Nose and sinuses
SALAH D. SALMAN
The evaluation of sinonasal complaints does not always require training in otolaryngology or the use of sophisticated diagnostic techniques. Some surgical procedures such as incision and drainage of an abscess, nasal packing for epistaxis, or biopsy of a nasal mass, may also be performed safely by non-specialists.
A clinical impression is acquired from history taking, physical examination, laboratory tests, and possibly from diagnostic procedures. Some apparent abnormalities may not be significant: an asymptomatic deviation of the nasal septum may be ignored, even if it is severe, as may asymptomatic sinus mucosal thickening seen on radiographs, CT scans, or MR images.
Sinonasal disease may cause referred pain in the upper teeth, zygoma, temples, or elsewhere in the head. It may also be responsible for unexplained postnasal drip, cough, fever, systemic symptoms, and even recurrent otitis media. The non-specialist therefore needs some knowledge of the nose and the sinuses.
The symptoms of nasal disease include bleeding, anterior and posterior discharge, sneezing, a feeling of congestion or blockage, crusting, and dryness. Nasal pain without trauma is rare and may indicate disease affecting the bony structure.
Absent or decreased sense of smell (anosmia or hyposmia) is usually accompanied by an absence or decrease in taste sensations.
Sinus disease often coexists with nasal disease, and the symptoms may be similar. Additional symptoms of sinusitis include pain in the infraorbital, supraorbital, and/or intercanthal areas, depending on the sinuses involved (maxillary, frontal, or ethmoid). The pain of sphenoid sinusitis may be occipital, frontal, temporal, periorbital, or retro-orbital. Other symptoms include congestion and discharge (thin, purulent, and/or bloody). The pain of sinus disease may also be referred to the upper teeth, gums, or temples.
Opposite mucosal contact, septal deviations or spurs may cause unexplained headaches affecting the forehead, the glabella, the temples, or the occiput.
Fever and systemic symptoms such as fatigue, generalized pains, apathy, and nausea, may be present in patients with acute sinonasal disease or may reflect systemic diseases affecting the sinonasal region, such as Wegener's granulomatosis, sarcoidosis, and polymorphic reticulosis.
The sinonasal disease commonly seen in asthma is the result of the same allergic tendency that causes both, rather than a direct result of the asthma.
Examination starts with observation of any noticeable abnormalities, such as swellings or asymmetry of the face. Mouth breathing suggests nasal blockage. An increase in tearing may indicate an obstruction of the nasolacrimal duct which drains into the inferior meatus in the nose. Lid swelling and exophthalmus indicate spread of the pathology into the orbit.
Palpation for discrete masses and tenderness should be directed mainly over the maxillary and frontal sinuses and over the nose. An eye examination is important to detect possible spread of sinonasal disease into the orbit: pupil size, reaction to light, and testing of eye movements are the minimum requirement.
Intranasal examination should be performed using a nasal speculum and a light source—usually a head mirror or a head light. An otoscope with a large speculum may also be used. The anterior few centimetres of the nose may thus be examined: application of a topical decongestant allows a better view. Although topical anaesthetic administered by spray is sufficient for examination, infiltration anaesthesia is usually required for biopsy and surgery.
Fibreoptic telescopes may be used to inspect, aspirate, and even biopsy the maxillary sinus, approaching from the inferior meatus or the canine fossa. Frontal sinoscopy can be performed through a burr hole in the anterior table. Sphenoid sinoscopy may also be undertaken through the natural ostium or through a sphenoidotomy.
Sinus transillumination is an old technique with limited value because the thickness of tissues varies greatly in different people. In any one patient, however, transillumination of a previously opaque sinus after treatment may indicate drainage of the fluid and improvement.
Plain radiographs of the sinuses are useful for detecting erosions, air–fluid levels, and other opacities. Discrete pathological findings are, however, usually missed. Tomographic cuts allow better visualization with more detail.
CT scans with cuts as thin as 2mm allow a detailed study to be performed in axial and coronal projections. Different windows and centring are used to evaluate soft tissues and bones.
Magnetic resonance imaging (MRI) allows study of the soft tissues and soft tissue lesions, at the expense of bone detail. MRI is not recommended for the routine study of the nose and sinuses.
Ultrasound of the sinuses may help differentiate fluid from solid lesions in a radiologically opaque sinus, but it is unreliable.
Other diagnostic aids include examination of nasal smears for eosinophils: absence of eosinophils, however, does not rule out allergy. Nasal swabs may also be taken for Gram stain and aerobic and anaerobic culture. The results of cultures do not necessarily reflect the organisms responsible for sinusitis, and sinus taps for specimen need to be performed if knowledge of the offending organism is essential.
Biopsy specimens for histological diagnosis may be taken with a cup forceps after topical anaesthesia, with or without infiltration anaesthesia, prior to planning of treatment.
As the number of elderly and immunosuppressed patients increases, and perhaps because of the wide availability and use of antibiotics, the incidence of fungal infection affecting the sinonasal region seems to be increasing. If this is suspected clinically smears should be cultured for confirmation. In some fungal diseases, such as mucormycosis and aspergillosis, a biopsy examination is needed before aggressive surgical and systemic treatments are instituted.
An encephalocele, a term used to include meningocele, meningoencephalocele and meningoencephalocystocele, is a congenital herniation of the intracranial contents secondary to a defect in the base of the skull. It may present externally around the glabellar area of the nose or internally inside the nasal cavity or nasopharynx. The condition may be present at birth or may manifest itself in adult life either as a mass or as recurrent meningitis. If the dural defect through which herniation took place during fetal life closes, gliosis develops and the mass becomes known as a glioma: this is a misnomer since no neoplasia is involved.
A dermoid cyst or tract present along or close to the midline of the nasal dorsum is a remnant of the dural projection that reaches the nasal tip before retracting intracranially during fetal life.
The embryology of encephaloceles, gliomas, and dermoids of the nose needs to be understood because of the surgical implications. Their removal may require intracranial dissection, causing a dural defect, which needs to be closed. Although the closure of defects has been performed through a craniotomy, closure can sometimes be achieved through an external ethmoidectomy or an endoscopic intranasal approach.
Obstructed posterior nasal choanae (choanal atresia) may be bony or membranous. If bilateral, death may ensue shortly after birth, since newborns breathe exclusively through the nose. Bilateral choanal atresia therefore has to be perforated surgically to facilitate nasal breathing. During this procedure the roof of the nasopharynx needs to be protected with a malleable retractor to prevent injury to the base of the skull with the trocar. The new openings need to be stented with tubes or catheters to prevent their closure: careful observation for columellar, alar, or septal pressure necrosis is required.
If the openings narrow with time, or if an older child complains of nasal blockage, new openings need to be made either transpalatally or endoscopically via the transnasal route.
