Disease of the Nasal Cavity, Sinuses, Pharynx, and Larynx

Sinus pathology

- Acute sinusitis - Chronic sinusitis

Nasal pathology

- Allergic rhinitis - Epistaxis - Polyps - Tumors

Considerations with pediatric nasal passage and sinuses

- Babies are obligate nasal breathers - Nasal obstruction = respiratory distress, cyanosis (cyclical, because when babies start crying they breathe through their mouth and turn pink again, and then stop crying and cannot breathe)

Causes of nasal passage obstruction

- Deviated septum - Inferior turbinate hypertrophy (can be caused by allergies) - Foreign bodies in the nose - Large adenoids, which block the back of the nose - Swelling of the lining of the nose from allergies - Choanal atresia: congenital condition in which tissue narrows or blocks the nasal passage - Pyriform aperture stenosis (overgrowth of maxillary bone causes narrow anterior opening of nose) - Polyps - Tumor

The sinuses MRI

- Frontal - Ethmoid air cells - Maxillary - Sphenoid (not pictured)

Two most important things in sinus health

- Mucociliary clearance - Opening for exit (ostium)

Choanal atresia

A congenital defect that results in the obliteration or blockage of the posterior nasal aperture due to failure of canalization - Girls > boys - 2/3 of cases are unilateral Most common causes: - Abnormalities in pterygoid plates (of sphenoid bone) - Midfacial growth abnormalities Choanal atresia is found both as an isolated anomaly, or part of a multiple congenital anomaly syndrome, such as: - Treacher-Collins - CHARGE - Kallman - VACTERL/VATER (mesodermal defects) Aside from congenital anomaly syndromes, anomalies that can be found concurrently with choanal atresia include: - Facial, nasal, or palatal deformities - Polydactylism - Congenital heart disease - Malformations of the external ear - Esophageal atresia Presentation varies depending on whether there is unilateral or bilateral involvement 1. Bilateral present in infancy: - Upper airway obstruction - Noisy breathing - Cyanosis that worsens when the infant feeds and improve when the infant cries 2. Unilateral presents later in life: - Unilateral nasal discharge and/or unilateral nasal obstruction Diagnosis: - CT with intranasal contrast, which will show narrowing of the posterior nasal cavity at the pterygoid plate - Choanal atresia should be suspected if a *french catheter cannot be passed from the nose to the oropharynx* Treatment: - Immediate management of infants with choanal atresia may require placement of an oral airway and garage feedings (through nose) - The definitive repair involves surgical correction

Acute Epiglottitis

A potentially life-threatening emergency where the epiglottis and surrounding tissue become severely swollen due to infection. - This can result in severe airway obstruction. Causes: - *Haemophilus influenza type b (H. flu)* was the most common causative pathogen prior to universal Hib immunization (but can present in child that has not been immunized) - Common pathogens now include non-typable Haemophilus influenza and Streptococcus species - Epiglottitis is no longer common in children due to the implementation of universal Hib immunization. Signs/symptoms: - Straight neck, inability to move, quiet - "Tripod position" because child cannot breathe or swallow - Fever - Drooling (difficulty swallowing) - "Hot potato voice" (indicates pathology of oropharynx or hypo pharynx) - Stridor (high pitched noise indicative of respiratory distress at high level) - Toxic appearance Course: - Progresses rapidly over several hours, has no preceding coryzal symptoms, and does not present with cough (unlike croup) - Without prompt treatment, epiglottitis can result in severe airway obstruction and respiratory distress. Diagnosis: - *Only visual inspection of the oropharynx* should be performed to confirm clinical suspicion - Manipulation of the airway in any way, including tongue depressor, screening for lymphadenopathy or anatomical findings, intubation, and ventilation should be deferred until an experienced otolaryngologist or anesthesiologist is present and prepared for intubation - On a *lateral x-ray*, a *"thumbprint sign"* will be visible as a result of the epiglottis masking the valleculae (air space) Approach/treatment: - Securing the airway is the most crucial step, even prior to making a definitive diagnosis (orotracheal intubation or slash tracheotomy if necessary) - Once the airway is secure, *IV antibiotics (ceftriaxone or cefuroxime)* for 2-5 days - Prophylaxis with *rifampicin* may be offered to close household contacts.

