耳鼻喉科Otolaryngology topic seven: Nose /paranasal sinuses_anatomy

Nose /paranasal sinuses_anatomy

1. Surface

-- root-->bridge/dorsum-->tip-->membranous septum-->columella

-- GNRTP: glabella-->nasion-->rhinion-->tip-defining point-->philtrum

2.  Upper lateral cartilage

-- lower border: limen vestibuli, internal valve(resistance MAX, narrowest) 

-- below limen vestibuli : nasal vestibules((stratified squamous epithehum)

3. Lower lateral cartilage

-- lower border: external valve

4. Lateral wall bones

-- nasal, frontal, lacrimal

-- sphenoid, palatine

-- ethmoid, inferior concha (independent)

5. Openings

-- inferior meatus: nasolacrimal duct; E-tube(posterior)

-- middle meatus( hiatus semilunar ): sphenoid, anterior ethmoid, frontal sinuses

-- superior meatus: posterior ethmoid sinus

***posterior to E-tube: torus tubarius

** division of ant./post. ethmoid: basal lamella

6. Concha

-- Agger nasi: anterior border of ethmoid air cell

7. Olfactory pathway

-- olfactory bulb: 1st & 2nd neuron conjugation

-- mechanism: air particles dissolved in excreted fluid 

8. Nerves

-- anterior-->incisive canal= canal of Stenson 

-- posterior-->greater palatine foramen=  descending palatine vessels , greater palatine nerve

-- surface-->CN5-1, 5-2

-- inside-->CN5-2-->foramen rotundum-->pterygopalatine ganglion-->concha, greater palatine foramen(posterior)

-- parasympathetic-->brain stem-->geniculate ganglion-->superficial petrosal n.-->vidian n.-->pterygopalatine ganglion-->secondary neuron 

-- sympathetic-->superior cervical ganglion-->deep petrosal n.-->vidian n.-->pterygopalatine ganglion-->gland

9. Arteries

-- external carotid: internal maxillary a. /facial a. 

-- internal carotid: ophthalmic a. 

10. Veins

-- ethmoid v.-->ophthalmic v.-->cavernous sinus-->thrombosis, meningitis, brain abscess

-- NO valves

11. Sinuses

-- development: E(14wks~birth, X ray:6 months)-->M(10wks~birth, X ray:6 months, nasal floor: 12 years)-->S(2~6 years)-->F(3~18 years, X ray: 7 years)

-- frontal sinus drainage: affected by uncinate process

-- ostiomeatal complex(OMC)

-- sphenoid sinus development: sellar >presellar > conchal type

耳鼻喉科Otolaryngology topic six: Basics about nasal cavity and paranasal sinuses

Basics about nasal cavity and paranasal sinuses

1. Nasal cavity: 8 bones

-- maxilla bone

-- ethmoid bone 

-- frontal bone

-- lacrimal bone

-- palatine bone

-- sphenoid bone

-- vomer bone

-- inferior concha

2. Post-nasal dripping

-- mechanism 1 : hypersecretion

-- mechanism 2: too dry to flow out smoothly

-- normal secretion amount: 20-30ml/kg/day

3. Sinus and its effects
-- lighten the weight of cranial bones
-- secrete NO (↓pathogen)
-- affect eyes and related to teeth (maxillary sinus)

4. Cartilages of nose
-- lateral crus of greater alar
-- medial crus of greater alar
-- accessory alar
-- lesser alar
-- septal cartilage
-- lateral nasal cartilage

5. Concha
-- terminology: concha(bone) + mucosa = turbinate
-- function: create turbulent flow, ↑ surface area ( ↑ temperature, ↓ dusts)

6. Cavernous sinus ( DO NOT contain CN2, CN5-3)
-- pituitary gland
-- carotid artery
-- CN3
-- CN4
-- CN5-1
-- CN5-2
-- CN6, first influenced by sphenoid sinus lesions
*** Consider cavernous sinus lesions if headache(60%), cranial nerve related symptoms

7. Diagnostic tools in OPD
Indirect mirror: inferior concha

Endoscope

Rhinomanometry
-- check flow/pressure (steep slope=unobstructed, flat=obstructed )
-- 1, 3 quadrant= right nasal outlet; 2,4 quadrant= left nasal outlet

Acoustic rhinometry
-- sono
-- locate the obstruction site

Sinus echo: back wall echo (+) if effusion is present, good sensitivity

Olfactory test: GPCR-->cAMP-->Ca2+/Na+ in-->Cl- out-->depolarization

MAST (multiple antigens simultaneous test)  
-- for mites, cockroaches, seafood, pets...

Sinus routine
-- Caldwell view(forward 10~15°): for ethmoid sinus
-- Waters view(backward 45°): for maxillary sinus
-- lateral view

CT

Panorex

8. Rhinosinusitis
-- anterior / posterior sinus: divided by E-tube outlet
-- virus infection: within 10 days
-- secondary bac. infection: >10 days (aerobic earlier than anaerobic)

-- acute: <4 wks
-- recurrent: >4 episodes, 7~10 days
-- chronic: >12 wks, often iatrogenic/odontogenic ( 1st molar )

-- treatment: Otrivin nasal spray(use <5 days), irrigation, steroid(oral-->spray), FESS, Caldwell-Luc operation ...