Unilateral choanal atresia may not be diagnosed until later in life; surgical treatment is then undertaken. Constant unilateral nasal discharge that is present from birth and fails to respond to treatment should raise suspicion of atresia. The diagnosis may be confirmed by failure to pass a catheter, by endoscopic examination, by indirect nasopharyngoscopy, and/or by radiological examination with or without a radio-opaque dye instilled in the nose with the patient in the supine position.
Cleft lips are usually associated with various degrees of deformities of the nose, the most common of which involves the nasal tip. Definitive cosmetic surgery is best delayed until the end of the growth period in the late teens.
Congenital anomalies of the sinuses are rare and limited to absence or asymmetry of one or more of the sinuses. They are usually of no clinical significance and are rarely associated with cosmetic deformities.
Rare congenital fissural cysts appear in adulthood. The nasoalveolar (or nasolabial) cysts bulge in the floor of the nose anteriorly under the insertion of the ala of the nose. They are entirely within soft tissue and may cause a depression on the maxilla. They arise from epithelium trapped during the fusion of the globular, lateral nasal, and maxillary processes. They may be left untreated unless they enlarge or become symptomatic.
Globulomaxillary cysts are usually accidentally discovered on radiography, and appear as an inverted pear-shaped radiolucency between an upper lateral incisor and a canine. They are thought to arise from epithelium trapped during the fusion of the maxillary process and the globular part of the medical nasal process. Treatment involves enucleation, following which the defect fills with bone.
Anatomical abnormalities and variants
The shape and size of the nose varies: genetic and racial factors play a role. Minor nasal traumas during active growth have been suspected of being responsible for nasal deformities and septal deviations later in life. The shape and size of a nose whose function is normal can be changed by cosmetic rhinoplasty. If nasal function is abnormal, usually in the form of blockage, a functional septorhinoplasty is recommended. This operation often satisfies both functional and cosmetic requirements.
Septal deviations are common in adults and require surgical attention only if they produce blockage of the nasal airways on one or both sides. Anterior dislocation of the septal cartilage may occasionally be asymptomatic: a cosmetic septoplasty is then recommended.
The bony and/or soft tissue components of the inferior turbinates may be prominent, and may contribute to nasal blockage. Reduction can be achieved by partial turbinectomies, submucous turbinectomies, cauterization, submucosal cauterization, and cryosurgery. No one technique is superior to the other, although submucous turbinectomy avoids the creation of raw areas and the two common complications of turbinate surgery: namely, crusting and bleeding.
A large cellular middle turbinate (concha bullosa) and a middle turbinate with a lateral convexity instead of a medial one (paradoxical turbinate) may occur in asymptomatic individuals. They are thought to be capable of narrowing the middle meatus enough to interfere with the ventilation and drainage of the maxillary and frontal sinuses, and to cause or potentiate sinusitis. The uncinate process may also be large enough to narrow the drainage tract of the maxillary sinus, the so-called infundibulum.
Thin or dehiscent bones in the roof and lateral walls of the ethmoid sinuses and in the cribiform plate area are not uncommon. These are of no clinical importance unless injured by accidents or surgery.
Nasal fractures can usually be managed by closed reduction or manipulation. If the reduction is stable, no support is needed; when required, support can be provided in the form of a cast or a metallic splint applied for approximately 1 week. Radiological confirmation of a fracture may be needed for documentation or medicolegal purposes, but it is not a necessity since the aim of treatment is to restore appearance and function. If these are not affected, fractures need no treatment. Nasal fractures heal within a few weeks. Pain may be a prominent symptom if the nasal cartilages are damaged.
Septal fractures with dislocation and deviation need to be reduced and supported with a nasal pack or septal splints for a few days. Septal haematomas have to be drained and the nasal cavities packed to avoid re-accumulation of blood, secondary infection, abscess formation, necrosis of cartilage, septal perforations, or a saddle deformity of the nasal dorsum.
The diagnosis of other facial fractures is made by clinical and radiological examinations. Plain radiographs may be adequate: but tomographic cuts are better, and CT scans are best for showing fractures and resultant displacements. Facial fractures usually heal very well. The ultimate aim of management is to restore appearance and function, and to prevent immediate or delayed complications. Reduction may be closed or open depending on the site and displacement. If there is instability, immobilization is achieved by interdental fixation or by direct stainless steel wiring. Small compression plates are effective: their use should not be routine, however, but reserved for cases in which stability is at risk and early mobilization is desired. Since restoration of proper dental occlusion is essential, interdental fixation is commonly used in the treatment of facial fractures.
Enophthalmos and diplopia are indications for surgical treatment of blow-out fractures of the orbit floor. Injury to the infraorbital nerve is common in patients with maxillary fractures, and results in cheek numbness. Decompression of the nerve and removal of the bony spicules may hasten or facilitate recovery.
Fractures of the posterior table of the frontal sinus need to be explored, to treat or prevent CSF leaks and possible future meningitis or other intracranial complications.
Nose bleed or epistaxis is a common problem with several causes. Epistaxis may be mild, requiring no active treatment or may be life-threatening. The blood supply of the nasal cavities is rich, arising from both the external and internal carotid arteries. In children, epistaxis is usually more alarming than serious. It usually starts in the anterior aspect of the septum, an area known as Little's area where branches of the sphenopalatine, anterior ethmoidal, superior labial, and greater palatine arteries anastomose, forming the so-called Kiesselbach's plexus. This plexus is more prominent in some people than in others. Its anterior location makes it vulnerable to nose picking and environmental factors such as dryness.
In older people, with or without hypertension or other evidence of arteriosclerotic disease, epistaxis tends to be more severe and to arise from the posterior nasal cavities, so-called posterior epistaxis. The source of bleeding is the sphenopalatine artery, located posterior to the posterior tip of the middle turbinate, or one of its branches. A less common source of posterior epistaxis is one of the ethmoidal arteries, usually the anterior, which is the largest. It is not always possible to identify the site of bleeding in posterior epistaxis, and it may not be wise to spend a lot of time trying since blood loss may be appreciable.
There is no clear-cut definition of anterior versus posterior epistaxis. Anterior tends to be used to refer to bleeding from a site, usually on the septum, which is easily seen, and which can be controlled by an anterior pack. Posterior epistaxis is usually more severe, affects older patients, also presents as bleeding from the throat, and cannot be stopped purely by application of an anterior pack.
Initial treatment of epistaxis should centre on stopping the bleeding. Further examination can be performed later. Following a rapid attempt to identify the bleeding site, packing is applied: application of topical anaesthesia and decongestants will make this more tolerable. General anaesthesia may be required if the patient is unco-operative or difficult.
Other methods of treatment are available in severe, refractory, and selected cases. The internal maxillary artery may be ligated or clipped in the pterygomaxillary space, and the anterior ethmoidal artery may be cauterized through an external ethmoidectomy incision as it leaves the orbit. Selective embolization of the internal maxillary artery is possible.
In patients with hereditary haemorrhagic telangiectasia and recurrent epistaxes, the bleeding vulnerable nasal mucosa can be replaced by a skin graft (septal dermoplasty).
