinaphils. ThramboxaneASpasmogenic TNFa:Tumour necrosisfactor.Helpstransmigration of neutraphilsandeasinaphilsandattracts themtothesiteof reaction. Fig.30.2Releaseofmediatorsfrommastcellwhen challengedbyallergicornon-specific stimuli. Itchingmayalsoinvolveeyes,palateorpharynx.Some may get bronchospasm. The duration and severity of symp-tomsmayvarywiththe season. Symptomsof perennialallergyarenotsosevereasthat of the seasonal type.They include frequent colds,persist-entlystuffynose,lossof senseof smellduetomucosal oedema,postnasaldrip,chroniccoughandhearing impairmentduetoeustachiantubeblockageorfluidin themiddleear. Signsof allergymaybeseeninthenose,eyes,ears, pharynx or larynx. Nasal signsincludetransversenasal crease-a black line acrossthemiddleofdorsumofnoseduetoconstant upwardrubbingofnosesimulatingasalute(allergic salute),paleandoedematousnasalmucosawhichmay appearbluish.Turbinatesareswollen.Thin,wateryor mucoiddischargeisusuallypresent. Ocularsignsincludeoedemaoflids,congestionand cobble-stone appearance of theconjunctiva, dark circles undertheeyes(allergicshiners). Otologicsignsinclude retractedtympanicmembrane or serous otitis media asa result of eustachian tubeblockage. Pharyngealsignsincludegranularpharyngitisdueto hyperplasiaof submucosallymphoidtissue.Achildwith perennial allergicrhinitis may show all the features of pro-longedmouthbreathing asseeninadenoidhyperplasia. Specificallergic stimulus (lgE-mediated) Non-specificstimuli Weather changes Increasedvascular permeabilityand vasodilatation Tissueoedema ~ Nosalblockage (Temp-humidity) Emotionalstimuli Salicylates Viralinfections Airpollution Changeinsmooth muscletone Bronchospasm Hyperactivity of glands 1 Increasedsecretion Rhinorrhoea Fig.30.3Bothallergicandnon-specificstimuliacton mast cellsor bloodbasophilsreleasingseveralmediator substancesresponsibleforsymptomatology of allergy. Laryngealsignsincludehoarsenessofvoiceand oedema of the vocalcords. Diagnosis Adetailedhistoryandphysicalexaminationishelpful, andalso givesclues to the possible allergen.Other causes of nasalstuffiness shouldbeexcluded. Investigations 1.Totalanddifferentialcount.Peripheraleosinophilia maybeseen butisaninconsistent finding. 2.Nasalsmearshowslargenumberofeosinophilsin allergicrhinitis.Nasal smear shouldbetaken atthe timeof clinicallyactivediseaseorafternasalchal-lengetest.Nasal eosinophiliaisalsoseenincertain non-allergicrhinitis,e.g.NARES(non-allergic rhinitiswith eosinophilia syndrome). 3.Skintestshelptoidentifyspecific allergen.They are prick,scratch andintradermaltests. 4.Radioallergosorbent test(RAST)isan in vitro test and measuresspecificIgEantibody concentration inthe patient's serum. 5.Nasalprovocationtest.Acrudemethodistochal-lengethe nasal mucosawith a small amount of aller-genplacedatthe end of atoothpick and askingthe patienttosniffintoeachnostrilandtoobserveif allergicsymptomsarereproduced.Moresophisti-catedtechniquesareavailablenow. a 3 Complications Nasal allergymaycause: 1.Recurrent sinusitis because of obstruction to the sinus ostia. 2.Nasalpolypi. 3.Serous otitismedia. 4.Orthodonticproblemsandotherill-effectsofpro-longedmouthbreathing especiallyinchildren. 5.Bronchial asthma.Patients of nasal allergy have four timesmorerisk of developingbronchial asthma. Treatment Treatment can bedividedinto: 1.Avoidance of allergen 2.Treatment with drugs 3.Immunotherapy 1.Avoidanceofallergen.Thisismostsuccessful iftheantigeninvolvedissingle.Removalof apet from thehouse,encasingthepillowormattresswithplastic sheet,changeof placeof workorsometimeschangeof jobmayberequired.Aparticularfoodarticletowhich thepatientisfoundallergiccanbeeliminatedfrom the diet. 2.Treatment withdrugs (a)Antihiswminics.Theycontrolrhinorrhoea,sneez-ingandpruritis.Allantihistaminicshavethe sideeffect of drowsiness; somemorethantheother.Thedoseand type of the antihistaminic has tobeindividualised.If one antihistaminic isnot effective, another maybetried from a differentclass. (b)S)'mpathomimeticdrugs(oralortopical).Alpha-adrenergic drugs constrict bloodvesselsandreducenasal congestionandoedema.TheyalsocauseCNSstimula-tionandareoftengivenincombinationwithantihista-minicstocounteractdrowsiness.Pseudoephedrineand phenylpropanolamine areoften combinedwithantihist-aminicsfororaladministration. ALLERGICRHINITIS Topicaluseofsympathomimeticdrugscausenasal decongestion.Phenylephrine,oxymetazolineand xylometazolineareoftenusedtorelievenasalobstruc-tion,butarenotorioustocauseseverereboundconges-tion.Patientresortstousingmoreandmoreof themto relievenasalobstruction.Thisviciouscycleleadsto rhinitis medicamentosa. (c)Corticosteroids.Oralcorticosteroidsareveryeffec-tiveincontrollingthesymptomsofallergicrhinitisbut theiruseshouldbelimitedtoacuteepisodeswhichhave not been controlledbyother measures.They have several systemic sideeffects. Topical steroids such asbeclomethasone dipropionate, budesonide,flunisolideacetatefluticasoneandmometa-soneinhibitrecruitmentofinflammatorycellsintothe nasalmucosaandsuppresslate-phaseallergicreaction, areusedasaerosolsandareveryeffectiveinthecontrol ofsymptoms.Theyhavealsobeenusedinrhinitis medicamentosa whilewithdrawingtopicaluseof decon-gestant nasaldrops.Topicalsteroidshavefewersystemic sideeffectsbuttheircontinuoususemaycausemucosal atrophyandevenseptalperforation.Itiswisetobreak their usefor1-2 weeks every 2-3months. They maypro-mote growthof fungus. (d) Sodium cromoglycate. It stabilises the mast cells and preventsthem fromdegranulation despitethe formation ofIgE-antigencomplex.Itisusedas2%solutionfor nasaldropsorsprayorasanaerosolpowder.It isuseful bothinseasonalandperennial allergicrhinitis. 3.Immunotherapy.Immunotherapyorhyposensiti-sat ionisusedwhen drugtreatment failstocontrol symp-tomsorproducesintolerablesideeffects.Allergenis giveningraduallyincreasingdosestillthemaintenance doseisreached.Immunotherapysuppressestheforma-tionof IgE.Italsoraisesthetitreof specificIgGanti-body.Immunotherapyhastobegivenforayearorso beforesignificantimprovementofsymptomscanbe noticed.It isdiscontinuedif uninterrupted treatment for 3yearsshowsnoclinicalimprovement. 160 VASOMOTORANDOTHERFORMS OFNON-ALLERGICRHINITIS VasomotorRhinitis(VMR) Itisnon-allergicrhinitisbutclinicallysimulatingnasal allergywith symptomsof nasal obstruction,rhinorrhoea andsneezing.Oneortheother of thesesymptomsmay predominate.Theconditionusuallypersiststhroughout the yearandallthetests of nasalallergyarenegat ive. Pathogenesis Nasalmucosahasrichbloodsupply.Itsvasculatureis similartotheerectiletissueinhavingvenoussinusoids or "lakes" which are surroundedbyfibresof smoothmuscle which act assphincters and control the filling or emptying of thesesinusoids.Sympathetic stimulation causesvaso-constrictionandshrinkageof mucosa,whileparasympa-thetic stimulationcausesvasodilation andengorgement. Overactivity of parasympathetic system also causes exces-sivesecretion fromthenasal glands. Autonomicnervoussystemisunderthecontrolof hypothalamusandtherefore emotionsplaya greatrolein vasomotor rhinitis.Autonomic system isunstable in cases of vasomotorrhinitis.Nasalmucosaisalsohyperreactive andrespondsto several non-specific stimuli, e.g.change in temperature,humidity,blastsof air,small amounts of dust or smoke. Symptoms 1.Paroxysmal sneezing. Bouts of sneezing start just after getting out of thebedinthemorning. 2.Excessiverhinorrhoea.Thisaccompaniessneezing orthismaybethe onlypredominant symptom.It is profuseandwatery andmay even wet severalhand-kerchiefs.The nosemay drip when the patient leans forward,andthis mayneedto be differentiatedfrom CSF rhinorrhoea(seepage155). 3.Nasal obstruction. This alternates from sideto side. Usuallymoremarkedatnight.Itisthedependent sideof nosewhichisoftenblockedwhenlyingon one side. 4.Postnasaldrip. Signs.Nasalmucosaovertheturbinatesisgenerally congestedandhypertrophic.In some,itmaybenormal. Complications.Long-standing casesor VMR develop nasalpolypi,hypertrophicrhinitis andsinusitis. Treatment Medical 1.Avoidance of physical factors which provoke symptoms, e.g. suddenchangeintemperature,humidity,blastsof airor dust. 2.Antihistaminicsandoralnasaldecongestantsare helpfulinrelievingnasalobstruction,sneezingand rhinorrhoea. 3.Topicalsteroids(e.g.beclomethasone dipropionate, budesonideor fluticasone),usedassprayor aerosol, areuseful tocontrol symptoms. 4.Systemicsteroidscanbegivenforashorttimein veryseverecases. 5.Psychological factors shouldberemoved. Tranquillizers maybeneededin somepatients. Surgical 1.Nasal obstruction can berelievedbymeasures which reducethe sizeof nasalturbinates(seehypertrophic rhinitis).Otherassociatedcausesof nasalobstruc-tion,e.g.polyp,deviatednasalseptum,shouldalso becorrected. 2.Excessive rhinorrhoea, not corrected bymedicalther-apyandbothersometothepatient,canberelieved bysectioning the parasympathetic secretomocor fibres tonose(vidian neurectomy) . Other Formsof Non-allergic Rhinitis Nasal mucosaresponds to several different stimuli produc-ing symptoms of rhinitis.Some of theseconditions have acquiredspecificeponyms.Someauthoritiescategorise them underthe catch-allterm of vasomotorrhiniti s. 1.Drug-inducedrhinitis.Severalantihypertensive drugssuchasreserpine,guanethidine,methyldopaand propranololaresympatheticblockingagentsandcause nasal stuffiness. Some anticholinesterase drugs, e.g.neostig-mine,usedinthetreatmentof myastheniagravis,have acetylcholinelikeactionandcausenasalobstruction. Contraceptivepillsalsocausenasalobstructionbecause of oestrogens. 2.Rhinitismedicamentosa.Topicaldecongestant nasaldropsarenotorioustocausereboundphenomenon. Theirexcessiveusecausesrhinitis.Itistreatedbywith-drawal of nasal drops, short course of systemic steroid ther-apyandinsomecases,surgicalreductionof turbinates,if they havebecome hypertrophied. 