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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 • • • • • • • • 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 • • • • • • 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 • • • • Orbital cellulitis or abscess Meningitis Brain abscess Intractable wheezing in children with asthma • Cavernous sinus thrombosis • Subdural empyema Subjective Symptoms of Sinusitis • • • • • • • • • • • • • 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 • • • • • • • • • 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 • • • • • • • • • • 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 Any Question?