If the bleeding is intermittent or not profuse, more time may be spent on examination, after application of topical anaesthesia and decongestion. If the bleeding site is identified, treatment can be by immediate cauterization or packing: neither method is clearly superior to the other. Bleeding from the anterior septum can be stopped by pinching the nose between the thumb and the index finger for 5 to 10 min. Cautery may use chemical (silver nitrate sticks or trichloracetic acid on a small cotton applicator), thermal (hot metal), or electric means; a suction cautery is convenient.
If bilateral or posterior packing is required, especially in older patients, admission to hospital is advisable for monitoring of respiratory function: a pulse oximeter should be used. If hypoxaemia occurs oxygen, orotracheal intubation, or even a tracheotomy may be required. Sedatives and respiratory depressants should be used cautiously in patients with bilateral nasal packs and poor or borderline pulmonary or cardiac function.
Once the acute episode is over, a thorough examination should be performed to try and establish the cause. A detailed history needs to include questions relating to a history of trauma (nose picking, surgical, falls, etc.), bleeding tendency in the patient or the family, sinonasal infection, nasal blockage, associated symptoms (snoring, diplopia, cheek numbness), or systemic symptoms (fever, fatigue, poor appetite, jaundice). Examination may disclose ecchymoses, suggesting a bleeding disorder, lip and tongue telangiectasia of hereditary hemorrhagic telangiectasia, or the pallor of severe anaemia. Intranasal examination may be performed with the nasal speculum and head light. A deeper examination of the nasopharynx is possible with a flexible fibreoptic scope or a rigid scope. Such potentially traumatic examinations should not be undertaken while bleeding is active.
Haematological studies need to be undertaken in patients with recurrent epistaxis of unknown aetiology. These should include a complete blood count, a platelet count, prothrombin time, partial thromboplastin time, and bleeding time.
Plain radiographs may show large tumours or large erosions, but a CT scan or MRI may be required to detect smaller areas of pathology. If the site of bleeding needs to be known accurately, angiography should be performed.
Juvenile nasopharyngeal angiofibromas are histologically benign tumours that invade the contiguous areas and may cause mild to severe epistaxis. Other causes of recurrent epistaxis include carcinoma of the sinuses and nasopharynx, and granulomatous diseases such as sarcoidosis, Wegener's granulomatosis, polymorphic reticulosis, scleroma, tuberculosis, and syphilis.
Allergy and infection
The nasal cavities and the sinuses are lined with a pseudostratified columnar ciliated epithelium containing goblet cells. The submucosal layer in the nose includes mucous glands and is richly supplied with blood vessels, the diameter of which is constantly controlled by autonomic nerves.
The secretions in the nose and sinuses form a blanket on top of the ciliated epithelium, and move constantly towards the nasopharynx. This mucociliary blanket traps foreign particles in the inspired air; these are then swallowed along with the mucus. About 300 ml of sinonasal secretions are swallowed every 24 h usually without awareness. The temperature and air-conditioning function of the nose is fulfilled by the blood vessels that dilate when the inspired air is cold. Humidity is controlled by the autonomic regulation of the glands that produce more secretions when the air is dry. In the short time that it takes for the inspired air to reach the pharynx, it is filtered and air conditioned to body temperature and humidified so that it can enter the lower respiratory passages without causing any irritation.
Clinical examination, CT scanning, and MRI show vasodilation on one side of the nose and vasoconstriction on the other: this physiological cycle may allow one side of the nose to ‘rest’, while the other performs the required functions. When this physiological nasal cycle is exaggerated, individuals become conscious of nasal functioning and complain of alternating nasal obstruction. An increase in the amount of nasal secretions to a level beyond the capacity of the mucociliary clearing system causes anterior nasal discharge. When the consistency of the secretions increase and/or their composition and taste change, the individual becomes aware of the normally subconscious act of swallowing: this is known as postnasal drip.
Blockage of the ostia of the sinuses by congestion or other pathological processes interferes with the ventilation of the sinuses and their drainage: sinusitis may then develop. The movement of the mucociliary blanket may be reduced if it is too thick or if the cilia are not beating effectively. Micro-organisms are then in prolonged contact with the underlying cells, which they can then penetrate. The effect of cold on the speed of the mucociliary flow contributes to the higher incidence of respiratory infections in cold seasons.
Upper respiratory tract infections
These infections are usually caused by viruses invading the respiratory epithelium of the nose. An upper respiratory tract infection, or common cold, is the clinical condition in which the symptoms are localized to the nose. If sinus symptoms such as pain and congestion develop, the diagnosis of sinusitis needs to be added. Accompanying systemic symptoms of fever, fatigue, and muscle pains makes the diagnosis of an ‘influenza syndrome’ appropriate. Although the diagnosis is rarely clear, such a simplified classification facilitates the planning and understanding of therapy. Bacterial infection often occurs within a few days of viral infection.
Allergic and vasomotor rhinitis
Allergic rhinitis appears as nasal blockage, clear nasal discharge, sneezing, and nasal itching. It is triggered by a variety of environmental allergens, and tends to occur more in patients with other allergic disorders and with a positive family history of allergy. The serum level of total IgE antibodies is usually increased. Elevated levels of specific IgE antibody may be proven by skin testing or by in-vitro tests such as the radio allergosorbent test.
Vasomotor rhinitis is a clinical syndrome of nasal obstruction, stuffiness, or congestion; these usually alternate. Episodic sneezing and clear rhinorrhoea are characteristically absent. This syndrome may be due to a variety of non-allergic conditions, including changes in temperature and humidity, sympathetic blocking drugs used in the treatment of hypertension (reserpine, propranolol), overuse of vasoconstrictive nose drops, hormonal factors, and even emotional factors.
Although systemic symptoms are usually absent in allergic and vasomotor rhinitis, unless secondary infection develops, their severity and psychological effects may be distressing. In the absence of polyps or secondary infection, the treatment is usually medical. Surgical treatment to correct a septal deviation and to reduce the size of one or more turbinates may also be needed.
Polyps are thought to be caused by nasal allergy, with or without accompanying sinonasal infection. In some cases, however, they seem to occur without any evidence of allergy. The most common sites of origin are the middle meatus and the ethmoid sinuses. Polyps are usually multiple and bilateral, and cause nasal obstruction and anosmia if they prevent the air current from reaching the olfactory areas in the roof of the nasal cavities.
Some polyps arise from the maxillary, frontal, or sphenoid sinuses. They may be asymptomatic and discovered on radiological examination. The antrochoanal polyp arises from the maxillary sinus or ostium. It is single and grows posteriorly towards the posterior choanae, hence its name. It may even fill the nasopharynx completely.
The treatment of polyps is aimed at the underlying cause. Small ones may disappear on medical treatment such as the use of a corticosteroid spray. Larger ones usually require surgical removal. Polyps have a tendency to recur, even after several years and in spite of proper medical treatment. Patients with asthma or with aspirin intolerance are more difficult to cure because of their high tendency to recur.
