Download ENT醫五教學-Rhinology

ENT醫五教學-Rhinology
ENT V.S. 林志峰醫師
Allergic Rhinitis
Allergic Rhinitis
• Inflammation to the mucosal lining
of the nose caused by
inappropriate hypersensitivity
reaction to an aeroallergen.
• IgE mediated immune response,
with mast cell activation and
release of cytokines
Allergic rhinitis
• Affects approximately 1/3 of
people
• Causes significant morbidity
• Lost work/school days
• Decreased productivity
• Costs of continued medication
Relevant Immunology
• Atopic individuals
produce IgE-mast cell
TH2 lymphocytic
response.
• low level exposure to
antigen, antigen is
taken up by APC
(antigen presenting
cells)
• Antigen is processed,
and epitope is
expressed on the cell
surface by MHC II.
Immunology Cont.
• CD4+ cells interact
with APC’s and
release cytokines
IL3, IL4, IL5, and
GM-CSF.
• These promote IgE
production by
plasma cells, mast
cell proliferation and
infiltration into nasal
mucosa, and
eosinophilia
Pathophysiology
• Early response –
– IgE coated mast cells recognize allergens
in the mucosal lining, and undergo
degranulation.
– Preformed histamine, heparin, tryptase,
kininogenase, and chymase cause initial
damage.
– Newly formed mediators leukotrienes (and
prostaglandins) are produced by
breakdown of phospholipid cell membrane.
• These cause vessels to leak leading to watery
rhinorrhea, nasal edema/congestion, and
sneezing/pruritis
Pathophysiology
• Late response –
– mast cells also secrete chemokines that
promote VCAM, and E-selectin expression
on endothelial cells.
– These allow other leukocytes to attach, and
migrate into tissues.
– IL-5 is a potent chemoattractant of
eosinophils, T lymphocytes, and
macrophages.
• Over the course of 4 to 8 hours, these cells
release there contents, causing further
inflammation.
So ,what do you do with a
suspected allergy patient?
History
• Onset, timing, duration,
seasonality, severity, associated
symptoms, aggravating/alleviating
factors
• Thorough environmental history
• Family history of atopy
• Suspected allergens
• Nasal trauma
Symptoms
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Rhinorrhea
Cough/sneezing
Nasal congestion
Post nasal drip
Nasal pruritis
Watery eyes
General fatigue
Diminished quality of life
Physical
• General appearance
– Allergic shiners, allergic salute, malaise
• Nose
– Septal deviation, polyps, drainage, turbinate hypertrophy,
hyponasality
• Mouth
– Cobblestoning of oropharynx
• Ear
– Middle ear pathology
• Neck
– Lymphadenopathy, thyroid enlargement
• Chest
– wheezing
• Skin
– Eczema, dermatographism
Differential Diagnosis
• Non-allergic rhinitis
– Infectious, vasomotor rhinitis, atrophic
rhinitis, drug induced, hormonally induced,
exercise, reflex
• Structural/mechanical factors
– Septal deviation, turbinate hypertrophy,
adenoid hypertrophy, foreign body, tumor
• Inflammatory/immunologic
– Wegener’s, sarcoidosis, midline granuloma,
SLE, Sjogren’s
• CSF rhinorrhea
Medical Management
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nasal steroids
decongestants
mast cell stabilizers
leukotriene receptor antagonists
anti-IgE globulin
When symptoms persist despite
optimal medical management,
immunotherapy is an option
Immunotherapy
• Successful immunotherapy is
associated with:
– Shift from TH2 to TH1 lymphocyte
immune response to allergen
– Immunologic tolerance – decline in
allergen specific responsiveness
– Increases in allergen specific IgG
blocking antibody
– Relationship between efficacy and
specific IgE titers are variable
SINUSITIS
Anatomy
• Paranasal Sinuses
Anatomy
• Lateral View of Sinuses
Where are the sinuses?
• Four pairs of paranasal sinuses
– Frontal-above eyes in forehead bone
– Maxillary-in cheekbones, under eyes
– Ethmoid-between eyes and nose
– Sphenoid-in center of skull, behind
nose and eyes
What are the sinuses?
• The sinuses are hollow air-filled
sacs lined by mucous membrane.
The ethmoid and maxillary
sinuses are present at birth. The
frontal sinus develops during the
2nd year and the sphenoid sinus
develops during the 3rd year.
What are the sinuses? (cont’d)
• Sinuses have small orifices (ostia)
which open into recesses (meati)
of the nasal cavities.
• Meati are covered by turbinates
(conchae).
• Turbinates consist of bony
shelves surrounded by erectile
soft tissue.
• There are 3 turbinates and 3 meati
in each nasal cavity (superior,
middle, and inferior).
Sinusitis
• Inflammation of paranasal sinuses
What is sinusitis?
• An acute inflammatory process
involving one or more of the
paranasal sinuses.
• A complication of 5%-10% of URIs
in children.
• Persistence of URI symptoms >10
days without improvement.
• Maxillary and ethmoid sinuses are
most frequently involved.
How Does Sinusitis Develop?
• Usually follows rhinitis, which
may be viral or allergic.
• May also result from abrupt
pressure changes (air planes,
diving) or dental extractions or
infections.
• Inflammation and edema of
mucous membranes lining the
sinuses cause obstruction.
• This provides for an opportunistic
bacterial invasion.
Development (cont’d)
• With inflammation, the mucosal lining
of the sinuses produce mucoid
drainage. Bacteria invade and pus
accumulates inside the sinus cavities.
• Postnasal drainage causes obstruction
of nasal passages and an inflamed
throat.