3.Rhinitisofpregnancy.Pregnantwomenmay developpersistentrhinitisduetohormonalchanges. Nasalmucosabecomesoedematousandblockstheair-way.Somemaydevelopsecondaryinfectionandeven sinusitis.Insuchcases,careshouldbetakenwhilepre-scribingdrugs.Generally,localmeasuressuchaslimited useofnasaldrops,topicalsteroidsandlimitedsurgery (cryosurgery)toturbinatesaresufficienttorelievethe VASOMOTORANDOTHERFORMSOFNON-ALLERGICRHINITIS symptoms. Safety of the developing fetusisnot etblished fornewer antihistaminics andthey shouldbeavoided. 4.Honeymoonrhinitis.Thisusuallyfollowssexual excitementleadingtonasal stuffiness. 5.Emotionalrhinitis.Nosemayreacttoseveral emotional stimuli.Psychological states likeanxiety,ten-sion,hostility,humiliation,resentmentandgriefareall knownto causerhinitis. Treatmentisproper counselling forpsychologicaladjustment.Imipramine,whichhas both antidepressant andanticholinergic effectshasbeen founduseful. 6.Rhinitisduetohypothyroidism.Hypothyroidism leadsto hypoactivity of the sympathetic systemwith pre-dominanceofparasympatheticactivitycausingnasal stuffinessand'colds'.Replacementofthyroidhormone relievesthe conditi.on. 7. Gustatory rhinitis. Spicy andpungent foodmayin some people produce rhinorrhoea, nasal stuffiness, lacrima-tion, sweating andeven flushing of face.This isa cholin-ergicresponseto stimulation of sensoryreceptorsonthe palate.Spicyfood,particularlytheredpepper,contains capsaicinwhichisknownto stimulate sensoryn e r v e ~ .It canberelievedbyipratropiumbromidenasalspray(an anticholinergic),afewminutesbeforemeals. 8. Non air-flowrhinitis.It isseeninpatients of laryn-gectomyandtracheostomy.Noseisnotusedforairflow andthe turbinates become swollen due to loss of vasomotor control.Similar changes are alsoseeninnasopharyngeal obstruction due to choana I atresia or adenoidal hyperpla-sia,thelatterhavingtheadditionalfactorofinfection dueto stagnationof dischargeinthe nasalcavitywhich should otherwise drainfreelyinto thenasopharynx. 161 162 NASALPOLYPI NasalPolypiarenon-neoplasticmassesofoedematous nasalor sinusmucosa. They aredividedintotwomainvarieties: (a)Bilateralethmoidal polypi. (b)Antrochoanalpolyp. BilateralEthmoidalPolypi Aetiology.Aetiologyof nasalpolypiisverycomplex and not well -understood. They may arisein inflammarory conditionsof nasalmucosa(rhinosinusitis),disordersof ciliarymotilityorabnormalcomposition of nasalmucus (cysticfibrosis).Various diseasesassociatedwith the for-mation of nasalpolypi are: (i)Chronicrhinosinusitis.Polypiareseeninchronic rhinosinusitis of both allergicandnon-allergicori-gin.Non-allergicrhinitiswitheosinophiliasyn-drome(NARES)isaformofchronicrhinitis associated withpolypi. (ii)Asthma.7%of thepatients with asthmaof atopic or non-atopicoriginshownasalpolypi. (iii)Aspirin intolerance.36% of the patients with aspirin intolerancemayshowpolypi.Sampter'striadcon-sists of nasal polypi, asthma and aspirinintolerance. (iv)Cysticfibrosis.20%of patientswith cysticfibrosis formpolypi.It isdueto abnormalmucus. (v)Allergicfungalsinusitis.Almostallcasesof fungal sinusitisformnasalpolypi. (vi)Kartagener'ssyndrome.Thisconsistsof bronchiec-tasissinusitis,situsinversus and ciliary dyskinesis. (vii)Young's syndrome.It consists of sinopulmonary dis-easeandazoospermia. (viii)Churg-Strausssyndrome.Consists of asthma,fever, eosinophilia, vasculitisand granuloma. (ix)Nasalmastocytosis.Itisaformof chronicrhinitis in which nasal mucosais infiltrated with mast cells butfeweosinophils.SkintestsforallergyandIgE levels arenormal. Pathogenesis.Nasalmucosa,particularlyinthe region of middlemeatusandturbinate becomes oedema-tousdueto collection of extracellular fluidcausing poly-poidalchange.Polypiwhicharesessileinthe beginning becomepedunculatedduetogravityandtheexcessive sneezing. Pathology.Inearlystages,surfaceofnasalpolypiis covered by ciliated columnar epithelium like that of normal nasalmucosabut lateritundergoes ametaplastic change totransiti onaland squamoustype on exposureto atmos-phericirritation.Submucosashowslargeintercellular spacesfilledwithserousfluid.Thereisa(sointlItration with eosinophils androundcells. Site of origin.Multiple nasal polypi always arise from thelateralwallof nose,usuallyfromthemiddlemeatus. Common sites are uncinate process,bulla ethmoidalis, ostia of sinuses,medialsurfaceandedgeof middleturbinate. Allergicnasalpolypi almost never arisefromthe septum or the floorof nose. Symptoms 1.Multiplepolypican occur at anyagebut aremostly seeninadults. 2.Nasal stuffiness leading rototal nasal obstruction may bethepresenting symptom. 3.Partial ortotal lossof senseof smell. 4.Headache duetoassociatedsinusitis. 5.Sneezing and watery nasal discharge due to associated allergy. 6.Massprotruding fromthenostril. Signs.On anterior rhinoscopy, polypi appear as smooth, glistening,grape-likemassesoftenpaleincolour.They maybesessileorpedunculated,insensitivetoprobing anddonot bleedontouch.Oftentheyaremultipleand bilateral. Long-standing cases present with broadening of noseandincreasedintercanthaldistance.Apolypmay protrudefromthenostrilandappearpinkandvascular simulating neoplasm(Fig.32.1).Nasalcavitymayshow purulent dischargeduetoassociated sinusitis. Probingof asolitaryethmoidalpolypmaybeneces-saryto differentiateitfromhypertrophy of theturbinate or cysticmiddleturbinate. Diagnosis.Diagnosiscanbeeasilymadeonclinical examination. CT scan of paranasal sinusesisessentialto exclude the bony erosion and expansion suggestive of neo-plasia. Simplenasalpolypimaysometimesbeassociated Fig.32.1Apolypprotrudingfromtheleftnostrilina patient withbilateralethmoidalpolypi . withmalignancyunderneath,especiallyinpeople.lbove 40 yearsandthismust beexcludedbyhistolgi cal exam-inationofthesuspectedtissue.CTscanalsohelpsto plan surgery. Treatment Conservative 1.Earlypolypoidalchangeswithoedematousmucosa mayrevert to normalwith antihistaminics andcon-trolof allergy. Ashort course of steroids may prove usefulin case of peoplewhocannottolerateantihistaminicsand/or inthosewithasthmaandpolypoidalnasalmucosa. Theymayalsobeusedtopreventrecurrenceafter surgery.Contra indicationstouseofsteroids,e.g. hypertension,pepticulcer,diabetes,pregnancyand tuberculosis shouldbeexcluded. Surgical 1.Polypectom)t.Oneortwopolypswhicharepedun-culatedcanberemoved . withsnare.Multipleand sessilepolypirequire special forceps. 2.Intranasalethmoidectomy.Whenpolypiaremultipl e and sess iletheyrequireuncapping of the ethmoidal airce llsbyintranasalroute,aprocedurecalled intranasalethmoidectomy. 3.Extranasalethmoidectomy.Thisisindicatedwhen polypirecurafterintranasalproceduresand surgical landmarksareill-definedduetoprevioussurgery. Approachisthroughthemedialwallof the orbit by anexternalincision,medialtomedialcanthus. 4.TransantralethmoU:l.ectomy.Thisisindicatedwhen infection andpolypoidal changes arealsoseeninthe maxillaryantrum.Inthiscase,antrumisopenedby Caldwell-Lucapproachandtheethmoidaircell approachedthroughthemedialwallof theantrum. B NASALPOLYPI This procedure is also superceded byendoscopic sinus surgery. 5.Endoscopicsinussurgery.Thesedays,ethmoidal polypi areremovedbyendoscopic sinus surgerymore popularlycalledFESS(functionalendoscopicsinus surgery).It isdonewithvariousendoscopes 0(00,300 and 70 angulation. Polypi can be removed more accu-ratelywhen ethmoidcellsareremoved,anddrainage and ventilation provided to the other involved sinuses such asmaxillary, sphenoidal or frontal. AntrochoanalPolyp Thispolyparisesfromthemucosaofmax illaryantrum nearitsaccessoryostium,comesoutofitandgrowsin thechoanaandnasalcavity.Thusithasthreeparts. (a)Antral:whichisathin stalk. (b)Choanal:whichisroundand globular. (c)Nasal:whichisflatfromsideto side. Aetiology.Exact causeisunknown. Nasal allergy cou-pledwithsinusinfectionisincriminated.Antrochoanal polypiareseeninchildrenandyoungadults.Usually theyaresingleand unilateral. Symptoms.Unilateralnasalobstructionisthepre-senting symptom.Obstruction may become bilateral when polypgrowsintothenasopharynxand starts obstructing theoppositechoana.Voicemaybecomethickanddull duetohyponasality.Nasaldischarge,mostlymucoid, maybeseen on one or both sides. Signs.Astheantrochoanalpolypgrowsposteriorly, itmaybemissedonanteriorrhinoscopy.Whenlarge,a smooth greyish mass covered with nasal dischargemay be seen.Itissoftandcanbemovedupanddownwitha probe.Alargepolypmayprotrudefromthenostriland showapink congestedlookonitsexposedpart. Fig.32.2(AlAntrochoanalpolypseenhangingintheoropharynxfrombehindthesoftpalateontherightsideof uvula.(B)Polypafterremoval. 163 164 DISEASESOFNOSEANDPARANASALSINUSES Table32.1Differencesbetweenantrochoanalandethmoidalpolypi Age Aetiology Number Laterality Origin Growth Size& shape Recurrence Treatment Antrochoanalpolypi Commoninchildren Infection Solitary Unilateral Max.sinusnear theostium Growsbackwardstothechoana;may hangdownbehindthesoftpalate Trilobedwithantral ,nasalandchoanal parts.Choanalpartmayprotrude throughthechoana&fillthe nasopharynxobstructingbothsides Uncommon,ifremovedcompletely Polypectomy;endoscopicremoval or Caldwell-Lucoperationifrecurrent Table32.2Commoncausesofunilateralnasal obstruction Vestibule Furuncle Vestibulitis Stenosisof nares Atresia Nasoalveolar cyst Papilloma Squamouscellcarcinoma Nasalcavity Foreignbody DNS Hypertrophicturbinates Conchabullosa Antrochoanalpolyp Synechia Rhinolith Bleedingpolypusofseptum Benignandmalignant tumoursofnoseandparanasal sinuses Sinusitis,unilateral Nasopharynx Unilateralchoanalatresia Ethmoidalpolypi Commoninadults Allergyormultifactorial Multiple Bilateral Ethmoidalsinuses,uncinateprocess,middle turbinateandmiddlemeatus Mostlygrowanteriorlyandmaypresent atthenares Usuallysmallandgrape-likemasses Common Polypectomy Endoscopicsurgeryor ethmoidectomy (whichmaybeintranasal,extranasal or transantral) Table32.3Commoncausesofbilateralnasal obstruction Vestibule Bilateralvestibulitis Collapsingnasalalae Stenosisof nares Congenitalatresiaof nares Nasalcavity Acuterhinitis(viral,bacterial ) Chronicrhinitis&sinusitis Rhinitismedicamentosa Allergicrhinitis Hypertrophic turbinates DNS Nasalpolypi Atrophicrhinitis Rhinitissicca Septalhaematoma Septalabscess Bilateralchoanalatresia Nasopharynx Adenoidhyperplasia Largechoanalpolyp Thornwaldt'scyst Adhesionsbetweensoftpalateandposterior pharyngeal wall I Largebenignandmalignant tumoursPosterior rhinoscopy may reveal a globular massfilling the choana or thenasopharynx.Alargepolypmayhang down behind the soft palate and presentinthe oropharynx (Fig.32.2A,B).