The simplest surgical treatment consists of polypectomy; the most radical involves cleaning the maxillary sinuses (Caldwell-Luc operation) and external ethmoidectomy.
The current understanding and use of the term ‘sinusitis’ requires better definition. The presence of inflammatory cells on sections is pathological evidence of sinusitis. For a radiologist, soft tissue thickening within the sinuses on plain films, CT scans, or on MRI is evidence of sinusitis, or is at least compatible with such a diagnosis. However, radiological evidence of membrane thickening within the sinuses or inflammatory cells in nasal or sinus specimens is often seen in normal and asymptomatic patients.
Acute sinusitis is clinically well defined and not difficult to diagnose. Chronic sinusitis is not so well clinically defined. Its presenting symptoms may be only a postnasal drip or cough. Acute sinusitis is often accompanied by systemic symptoms (fever, fatigue, toxicity); local symptoms depend on the sinuses involved. Pain in the frontal area suggests frontal sinusitis; pain below the eyes suggests maxillary sinusitis; and pain between the eyes suggests ethmoid sinusitis. Sphenoid sinusitis usually produces pain behind the eyes or in the occipital area.
In chronic sinusitis, systemic symptoms are usually lacking. The symptoms may include nasal discharge, anterior and/or posterior nasal stuffiness, pressure, facial pains, cough (especially in children), and even recurrent otitis media. Local tenderness is present less often than in acute sinusitis. Congestion of the mucosa and discharge may be seen in the nose or in the nasopharynx. Radiographic studies are not required, unless doubt exists about the diagnosis, or documentation is required. Radiography should certainly be performed prior to surgery. Plain films demonstrate air–fluid levels well, but they may miss discrete pathology. CT scans are superior, especially for evaluation before surgery.
The results of nasal cultures do not necessarily reflect the organisms responsible for sinusitis: sinus taps are necessary if knowledge of the exact offending organism is important. Otherwise, empirical antibiotic treatment is instituted depending on the prevalent local organisms.
The treatment of sinusitis aims at the offending organisms, and at the underlying cause if any (allergy, septal deviations). Local and systemic decongestants are supposed to widen the passages for better sinus drainage and ventilation. Symptomatic treatment will make the patient feel better until the disease process is reversed.
Most cases of sinusitis are amenable to medical treatment. If this fails or if the patient suffers recurrence of acute attacks in spite of proper treatment, surgical intervention becomes necessary (see below).
The incidence of fungal sinusitis is increasing for many reasons, including the widespread use of antibiotics, the poor immune function in an increasingly elderly population, the increasing number of patients on immunosuppressive treatment, and the advent of AIDS. Aspergillus is the most common cause of fungal sinusitis: infection follows inhalation of spores of this ubiquitous soil saprophyte. Mucormycosis usually affects patients with debilitating diseases or depressed immune systems. Candida species are normal commensal organisms and rarely infect the nose and the sinuses. Amphotericin B remains the most effective treatment for invasive fungal infections. Histological proof of invasion must be obtained prior to its use.
Non-invasive fungal balls discovered in the sinuses at surgery require removal, debridement, and follow-up only. Topical nystatin may be used if Candida is the offending fungus.
Tumours of the nose and sinuses are considered together: sinus tumours frequently present with nasal symptoms, and the exact site of origin of the tumour may not be found.
The most common benign tumours are the osteomas, which are usually discovered on routine radiographic studies. Surgical treatment is required only if they grow and produce deformity or if they obstruct sinus drainage. Ossifying fibromas or fibrous osteomas may be hard to differentiate histologically from fibrous dysplasia. Haemangiomas, chondromas, minor salivary gland tumours, odontogenic tumours, lipomas, and angiolipomas may also occur in the nose. Juvenile nasopharyngeal angiofibroma is a histologically benign tumour which affects adolescent males. It may grow anteriorly and present with nasal symptoms. An inverted papilloma may be considered a benign neoplasm, although it may prove to be an inflammatory response to a virus.
Individuals with a history of occupational exposure to nickel and wood dust have a higher incidence of carcinomas of the nose and sinuses. Squamous cell carcinoma is the most common malignant tumour. All varieties of adenocarcinomas of minor salivary gland origin have been reported. Uncommon tumours include chondrosarcomas and malignant melanomas. Olfactory esthesioneuroblastoma, a tumour, arising from the olfactory neuroepithelium, is also rare.
Metastases from breast, kidney, and lung carcinomas have been reported, but are very rare.
Involvement of the nose and sinuses in acute systemic infection is common, and presents with the non-specific symptoms of congestion and discharge. Chronic systemic infections may also manifest themselves in the nose and sinuses, alone or with other sites. They may produce crusting, bleeding, discharge, and deformity.
Intranasal tuberculosis may or may not be associated with pulmonary disease. The nasal mucosa becomes thickened and ulcerated; the cartilage of the septum eventually necroses, leading to perforation or collapse. Tertiary syphilis may also affect the nose, leading to cartilage and bone destruction and nasal deformity.
Rhinoscleroma or scleroma, an endemic disease in Africa, Eastern Europe, and Central America, is occurring more frequently in the United States. It may affect the nose or other parts in the upper respiratory tract, producing scarring and stenoses.
Immune deficiency diseases
Wegener's granulomatosis is a necrotizing granulomatous disease associated with vasculitis of the upper and lower respiratory tracts, focal necrotizing glomerulonephritis, and systemic angiitis. Not all of these lesions need to be present for the diagnosis to be made. The symptoms include nasal obstruction, crusting, discharge and midfacial pain, in addition to malaise, sweats, and myalgia. Crusting, ulcerations, and granulations are found in the nasal mucosa, medially and laterally. The treatment is cyclophosphamide: steroids are reserved for fulminant cases.
Polymorphic reticulosis is a necrotizing lymphoproliferative lesion with a predilection for the upper respiratory tract; it is considered by some to be a neoplastic lymphoproliferative disorder. The lesions may be single and ulcerative, diffuse and ulcerative, or single and nodular. If the lesion is single, systemic symptoms are usually absent. The treatment is irradiation.
Sarcoidosis is a multisystem self-limited granulomatous disease, related to an alteration in the immune system. It may be discovered incidentally on routine chest radiographs. Nasal sarcoidosis affects the mucosa of the septum and inferior turbinates, causing dryness and crusting. Single or multiple submucosal nodules may appear. Sinusitis is usually secondary to the nasal involvement. Treatment is symptomatic: steroids are reserved for cases with functional impairment.
The underlying cellular immunodeficiency of AIDS facilitates the development of opportunistic diseases such as Kaposi's sarcoma and Pneumocystis carinii infections. The violaceous nodules of Kaposi's sarcoma occur in the anterior aspects of the nasal cavities. Rhinosinusitis is common, recurrent, and may be resistant to medical treatment.