Pituitary tumors

Access and remove tumor through nose --> sphenoid sinus (transsphenoidal) - Pituitary sits right on top of sphenoid sinus

Normal anatomy of choana

Adenoid tissue is present in children but should not be present after teenage years

Adenoids

Adenoiditis is inflammation of the adenoid tissue and is most commonly seen in children, although it can occur in adults - Adenoids begin decreasing in size by age 5-6, and often disappear by the teenage years (adenoids are enlarged pharyngeal tonsils) - They function to trap pathogens and produce antibodies to fight infection. Cause: - Adenoiditis is typically viral in nature, but can also be bacterial - Common viral causes of adenoiditis are Adenovirus, Rhinovirus, Paramyxovirus - Common bacterial causes of adenoiditis are Strep pyogenes, Strep pneumonia, Moraxella catarrhalis, Staph aureus Presentation: - Sore throat - Rhinorrhea - Fever - Airway obstruction - Ear pain Treatment involves: - Steroidal spray (to reduce congestion) - Antibiotics (if bacterial etiology) - Surgical removal of adenoids (often tonsils at the same time for recurrent infection)

What is the hallmark of acute sinusitis?

Air-Fluid levels in the sinuses

Allergic rhinitis

Aka "hay fever," an *inflammation of the nasal passage (entire sinonasal lining) caused by exposure to airborne allergens* - The most common type of atopy; Atopic Disorders are localized type I hypersensitivity reactions that generally carry a strong family history (such as eczema and asthma) - Common condition, affecting 10-30% of children - Dependent on allergen sensitivity and can *take years to develop*; persistent nasal sxs in a child <2 years suggests another diagnosis Pathogenesis: 1. Inhalation of allergen 2. IgE-mediated mast cell degranulation (histamine), responsible for symptoms (type 1 hypersensitivity reaction) Physical exam findings: - Pharyngeal "cobblestoning" (due to hyperplastic lymphoid tissue) - Transverse nasal crease (from rubbing nose) - Infraorbital edema and darkening (from vasodilation) - Creases below inferior eyelid (due to coexisting allergic conjunctivitis) Symptoms: - Sneezing - Rhinorrhea - *Nasal obstruction: increased mucus production, thickened mucus, tissue swelling, congestion* - Nasal/eye itching - Cough (from post-nasal drip) - Disturbances in sleep = generalized malaise and fatigue Intermittent allergic rhinitis: - Sxs appearing <4 times/week for <4 weeks Persistent allergic rhinitis: - Sxs appearing >4 times/week for >4 weeks Considered mild unless any of these criteria are present, in which case it is considered moderate/severe: - Sleep disturbance - Impairment of school or work performance - Impairment of daily, leisure, or sport activities Diagnosis: - Clinical grounds - Allergen specific testing generally not necessary Treatment: - Allergen avoidance - *Nasal glucocorticoid (steroid) spray* (eg fluticasone, mometasone): prevents mucus production - Oral or nasal *Antihistamines (allergy medication)* - *Allergy immunotherapy* (immune tolerance via "allergy shots" or sublingual immunotherapy) - *Surgery*: can break turbinates to make nasal cavity larger; does not directly treat cause but can improve sxs - Nasal decongestant sprays should not be used for routine treatment, as they may cause severe rebound rhinitis when discontinued (rhinitis medicamentosa)

Angiofibroma

Benign vascular tumor - classic patient: an adolescent male with recurrent nosebleeds Presentation: - Unilateral nasal obstruction - Hx of recurrent nosebleeds Dx: - CT or MRI can help show extent of tumor - Angiography helps identify vessel(s) of origin Treatment: - Hormonal therapy - Radiation - Surgical removal

Mucociliary clearance

Cilia move mucus towards osmium Affected by: - Distorted anatomy (surgery) - Cilia pathology (smoking, illness, many others) - Mucus viscosity (thicker mucus = harder to move)

Orbital cellulitis/abscess

Complication of acute sinusitis - Infection can compress or invade orbital structures Presentation: - 2 weeks ago had cold - 1 week ago worsening, increasing nasal discharge, some facial pain and pressure - 2 days ago eye began to swell, felt terrible, severe pain in right eye, inability to open eye Treatment: 1. Small collections - Antibiotics - Steroids - Nasal decongestant spray 2. Large collections, vision changes - Surgical drainage - Direct through skin - Endoscopic through the sinuses