(seeTable32.1for differencesbetween antrochoanal andethmoidalpolypi .) Differentialdiagnosis 2.Hypertrophiedmiddleturbinateisdifferentiatedby itspinkappearanceandhardfeelof boneon probe testing. 1.Ablob of mucus often lookslikea polypibut it would disappear onblowingthenose. 3.Angiofibroma has history of profuse recurrent epistaxis. It isfirmin consistency andeasilybleeds on probing. 4.Other neoplasms may be differentiatedbytheIrfleshy pink appearance, friablenature and their tendency to bleed. X-raysofparanasalsinusesmayshowopacityofthe involved antrum. X-ray,(lateralview)soft tissuenasophar-ynx,revealsaglobularswellinginthepostnasalspace. It is differentiatedfromangiofibromabythe presence of a column of airbehind thepolyp. Treatment.Anantrochoanalpolypiseasilyremoved byavulsion eitherthroughthe nasal or oralroute.Recur-renceisuncommonaftercompleteremoval.Incases whichdorecur,Caldwell-Lucoperationmayberequired toremovethepolypcompletely fromthe siteof itsorigin andtodealwithco-existentmaxillarysinusitis.These days,endoscopic sinus surgery has superceded other modes of polypremoval.Caldwell-Luc operation isavoided. NASALPOLYPI SomeImportant PointstoRemember in aCaseofNasalPolypi 1.If a polypusisredandfleshy,friableand has granular surface,especiallyinolderpatients,thinkof malig-nancy. 2.Simplenasalpolypmaymasqueradeamalignancy underneath. Hence allpolypi shouldbesubjectedto histology. 3.Asimplepolypinachildmaybeaglioma,an encephalocele orameningoencephalocele. It should alwaysbeaspiratedandfluidexaminedforCSF. Carelessremovalof suchpolypwouldresultinCSF rhinorrhoea andmeningitis. 4.Multiplenasalpolypiinchildrenmaybeassociated withmucoviscidosis. 5.Epistaxis and orbital symptoms associated with a polyp shouldalways arousethe suspicion of malignancy. 165 166 EPISTAXIS Bleedingfromimidethenoseiscalledepistaxis.Itis fairlycommonandisseeninallagegroups-children, adultsandolderpeople.Itoftenpresentsasanemer-gency.Epistaxisisasignandnotadiseaseperseand anattempt shouldalwaysbemadetofindanylocalor constitutional cause. BLOODSUPPLY OFNOSE(Figs33.1and33.2) Noseisrichly suppliedbyboth the external andinternal carotid systems,both on the septum and the lateral walls. Nasal Septum Internal Carotid System (a)Anterior ethmoidal artery} Branches of ophthalmic (b)Posterior ethmoidal arteryartery ExternalCarotid System (a)Sphenopalatineartery(branchof maxillaryartery) givesnasopalatineandposteriormedialnasal branches. (b)Septal branch of greater palatine artery(Br.of max-illaryartery). (c)Septalbranchof superiorlabialartery(Br.of facial artery) . Internal carotid artery

OphthalmiC artery

AnteriorPosterior ethmoi dolorteryethmoidal ortery ..." Little'sorea Branchesof sphenopolat ine Superior labialartjery a rtf ry FacialarteryMaxillaryartery tExternalcarotidt artery Fig.33.1Bloodsupply of nasalseptum. LateralWall Internal Carotid System (a)Anterior ethmoidal}Branches of (b)Posteriorethmoidalophthalmic artery ExternalCarotid System (a)PosteriorlateralnasalFrom sphenopalatine arterybranches (b)Greater palatine artery (c)Nasalbranch of anterior superior dental From maxillary artery From infraorbital branch of maxillary artery (d)Branches of facialartery to nasalvestibule Little'sArea Itissituatedintheanteriorinferiorpart of nasal septum, justabovethevestibule.Fourarteries-anterioreth-moidal,septalbranchof superiorlabial,septalbranchof sphenopalatine and the greater palatine, anastomose here toformavascularplexuscalled"Kiesselbach'splexus". This area isexposed to the drying effect of inspiratory cur-rentandtofingernailtrauma,andistheusualsitefor epistaxisinchildren andyoung adults. Retrocolumellar vein.This veinruns vertically down-wardsjust behindthe columella,crossesthe floorof nose Branchesof 10dOf'" Internal carotid artery Ophthalmic artery

AnteriorPosterior ethmoidalarteryethmoidolartery / GreaterLesserpalat ine palatine arteryartery sphenopolotine artery i Sphenopalatine artery i _ ___-,-t _ __ Maxillary artery Facialortery tL ______ Externalcarotid_ ___---' artery Fig.33.2Bloodsupply of lateralwallof nose. 8 andjoins venous plexusonthelateralnasalwall.Thisis dcommon site of venousbleeding in young people. Woodruff's Area Thisvascularareaissituatedundertheposteriorendof nferiorturbinatewheresphenopalatinearteryanasto--eswith posterior pharyngeal artery.Posterior epistaxis y occurinthis area. 5.Drugs.Excessiveuseofsalicylatesandotheranal-gesics(asforjointpainsor headaches),anticoagul-anttherapy(forheart disease). 6.Mediastinalcompression.Tumoursofmediastinum (raisedvenouspressureinthenose). 7.Acutegeneralinfection.Influenza,measles,chicken-pox,whoopingcough,rheumaticfever,infectious mononucleosis,typhoid,pneumonia, malaria, dengue fever . .q" 'fit:W:;R;JWtLV .. VJ",1JtJ1jw"VI..t"L"'R.CAUSESOFEPISTAXIStimeof menstruation). Theymaybedividedinto: .'\. .Local,inthe noseor nasopharynx. B.General. C.Idiopathic. A.LocalCauses Nose 1.Trauma.Finger nail trauma,injuries of nose, intranasal surgery,fracturesofmiddlethirdof faceandbaseof skull,hard-blowing of nose,violent sneeze. 2.Infections. Acute:Viralrhinitis,nasaldiphtheria,acute sinusi-tis. Chronic:Allcrust-formingdiseases,e.g.atrophic rhinitis,rhinitissicca,tuberculosis,syphilisseptal perforation,granulomatouslesionofthenose,e.g. rhinosporidiosis. 3.Foreignbodies. Non-living:Any neglectedforeignbody,rhinolith. Living:Maggotsleeches. 4.Neoplasmsof noseandparanasalsinuses. Benign:Haemangioma,papilloma. Malignant:Carcinoma or sarcoma. 5.Atmosphericchanges.Highaltitudes,suddendecom-pression(Caisson's disease). 6.Deviatednasalseptum. Nasopharynx 1.Adenoiditis 2.Juvenileangiofibroma 3.Malignanttumours B.GeneralCauses 1.Cardiovascularsystem.Hypertension,arteriosclero-sis,mitralstenosis,pregnancy(hypertensionand hormonal). 2.Disordersof blood and blood vessels.Aplastic anaemia, leukaemia, thrombocytopenic and vascularpurpura, haemophilia,Christ masdisease,scurvy,vitaminK deficiency,hereditaryhaemorrhagictelangectasia. 3.Liverdisease.Hepaticcirrhosis(deficiencyof factor II,VII,IX&X). 4.Kidneydisease.Chronic nephritis. C.Idiopathic Manytimesthe causeof epistaxisisnot clear. SITESOFEPISTAXIS 1.Little'sarea.In90%casesofepistaxis,bleeding occursfromthis site. 2.Abovethelevelofmiddleturbinate.Bleedingfrom abovethemiddleturbinateandcorresponding area on the septumisoftenfromthe anterior andposte-rior ethmoidal vessels(internal carotid system). 3.Below thelevel of middle turbinate.Here bleeding isfrom thebranchesofsphenopalatineartery.Itmaybe hidden,lyinglateraltomiddleorinferiorturbinate andmayrequireinfrastructureoftheseturbinates forlocalisation of the bleeding site and placement of packing to controlit. 4.Posteriorpartofnasalcavity.Herebloodflows directlyintothe pharynx. 5.Diffuse.Bothfromseptumandlateralnasalwall. Thisisoftenseeningeneralsystemicdisordersand blooddyscrasias. 6.Nasopharynx. CLASSIFICATIONOFEPISTAXIS AnteriorEpistaxis Whenbloodflowsoutfromthefrontof nosewiththe patientin sitti ngposition. Posterior Epistaxis Mainly the blood flowsback into the throat.Patient may swallowitandlaterhavea"coffeecoloured"vomitus. Thismayerroneouslybediagnosedashaematemesis. The differencesbetween thetwotypesof epistaxis are tabulatedherewith(Table 33.1). Management In any caseof epistaxis,itisimportanttoknow: 1.Mode of onset.Spontaneous or fingernailtrauma. 2.Duration and frequencyof bleeding. 3.Amount of bloodloss. 167 168 DISEASESOFNOSEANDPARANASAlSINUSES 4.Side of nosefromwherebleedingisoccurring. 5.Whether bleeding isof anterior or posteriortype. 6.Anyknownbleedingtendencyinthepatientor family. 7.Historyofknownmedicalailment(hypertension, leukaemias,mitralvalve disease,cirrhosis,nephritis). 8.Historyof drugintake(analgesics,anticoagulants, etc.).. FirstAid Mostof thetime,bleedingoccursfromtheLittle'sarea andcanbeeasilycontrolledbypinchingthenosewith thumbandindexfingerforabout5minutes.Thiscom-pressesthevesselsof theLittle's area.In Trotter'smethod patient ismadeto sit,leaning alittle forwardover abasin tospitanyblood,andbreathequietlyfromthemouth. Table33.1Differencesbetweenanteriorandposte-riorepistaxis Anterior epistaxisPosteriorepistaxis IncidenceMorecommonLesscommon SiteMostlyfromLittle'sMostlyfrom areaor anteriorpartposterosuperiorpart oflaterolwal lofnasalcavity;often difficulttolocali se thebleedingpoint AgeMostlyoccursinAfter40yearsofage childrenoryoung adults CauseMostlytroumaSpontaneous;often duetohypertension or arteriosclerosis BleedingUsuallymild,canbeBleedingissevere, easilycontrolledbyrequireshospitali-sation;postnasal localpressureorpackoftenrequired anteriorpack Coldcompressesshouldbeappliedtothenosetocause reflexvasoconstriction. Cauterisation ThiSISusefulll1antenorepistaxIswhenbleedll1gpoint hasbeenlocated.The areaisfirstanaesthetisedandthe bleedingpoint cauterisedwith abeadof silvernitrate or coagulatedwith electrocautery. Anterior NasalPacking In cases of active anterior epistaxis,n o s ~iscleared of blood clots bysucti on and attemptismadetoloca lisethebleed-ing si te.Inminor bleeds,fromthe access ible sites,cauteri-sationofthebleedingareacanbedone.Ifbleedingis profuseand/orthesiteof bleedingisdifficulttolocalise, anteriorpackingshouldbedone.Forthis,usearibbon gauzesoakedwithliquidparaffin.About1metregauze (2.5cm widein adultsand12mminchildren)isrequired foreachnasalcavity.First,fewcentimetresof gauzeare foldeduponitselfandinsertedalongthefloor,andthen thewholenasalcavityispackedtightlybylayeringthe gauzefromfloortotheroofandfrombeforebackwards. Packing can alsobedoneinverticallayersfrombackto thefront(Fig.33.3).Oneorbothcavitiesmayneedto bepacked.Pack can beremoved after24hoursif bleeding hasstopped.Sometimes,ithastobekeptfor2to3days; inthatcase,systemicantibioticsshouldbegiventopre-vent si nusinfection andtoxicshock syndrome. PosteriorNasal Packing It isrequiredforpatientsbleedingposteriorlyintothe throat.Apostnasalpackisfirstpreparedbytyingthree silktiestoapieceofgauzerolledintotheshapeof a cone.Arubbercatheterispassedthroughthenoseand itsendbroughtoutfromthemouth(Fig.33.4).Endsof thesilkthreadsaretiedtoitandcatheterwithdrawn fromnose.Pack,whichfollowsthesilkthread,isnow guidedintothenasopharynxwiththeindexfinger. Anterior nasal cavity isnowpacked and silk threadstied overadental roll.Thethirdsilkthreadiscut shortand Fig.33.3Methodsofanterior nasalpacking.