Mucoceles are chronic cysts, lined with epithelium and filled with mucus that occupy one or more of the sinuses, and expand over years to erode or expand surrounding bone and to invade contiguous areas. When infected, they become known as mucopyoceles. The symptoms depend on the size and the location.
Mucoceles may be spontaneous or may complicate infections. They are thought to arise either from obstruction of the sinus outlet, with secondary retention of mucous within the sinus cavity or from obstruction of the duct of a mucous gland. Some authors distinguish between mucoceles, which show evidence of expansion of the sinus cavity, and mucosal cysts, which are asymptomatic, discovered on routine facial or dental radiographs and which usually require no surgical attention.
The frontal sinus is most commonly affected followed by the anterior ethmoids; the sphenoids and maxillary sinuses are rarely involved. Many cases of maxillary mucoceles appear years after a Caldwell-Luc procedure (radical maxillary sinusectomy).
Frontal and frontoethmoid mucoceles erode the orbital wall superomedially, and produce exophthalmos; the eye globe is also pushed laterally and inferiorly. The posterior wall of the frontal sinus and the skull base may also be eroded, exposing the dura. Sphenoid mucoceles may erode into and compress the sella turcica and the parasellar structures, including the optic nerve, cranial nerves III, IV, V, and VI, and the carotid artery. Mucoceles require surgical treatment. For frontal mucoceles the most popular procedure is the osteoplastic approach, with obliteration by transposed fat. Although endoscopic intranasal marsupialization may be sufficient, long-term follow-up is required before this conservative approach can be adopted.
Foreign bodies and rhinoliths
Children often introduce foreign bodies into their nose: unilateral nasal discharge in a child should be considered to be due to a foreign body until proved otherwise. Diagnosis is usually easy if proper examination with suctioning is possible. Removal of the foreign body, however, requires the co-operation of the patient if posterior slippage of the foreign body and aspiration are to be avoided. Administration of general anaesthesia is often appropriate.
Rhinoliths are calcified masses in the nasal cavities. They are thought to develop around a foreign body nidus. They become large enough to make removal difficult: crushing them, if possible, makes their extraction easier.
Rhinophyma is a disease of unknown aetiology that may follow acne rosacea. The sebaceous glands of the nasal skin, starting at the tip, enlarge. The subcutaneous tissue becomes hypertrophied, and blood vessels over the involved areas may become prominent. Treatment is undertaken for cosmetic purposes, and consists of shaving the affected areas, which are then covered with a split-thickness skin graft.
The most common causes of acute sinusitis in adults in the United States of America are H. influenzae, S. pneumoniae, and anaerobes. B. catarrhalis is a common cause in children. Chronic sinusitis is usually caused by anaerobes, S. viridans, or H. influenzae. Empirical antibiotic therapy should be undertaken on the basis of local information; specimens for culture and antibiotic sensitivity tests should ideally be obtained, but these do not necessarily produce the aetiological agents. Specimens collected from the middle meatus with the help of rigid endoscopes, or sinus taps, need to be cultured if exact bacteriological identification is necessary. A 10- to 14-day course of antibiotics is usually required: intravenous antibiotic treatment is recommended for severe infections. Local antibiotics are not popular in the nose.
Antihistamine therapy is indicated if allergy is suspected. Although earlier antihistamines notably produce drowsiness, newer agents do not bind so avidly to cerebral receptors and are thus easier to use during working hours.
Topical antihistamines are available in Europe. The antihistamines astenizole and terfenadine may provoke torsade de pointe and hepatic problems. Antiarrhythmic treatment may be required.
Local decongestant drops or sprays are effective in the treatment of nasal blockage due to congestion of the nasal mucosa. However, their use for more than a few days carries the risk of habituation and of rebound congestion. Oral decongestants (sympathomimetics) are helpful but their effect is less dramatic. They may be used over prolonged periods, although cautiously or not at all in hypertensive patients.
Local steroid sprays are effective in the treatment of allergic rhinitis. Small nasal polyps may even disappear after a few weeks of treatment. Oral and parenteral steroids have been used successfully to treat severe and refractory nasal allergy over a short period of time.
Cromolyn spray inhibits the release of histamine from mast cells and may be useful in allergic rhinitis. Nasal symptoms may also be alleviated by humidifiers in dry environments and saline sprays or drops. Nasal douches of warm saline or other soothing mucosolvent solutions administered with a rubber bulb relieve thick secretions and crusting. Severe crusting may need specialist intervention: fortunately, this occurrence is rare.
Oral mucolytic and expectorant agents have also been used. Two of the popular ones are guaifenesin and iodinated glycerol.
Atropine drops may also be used in the treatment of resistant rhinorrhoea.
Anterior nasal packing is a simple and effective way to stop nasal bleeding, irrespective of the underlying cause. It may also be used to prevent bleeding after septal and/or turbinate surgery. Several kinds of packs are commercially available; half-inch gauze, greased with Vaseline or an antibiotic ointment is also effective. Packing may be kept in place for one or more days, depending on the cause of bleeding and the risk of rebleeding. Caution must be exercised when packing patients with fractures or if major arterial bleeding is suspected, as intracranial or intraorbital haematomas can be serious sequelae. Spraying the nose with a topical decongestant and a topical anaesthetic agent may reduce the bleeding and make the intervention more tolerable. A 4 per cent cocaine solution or a solution of 0.25 per cent neosynephrine and 3 per cent lidocaine hydrochloride are appropriate.
A light source, a nasal speculum, a bayonet or a right angle forceps (Hartmann forceps) and a nasal suction tip are instruments needed. The patient is usually kept in the sitting position. Judgement has to be exercised regarding the pressure used when applying with the pack: too little pressure will not be effective, while too much pressure may cause necrosis. In an acute emergency and if the bleeding is profuse, too much pressure is better than too little: necrosis takes at least 24 h to develop, and the pack can be loosened or replaced if required.
If the anterior pack is not successful, or if the bleeding is posterior, anterior and posterior packing can be used. This either puts pressure on the bleeding site, or creates a closed cavity in which bleeding stops by tamponade. Although this technique is effective, it is unpleasant for the patient, and general anaesthesia may be required. Spraying the throat with local anaesthetic may diminish the patient's discomfort. Application of the pack involves introduction of a catheter through the nostril on the suspected side of bleeding. A double thread, not thinner than 0 silk, is attached to the tip of the catheter. The catheter is then withdrawn through the oropharynx, along with the thread, to which is tied a piece of 5 cm (2 inch) rolled gauze. This gauze may be dry, wet, greased with Vaseline or an antibiotic ointment, or soaked with tincture benzoin (to prevent a bad smell). While pulling at the thread the gauze is guided with the finger or a curved clamp behind the uvula and then above it to be impacted into the posterior choanae and in the nasopharynx. Anterior packing is then placed on one or both sides and the thread tied over a piece of gauze to prevent the posterior pack from falling backwards into the oropharynx. It is wise to tie another thread to the posterior pack that is taped close to the mouth: this makes removal of the pack easier: this usually occurs after 3 to 7 days. Another thread in place for 24 h after pack removal facilitates replacement should the need arise.