Eustachian tube

Connects middle ear to lateral wall of nasopharynx Functions: - Equalizes pressure across two cavities - Opens during activities such as swallowing, yawning, or Valsalva maneuver, as well as during changes in atmospheric pressure Four muscles responsible for function: 1. Tensor veli palatini (CN V3) 2. Levator veli palatini (CN X) 3. Salpingopharyngeus (CN X) 4. Tensor tympani (CN V3) Two muscles that open Eustachian tube: 1. Levator veli palatini (minor contribution) 2. Tensor veli palatini (major contribution)

Muscles responsible for Eustachian tube function

Four muscles responsible for function: 1. Tensor veli palatini 2. Levator veli palatini 3. Salpingopharyngeus 4. Tensor tympani Two muscles that open Eustachian tube: 1. Levator veli palatini (minor contribution) 2. Tensor veli palatini (major contribution) Innervation: - The *tensor veli palatini* is innervated by the *medial pterygoid nerve*, a branch of *mandibular nerve (V3)* - This is the only muscle of the palate not innervated by the pharyngeal plexus, which is formed by the vagal and glossopharyngeal nerves

Ethmoid bulla, uncinate process, and middle turbinate relationship

Green: ethmoid bulla Red: Middle turbinate Yellow: uncinate process Blue: lateral wall of nasal cavity

How to best stop the acute nose bleed?

Hold cartilaginous area for 10 minutes to squeeze blood vessels and lean forward (do not aspirate blood) - Will stop ~90% of nosebleeds

Innervation of tongue

Hypoglossal nerve (XII) - Innervates all the extrinsic and intrinsic muscles of the tongue except for *palatoglossus* which is innervated by the *vagus nerve* (one of muscles of oropharynx) - Solely motor function

Balloon sinuplasty surgery

Improves drainage of sinuses (frontal sinus pictured)

Why do children have recurrent ear infections?

Infections from the upper respiratory tract can track up the Eustachian tube and cause otitis media. - Eustachian tubes are smaller (less distance to travel) - Tube is more horizontal in children = nasal secretions can reflux into middle ear = continued exposure to bacteria - Adenoids can have increased growth and block ear; adenoids are removed in children who have Eustachian tube surgery

Sinusitis

Inflammation of nasal sinus causing symptoms - Acute rhinosinusitis (ARS): lasts <4 weeks - Chronic rhinosinusitis (CRS): lasts > 12 weeks (3 months) - Sinus ostia are very small 1. Most common cause of is *viral infection* associated with the common cold or a upper respiratory infection (URI) 2. Causes of acute sinusitis due to *obstruction* of sinus ostia: - Nasal polyps - Deviated septum - Foreign body - Edema (from allergy, irritants, viral inflammation) 3. *Bacterial infection* accounts for <2% of cases. Three most common bacteria causing sinusitis: - Streptococcus pneumoniae - Haemophilus influenzae - Moraxella catarrhalis *Acute bacterial sinusitis suspected if patients with symptoms of sinusitis present with any of the following: - Symptoms >10 days - Severe pain and fever >3 days - Symptoms that improve and the worsen after several days ("double sickening") 4. *Problems with mucociliary clearance* - Distorted anatomy - Cilia pathology (smoking, etc) - Mucus viscosity Presentation: - Sinus congestion - Purulent nasal discharge - Cough - Sinus pain - Sinus pressure - Maxillary sinusitis may present with pain over the cheeks that may mimic pain associated with dental caries Diagnosis dependent on physical exam findings: - Sinus congestion - Purulent discharge *(white, thick drainage out of ostia)* - Mucosal edema and inflammation - Pain upon palpation of sinuses (non-specific) *Imaging studies (Xray, CT) not indicated in initial evaluation of uncomplicated sinusitis Complicated sinusitis: - Imaged via CT scan Complications: *(brain and eye are very close to sinuses)* - *Orbital cellulitis,* *orbital abscess* - Mucoceles (swelling of a sac) - Osteomyelitis - *Intracranial infection* (eg epidural abscess, *meningitis*, brain abscess) - Cavernous sinus thrombosis (paired dural venous sinuses) - Pott's puffy tumor Treatment acute sinusitis: *Treatment is difficult because the sinus is pinched off and becomes infected and inflamed 1. Supportive, aimed at symptom management (improve nasal clearance, decrease mucosal edema) Improve nasal clearance: - Saline nasal irrigation - Oral decongestants - Mucolytics (guaifenesin) - Mild analgesics Decrease mucosal edema: - Steroid nasal spray - Oral steroids (not always necessary) 2. First line treatment for patients with suspected acute *bacterial* sinusitis - *Amoxicillin-clavulante* 3. Antihistamines - Reserved for patients with allergies due to their drying effect = can worsen congestion Chronic rhinosinusitis: - Diagnosed when sxs of sinusitis have been present for >3 months - Patients often present with nasal congestion with pain and headache w/o fever - Chronic sinusitis is a problem because recurrent abx use causes high risk for infection with Staph aureus - Treatment: broad-spectrum antibiotics and referral to otolaryngologist - *CT scan after antibiotic treatment* (see effectiveness of treatment) - *Surgery may be necessary:* Functional endoscopic sinus surgery (FESS) opens up sinuses (maxillary, frontal, sphenoid) and/or improve drainage (ethmoid), retains natural function of sinus