9. Allergic rhinitis
--  One air way one disease: allergic rhinitis associated with asthma
-- treatment: antihistamine, antileukotriene, steroid, cromolyn sodium, desensitization

10. Epistaxis
-- anterior:  Little’s area＝Kiesselbach's plexus
-- posterior: Woodruff‘s area, use Foley packing, flow↑

耳鼻喉科Otolaryngology topic five: Deep neck infection

Deep neck infection

***high mortality if diagnosis & treatment delayed***

***beware of air way***

1. Etiology: 

-- past: from tonsils and pharynx

-- now: odontogenic 

2. Anatomy: 

-- superficial cervical fascia*1+ deep cervical fascia*4 (if including carotid sheath)

Deep cervical fascia- superficial layer

-- rule of two's

Deep cervical fascia- middle layer

-- posterior midline raphe (=pharyngeal raphe) and pterygomandibular raphe

Deep cervical fascia- deep layer

-- alar portion

-- prevertebral portion

Spaces

-- retropharyngeal space:  between middle layer visceral division and alar ; nodes of Rouviere, drainage from sinus, infection more common in children

-- danger space: between alar  and prevertebral;  cervical sympathetic trunk

-- prevertebral space: phrenic nerve,  brachial plexus

-- carotid space:  vagus nerve

-- parapharyngeal space(pic below): common pathway for other cervical spaces; inverted pyramid, poststyloid compartment, prestyloid compartment

3. Infection source: odontogenic, sinusitis, pharyngitis, otitis 

-- Gram (+), consider MRSA

-- anaerobics

-- Gram (-) if immunocompromised, consider pseudomonas

-- atypical

4. Special symptoms

-- dyspnea

-- dsyphagia 

-- odynophagia  

-- voice changes

-- drooling 

-- trismus 

-- otalgia

5. Complications

--  neurovascular :carotid artery pseudoaneurysm and rupture, Lemierre’s syndrome or IJV thrombophlebitis

--  mediastinitis 

--  necrotizing cervical fasciitis 

6. Submandibular space and Ludwig angina 

-- between submandibular(posterior molar infection) and sublingual(anterior molar infection)

-- affect range from hyoid muscle to parapharngeal space

-- symptoms: rigid, trismus, voice change, dyspnea

-- need tracheotomy 

耳鼻喉科Otolaryngology topic four: salivary gland disease

Salivary gland disease

1. Development:

-- earliest start+ last completion: parotid gland

-- before lymphoid tissue development: submandibular, sublingual gland
   (Contain lymphoid tissue --> inflammation or malig., but few malig. at submandibular gland )

2. Parotid gland
-- serous gland, excreted via  Stensen duct 
-- mixed gland at accessory gland
-- connection: forehead, lateral temporal, frontal, periorbital --> intra-parotid lymph-->parotid gland

-- nerve passing: CN7 , 86.7% divided into two branches(tempofacial, cervicofacial), then finally divided into five terminals(temporal, zygomatic, buccal, marginal, cervical), among which buccal is the most variable

-- innervation: CN5-3; sym. n. traveling at external carotid a./ para. n, CN5-3, join CN9

3. Submandibular gland
-- mixed gland (more serous), excreted via  Wharton duct 
-- cross CN7 marginal mandibular nerve
-- related surgery: Hayes martin maneuver

-- innervation:  sym. n. traveling at lingual a./ para. n, CN5-3


4. Sublingual gland
-- mucus gland , excreted via  ducts of rivinus,  Bartholin duct

5. Others
-- minor salivary glands: trachea, oral cavity, nasal cavity, ...
-- histology: acinus cell secreting amylase(serous), mucin(mucus)
-- components: mostly water(99.5%), secreting K+, reabsorb Na+
-- amount:  1-1.5L per day( mostly from stimulation), too much--> hypersalivation, ptyalism
-- innervation: sym. for viscus (norepinepherine);
                        para. for watery part (acetylcholine)

6. Frey syndrome
-- CN5-3 for parotid gland--> change pathway to direct sweat glands
-- after parotidectomy-->80%

7. Acute suppurative sialadenitis
-- retrograde infection
-- more common in parotid gland, post-op pts
-- symptom: diffuse swelling
-- microbiology: 90% S. aureus

8. Mumps
-- symptoms:  fever, malaise, myalgia, anorexia,  orchitis、aseptic meningitis、pancreatitis、myocarditis
-- diagnosis tools:  anti-mumps S antigen and V antigen antibody, urine culture, PCR

9. HIV-related
-- more common in parotid gland (lymph related)
-- presented with xerostomia

10. Granulomatous infection
-- disseminated TB: submandibular gland

11. Cat-scratch disease
-- microbiology: Bartonella henselae

12. Sarcoidosis
-- more common in parotid gland

13. Sjogren’s syndrome
-- 40~60 y/o female
-- prone to have lymphoma

14. Chronic sialadenitis
-- due to sialolithiasis(80% submandibular, unilateral) or duct stricture
-- presented with xerostomia
-- tool for diagnosis: sialography(=x-ray+contrast at salivary glands)