(A)Packinginverticallayers.(8)Packinginhorizontallayers. h. \J ' Fig.33.4Techniqueofpostnasalpack. Fig.33.5Epistaxisballoonforposteriorepistaxis. Posteriorballoon(A)isinflatedwith10 mlandanterior balloon(B)with30 ml.Catheter providesnasalairway. allowedtohangintheoropharynx.Ithelpsineasy removalofthepacklater.Patientsrequiringpostnasal pack shouldalwaysbehospitalised.Insteadof postnasal pack,aFoley'scathetercanalsobeused.Thebulbis inflatedwithsalineandpulledforwardsothatchoana isblockedandthen an anterior nasalpackiskeptinthe usualmanner.Thesedaysnasalballoonsarealsoavail-able(Fig.33.5).Anasalballoonhastwobulbs,onefor thepostnasalspace andthe other fornasal cavity. EndoscopicCautery Posterior bleeding point can sometimes bebetter located withanendoscope.Itcanbecoagulatedwithsuction cautery. Local anaesthesia with sedation may be required. EPISTAXIS ( \ I Elevationof MucoperichondrialFlapand SMROperation In case of persistent or recurrent bleeds fromthe septum, just elevationof mucoperichondrialflapandthenrepo-sitioningitbackhelpstocausefibrosisandconstrict blood vessels.SMR operation can be done to achieve the sameresult or remove any septal spur which issometimes the causeof epistaxis. Ligationof Vessels (a)ExternalcarOM. Whenbleedingisfromtheexternal carotidsystemandtheconservativemeasureshave failed,ligationof externalcarotidarteryabovethe originof superiorthyroidarteryshouldbedone. It is avoidedthesedaysinfavourofembolisationor ligation of moreperipheralbranches. (b)Maxilla?")'arte?")'.Ligationofthisarteryisdonein uncontrollableposteriorepistaxis.Approachisvia Caldwell -Lucoperation.Posteriorwallof maxillary sinusisremovedandthemaxillaryarteryorits branchesareblockedbyapplying clips. Endoscopicligat ionof themaxillaryarterycan alsobedonethroughnose. (c)Ethmoidalarteries.Inanterosuperiorbleedingabove themiddleturbinate,notcontrolledbypacking, anterior andposterior ethmoidal arteries which sup-ply this area,can beli gated. The vessels areexposed inthemedialwallof theorbitbyanexternaleth-moidincision. General MeasuresinEpistaxis 1.Make the patient sit up with a back rest and record any bloodlosstaking placethrough spitting or vomiting. 169 170 DISEASESOFNOSEANDPARANASALSINUSES 2.Reassurethe patient. Mild sedation shouldbegiven. 3.Keepcheck on pulse,BPandrespiration. 4.Maintainhaemodynamics.Bloodtransfusionmay berequired. S.Antibioticsmaybegiventopreventsinusitis,if packisto bekeptbeyond24hours. 6.Intermittentoxygenmayberequiredinpatients with bilateral packsbecauseof increasedpulmonary resistancefromnasopulmonaryreflex. 7.Investigateandtreatthepatient foranyunderlying localor general cause. Hereditaryhaemorrhagictelangectasia:Itoccurson the anterior part of nasal septum andisthe cause of recur-rentbleeding.ItcanbetreatedbyusingArgon,KTPor Nd:YAGlaser.The proceduremayrequiretoberepeated severaltimesinayearastelangectasiarecursinthesur-roundingmucosa.Somecasesrequireseptodermoplasty where anterior part of septal mucosa isexcised and replaced bya split skin graft. 'I :1TRAUMATOTHEFACE Injuriesof facemayinvolvesofttissues,bonesorboth. Themajorityof facialinjuriesarecausedbyautomobile accidents.Othersresultfromsports,personalaccidents, assaults and fights.The management of facialtrauma can bedividedinto: (a)General management. (b)Softtissueinjuriesandtheir management . (c)Boneinjuries andtheir management. GENERALMANAGEMENT 1.Airway.Maintenanceof airwayshouldreceivethe highestpriority.Airwayisobstructedbylossof skeletalsupport,aspirationof foreignbodies,blood orgastriccontentsorswellingof tissues.Airwayis securedbyintubation orthetracheostomy. 2.Haemorrhage.Injuries of facemaybleedprofusely. Bleeding shouldbe stopped bypressure or ligation of vessels. areidentified and sutured over a polyethylenetube, with finesuture.The tubeisleft for3daysto2weeks. FacialNerve Ifsevered,thefacialnerveisexposedbysuperficial parotidectomyandcutendsareapproximatedwith8-0 or10-0 silkunder magnification. BONEINJURIESANDTHEIR MANAGEMENT The facecan be dividedintothreeregions: (a)Upper third:Abovethelevel of supraorbitalridge. (b)Middlethird:Betweenthesupraorbitalridgeand theupperteeth. (c)Lowerthird:Mandible andthelowerteeth. The various fracturesencounteredinthese regions are listedin Table 34.1. 3.Associated injuries.Facialinjuries maybeassociated withinjuriesof head,chest,abdomen,neck,larynx, cervical spine or limbsand shouldbeattendedto. A.FRACTURESOFUPPERTHIRDOFFACE SOFTTISSUEINJURIESANDTHEIR MANAGEMENT FacialLacerations Woundisthoroughlycleanedof anydirt,greaseorfor-eignmatter.Thelacerationsareclosedbyaccurate approximation of eachlayer. ParotidGland andDuct Parotidtissue,if exposed,isrepairedbysuturing.Injuries of parotidductaremoreserious.Bothendsof theduct Table 34.1Fractures of the face Upper third Frontalsinuses Supraorbitalridge Frontalbone Middlethird Nasa!bonesandseptum Nasa-orbitalarea Zygoma Zygomat icarch Orbita l floor Maxilla - LeFortI(transverse) - LeFaII(pyramidal) 1.FrontalSinus Frontal sinusfracturesmayinvolveanterior wall,poste-rior wallor thenasofrontal duct . (a)Anterior wallfracturesmaybedepressedor commin-uted.Defect ismainly cosmetic.Sinus isapproached throughawoundintheskinifthatispresent,or throughabrowincision.Thebonefragmentsare elevated,takingcarenottostripthemfromthe Theinteriorofthesinusisalways inspectedto ruleout fractureof the posterior wall. (b)Posterior wall fracturesmaybeaccompaniedby dural tears,braininjuryandCSF rhinorrhoea.Theymay Lower third Alveolar process Symphysis Body Angle Ascendingramus Condyle Temporomandibularjoint - LeFortII I(craniofacialdysjunction) ------------------- ------------------------------171 172 DISEASESOFNOSEANDPARANASALSINUSES requireneurosurgicalconsultation.DuraltearscanA becoveredbytemporalisfascia.Smallsinusescan beobli teratedwith fat. (c)Injur)'COnasofroncalductcauseobstructiontosinus drainageandmaylaterbecomplicatedbyamuco-cele.Insuchcases,makealargecommunication betweenthesinusandthenose.Smallsinusescan beobliteratedwithfatafterremovingthesinus mucosacompletely. 2.SupraorbitalRidge Ridgefracturesoftencauseperiorbitalecchymosis,flat-teningof theeyebrow,proptosisordownwarddisplace-mentof eye.Fragmentof bonemayalsobepushedinto theorbit and getimpacted.Ridgefracturesrequireopen reductionthroughanincisioninthebrowortransverse skinlineof the forehead. 3.Fracturesof FrontalBone They maybedepressedor linear, with or without separa-tion.They often extend into the orbit.Braininjurv and cerebraloedemaarecommonlyassociatedwitheach other andrequireneurosurgicalconsultation. B.FRACTURESOFMIDDLETHIRDOFFACE 1.NasalBonesandSeptum Fractures of nasal bones arethe most common because of the projection of noseon the face.Traumatic forcesmay act fromthe frontor side. Magnitude of forcewilldeter-minethe depth of injury. Typesof Nasal Fractures(Fig.34.1) Depressed.Theyareduetofrontalblow.Lowerpartof nasalboneswhichisthinner,easilygivesway.Asevere frontalblowwillcause"open-bookfracture"inwhich nasalseptumiscollapsedandnasalbonessplayedout. Still,greaterforceswillcausecomminutionofnasal bonesandeventhefrontalprocessesofmaxillaewith flatteningandwidening of nasaldorsum. Angulated.Alateralblowmaycauseunilateral depression of nasalbone on the same side or may fracture boththenasalbonesandtheseptumwithdeviationof nasalbridge. Nasalfracturesareoftenaccompaniedbyinjuriesof nasal septumwhichmaybesimplybuckled,dislocatedor fracturedinto several pieces.Septal haematoma may form. ClinicalFeatures 1.Swelling of nose.Appears within fewhours and may obscure detailsof examination. 2.Periorbital ecchymosis. 3.Tenderness. 4.Nasaldeformity.Nosemaybedepressedfromthe front or side, or the whole of the nasalpyramid devi-atedto one side. nn Fig.34.1Typesoffractures.(A)Normal,(8)Frontal blow causingdepressedfractureor open-bookfracture and(C)Lateralblow causing deviation of nasal bridge or depressionof onenasalbone. 5.Crepitus andmobilityof fracturedfragments. 6.Epistaxis. 7.Nasal obstruction due to septal injury or haematoma. 8.Lacerationsof thenasalskinwithexposureof nasal bonesandcartilagemaybeseenincompound fractures. Diagnosis Diagnosisisbestmadeonphysicalexamination.X-rays mayor maynot show fracture(Fig.34.2).Patient should not bedismissedashaving no fracturebecause X-rays did not revealit. X-raysshouldincludeWaters'view,right andleftlat-eralviewsandocclusalview. Treatment Simplefractureswithoutdisplacementneednotreat-ment;othersmayrequireclosedoropenreduction. Presence of oedema interferes with accurate reduction by closedmethods.Therefore,thebesttimetoreducea fractureisbeforetheappearanceof oedema,orafterit hassubsided,whichisusuallyin5-7days.Itisdifficult toreduceanasalfractureafter2weeksbecauseitheals bythattime.Healingisfasterinchildrenandtherefore earlierreductionisimperative. Fig.34.2Fracturednasalbone(arrow)asseenin radiograph. Closedreduction.Depressedfracturesof nasalbones sustained byeither frontal or lateral blow,can bereduced byastraightbluntelevatorguidedbydigitalmanipula-tionfromoutside. Laterally,displacednasalbridgecanbereducedby firmdigitalpressureintheoppositedirection.Impacted fragments sometimes require dis impaction with Walsham orAsche'sforcepsbeforerealignment.Septalfractures are also reducedbyAsche's forceps.Septal haematoma, if present,mustbedrained. Simplefracturesmaynotrequireintranasalpacking. Unstablefracturesrequireintranasalpackingandexter-nalsplintage. Openreduction.Earlyopenreductioninnasalfrac-turesisrarelyrequired.Thisisindicatedwhenclosed methodsfail.Certainseptalinjuriescanbebetter reducedbyopenmethods. Healednasaldeformitiesresultingfromnasaltrauma canbecorrectedbyrhinoplasty or septorhinoplasty. 