Large packs may depress the soft palate sufficiently to cause snoring and respiratory embarrassment. Sedation should therefore be used with caution and the patient's vital signs must be monitored carefully. Pulse oximeters are useful in patients with compromised cardiovascular or central nervous systems. Orotracheal intubation, or even a tracheotomy, may be needed to ensure adequate oxygenation.
Different kinds of sponges and single inflatable balloons are available commercially and may be used instead of the classical packs. Double balloons have been devised: these can be placed faster and with more ease than classical packs but are not widely used.
Anterior–posterior packs interfere with sinus drainage and eustachian tube function: therefore prophylactic antibiotics should be administered. The toxic shock syndrome is a serious but extremely rare risk of nasal packing. Carriers of Staphylococcus aureus and individuals with staphylococcol infections should receive antibioties effective against these organisms.
Surgery on the nose and sinuses can be classified as clean–contaminated: it is both impossible and unnecessary to sterilize the surgical field.
In spite of the lack of convincing evidence of the value of prophylactic antibiotics in sinus and nasal surgery, there is a tendency to use broad spectrum coverage including anaerobes.
Skin incisions in the face heal well following closure with non-absorbable fine sutures (4–0 to 6–0) or steristrips. Absorbable sutures (3–0 to 6–0 catgut) are used inside the nose and oral cavity. Incisions in the upper gingivolabial sulcus for operations on the maxillary sinus also heal very well. Postprandial mouth washing with an antiseptic solution or even saline protects the suture line.
Crusting that develops intranasally needs to be cleaned with saline douches applied by a small rubber bulb. Water picks have also been used successfully. Normal saline drops or sprays and humidifiers may also help. Severe crusting must be removed with suction or forceps after application of a local decongestant and topical anaesthetic agent.
Much surgery can be performed under local anaesthesia, except in very young children. Preoperative sedation can be used with or without intraoperative monitoring and further sedation. The nasal mucous membranes can be anaesthetized with topical anaesthetic spray (3–4 per cent lidocaine hydrochloride). Four per cent cocaine has an additional vasoconstrictor effect. Infiltration anaesthesia (1–2 per cent lidocaine hydrochloride with or without adrenaline 1:50000–1:200000) may also be used, especially in the nasal vestibule, columella, and gingivolabial sulcus. It has also been successful to reduce bleeding and to lessen the depth of general anaesthesia required.
Vasoconstriction and anaesthesia may also be obtained by painting appropriate solutions onto the mucosa with cotton applicators, and by blocking the sphenopalatine and anterior ethmoid nerves. These nerves, along with the infraorbital and greater palatine nerves, may also be blocked by infiltration anaesthesia.
Nasal growths may need to be sampled to allow a diagnosis to be made prior to planning of definitive therapy. Nasal polyps are easily recognizable and need not be sampled prior to treatment, although after removal they should be submitted for histopathological examination. If a polyp looks and feels fleshy, biopsy will exclude the diagnosis of an inverted papilloma. Cup forceps are used. Any bleeding may be stopped with cautery or packing.
Incision and drainage of abscess and haematoma
Septal haematomas usually follow surgical or other trauma. They need to be drained to prevent abscess formation, cartilage necrosis, and saddle deformity of the nose.
Incision and drainage are easily performed. The septal flaps are kept together by bilateral packing for a few days. A drain is inserted if pus is obtained.
The aim of treatment is to stop bleeding, to correct the deformity, and to relieve the obstruction. The last two aims may be achieved under local anaesthesia by closed reduction and manipulation immediately after the trauma, or 1 or 2 weeks later, when the swelling subsides. If the reduced nose is not stable, nasal packing stabilizes the septum and a cast stabilizes the external nose. Radiographs are usually only necessary for documentation. Fractures that do not result in haemorrhage, cosmetic deformity, or a functional impairment need not be treated.
Submucous resection - septoplasty
A submucous resection of deviated septal cartilage and bone may be performed to relieve nasal obstruction and restore adequate nasal passages. Deviated cartilage may be swung into the midline with or without morcellation, or reimplanted between the septal flaps after straightening. This procedure is known as septoplasty or septal reconstruction.
Rhinoplasty, also known as nasoplasty, aims to change the shape of the nose. It may be performed only for cosmetic reasons or to improve function also.
Correction of the bony structure of the nose requires removal of any hump that is present; osteotomies of the nasal bones narrow the width of the bony nose. The upper and lower lateral cartilages can be trimmed to the desired size. Prominent alae of the nose may also be elevated and trimmed: resultant scars are very acceptable. Rhinoplasty is usually performed intranasally, with no visible incisions or scars. The so-called external approach uses a transverse columellar incision, along with hidden rim incisions to dissect the skin from the cartilaginous nose if more direct sculpturing of the nose and cartilage implantation is necessary. The columellar scar is usually hardly noticeable after a few months.
Correction of cartilage and/or bone loss secondary to disease, surgery, or trauma, requires an augmentation rhinoplasty using autologous bone or cartilage. A variety of allografts are also available for implantation, and silicone injections have been used to fill in small defects or raise small depressions.
Nasal valve surgery
A deficiency of cartilage in the soft lateral nasal wall results in nasal obstruction when inspiration causes negative pressure. Cartilage grafts obtained from the nasal septum or external ear have been successfully implanted to strengthen the lateral nasal wall and to prevent its collapse on inspiration.
A lateral rhinotomy is an incision along the lateral nasal wall down to the nasolabial groove. It allows better access to the nasal cavity and the medial maxillary wall. Removal of part of the ascending process of the maxilla and the nasal bone may also improve access to the operative site. This approach is used most commonly for medial maxillectomies, usually performed for the treatment of inverted papilloma.
This approach may be resorted to in the surgical treatment of intranasal lesions, septal lesions, or nasopharyngeal masses. An incision is made in the upper gingivolabial sulcus to elevate the soft tissues from the mid-third of the face. Circular incisions are also needed inside both nostrils to facilitate the elevation and the exposure. These incisions heal well and the scars are hidden.
Lacrimal sac surgery
Dacryocystorhinostomy performed through an external incision is used to treat blockage of the nasolacrimal duct and resultant epiphora. The same result can be achieved by intranasal drilling of the lacrimal bone and removal of a large piece of the medial wall of the lacrimal sac. A short length of Silastic tubing may be left in place for several weeks to ensure patency if the fistula created is small.
Operating microscopes or rigid telescopes facilitate this procedure.
With the improvement of lighting, anaesthesia and imaging techniques, sinus surgery has developed beyond the drainage of abscess. The operating microscope provides better binocular vision and allows more aggressive and complete surgery to be undertaken with fewer risks of serious complications.
Sinus surgery is usually performed for the treatment of sequelae of infection or allergy. Tumours require local radical en bloc resections, which should not be attempted by the non-specialists.