• If the sinus orifices are blocked by
swollen mucosal lining, the pus cannot
enter the nose and builds up pressure
inside the sinus cavities.
Predisposing Factors
• Allergies, nasal deformities, cystic
fibrosis, nasal polyps, and HIV
infection.
• Cold weather
• High pollen counts
• Day care attendance
• Smoking in the home
• Reinfection from siblings
Acute or Chronic Sinusitis?
• Acute Sinusitis – respiratory
symptoms last longer than 10
days but less than 30 days.
• Subacute sinusitis – respiratory
symptoms persist longer than 30
days without improvement.
• Chronic sinusitis – respiratory
symptoms last longer than 3
months
Etiology of Sinusitis
70% of bacterial sinusitis is caused
by:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis
Other causative organisms are:
• Staphylococcus aureus
• Streptococcus pyogenes,
• Gram-negative bacilli
• Respiratory viruses
Complications of Sinusitis
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Orbital cellulitis or abscess
Meningitis
Brain abscess
Intractable wheezing in children
with asthma
• Cavernous sinus thrombosis
• Subdural empyema
Subjective Symptoms of Sinusitis
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History of URI or allergic rhinitis
History of pressure change
Pressure, pain, or tenderness over sinuses
Increased pain in the morning, subsiding in
the afternoon
Malaise
Low-grade temperature
Persistent nasal discharge, often purulent
Postnasal drip
Cough, worsens at night
Mouthing breathing, snoring
History of previous episodes of sinusitis
Sore throat, bad breath
Headache
Clinical Presentations of Sinusitis
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Periorbital edema
Cellulitis
Nasal mucosa is reddened or swollen
Percussion or palpation tenderness
over a sinus
Nasal discharge, thick, sometimes
yellow or green
Postnasal discharge in posterior
pharynx
Difficult transillumination
Swelling of turbinates
Boggy pale turbinates
Pale, Boggy Turbinates
Diagnostic Tests
• Imaging studies, such as sinus
radiographs, ultrasonograms, or
CT scanning – indicated if child is
unresponsive to 48 hours of
antibiotics and if the child has a
toxic appearance, chronic or
recurrent sinusitis, and chronic
asthma.
• Laboratory studies, such as
culture of sinus puncture
aspirates.
Differential Diagnoses
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Allergic rhinitis
Non-allergic rhinitis
Infectious rhinitis
Drug-induced rhinitis
Nasal polyps
Dental abscess
Carcinoma of sinus
Cluster headache
Structural defects (septum deviation)
Nasal foreign body
Pharmacological Plan of Care
Antimicrobials-treat for 10-14 days,
depending upon severity, with one
of the following:
• Amoxicillin:20-40mg/kg/d in 3
divided doses(>20kg, 250mg tid)
• Augmentin:25-45mg/kg/d in 2
divided doses(>20kg, 400mg q12)
Use chewable or suspension if
child is less than 40kg.
Pharmacological Plan of Care
• Biaxin:15mg/kg/d in 2 divided
doses(>30kg, 250mg q12)
• Cefzil:15mg/kg/d in 2 divided
doses (>35kg, 250mg bid)
• Lorabid: 30mg/kg/d in 2 divided
doses (>26kg, 400mg bid)
Other Relief Medications
• Codeine – for severe pain
• Rhinocort nasal spray – 2 sprays
in each nostril every 12 hours for
children over 6 years of age.
OTC Medications
• Acetaminophen or ibuprofen to
relieve pain
• Decongestants
• Antihistamines
• Nasal saline
Non-pharmacological treatment
• Humidifier to relieve the drying of
mucous membrances associated
with mouth breathing
• Increase oral fluid intake
• Saline irrigation of the nostrils
• Moist heat over affected sinus
• Prolonged shower to help
promote drainage
Patient Education
• Child should not dive.
• Child should not travel by airplane.
• Urge parent to eliminate triggers
in the home (dust, smoking)
• Have all members of the family
treated, if indicated.
Follow Up Guidelines
• Instruct parent to call in 48 hours
if condition of child has not
improved.
• Instruct parent to bring child in for
a recheck in 2 weeks.
Guidelines for Referral
• Child with complications or signs
of invasive infection.
• Child needing control of allergic
rhinitis.
• Child with chills and fever.
• Child with persistent headache.
• Child with edema of forehead,
eyelids.
• Child with orbital cellulitis
鼻血
 鼻部解剖
 尋找出血點
 Underlying disease, bleeding tendency
 Chemical vs Electrical cauterization
 Anterior vs Posterior packing
 Embolization vs Ligation of great vessel
 Endoscopic control
Internal carotid artery
External carotid artery
Light packing
Cocaine
Epinephrine
止血棉
Posterior packing
Foley catheter
Surgicel
Anterior packing
凡士林紗布
Merocel
Volume ratio 14:1 after
Absorbing liquid
Merocel
Embolization of internal maxillary
artery
before
after
www.chirurgie-ohne-messer.de/ tumoren/embo_all...
Endoscopic control of epistaxis
http://www.acmcb.es/societats/otorino/img/divul3.jpg
Foreign body in nose
• Children
• 2nd FB: H & N check & Chest
auscultation
• 單側鼻膿,臭味,痛,鼻血, nasal
whistling
• 種子, 水蛭,電池
• Avoid aspiration
• 不要擤!
夾，圈，鉤，三秒膠
Nasal bone fracture
• 臉部最常見骨折
• 打架，籃球，摩托車
• Cosmetic deformity, nasal
obstruction, epistaxis, pain, septal
deviation, periorbital ecchymosis
• Open & closed treatment
• Close reduction and fixation
Nasal bone
Fracture
前端兩刃自鼻孔插入至鼻骨下
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