2.Naso-orbitalFractures Directforceoverthenasionfracturesnasalbonesand displaces them posteriorly.Perpendicular plate of ethmoid, ethmoidalaircellsandmedialorbitalwallarefractured and driven posteriorly.Injury mayinvolve cribriform plate, frontalsinus,frontonasalduct,extraocularmuscles,eye-ball and thelacrimal apparatus.Medial canthal ligament maybeavulsed. TRAUMATOTHEFACE ClinicalFeatures 1.Telecanthus,duetolateraldisplacementof medial orbitalwall. 2.Pugnose.Bridgeofnoseisdepressedandtip turnedup. 3.Periorbitalecchymosis. 4.Orbitalhaematomaduetobleedingfromanterior andposterior ethmoidal arteries. 5.CSFleakageduetofractureof cribriformplateand dura. 6.Displacement of eyeball. Diagnosis Variousfacialfilmswillberequiredtoassesstheextent of fractureandinjury to other facialbones.CT scansare moreuseful. Treatment Closedreduction.Inuncomplicatedcases,fractureis reducedwithAsche'sforcepsandstabilisedbyawire passedthrough fracturedbony fragments and septum and thentiedovertheleadplates.Intranasalpackingis given.Splintingiskeptfor10daysor so. Open reduction.This isrequiredin cases with exten-sivecomminution of nasalandorbitalbones,andthose complicatedbyother injuriestolacrimalapparatus,medial canthal ligaments,frontalsinus,etc. AnH-typeincisiongivesadequateexposureofthe fracturedarea.This canbeextendedtotheeyebrowsif accesstofrontalsinusesisalsorequired. Nasal bones arereduced under vision and bridge height isachieved.Medial orbital wallscan bereduced.Medial canthal ligaments,if avulsed,are restoredwith athrough andthrough wire.Intranasal packingmayberequiredto restorethecontour.'iX/henbone comminutionissevere, restorationofmedialcanthalligamentsandlacrimal apparatusshouldreceivepreferenceoverreconstruction of nasalcontour. 3.Fractures of Zygoma(TripodFracture) Afternasalbones,zygomaisthe secondmostfrequently fracturedbone. Usually,the causeisdirect trauma.Lower segmentofzygomaispushedmediallyandposteriorly resultinginflatteningofthemalarprominenceanda step-deformity attheinfraorbitalmargin.Zygomaissep-aratedatitsthreeprocesses(Fig.34.3).Fractureline passesthroughzygomaticofrontalsuture,orbitalfloor, infraorbitalmarginandforamen,anterior wallof maxil-larysinusandthezygomaticotemporalsuture.Orbital contents mayherniateintothemaxillary sinus. ClinicalFeatures 1.Flattening of malarprominence. 2.Step-deformity of infraorbitalmargin. 3.Anaesthesiainthedistributionofinfraorbital nerve. 173 174 DISEASESOFNOSEANDPARANASALSINUSES Zygomotico-frontalfroctureZygomotico-temporolfrocture Infroorbitolfracture Fig.34.3Fracturezygomaleft. 4.Trismus,duetodepressionof zygomaon theunder-lyingcoronoidprocess. 5.Oblique palpebral fissure,duetothe displacement of lateralpalpebralligament. 6.Restrictedocularmovements,duetoentrapment of inferior rectusmuscle.It maycausediplopia. 7.Periorbital emphysema, dueto escape of air fromthe maxillarysinuson nose-blowing. Diagnosis Waters'orexaggeratedWaters'viewshowsthefracture anddisplacementthebest.Maxillarysinusmayshow cloudingduetothepresenceofblood.Comminution with depressionof orbital floorandherniation of orbital contents cannot beseen on plain X-rays.CT scan of the orbital willbemoreuseful. Treatment Onlydisplacedfracturesrequiretreatment.Open reductionandinternalwirefixationgivesbestresults. Fractureisexposedatthefrontozygomaticsuture throughlateralbrowincisionandreducedbypassingan elevatorbehindthezygoma.Wirefixationisdoneat frontozygomaticsutureandinfraorbitalmargin.The latterisexposedbyaseparateincisioninthelowerlid. Fractureoforbitalfloorcanalsoberepairedthrough thisincision. Transantralapproachislessfavourable.Antrumis exposedasin Caldwell-Luc operation,bloodisaspirated, fracturereducedandthenstabilisedbyapackinthe antrum.Fracturesof orbitalfloorcanalsobereduced. . Antralpackisremovedinabout10daysthroughthe buccalincision,whichisleftopenattheendof opera-tion,or throughtheintranasal antrostomyroute. J Fig.34.4Blowoutfracturewithherniationoforbital contentsintothemaxillarysinus. 4.Fracturesof Zygomatic Arch Zygomaticarchgenerallybreaksintotwofragments whichgetdepressed.Therearethreefracturelines,one at each end andthirdinthecentre of the arch. Clinical Features Characteristic featuresaredepression in the area of zygo-maticarch,localpainaggravatedbytalkingandchew-ing,trismus orlimitation of themovementsof mandible dueto impingement of fragments on the condyle or coro-noidprocess. Diagnosis Arch fractures arebest seen on submentovertical viewof the skull.Waters'viewisalsotaken. Treatment Averticalincisionismadeinthehair-bearingarea above orin front of the ear,cutting through temporal fas-cia.Anelevatorispasseddeeptotemporalfasciaand carriedunderthedepressedbonyfragmentswhichare then reduced.Fixation isusuallynot requiredasthe frag-mentsremain stable. 5.FracturesofOrbitalFloor ZygomaticandLeFortIImaxillaryfracturesarealways accompaniedbyfracturesof orbitalfloor.Isolatedfrac-tures of orbital floor,when a large blunt object strikes the globes,arecalled"blowoutfractures"Orbitalcontents mayherniateintothe antrum(Fig.34.4). ClinicalFeatures 1.Ecchymosisof lid,conjunctiva and sclera. 2.Enophthalmos withinferior displacement of the eye-ball.This becomes apparent whenoedema subsides. 3.Diplopia,whichmaybeduetodisplacementof the eyeballor entrapment of inferiorrectus andinferior obliquemuscles. 4.Hypoaesthesiaoranaesthesiaofcheekandupper lip,ifinfraorbital nerveisinvolved. Diagnosis Waters'viewshowsaconvexopacitybulgingintothe antrumfromabove(tear-dropopacity).CTscansmay c f ~__-4---- C ' ~ + - - - B Fig.34.5Fracturesof maxilla:(A)le FortI,(8)le Fort II,(C)le FortIII. confirm the diagnosis.Entrapment of inferiorrectus and inferiorobli quemusclesisdiagnosedbyaskingthe patient tolook upanddown,or bythetraction test. The latterisperformedbygraspingtheglobeandpassively rotatingitto check forrestriction of itsmovements. Treatment Indicationsforsurgeryincludeenophthalmosandper-sistentdiplopiaduetoentrapmentofmuscle.Orbital floorfracturescanbesatisfactorilyreducedbyafinger passedintotheantrumthroughatransantralapproach. Apackcanbekeptintheantrumtosupportthefrag-ments. Infraorbital approach, through a skin crease of the lower lid, can alsobe used either alone or in combination withtransantralapproach.Badlycomminutedfractures of orbitalfl oor canberepairedbyabonegraftfromthe iliac crest,nasal septum or the anterior wall of the antrum. Silicon or teflon sheets have also been usedto reconstruct the orbital floorbut autogenousgraftsarepreferable. 6.Fracturesof Maxilla(Fig.34.5) They areclassifiedinto3types. (a)LeFartI (transverse)fracturerunsaboveandparal-leltothepalate.Itcrosseslowerpartof nasalsep-tum,maxillaryantraandthe pterygoidplates. (b)LeFartII(pyramidal)fracturepassesthrough the root of nose,lacrimalbone,floorof orbi t,upperpartof maxillary sinus and pterygoid plates. This fracture has somefeaturescommon with the zygomatic fractures. (c)LeFortIII(craniofaciald)'sjunction).Thereiscom-pleteseparationoffacialbonesfromthecranial bones. The fractureline passesthroughroot of nose, ethmofrontaljunction,superiororbi talfissure,lat-eral wall of orbit, frontozygomatic andtemporozygo-matic suturesandtheupperpart of pterygoidplates. ClinicalFeatures (a)Malocclusionof teeth withanterior openbite. (b)Elongationof midface. TRAUMATOTHEFACE (c)Mobilityinthemaxilla. (d)CSFrhinorrhoea.CribriformplateisinjuredinLe Fort IIandLeFortJ11fractures. Diagnosis X-rays,helpfulindiagnosisofmaxillaryfracturesare Waters'view,posteroanteriorview,latera lviewandthe CT scans.Theyhelptodel ineatefracturelinesandthe displacement of fragments. Treatment Treatment of maXillaryfracturesiscomplex.Immediate attenti onispaidtorestoretheairwayandstopsevere haemorrhagefrommaxillaryarteryoritsbranches.For goodcosmetic and functionalresults,fracturesshouldbe treated asearly asthe patient's condition permits.Associ-atedintracranialandcervicalspi neinjuriesmaydelay specifictreatment . Fixation of maxillaryfracturescanbeachievedby: (a)Interdentalwiring. (b)Intermaxillarywiringusi ng archbars. (c)Openreductionandinterosseouswiringasinzygo-matic fractures. (d)Wire slingsfromfrontalbone, zygoma or infraorbital rimtotheteeth orarchbars. C.FRACTURESOFLOWERTHIRD Fracturesof Mandible Fracturesof mandiblehavebeenclassifiedaccordingto theirlocation(Fig.34.6).Condylarfracturesarethe mostcommon.Theyarefollowed,infrequency,byfrac-turesoftheangle,bodyandsymphysis(mnemonic CABS).Fracturesoftheramus,coronoidandalveolar processesareuncommon. Multiple fractures are seen asfrequently as single ones. Mostof themandibularfracturesaretheresu Itof direct trauma;however,condylarfracturesarecausedbyindi-recttraumatothechinoroppositesideof thebodyof mandible.Displacement of mandibular fracturesisdeter-minedby(i)thepullofmusclesattachedtothefrag-ments,(ii)direction of fractureline and(iii)bevel of the fracture. ClinicalFeatures Infracturesofcondyle,iffragmentsarenotdisplaced, painandtrismusarethemainfeaturesandtenderness iselicitedatthesiteoffracture.Iffragmentsaredis-placed,thereisinaddition,maloccl usi onofteethand deviationofjawtotheoppositesideonopeningthe mouth. Mostof the fracturesof angle,bodyandsymphysis,can bediagnosedbyintraoralandextraoralpalpation.Step-deformity,malocclusionofteeth,ecchymosisoforal 175 176 DISEASESOFNOSEANDPARANASALSINUSES -'r---------Coronoid Condylar- -\--process process Alveolarprocess Ramus---'"11la.Itismoreoftenseenin infants and children than adultsbecause of the pres-ence of spongy bone in the anterior wallof themax-illa.Infectionmaystartinthedentalsacandthen spreadtothemaxilla,butlessoften,itisprimary infection of the maxill arysinus. Clini ca l features are erythema,swellingof cheek,oedemaoflowerlid, purulentnasaldischargeandfever.Subperiosteal COMPLICATIONSOFSINUSITIS abscessfollowedbyfistulaemayformininfraorbital region(Fig. 38.3),alveolusorpalate,orinzygoma. Sequestrationofbonemayoccur.Treatmentcon-sistsoflargedosesofantibiotics,drainageofany abscessand removal of the sequestra. Osteomyelitis of maxi ll a may cause damage to tem-porary or permanent tooth-buds,maldevelopment of maxilla,oroantral fistula,persistentlydraining sinus or epiphora. (b)Osteomyelitisof frontalbone(Fig.38.4).Itismore often seenin adults asfrontal sinusisnot developed ininfantsandchildren.Osteomyelitisoffrontal boneresultsfromacuteinfectionoffrontalsinus either directlyorthroughthevenous spread.It can alsofollowtraumaor surgeryof frontalsinusinthe presence of acute infection.Pusmayformexternally Fig.38.3Osteomyelitis of maxilla with fistulaformation ininfraorbitalregion(arrow). Fig.38.4Caseofchronicfrontalsinusitispresenting withafistulainthe floor of thesinus. 