15. Juvenile recurrent parotitis
-- only happens to the "juvenile" group (XDDD I won't get this!)

16. Cystic lesions
-- most common at parotid gland ,second pair
-- mucous extravasation phenomenon(mucoceles at lips, called ranula if from sublingual)
-- ranula: needs transoral resection

17. Radiation injury (including iodine-induced sialadenitis)
-- parotid, >20-30 Gy or I-131(dose depedent) 
-- needs F/U neoplasms

18. Trauma: CN7
-- posterior to the border line from lateral canthus to mental foramen: end to end repair

耳鼻喉科Otolaryngology topic three: Diseases of Nasopharynx and Related areas

Diseases of Nasopharynx and Related areas

1.  Most common site of nasopharyngeal carcinoma(NPC)= Fossa of Rosenmüller

2. Histology: 

-- epithelial
(ciliated pseudostratified >  stratified squamous epithelium)

-- lymphoid

-- salivary gland

3. Benign diseases:

Adenoid hypertrophy (inflammatory)

-- may obstruct E-tube, sinus outlet

-- adenoid face

Nasopharynx cyst- Tornwaldt’s bursa (cyst)/ bursitis  (inflammatory)

-- caudal end of notochord in communication with nasopharyngeal epithelium

-- position: midline, posterior wall of nasopharynx

-- treatment: antiobiotics, marsulpialization

Nasopharynx cyst- retention cyst  (inflammatory)

-- chronic inflammation of lymphoid tissue

Juvenile angiofibroma (tumor)

-- teenager, boy

-- unilateral epistaxis (vessels lack of intervening smooth muscle layer)

-- DO NOT perform BIOPSY!!! -->avoid massive bleeding, do imaging first

-- pre-op 24~72 hrs : perform artery embolization 

NPC

-- influenced by environment, race, gene; related to EBV

-- peak age: 40 y/o, reach plateau afterwards

-- prognosis:  Type I Keratinizing Carcinoma >  Type II Non-Keratinizing Carcinoma (more common in South-East China and Taiwan)

-- features:  cervical lymphadenopathy(jugulodigastric), unilateral nasal congestion(cp. inverted papilloma), blood-stained rhinorrhea, middle-ear effusion, hearing impairment, unilateral headache and other neurological symptoms
-- diagnosis tool: BIOPSY for both new case and recurrence!!!
                            liver sono & bone scan for metastasis, meta. LN > 6cm in distance

-- F/U: IgA toward EBV capsule antigen(VCA), early antigen(EA)/ DNA
-- treatment:
                    less sensitive to radiation and  chemo, but initial therapy still preferring chemo-->CCRT-->chemo or RT(IMRT), CCRT alone
                   in field recurrence-->surgery; metastasis at margin-->re-irradiation; metastasis at neck-->surgery

-- prognosis: good if no metastasis, local recurrence 25%, distal metastasis 20%

實戰課題Medical Internship topic 1-1: Antibiotics_Penicillin

Antibiotics_Penams

1. Antibiotics targeting  at bac.'s cell wall

-- beta-lactam:    penicillin; G(+)

                           cephems; G(+)

                           carbapenems; G(-) 

-- glycopeptide:  vancomycin, teicoplanin 

2.  Penams (Click to have a clearer view.)

E: E.coli.

P: Proteus

H: H. influenza

S: Salmonella, Shigella?

L: Listeria

K: Klebsiella 

AB: Actinetobacter baumanni

耳鼻喉科Otolayngology topic two: paranasal sinuses and non-epithelial tumors

Paranasal sinuses and non-epithelial tumors

1. Benign non-epithelial tumors

-- Fibroosseous lesion: osteoma, fibroma, chordoma...slow in growth

 Osteoma

                              <epi.>       associated: Gardner’s syndrome

                              <location> Frontal sinus

                             <prog.>      5 year survival 74~100%

                             <DDx>        fibrous dysplasia (GGO on CT, do not suggest surgery)

 Peripheral nerve sheath tumor (mostly benign)

                              <location> CN2, 

                              <micro>    2/3 schwannomas, 1/3 neurofibromas

                             <treat>      surgery if symptoms(+)

2. Malig. non-epithelial tumors (more common than benign non-epi.)

Three large groups

-- non-epithelial 

-- lymphoreticular

-- metastatic

3. Group one: non-epithelial 

-- Neurogenic sarcoma associated with neurofibromatosis 

-- Rhabdomyosarcoma with bimodal occurrence/worse outcome in adults

-- Fibrosarcoma associated with trauma and radiation 

-- Chondrosarcoma at jaw

-- Hemangiopericytoma from pericytes

-- Lymphoma : NK/T  cell in Asians, B cell in Westerners; recur @ abd., need CHEMO

4. Group three: metastatic

-- usually from kidney, breast, lung

5. Radiation therapy

-- Adenoid cystic carcinomas

-- Melanoma

6. Surgeries: Weber Ferguson, Maxillectomy, Mid-facial Degloving, Skull base surgery, Craniofacial resection, Orbit exenteration...