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What is the treatment? Surgical resection, radiation therapy for poor operative candidates or for recurrences

NOSE AND PARANASAL SINUSES

EPISTAXIS

What is it?

Bleeding from the nose

What are the predisposing Trauma, “nose picking,” sinus infection, factors? allergic or atrophic rhinitis, blood

dyscrasias, tumor, environmental extremes (hot, dry climates; winters)

What is the usual cause?

Rupture of superficial mucosal blood vessels (Kiesselbach’s plexus if anterior, sphenopalatine artery if posterior)

What is the most common type?

Which type is more serious?

Anterior (90%); usually the result of trauma

Posterior; usually occurs in the elderly or is associated with a systemic disorder (hypertension, tumor, arteriosclerosis)

What is the treatment? Direct pressure; if this fails, proceed to anterior nasal packing with gauze strips, followed if necessary by posterior packing with Foley catheter or lamb’s wool; packs must be removed in 5 days to prevent infectious complications

What is the treatment of last resort?

What infectious disease syndrome is seen with nasal packing?

What is the treatment of this syndrome?

Ligation or embolization of the sphenopalatine artery (posterior) or ethmoidal artery (anterior)

Toxic shock syndrome: fever, shock, rash caused by exotoxin from Staphylococcus aureus

Supportive with removal of nasal packing, IV hydration, oxygen, and antistaphylococcal antibiotics

Chapter 70 / Otolaryngology: Head and Neck Surgery 601

ACUTE RHINITIS

What is it?

What is the most common cause?

Inflammation of nasal mucous membrane

URI infection; rhinovirus is the most common agent in adults (other nonallergic causes: nasal deformities and tumors, polyps, atrophy, immune diseases, vasomotor problems)

ALLERGIC RHINITIS

What are the symptoms?	Nasal stuffiness; watery rhinorrhea;
	paroxysms of morning sneezing; and
	itching of nose, conjunctiva, or palate
How is the condition	Early onset (before 20 years of age),
characterized?	familial tendency, other allergic disorders
	(eczema, asthma), elevated serum IgE,
	eosinophilia on nasal smear

What are the findings on physical examination?

Pale, boggy, bluish nasal turbinates coated with thin, clear secretions; in children, a transverse nasal crease sometimes results from repeated “allergic salute”

What is the treatment?	Allergen avoidance, antihistamines,
	decongestants; steroids or sodium
	cromylate in severe cases; desensitization
	via allergen immunotherapy is the only
	“cure”
ACUTE SINUSITIS

What is the typical history?

Previously healthy patient with unrelenting progression of a viral URI or allergic rhinitis beyond the normal 5- to 7-day course

What are the symptoms? Periorbital pressure/pain, nasal obstruction, nasal/postnasal mucopurulent discharge, fatigue, fever, headache

602 Section III / Subspecialty Surgery
What are the signs?	Tenderness over affected sinuses, pus in
	the nasal cavity; may also see reason for
	obstruction (septal deviation, spur, tight
	osteomeatal complex); transillumination
	is unreliable
What is the pathophysiology?	Thought to be secondary to decreased
	ciliary action of the sinus mucosa and
	edema causing obstruction of the sinus
	ostia, lowering intrasinus oxygen tension
	and predisposing patients to bacterial
	infection
What are the causative	Up to 50% of patients have negative
organisms?	cultures and cause is presumably
	(initially) viral; pneumococcus, S. aureus,
	group A streptococci, and H. influenzae
	are the most common bacteria cultured
What is the treatment?	14-day course of antibiotics (penicillin G,
	amoxicillin, Ceclor®, and Augmentin® are
	commonly used), topical and systemic
	decongestants, and saline nasal irrigation

What is the treatment for fungal sinusitis?

Fungal sinusitis is commonly caused by Mucor and seen in immunosuppressed patients; treatment is IV antifungals (e.g., amphotericin or caspofungin) and surgical débridement of all necrotic tissue

CHRONIC SINUSITIS

What is it?	Infection of nasal sinuses lasting longer
	than 4 weeks, or pattern of recurrent
	acute sinusitis punctuated by brief
	asymptomatic periods
What is the pathology?	Permanent mucosal changes secondary
	to inadequately treated acute sinusitis,
	consisting of mucosal fibrosis, polypoid
	growth, and inadequate ciliary action,
	hyperostosis (increased bone density on
	CT scan)

Chapter 70 / Otolaryngology: Head and Neck Surgery 603

What are the symptoms?	Chronic nasal obstruction, postnasal drip,
	mucopurulent rhinorrhea, low-grade
	facial and periorbital pressure/pain
What are the causative	Usually anaerobes (such as Bacteroides,
organisms?	Veillonella, Rhinobacterium); also
	H. influenzae, Streptococcus viridans,
	Staphylococcus aureus, Staphylococcus
	epidermidis
What is the treatment?	Medical management with decongestants,
	mucolytics, topical steroids, and
	antibiotics; if this approach fails, proceed
	to endoscopic or external surgical
	intervention
What is FESS?	Functional Endoscopic Sinus Surgery
What are the complications	Orbital cellulitis (if ethmoid sinusitis),
of sinusitis?	meningitis, epidural or brain abscess
	(frontal sinus), cavernous sinus thrombosis
	(ethmoid or sphenoid), osteomyelitis
	(a.k.a. Pott’s puffy tumor if frontal)

CANCER OF THE NASAL CAVITY AND PARANASAL SINUSES

What are the usual	Maxillary sinus (66%)
locations?	Nasal cavity
	Ethmoid sinus
	Rarely in frontal or sphenoid sinuses
What are the associated cell	Squamous cell (80%)
types?	Adenocellular (15%)
	Uncommon: sarcoma, melanoma
What rare tumor arises from	Esthesioneuroblastoma; usually arises
olfactory epithelium?	high in the nose (cribriform plate) and is
	locally invasive
What are the signs/	Early—nasal obstruction, blood-tinged
symptoms?	mucus, epistaxis
	Late—localized pain, cranial nerve
	deficits, facial/palate asymmetry, loose
	teeth

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How is the diagnosis made?	CT scan can adequately identify extent of
	the disease and local invasion; MRI is often
	also used to evaluate soft-tissue disease
What is the treatment?	Surgery with or without x-ray therapy
What is the prognosis?	5-year survival for T1 or T2 lesions
	approaches 70%
JUVENILE NASOPHARYNGEAL ANGIOFIBROMA
What is it?	Most commonly encountered vascular
	mass in the nasal cavity; locally aggressive
	but nonmetastasizing

What is the usual history?

Adolescent boys who present with nasal obstruction, recurrent massive epistaxis, possibly anosmia

What is the usual location?

Site of origin is the roof of the nasal cavity at the superior margin of sphenopalatine foramen

Into what can the mass	Fibrosarcoma (rare cases reported)
transform?
How is the diagnosis made?	Carotid arteriography, CT scan; biopsy is
	contraindicated secondary to risk of
	uncontrollable hemorrhage
What are indications for	None!
biopsy?
What is the treatment?	Surgery via lateral rhinotomy or sublabial
	maxillotomy with bleeding controlled
	by internal maxillary artery ligation or
	preoperative embolization, in the setting
	of hypotensive anesthesia; preoperative
	irradiation has also been used to shrink
	the tumor