Irrigation of the sinuses with saline, antiseptic, or antibiotic solutions was very popular prior to the advent of modern antimicrobial and antiallergic therapies. The ethmoid sinuses may be irrigated through the nose; maxillary, frontal, and sphenoid sinuses may be irrigated through the natural ostia or through surgically created openings.
Surgery on the ethmoid sinus may be performed through the intranasal route with the help of the headlight or the operating microscope. Rigid endoscopes allow procedures to be performed in areas inaccessible to direct vision. The surgeon must remain lateral to the middle turbinate to avoid injury to the cribriform plate, which results in loss of smell and CSF leak. The roof of the ethmoid (fovea ethmoidalis) is the floor of the anterior cranial fossa: this may be thin and even dehiscent. The lateral wall (the lamina papyracea) separates the ethmoid from the orbital contents. Posteriorly, the optic nerve may be very close to the lateral bony wall of a posterior ethmoid cell; anteriorly the lacrimal fossa and sac are close.
The ethmoid cells may also be reached through the so-called transantral route, although this does not allow easy access to the most anterior cells. The external route is safest. An incision is made between the dorsum of the nose and the medial canthus, the bony area is exposed subperiosteally, and the ethmoid cells are entered after removal of the lacrimal plate and part of the lamina papyracea of the ethmoid bone. Working intranasally and externally, the ethmoid cells are exenterated. The middle turbinate may be partially removed to facilitate surgery. The anterior ethmoidal artery encountered in this approach has to be coagulated with bipolar cautery, ligated, or clipped to avoid haemorrhage. The external incision usually heals well and the scar is hardly noticeable. Contracture of the scar can be avoided by breaking the straightness of the incision. The operative cavity may be packed for 24 h if bleeding is a problem.
The natural ostium of the maxillary sinus lies usually lateral and deep to the uncinate process and it is therefore not easily accessible. Cannulation can be achieved through an accessory ostium, if present, or through antrostomies performed in the inferior nasal meatus or in the canine fossa on the anterior wall of the maxilla.
For better drainage and ventilation in chronic infection, or in the management of recurrent infections or vacuum sinus pains (aerosinusitis), a permanent antrostomy, about 1cm in diameter, may be created in the inferior meatus. Middle meatal antrostomies may also be created.
The classical Caldwell-Luc operation (radical antrectomy) consists of exposing the anterior wall of the maxilla through an incision in the upper gingivolabial sulcus and canine fossa. The soft tissues are elevated subperiosteally until the infraorbital neurovascular bundle is identified; this is then protected. A bony window is created with a chisel and bone rongeurs: the size of this window varies, depending on the surgery planned. Usually the entire contents of the sinus are removed, along with the mucoperiosteum. Dehiscences in the infraorbital canal and the roof of the sinus, which is the floor of the orbit, are rare, but should be looked for. An inferior meatal antrostomy is then performed, through which a drain is inserted. This is left in place for about 24 h. The incision is sutured with 3–0 or 4–0 chromic catgut. Postoperatively, ice bags placed on the cheeks reduce swelling. Cheek numbness, usually due to retractor injury, is common and is almost always totally reversible, although this may take several weeks.
Oroantral fistulae with secondary maxillary sinusitis may follow molar extraction when the maxillary sinus pneumatization reaches the dental roots. The fistula is closed with local flaps and a Caldwell-Luc procedure performed.
Medial maxillectomy is performed through a lateral rhinotomy approach. The indication is usually inverted papilloma, although it may also be performed for localized tumours.
Cannulation of the nasofrontal duct is not usually possible. This duct has a natural tendency to stenose, and attempts at cannulation are accompanied by serious complications including expansile mucoceles when the duct closes.
If aspiration, irrigation, or drainage are required for the treatment of acute frontal sinus infections, a 1cm external incision in the medial aspect of the eyebrow allows the floor of the frontal sinus to be identified subperiosteally. A hole can then be made in the floor to penetrate the sinus. A catheter placed inside the sinus and sutured to the brow allows irrigation to be undertaken until the nasofrontal duct reopens.
Treatment of chronic infection usually requires more extensive surgery. The most effective procedure is the osteoplastic frontal sinus operation. The contents of the sinus and its lining mucoperiosteum are removed, and the cavity is filled with abdominal fat. Coronal incisions are usually used, and these heal well. Brow and midfrontal incisions have also been used.
Surgery on the sphenoid sinus is made difficult by its proximity to the optic nerve, carotid artery, pituitary gland, and the cavernous sinus and its contents. Its bony walls may be dehiscent or paper thin. Fortunately diseases of the sphenoid sinus are not common.
Aspiration may be performed through the natural ostium. The classical approach for more extensive surgery is intranasal: the middle turbinate is removed, a posterior ethmoidectomy is performed, and the anterior wall of the sphenoid sinus is identified and removed. The external ethmoidectomy approach may also be used.
Midline approaches to the sphenoid sinus have the advantage of more reliable anatomical landmarks. The trans-septal approach may be undertaken either through a columellar hemitransfixing incision or through a sublabial incision in the gingivolabial sulcus. The external rhinoplasty trans-septal approach has been proposed as the procedure which affords the most direct midline approach.
Unlike operations on the maxillary and frontal sinuses, in which all the lining mucoperiosteum is removed, the sphenoid sinus is not totally cleaned because of the anatomical considerations mentioned above. A large window in the anterior wall, the so-called sphenoidotomy, allows ventilation, drainage, and future examination, and is usually sufficient.
Surgery for CSF leaks
CSF leakage into the sinuses and the nose may be due to surgical or other trauma, eroding lesions, or may be spontaneous.
Dural defects may present with meningitis in the absence of overt CSF leaks. Determination of the glucose level of the leaking fluid will confirm its nature: the CSF glucose level is about two-thirds that of the blood. The discharge seen in patients with allergic rhinitis contains hardly any glucose. The site of the leak may be indicated on CT scans, although this is not always the case. Installation of fluorescein into the subarachnoid space after a lumbar puncture will usually locate the dural defect. This can be patched with a fascial graft supported by muscle or fat. If the defect is in the roof of the ethmoid sinus or in the sphenoid sinus, a septal mucoperichondrial and mucoperiosteal flap may be rotated and packed in placed to seal the leak.
Trans-sphenoidal pituitary surgery may be complicated by CSF leaks that require surgical attention. The recent increase in interest in intranasal ethmoid surgery has resulted in more CSF leaks from the fovea ethmoidalis.
Functional endoscopic sinus surgery
Rigid endoscopes and associated instruments may be used to biopsy lesions deep in the nose or nasopharynx. These have also been used to identify the sphenoid ostium for aspiration, and to locate the bleeding vessels to allow a suction cautery to be applied under direct vision. CSF leaks have also been sealed endoscopically. Endoscopic medial and inferior wall orbital decompressions, and even optic nerve decompressions, are also successful. Revisions and primary dacryocystorhinostomies are also possible endoscopically.