Eustachian tube in children vs adults

Kids: - Size of passageway is smaller - Direction of drainage into throat is more horizontal vs vertical - Adenoids can also block passageway

Oropharyngeal cancer

Locations: - Tonsillar carcinoma - Soft palate and pharyngeal wall - Tongue base Two distinct SCC entities: - HPV+ - HPV- Risk factors: - HPV 16 and 18 (not oral cavity or laryngeal cancers, only oropharyngeal) - Tobacco/alcohol Symptoms: - Persistent sore throat - Difficulty swallowing - Ear ache (referred pain) - Difficulty opening mouth - Change in voice - Lump in the neck

Lung cancer causing hoarseness and cough

Lung cancer can press on *left recurrent laryngeal nerve*, affecting function of vocal cords (most intrinsic muscles innervated by recurrent laryngeal nerve) - Left recurrent laryngeal nerve wraps around aortic arch; right recurrent laryngeal nerve wraps around subclavian artery - Can paralyze one or both vocal cords - Other vocal cord can become lit up on PET scan because it is working overtime and using more glucose

Nasopharyngeal carcinoma

Most common cancer of nasopharynx - Strongly associated with *Epstein-Barr virus (EBV) infection* - High prevalence amongst *Chinese adults* and African children (rare in US) - Metastasizes to *cervical lymph nodes* in 70% of cases Three subtypes: - Squamous cell carcinoma - Nonkeratinizing squamous carcinoma - Undifferentiated cancer Presenting symptoms depend on location of tumor: - *Neck masses* (metastases to cervical lymph nodes) - *Ear symptoms* (pain, tinnitus, infections, dizziness) - *Bloody nasal discharge* - *Cranial nerve palsy* (Trigeminal or facial, causing facial numbness/pain, diplopia/double vision/blurring, difficulty with speech/swallowing) - Unilateral obstruction - Horner's syndrome Exam: - Bubbles in ear - Mass in nasal cavity - Neck mass

Epistaxis

Most frequently from anterior septum (Kiesselbach's area/plexus) Causes: - Dryness (cracked mucosa): dry air or turbulent air flow that dries out mucosa from anatomical deformity - Nose picking - Blood coagulation problems - Superficial vessel anatomy - Angiofibroma (recurrent nosebleeds) Treatment: - Acute bleed: Pinch and lean forward - Multiple bleeds: Moisturization, stop irritating nasal meds, consider cauterization, consider tumors (angiofibroma or nasopharyngeal carcinoma)

Nasal vs Sinus function

Nasal function: - Warm and humidify air - Trap foreign particles - First line immune defense (innate immunity, IgA) - Smell Sinus function: - Resonance - Lighten head - Protection of vital structures - Produce secretions to keep nasal cavity moist