189 DISEASESOFNOSEANDPARANASAlSINUSES 190 ABc La min a papyracea Fig38.5Orbitalcomplicationsof sinusitis:(A)Normal.(8)Subperiostealabscess.(C)Orbitalabscess. under the periosteum assoft doughy swelling(Pott's puffytumour), or internally as an extradural abscess. Treatmentconsistsoflargedosesofantibiotics, drainageof ahscessandtrephiningof frontalsinus throughitsfloor.Sometimes,itrequiresremovalof sequestraandnecroticbonebyraisingascalpflap through acoronalincision(Fig.38.4). B.ORBITALCOMPLICATIONS Orbit anditscontentsarecloselyrelatedtotheethmoid, frontal,andmaxillarysinuses,butmostof thecomplica-tions,however,followinfectionof ethmoidsastheyare separatedfromtheorbitonlybyathinlaminaoflaminapapyracea.Infectiontravelsfromthesesinuses eitherbyosteitisorasthrombophlebiticprocessof eth-moidalveins. Orbital complicationsinclude: (a)Inflammatoryoedemaof lids.Thisisonlyreactionary. Thereisno erythemaortenderness of thelidswhich. characteriseslidabscess.Itinvolvesonlypreseptal space,i.e.liesin front of orbital septum. Eyeball move-mentsandvisionarenormal.Generally,upperlidis swolleninfrontal,lowerlidinmaxillary,andboth upper andlowerlidsin ethmoid sinusitis. (b)Subperiostealabscess.Puscollectsoutsidethebone undertheperiosteum.Asubperiostealabscessfrom ethmoids formsonthemedialwallof orbitanddis-placestheeyeballforward,downwardandlaterally; fromthefrontalsinus,abscessissituatedjustabove andbehindthemedialcanthusanddisplacesthe eyeball downwardsandlaterally;fromthemaxillary sinus,abscessformsintheflooroftheorbitand displacesthe eyeballupwardsandforwards. (c)Orbitalcellulitis .Whenpusbreaksthroughthe periosteumandfindsitswayintotheorbit,it spreadsbetween theorbital fat,extraocular muscles, vesselsandnerves.Clinicalfeatureswillinclude oedemaoflids,exophthalamos,chemosisofcon-junctivaandrestrictedmovementsoftheeyeball. Visionisaffectedcausingpartialortotallosswhich issometimespermanent.Patientmayrunhigh fever.Orbitalcellulitisispotentiallydangerous because of the risk of meningitis and cavernous sinus thrombosis. (d)Orbitalabscess.Intraorbitalabscessusuallyforms alonglaminapapyraceaorthefloorof frontalsinus. Clinical pictureissimilartothat of orbital cellulitis. DiagnosiscanbeeasilymadebyCTscanorultra-soundoftheorbit.Treatmentisi.v.antibioticsand drainageoftheabscessandthatofthesinus(eth-moidectomy or trephination of frontalsinus). (e)Superior orbital fissuresyndrome.I nfection of sphenoid sinuscanrarelyaffectstructuresof superiororbital fissure.Symptomsconsistofdeeporbitalpain, frontalheadache andprogressiveparalysisof CN VI, m andIV,inthat order. (f)Orbitalapexsyndrome.Itissuperiororbitalfissure syndromewithadditionalinvolvementof theoptic nerve andmaxillarydivisionof thetrigeminal(Vz) (Fig.38.5). C.INTRACRANIALCOMPLICATIONS Frontal,ethmoidandsphenoidsinusesarecloselyrelated to anterior cranial fossaandinfection fromthese can cause: (a)Meningitis and encephalitis, (b)Extradural abscess, (c)Subduralabscess, (d)Brain abscess, (e)Cavernous sinusthrombosis. Cavernous Sinus Thrombosis Aetiology.Infection of paranasal sinuses,particularlythose of ethmoidandsphenoidandlesscommonlythefrontal, and orbital complications fromthese sinusinfections can Table38.2Sourceandrouteof infectionincav-ernous sinusthrombosis SourceDiseaseRoute NoseanddangerFu ru ncleandseptalPharyngeal areaof faceabscessplexus EthmoidsinusesOrbitalcellulitesorOphthalmic abscessveins SphenoidsinusSinusitisDirect FrontalsinusSinusitisandSupraorbital osteomyelitisofandophthalmic frontalboneveins OrbitCellulitisandOphthalmic abscessvei ns UpperlidAbscessAngular vein andophthalmic veins PharynxAcutetonsilliti s orPharyngeal peritonsillar abscessplexus EarPetrositisPetrosalvenous sinuses cause thrombophlebitis of the cavernous sinus( es).Other sourcesofinfectionarelistedinTable38.2.Thevalve-lessnatureof theveinsconnectingthecavernoussinus causeseasyspreadof infection. Clinicalfeatures.Onsetofcavernoussinusthrom-bophlebitisisabruptwithchillsandrigors.Patientis acutely ill.Eyelids get swollen with chemosis andpropto-sisof eyeball.Cranial nerves III, IV,VIwhich arerelated tothesinusgetinvolvedindividuallyandsequentially causingtotalophthalmoplegia.Pupilbecomesdilated and fixed,optic discshowscongestion andoedema with diminutionofvision.Sensationinthedistributionof VI(ophthalmicdivisionofCNV)isdiminished.CSF isusuallynormal.Conditionneedstobedifferentiated fromorbitalcellulitis(Table38.3).CTscanisuseful forthis. Treatmentconsistsof i. v.antibioticsandattentionto thefocusofinfection,drainageofinfectedethmoidor sphenoidsinus.Bloodcultureshouldbetakenbefore starting antibiotictherapy.Role of anticoagulantsisnot clear. COMPLICATIONSOFSINUSITIS Table38.3Differencesbetweenorbitalcellulitis andcavernoussinusthrombosis OrbitalcellulitisCavernoussinus thrombosis SourceCommonlyNose,sinuses,orbit, ethmoidsi nusesearorpharynx OnsetSlow;starlswithAbruptwi thhighfever oedemaof eyelidsandchillswi thnear theinner canthus-->signsoftoxaemia chemosis-->Oedemaof proplosiseyelids,chemosis andproptosis CranialInvolvedconcurrentlyInvolvedindividually nervewithcompleteandsequentially involvementophthalmoplegia LateralityOfteninvolvesInvolvesbotheyes oneeye D.DESCENDINGINFECTIONS Insuppurativesinusitis,dischargeconstantlyflowsinto thepharynx andcan causeoraggravate: (a)Otitismedia(acute or chronic). (b)Pharyngitisandtonsillitis.Hypertrophy of laterallym-phoidbandsbehindtheposteriorpillars(lateral pharyngitis)isindicative of chronic sinusitis.It maybe unilateralandaffectthesideof theinvolvedsinus. Chronic sinusitismayalso causerecurrenttonsillitis or granularpharyngitis. (c)Persistentlaryngitisandtracheobronchitis.Sinusitismay be associated with recurrent laryngitis,bronchiectasis andasthmabutthelatterarenotnecessarilycaused bysinusitis. E.FOCALINFECTIONS Theroleof sinusinfectiontoactasfocusof infectionis doubtful.Afewconditions suchaspolyarthritis,tenosyn-ovitis,fibrositisandcertainskindiseasesmayrespondto eliminationofinfectioninthesinuses.However,sinus infection,ifpresentinthesecases,istreatedonitsown merit. 191 192 NEOPLASMSOFNASALCAVITY Bothbenignandmalignanttumoursof thenasalcavity (Table39.1)per seareuncommon.Veryoften their sep-arationfromtumoursofparanasalsinusesisdifficult exceptinearlystages.Inadditiontoprimarytumours, nasalcavitycanbeinvadedbygrowthsfromparanasal sinuses,nasopharynx,cranial or buccalcavity. Benignlesionsareusuallysmooth,localisedandcov-ered with mucous membrane.Malignant ones areusually friable,haveagranular surfaceandtendtobleedeasily. BENIGNNEOPLASMS 1.Squamouspapilloma.Verrucouslesionssimilarto skinwarts can arisefromthenasalvestibuleorlowerpart of nasal septum.They maybe singleor multipl e,peduncu-latedor sessile.Treatment islocal excisionwith cauterisa-tionof thebasetopreventrecurrence.Theycanalsobe treatedbycryosurgeryor laser. 2.Invertedpapilloma(Transitionalcellpapilloma or Ringertz tumour).It isso-named becausemicroscop-icallyneoplasticepitheliumisseentogrowtowards underlyingstromaratherthanonthesurface.Mostly seenbetween40-70yearswithmalepreponderance (5: 1).It arisesfromthelateralwallof noseandisalways unilateral.It presents asred or greymasseswhich maybe translucentandoedematous,simulatingsi mplenasal polypi.Invertedpapillomahasamarkedtendencyto recuraftersurgica lremovalandmaybeassociatedwith squamouscellcarcinomain10-15%ofpatients. Treatmentiswidesurgical excisionbylateralrhinoromy ormedialmaxi llectomy andenbloc ethmoidectomy. 3.Pleomorphicadenoma.Raretumour,usuallyarises fromthenasal septum.Treatment is wide surgical excision. Table39.1Tumoursof nasalcavity Benign Squamouspapilloma Invertedpapilloma Schwannoma Meningioma Haemangioma Chondroma Angiofibroma Encephalocele Glioma Dermoid Malignant Carcinoma - Squamouscellcarcinoma - Adenocarcinoma Malignantmelanoma Olfactoryneurobl astoma Haemangioperi cytoma Lymphoma Solitaryplasmacytoma Varioustypesofsarcoma 4.Schwannoma andmeningioma.They areuncom-montumourswhich arefoundintranasally.Treatmentis surgical excisionbylateralrhinotomy. 5.Haemangioma.It maybe: (a)Capillaryhaemangioma(Bleedingpolypusofthesep-tum).Itisasoft,darkred,pedunculatedorsessile tumourarisingfromanteriorpartofnasalseptum (Fig.39.1).Usuallyitissmoothbutmaybecome ulceratedandpresentwithrecurrentepistaxisand nasalobstruction.Treatment islocalexcisionwitha cuff of surrounding mucoperichondrium. (b)Cavernoushaemangioma.It arisesfromtheturbinates onthelateralwallof nose.Itistreatedbysurgical excisionwithpreliminarycryotherapy.Extensive lesions mayrequire radiotherapy and surgical excision. 6.Chondroma.It canarisefromthe ethmoid,nasal cavityornasa lseptum.Purechondromasaresmooth. firmandlobulated.Othersmaybemixedtypefibro-. osteo-,orangiochondromas,Treatmentissurgicalexci-sion.For recurrent or largetumours,wide excision shoul d bedonebecause of their tendencytomalignant transfor-mation afterrepeatedinterference. 7.Angiofibroma.Itisincludedinnasaltumour, becauseitsprimarysite of originissupposedtobeposte-rior part of nasa l cavity near the sphenopalatine foramen (seepage230). 