The angular vision allowed by endoscopes is of benefit in the surgical treatment of sinus disease. Mucociliary clearance is directed towards natural ostia this remains so even if larger windows are created elsewhere. Middle meatal antrostomies are therefore more applicable in the treatment of maxillary sinus disease.
Endoscopic surgery also allows the removal of anatomical or pathological structures in the so-called ostiomeatal complex in the middle nasal meatus. An anterior ethmoidectomy and a middle meatal antrostomy may be sufficient to treat chronic or recurrent acute maxillary or frontal sinusitis. An anterior ethmoidectomy, performed with special attention to the frontal recess area, may cure mucoceles of the frontal sinus, by enlarging the nasofrontal duct and enhancing drainage.
The mastery of the surgical approaches to sinus disease has opened avenues for the surgical treatment of other than sinus disease, in areas adjacent to the sinuses.
The Caldwell-Luc approach allows the internal maxillary artery to be ligated in the treatment of severe posterior epistaxis. The posterior wall of the maxillary sinus has to be removed before the artery can be dissected and clipped or tied.
The vidian nerve may be reached through the same approach: its severance may be resorted to in the treatment of allergic rhinitis accompanied by intractable rhinorrhoea.
Packing of the maxillary sinus has been used to reduce and support blowout fractures of the orbital floor, although this technique is not recommended for routine use. The ethmoid sinus route can be used for decompression of the orbit and optic nerve. External ethmoidectomy may also be used to drain orbital abscesses or to biopsy medial or superior orbital masses.
The trans-sphenoid approach to the pituitary is not associated with the same morbidity and mortality as those of the transcranial approach. Pituitary surgery may be performed through either the midline trans-septal or the lateral external ethmoidectomy approach.
The geographic location of the nose and sinuses in the head makes the understanding of the possible complications of their diseases and surgery easier.
The vascular connections and the thin or dehiscent bony partitions separating them from the cranial and orbital contents facilitate the spread of infection or tumours and the surgical injuries or the postoperative complications.
Complications of diseases
A septal abscess may occur spontaneously, but it usually follows a haematoma. Unless treated promptly and adequately, cartilage necrosis and saddle deformity follow.
Disease affecting the proper structure or functioning of the respiratory epithelium results in dryness and crusting of the nasal cavities. Cocaine may cause ischaemic septal perforations because of its vasoconstrictive effect. Cavernous sinus thrombosis may follow nasal infections.
Mucoceles that arise in blocked sinuses enlarge and erode the surrounding bone. Symptoms and signs depend on the direction and extent of mucocele growth: frontal mucoceles tend to push the eyeball anteriorly, inferiorly and laterally. Sphenoid mucoceles may erode the base of skull or press on the optic nerve.
Infection that spreads beyond the sinuses may be associated with osteomyelitis of the frontal bone: this still occurs, although it has become less common since the advent of antibiotics. Treatment requires large doses of antibiotics administered intravenously. This removes the need for curettage of the bone, and the associated deformity.
Lid oedema and congestion may complicate ethmoid and frontal sinusitis. A more aggressive infection may lead to periorbital cellulitis, an orbital cellulitis, a subperiosteal abscess, or an orbital abscess. Surgical drainage of abscesses is mandatory. Ophthalmoplegia (superior orbital fissure syndrome) may result when cranial nerves III, IV, and VI are affected.
Disease processes may spread intracranially, either by direct extension or through the emissary veins that drain into the intracranial venous sinuses. Spread may cause cavernous sinus thrombosis, meningitis, encephalitis, or epidural, subdural or brain abscesses.
Complications of surgery
The most common complication during and after nasal surgery is bleeding. Surgery should not be undertaken unless a negative history of bleeding tendency and a normal bleeding profile (platelet count, prothrombin time, partial thromboplastin time, bleeding time) have been obtained. Intraoperative bleeding may be controlled by cautery and packing; postoperative bleeding is usually controllable with packing.
If septal surgery is accompanied by mucosal tears and loss of tissue, a septal perforation may follow.
Postoperative infection may lead to abscess formation and deformity unless it is promptly recognized and treated.
Nasal septum and cartilage grafts may deviate after septal surgery, and an apparently successful rhinoplasty may be less pleasing after a few months. Anosmia and hyposmia may also follow nasal surgery. The exact reason is not clear, but fracture of the cribriform plate secondary to removal of the deviated parts of the ethmoid perpendicular plate or the infracturing of the middle turbinates may be involved.
Complications of sinus surgery may become apparent during, immediately after, or even weeks after the operation. Unless the patient has a bleeding disorder, mucosal bleeding is rarely a problem. Serious bleeding may follow injury to one or more of the major arteries in the operative area. The infraorbital artery may be injured during the elevation of the soft tissues from the anterior wall of the maxillary sinus. In the roof of the sinus, this artery is covered by a protective bony wall that is rarely dehiscent, and injury at this site is unlikely.
The anterior ethmoidal artery is vulnerable as it crosses the roof of the sinus, either above the base of the skull or within a bony mesentery. If injury is not recognized, the artery may retract into the orbit, causing an orbital haematoma. This may produce pressure on the optic nerve and blindness. The posterior ethmoidal arteries are usually small and do not cause significant haemorrhage, even if cut.
Brisk haemorrhage follows injury to the sphenopalatine artery and the descending palatine artery during surgery on the posterior ethmoid cells, the posterior wall of the maxillary sinus, or the sphenoid sinus.
Penetration of sinus walls
Injury to the skull base and dura may result in CSF leaks, pneumocephalus, and intracranial haemorrhage. Entry of the medial orbital wall and the periorbita may cause significant haemorrhage, and infection may occur. Sneezing or nose blowing then may result in subcutaneous emphysema of the eyelids. The optic nerve may also be bruised or even cut, especially if there is a bony dehiscence in the lateral wall of the posterior ethmoid cells or sphenoid sinus.
Sphenoid sinus surgery may result in injury to the internal carotid artery, the cavernous sinus, and the pituitary gland. Surgery on the anterior aspect of the medial wall of the maxillary sinus may injure the nasolacrimal duct, which lies in a bony canal in the lacrimal bone. This results in epiphora.
The healing process may cause complications. The nasofrontal duct has a tendency to stenose, and a frontal mucocele may result. For this reason, frontal osteoplastic flap operations and fat obliteration have gained popularity. Closure of an antrostomy may result in a recurrence of the infection and a mucocele. Adhesions or synechiae may develop in the nose. Symptoms depend on their location and their extent. Such adhesions may produce nasal obstruction if they block the air current or sinusitis if they interfere with the sinus drainage and ventilation in the superior and middle nasal meati.
Cummings CW, Frederickson JM, Harker LA, Schuller DE. Otolaryngology—Head and Neck Surgery. Vol. I. St Louis, MO: Mosby, 1986.
Montgomery WW. Surgery of the Upper Respiratory System. Vol. I. 2nd edn. Philadelphia, PA: Lea and Febiger, 1979.