Pott's Puffy Tumor

Non-neoplastic complication of acute sinusitis characterized primarily by subgaleal swelling (potential space between the skull periosteum and the scalp galea aponeurosis) and osteomyelitis, usually of frontal bone, causing subperiosteal abscess - Usually related to the frontal sinus - Presents with forehead swelling (subgaleal collection)

Nasal polyps

Non-neoplastic edematous protrusions in the lining of the nasal cavity - Are a *response to chronic inflammation* Gross: - "Grapes" - Tissue that is watery, not fully solid (edematous) Causes: - *Allergic polyps* (most common): IgE mediated; eosinophils seen in peripheral smear - *Cystic fibrosis* (pediatric): thick secretions cause polyps to form; *sweat-chloride test is indicated in children with nasal polyps to rule out CF* - *Aspirin hypersensitivity* (adults) Approach: - If seen in a child, refer for CF testing (sweat chloride) - Test for allergies Treatment: - Antibiotics + steroids - Surgery in many, because tissue will not fix itself

Encephalocele (of nasal cavity)

Out pouching of meninges and/or glial tissues - May be pulsatile Cause: - Pulsations of brain can erode away bone over sinuses (this bone is very thin) Presentation: - Clear, watery drip from nose

Presentation of chronic sinusitis

Overall, the sinuses are thickened and inflamed - Pus is thick and yellow/differnet colors vs white pus like acute sinusitis - Diagnosed when sxs of sinusitis have been present for >3 months - Patients often present with nasal congestion with pain and headache w/o fever - Recurrent abx use = high risk for infection with Staph aureus - Treatment: broad-spectrum antibiotics and referral to otolaryngologist (surgery may be necessary; CT scan to determine effectiveness of treatment)

What is referred otalgia?

Pain in the ear that is not caused by something in the ear - Jacobson's nerve - Arnold's nerve - Ramsey Hunt nerve Noxious stimuli of any branch of the nerves providing sensory innervation to the ear may be interpreted as otalgia - CN V3 (auriculotemporal branch) - C2, C3 - Glossopharyngeal nerve (Jacobson branch) - Vagus nerve (Arnold branch) - Facial nerve (Ramsey Hunt branch) Areas that have the same sensory output as the ear: - Tonsils - Pharynx - Larynx - Thyroid - Tooth

Result of paralysis of recurrent laryngeal nerve vs superior laryngeal nerve?

Paralysis of recurrent laryngeal nerve: - Vocal cord paralysis Paralysis of superior laryngeal nerve: - Pitch problems - Paralysis of the cricothyroid muscle = inability to lengthen vocal cords

Normal nasal airflow

Shaped in order to expose air to as much of nasal cavity as possible to warm and humidify the air without drying out the mucosa - Turbulent flow tires out nose, impedes air flow, and causes congestion

Development of sinuses

Sinuses are not completely present at birth, but grow as baby grows - Small maxillary, ethmoid, sphenoid sinuses are present at birth and keep growing - Frontal sinus is not present until ~4 years - As a result, babies do not usually get sinus problems

Post-surgical tongue complications

Surgery in cervical region can damage motor nerve to tongue (hypoglossal) Side of injury can be determined via: 1. Atrophy of one side of the tongue causing tongue to tilt in that direction 2. Unopposed muscle of innervated side of the tongue will push tongue towards affected side (Genioglossus) Image: - Injury is on left side (atrophy and leftward deviation) - Can appear like a mass on CT scan

Process of olfaction

Through olfactory epithelium (near top of septum at the top of middle turbinate) Requirements for smell: - Air to olfactory epithelium - Working epithelium - Working brain Pungent odors: - Ammonia, vinegar, etc go through different system (trigeminal nerve (CNV) pain fibers)

Tracheotomy vs tracheostomy vs cricothyroidotomy

Tracheotomy: - Incision/opening in trachea - No implication of permanence - Mouth/nose/lungs are still connected Tracheostomy: - Surgical opening into the trachea through the neck, with the cut off trachea being brought into continuity with the skin - Usually permanent - Mouth and nose no longer connected to lungs (cannot be ventilated with a mask) - Mandatory neck breathers Cricothyroidotomy: - No bleeding during incision because there are no vessels to hit in the midline - Incision in cricothyroid membrane (between cricoid cartilage and thyroid)

Drainage in acute sinusitis

White, thick drainage out of ostia