8.Intranasalmeningoencephalocele.Itisherniation of brain tissuesandmeningesthroughforamen caecumr cribriform plate.It presentsasa smooth polypinthe upper partof nosebetweentheseptumandmiddleturbinate usuallyininfants and young children.Themassincreases in sizeon crying or straining.Unless careistaken,itrna ' Fig.39.1Bleedingpolypusarisingfromrightsideof nasalseptum. :I ,r :r :s y be misdi agnosedasa simple polyp and mistakenly avulsed, resultinginCSF rhinorrhoeaormeningitis.Forthesame reasonbiopsyshouldnot betaken. CT scanisto demonstrateadefectinthebaseofskull.Treatmentis frontalcraniotomy,severingthe stalk fromthebrflin,and repair of dural andbony defect.Intranasal massisremoved assecondaryprocedure after cranial defect hassealed. 9.Gliomas.Of allthegliomas,30%areintranasal and10%bothintraandextranasal.Theyareseenin infantsandchildren.Anintranasal gliomapresenrs asa firmpolypsometimesprotruding at the anteriornares. 10.Nasaldermoid.Itpresentsaswideningof upper partofnasalseptumwithsplayingofnasalbonesand hypertelorism.Apit or a sinus maybe seen inthe midline of nasaldorsumwithhair protruding fromthe opening. MALIGNANTNEOPLASMS 1.Carcinomaofnasalcavity.Primarycarcinoma per seisrare. Itmaybean extension of maxi llaryor eth-moidcarcinoma. Squamous cell varietyisthemost com-mon,seeninabout80%of cases.Restmaybeadenoid cysticcarcinoma or an adenocarcinoma. (a)Squamouscellcarcinoma.Itmayari sefromthe vestibule,anteriorpartofnasalseptumorthelat-eralwallof nasalcavity.Mostof themareseenin men past50years of age. (i)Vestibular:Itarisesfromthelateralwallof nasalvestibuleandmayextendintothecol-umella,nasalfloorandupperlipwithmeta-stasestoparotidnodes. (ii)Septal: Mostly arises frommucocutaneous junc-tionandcausesburningandsorenessinthe nose.It hasoften beentermedas"nose-picker's cancer". Usually,itisof lowgrademalignancy. (iii)Lateralwall:Thisisthesitemostcommonly involved.Easilyextendsintoethmoidormax-illarysinuses.Grossly,itpresentsasapolypoid massinthelateralwallof nose. Metastases are rare. Treatment iscombination of radiotherapy andsurgery. (b)Adenocarcinomaandadenoidcysticcarcinoma.They arise fr omthe glands of mucousmembrane or minor salivaryglands andmostlyinvolveupperpart of the lateral wallof nasal cavity. 2.Malignantmelanoma.Usuall yseeninpersons about50yearsofage.Bothsexesareequallyaffected. Grossly,itpresentsasaslaty-greyorbluish-blackpoly-poidmass.Withinthe nasalcavity,mostfrequentsiteis anteriorpartofnasalseptumfoll owedbymiddleand inferiorturbinate.Amelanoticvarietiesarenonpig-mented. Tumour spreads bylymphatics and blood stream. Cervicalnodalmetastasesmaybepresentatthetime NEOPLASMSOFNASALCAVITY Fig.39.2RhabdomyosarcomaofthenoseIna21/2 -yearsoldmalechild. of initialexamination.Treatmentiswidesurgicalexci-sion.Immunologicaldefences of thepatient playa great roleinthecontrolofthisdisease.Radi otherapyand chemotherapysuppresstheimmuneprocessesandare avoided.Afive-yearsurvivalrateof30%canbe expectedafter surgical excision. 3.Olfactoryneuroblastoma.Itisatumourof olfac-toryplacode seen in persons of either sexat any age group. Itpresentsasacherryred,polypoidalmassintheupper third of thenasal cavity.It is avascular tumour andbl eeds profuselyonbiopsy.Lymphnodeorsystemicmetastases canoccur.Thetumourismoderatelyradiosensitiveand hasbeencuredbyradiationalone.Presently,favoured treatmentissurgical excision followedbyradiation.Cran-iofacialresectionmayberequiredfortumoursof thecrib-riformplate. 4.Haemangiopericytoma.It isararetumour of vas-cular origin.It arises from the pericyte-a cell surrounding the capillaries.It isusually seen in the agegroup of 60-70 andpresentswith epistaxis.Briskbleedingmayoccur on biopsy.Thetumourmaybebenignormalignantbutit cannot bedistinguished histologically.Treatment iswide surgicalexcision.Radiotherapyisusedforinoperableor recurrentlesi ons. 5.Lymphoma.Rarelyanon-Hodgkinlymphoma presents onthe septum. 6.Plasmacytoma.Solitaryplasmacytomawithout generalisedosseousdiseasemaybeseeninthenasal cavity.Itpredominantlyaffectsmalesover40years. Treatment isbyrad iotherapy followedthree months later bysurgeryiftotalregressiondoesnotoccur.Long-term followupisessenti al to exclude development of multiple myeloma. 7.Sarcomas.Osteogenicsarcoma,chondrosarcoma, rhabdomyosarcoma(Fig.39.2), angiosarcoma,malignant histi ocytoma areotherraretumoursaffecting thenose. 193 DISEASESOFORAL CAVITY AND SALIVARYGLANDS 41.Anatomy of OralCavity201 42.CommonDisordersof OralCavity202 43.Tumoursof OralCavity208 44.Non-neoplasticDisordersof Salivary Glands216 45.Neoplasms of Salivary Glands218 III THIS Page is intentionally kept Blank194 NEOPLASMSOFPARANASAL SINUSES Paranasalsi nusesmaybeaffectedbybothbenignand malignantneoplasmsbutthelatteraremuchmore common. BENIGNNEOPLASMS Osteomas.Theyaremostcommonlyseeninthe frontal sinus followedin tum bythose of ethmoid and max-illary.Theymayremainasymptomatic,beingdiscovered incidentallyonX-rays(Fig.40.1) . Treatmentisindicated whentheybecomesymptomatic,causingobstructionto thesinusostium,formationof mucocele,pressuresymp-toms duetotheir growthinthe orbit,noseor cranium. Fibrous dysplasia.In this cond ition, boneisreplaced byfibroustissue;mostlyinvolvesmaxillarybutsome-timestheethmoidandfrontalsinuses.Patientseeks advicefordisfigurementoftheface,nasalobstruction anddisplacementoftheeye.Treatmentissurgicalres-culpturingof theinvolvedbonetoachieveagoodcos-meticand functionalresult(Fig.40.2). Ossifyingfibroma.Seeninyoungadults.The tumour canbeshelled out easily. Ameloblastoma(adamantinoma).Itisalocallyaggres-sivetumourthatarisesfromtheodontogenictissueand invadesthe maxillary sinus. Treatmentissurgical excision. Otherraretumoursincludeinvertedpapilloma,menin-giomaandhaemangioma(seeChapter 39). AB MALIGNANTNEOPLASMS Incidence.Cancer of noseand paranasal sinuses con-sti tutes0.44%ofallbodycancersinIndia(0.57%in Fig.40.1Osteomaright frontalsinus(arrow). Fig.40.2Fibrousdysplasiaof maxillaina13-years-old girl.(A)Asseenexternally.(B)Afterretractionof thelip. NEOPLASMSOFPARANASALSINUSES ~ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ~ - - - - - - - - - - - - - - - - - - - - ~ malesand0.44%infemales).Itsincidenceduringthe sameperiod(year2000)was0.3per100,000persons."' Mostfrequentlyinvolvedarethemaxillarysinusesfol-lowedinturnbyethmoids,frontalandsphenoid. Aetiology.Causeofsinusmalignancyislargely unknown.Peopleworkinginhardwoodfurnitureindus-try,nickelrefining,leatherworkandmanufactureof mustardgashaveshownhigherincidenceofsinunasal cancer.Cancerofthemaxillarysinusiscommonin Bantusof South Africawherelocallymade snuff isused, whichisfoundrichinnickelandchromium. Workersoffurnitureindustrydevelopadenocarci-nomaoftheethmoidsanduppernasalcavity,while thoseengagedinni ckelrefininggetsquamousce lland anaplastic carcinoma. Histology.Morethan 80%of themalignant tumours areof squamouscelivariet y.Restareadenocarcinoma, adenoidcysticcarcinoma,melanomaandvari oustypes of sarcomas. Carcinomaof Maxillary Sinus It arisesfromthesi nusliningandmayremainsilent for along timegivi ng onlyvaguesymptomsof "sinusitis".It thenspreadstodestroythebonyconfi nesof themaxil-larysinusandinvadesthesurrounding structures. Clinical Features(Fig.40.3) Diseaseiscommonin40-60 agegroupwithpreponder-anceinmales. Earlyfeaturesof maxill arysi nusmalignancyarenasal stuffiness,blood-stainednasaldischarge,facia lparaes-thesiasorpainandepiphora.Thesesymptomsmaybe missedor simplytreatedassinusitis. Latefeatureswilldependonthedirectionof spread and extent of growt h. Medialspread.to nasal cavity givesrisetonasal obstruc-tion, discharge andepistaxis.It mayalso spreadintoante-riorandposteriorethmoidsinusesandthatiswhymost antralmalignancies areantroethmoidal innature. Anteriorspreadcausesswellingof the cheekandlater invasion of thefacialskin. Infel10rspread causes expansion of alveolus with dental pain,looseni ng of teeth, poor fitting of dentures,ulcerat ion of gingivaand swellinginthe hardpalate. Superiorspreadinvadestheorbitcausingproptosis, diplopia,ocularpainandepiphora. Posteriorspreadisintopterygomaxi ll aryfossa,ptery-goidplates andthe muscles causing trismus.Growthmay alsospreadtothenasopharynx,sphenoidsinusandbase of skulL Intracranialspread can occurthroughethmoids,cribri-formplate or foramenlacerum. Lymphaticspread.Nodal metastases areuncommon and occuronlyinthelatestagesof disease.Submandibular andupper jugular nodes are enlarged.Maxillary and eth-moidsinusesdrainprimarilyintoretropharyngealnodes, butthesenodesareinaccessibletopalpation. Systemicmetastasesarerare.Maybeseeninthelungs (most commonly)andoccasionallyinbone. Diagnosis Radiographof sinuses.Opacity of theinvolved sinus with expansionanddestruction of thebonywalls. CTscan.Ifavail able,thisisthebestnon-invasive methodto findtheextent of disease.CT scanshouldbe donebothinaxialandcoronalplanes.Italsohelpsin thestagingof disease. Biopsy. If growth presents inthe nose or mouth, biopsy canbeeasilytaken.Inearl ycases,withsuspicionof malignancy,si nusshouldbeexploredbyCaldwell -Luc Fig.40.3Antroethmoidalcarcinomaleft side.Note(A)Swellingof left cheek,(8)Expansionof alveolusandpalate. '" NationalCancer Regi stryProgramme.IndianCouncil of Medical Research,April2005. 195 DISEASESOFNOSEANDPARANASAlSINUSES ~ - - - - - - - - - - - - - -196 operation.Direcrvisualisationof[hesiteoftumourin the sinusalsohelpsinstagingof thetumour. Endoscopyof thenoseandmaxillarysinuswillprovide detailed examination. An accurate biopsy can also betaken. Classification Thereisno universallyacceptedclassificationformaxil-larycarcinoma. Ohngren's line -'Hf----Infroslructure Fig.40.4Ohngren'slineextendsfrommedialcanthus of eye to theangleofmandible.Growthsanteroinferior tothisplane(infrastructural)haveabetterprognosis thanthoseposterosuperior toit(suprastructural) . 1.Ohngren's classification.An imaginaryplaneisdrawn, extendingbetweenmedialcanthusof eyeandthe angle of mandible (Fig.40.4). Growths situated above thisplane(suprastructural)haveapoorerprognosis thanthosebelowit(intrastructural). 2.AlCC(AmericanJointCommitteeonCancer)classi-fication.(Tables40.1to40.3) .AJCCclassification isonlyforsquamouscellcarcinomaanddoesnot includenon-epithelialtumoursoflymphoid tissue,softtissue, cartilageandbone.Histopatholo-gically,squamouscellcarcinomaisfurthergraded into: (a)Well differentiated (b)Moderately differentiatedand (c)Poorly differentiated Inhistopathology,note shouldalsobemadeof vas-cular or perineuralinvasion. 3.Lederman's classification(Fig. 40.5).It usestwohori-zontallinesofSebileau;onepassingthroughthe floorsof orbits andthe other throughfloors of antra, thusdividingtheareainto: (a)Suprastructure:Ethmoid,sphenoidandfrontal sinusesandthe olfactoryarea of nose. (b)Mesostructure: Maxillarysinusandtherespira-torypart of nose. Table40.1TNM classificationand stagingsystemof cancer ofmaxillary sinus Maxillarysinus T1Tumourlimited tomaxillarysinusmucosawi thnoerosionor deslructionofbone T2Tumourcausingboneerosionor destructionincludingextensionintothehardpalateand/or middlenasalmeatus, exceptextension10posteriorwallofmaxillarysinusandplerygoidplates T3Tumourinvadesanyof thefollowing:boneof theposterior wallofmaxillarysinus,subculaneoustissues,flooror medialwallof orbit,pterygoidfossaandethmoidsinuses T 40Tumourinvadesanterior orbilalcontenls,skinof cheek,plerygoidplates,infratemporalfossa,cribriformplate, sphenoidor fronlalsinuses T4bTumour invadesanyof thefollowing:orbitalapex,dura,brain,middlecranialfossa,cranialnerves other Ihan maxillarydivisionof trigeminalnerve(V2),nasopharynxor clivus Regionallymphnodes(N) Nx Regionallymphnodescannotbeassessed NoNo regionallymphnodemetastasis N1Melastasisinasingleipsilaterallymphnode,3 cmor lessingreatestdimension N2Metastasisinasingleipsilaterallymphnode,more Ihan3cmbutnotmorethan6cmingrealestdimension;or in multipleipsilaterallymphnodes,nonemorethan6cmingreatestdimension;or inbilateralor contralaterallymph nodes,nonemorethan6cmingreatestdimension N20Metastasisinasingleipsilaterallymphnode,morethan3 cmbutnotmorethan6cmingreatestdimension N2b Metastasisinmullipleipsilaterallymphnodes,nonemoreIhan6cmingreatesldimension N2cMetastasisinbilateralor conlralaterallymphnodes,nonemorethan6cmingreatestdimension N3Metastasisinalymphnode,more than6cmingreatestdimension Distantmetastasis(M) MxDistantmelastasiscannotbeassessed MoNo dislantmetastasis M1Distantmetastasis 'Source:AJCC,Cancer StagingManual,fiflhed.Chicago,2002. (c)Infrastructure:Containingalveolarprocess.This classificat ion further uses vertical lines, extending downthemedialwallsof orbittoseparateeth-moidsinusesandnasal fossafromthemaxillary sinuses. Thestudentmaynoteherethatsuprastructureand infrastructure of Lederman's classification is not the same asin Ohngren's classificat ion. Treatment Histologically,natureofmali gnancyisimportantin decidingthelineoftreatmentasisthelocationand extent of disease. Forsquamous cellcarcinoma,a combination of radio-therapy and surgery gives better resultsthan either alone. Radiotherapycanbegivenbeforeoraftersurgery.Very often,afullcourseofpre-operat ivetelecobalttherapyis given,followed4-6weekslaterbysurgicalexcisionof the growthbytotalor extendedmaxillectomy(Figs40.6 and40.7A,B). Table40.2Stagegroupingofcancerofmaxillary andethmoidsinuses StageI StageII StageIII StageIV A StageIVB StageIV C TlNo Mo T2NoMo T3No Mo TIor T2or T3withNIMo T4NoMo T4NIMo AnyT N2Mo AnyTN3 Mo AnyT AnyNM j Regionallymphnodesanddistantmetastasis.Theyaredivided intheusualmanner intoNo,NI,N2 &N3(seepage213)and Mo,MI' Table40.3Classificationofcancerofnasalcavity andethmoidsinuses(AJCC,2002) TITumourrestrictedtoanyonesubsite,withor without bonyinvasion T 2Tumourinvadingtwosubsitesinasingleregionor extending10invol veonadjacentI'egionwithinthe nasoethmoidalcomplex,withor withoutbonyinvasion T3Tumourextendstoinvadethemedialwallor floor of theorbit,maxillarysinus,palateor cribriformplate T40 Tumourinvodesanyofthefollowing:anterior orbitalcontents,skinof noseor cheek,minirnal extensiontoanterior cronialfossa,pterygoidplates, sphenoidor frontalsinuses T4bTumour invadesanyof thefollowing:orbitalapex, duro,brain,middlecranialnervesother than(Y21, nasopharynxorcl ivus NEOPLASMSOFPARANASALSINUSES Prognosis Overall,5-yearscurerateof30%canbeexpected. However,thepresent concept of multimodaltreatment, i.e.combining chemotherapy,radiationandsurgerywill furtherimprovetheresults. EthmoidSinusMalignancy Ethmoid sinuses areoften involved fromextension of the primarygrowthsof themaxillarysinus.Primarygrowth of ethmoidsinusesper searenot common. ClinicalFeatures Earlyfeaturesincludenasalobstruction,blood-stained nasaldischargeandretro-orbital pain. Latefeaturesare:broadening of the nasalroot,lateral displacementof eyeballanddiplopia(Fig.40.8).Exten-sionthrough cribriformplatemaycausemeningitis. Nodal involvement is not common. Upper nodes may beinvolved. Suprastructure Meso structure Infrastructure Fig.40.5Lederman'sclassification. Orbit Fig.40.6Weber-fergusson'sinCISionusedInmaxil-lectomy. 197 198 DISEASESOFNOSEANDPARANASALSINUSES B Fig. 40.7(A)Maxillectomy with orbital exenteration on the right side.(8)Samepatient after rehabilitation with amax-illary prosthesisandanartificialeye. Fig.40.8Carcinomaethmoid. Treatment CT scanisessentialtoknowtheextentof diseaseand intracranial spread. Inearlycases,treatmentispre- operativeradiation, followedbylateralrhinotomy andtotal ethmoidectomy. If cribriformplateisinvolved,anterior cranialfossais exposedbyaneurosurgeonandtotal exenteration of the growthinonepieceisaccomplishedbywhatiscalled craniofacialresection. Prognosis Five-years-curerateof about30% can be expected. FrontalSinusMalignancy Frontal sinusmalignancies areuncommon andareseenin the age group of 40-50 years with male predominance (5: 1). ClinicalFeatures Pain and swe lling of the frontalregion are the presenting features.Growthsmayerodethroughthefloorof frontal sinus and present asa swelling above the medial canthus. Growthsoffrontalsinusmayextendthroughtheeth-moidsintotheorbit.Duraof anteriorcranialfossamay beinvolvedif growth penetrates the poste rior wall of the sinus. Treatment Frontalsinusmalignancyistreatedbypre-operative radiationfollowedbysurgery.Surgeryincludesfrontal sinusectomywithethmoidandorbitalexenteration. Neurosurgicalapproachmayberequiredtoresectthe duraof anterior cranialfossa,ifinvolved. SphenoidSinusMalignancy Primarymalignancyof the sinusisrare.Ithastobedif-ferentiatedfromtheinflammatorylesionsinthisarea. Plain X-rays, CT scan and biopsythrough sphenoidotomy areessentialtoknowthenatureandextentof disease. Radiotherapyisthemainstayof treatment. ANATOMYOFORALCAVITY AppliedAnatomy Theoralcavityextendsfromthelipstotheoropharyn-gealisthmus,i.e.uptothelevel of anterior pillar of ton-sils.Itis di videdinto the foll owing sites(Fi g. 41.1): 1.Lips.Theyformanteri orboundaryoftheoral vestibu Ie. 2.Buccalorcheekmucosa.Itlinestheinner surface of cheeksandlips andextends uptopterygomandi-bularraphe.Anteriorly,itextendstothemeeting lineof lips. 3.Gums(gingivae). They surroundtheteeth andcover theupper andloweralveolarridges. 4.Retromolar trigone.It is a tri angular area of mucosa coveringanteriorsurfaceoftheascendingramusof mandible.Itsbaseisposterior to the last molar while itsapexisadjacent tothetuberos ityof maxilla. 5.Hardpalate.Itformsroof of theoral cavity. 6.Oraltongue. Only anterior t wo- thirds of tongueare includedintheoralcavity.Posteri orone-thirdor baseoftongueissituatedbehindthecircumvallate papillaeandformspartoftheoropharynx.Oral tongueisdi videdintotip,lateralborders,dorsum andtheundersurface. 7.Floor of mouth.It isacrescent-shapedareabetween thegingivaeandundersurfaceoftongue.Anterior portionof thefloorisbestseenwhenpatientraises thetipof tonguetotouchthehardpalate.Frenulum andsublingualpapillaewithopeningsofsub-mandibularductscanbeeas ilyseen.Lateralportion of floor of mouthis best seenby displacing the lateral surfaceof tongueinmedial directionwiththe help of atongue depressor. LymphaticDrainageof OralCavity 1.Lips.Lower:Medi alportionoflowerlipdrainsinto submental andlateral portion to submandibular nodes. Upper:Drainintopreauricular,infraparotidandsub-mandibular nodes. 2.Buccalmucosa.Submentaiandsubmandibular nodes. 3.Upperandloweralveolarridges.Buccalaspectof mucosadrainsintosubmentalandsubmandibular nodes. Lingual aspect of upper alveolus drains into upper deepcervical andlateralretropharyngealnodes. Lingualaspectof loweralveolusdrainsintosub-mandibul arnodes. 4.Hardpalate.Upperdeepcervicalandlateral ret ropharyngealnodes.Anteriorpartofpalate drainsinto submandibular nodes. 5.Floor of mouth.Anteri or portion of fl oor of mouth drainsintosubmandibularnodes.Lymphaticsfrom thi s areaalsocrossthemidline. Posteri orportiondrainsintoupperdeepcerv ical nodes. 6.Tongue.Tipoftonguedrainsintosubmentaland jugulo-omohyoidnodes;lateralportiondrainsinto ipSil ateral,submandibularanddeepcervicalnodes. CentralportionanJhaseJrainintoJeepcervical nodes of bothsides. Li P - ------,JiIC'--Buccalmucasa h ; ~ - - : : : : ~ ~ ~ ~ - : -- Hardpalat e Retromolar trigone mout h Fig.41.1Varioussitesinoralcavity. 201 202 COMMONDISORDERSOF ORALCAVITY UlcersofOralCavity Someofthecommonulcersaredescribedinthischap-ter.Thecausesoftheulcersof oralcavityarelistedin Table42.1. Infection Herpangina.Itisacoxsackieviralinfectionmostly affecting children. To beginwith,multiple smallvesicles appearonthefaucialpillars,tonsils,softpalateand uvula.Theyrupturetoformulcerswhichareusually 2-4 mminsize,have a yellowbaseandredareola around them.They seldompersistbeyondoneweek. Herpeticgingivostomatitis.Alsoknownasorolabial herpes.Itiscausedbyherpes simplexvirusandisof two types:primary andsecondary. Theprimaryinfectionaffectschildrenandischarac-terisedbyclusters of multiplevesicles which soon rupture to formulcers.Any part of the oral cavity may beaffected. Constitutional symptoms like fever,malaiseandheadache mayaccompany sorethroat andlymphadenopathy. Secondaryor recurrentherpes chieflyaffectsadults.Itis milder informasadults have someimmunity to thisvirus. Mostcommonly,itinvolvesthevermilionborderof the lip (herpes labialis)but lessoften lesions appear intraorally onthehardpalateandgingiva.Inrecurrentherpes,itis Table42.1Cousesof ulcersof theorolcavity 1.Infections (i)Viral:Herpan