Sinusitis(Rhinosinusitis)（鼻竇炎/鼻-鼻竇炎）Theparanasalsinusesareagroupofaircontainingspacesthatsurroundthenasalcavity(fourpairs)Eachsinusisnamefortheboneinwhichitislocated:Maxillary(onesinuslocatedineachcheek)Ethmoid(approximately6-12smallsinusesperside,locatedbetweentheeyes)Frontal(onesinusperside,locatedintheforehead)Sphenoid(onesinusperside,locatedbehindtheethmoidsinuses,nearthemiddleoftheskull)AnatomyThedrainageofthesinusesFrontal,maxillary,anteriorethmiodmiddlemeatusPosteriorethmoidsuperiormeatusSphenoidsphenoethmoidalrecessostiomeatalcomplex,OMC(竇口鼻道復合體)EPOS2012CPOS2012Rhinology.2012Mar;50(1):1-12.EPOS2012:Europeanpositionpaperonrhinosinusitisandnasalpolyps2012.Asummaryforotorhinolaryngologists.FokkensWJ,LundVJ,MullolJ,BachertC,AlobidI,BaroodyF,CohenN,CervinA,DouglasR,GevaertsP,GeorgalasC,GoossensH,HarveyR,HellingsP,HopkinsC,JonesN,JoosG,KalogjeraL,KernB,KowalskiM,PriceD,RiechelmannH,SchlosserR,SeniorB,ThomasM,ToskalaE,VoegelsR,WangDY,WormaldPJ.EPOS2012Sinusitis/RhinosinusitisRhino-sinusitisreferstotheinflammationofthetissuesofthenose(rhino-)andthesinuses.Theinflammatoryprocessinvolvingoneormoreoftheparanasalsinuses.Maxillarysinusitisisthemostcommontypeofsinusitis.Sinusitisisrareinchildrenyoungerthan1yearbecausethesinusesarepoorlydevelopedbeforethatage.ClassificationAcuteRhinosinusitis(ARS):lastinglessthan12weeksChronicRhinosinusitis(CRS):lastingmorethan12weeksEPOS2012Acuterhinosinusitis:

<12weeks;Acuteviralrhinosinusits/Commoncold；

durationofsymptomsforlessthan10days;Acutepost-viralrhinosinusitis:increaseofsymptomsafter5daysorpersistentsymptomsafter10dayswithlessthan12weeksduration.Acutebacterialrhinosinusitis(ABRS)Acutebacterialrhinosinusitisissuggestedbythepresenceofatleast3symptoms/signsof.?Discoloureddischarge(withunilateralpredominance)andpurulentsecretionincavumnasi,?Severelocalpain(withunilateralpredominance)?Fever(>38℃)?ElevatedESR/CRP?‘Doublesickening’(i.e.adeteriorationafteraninitialmilderphaseofillness).

ARSClassificationinEPOS2012EPOS2012withsymptomfreeintervalsiftheproblemisrecurrent,withvalidationbytelephoneorinterview.ChronicRhinosinusitiswithoutnasalpolyps(CRSsNP)ChronicRhinosinusitiswithnasalpolyps(CRSwNP)

CRSClassificationinEPOS2012CausesandPathogenesis

A.Bacteria:Sinusitisiscausedbyavarietyofbacteriasuchasstreptococci,staphylococci,pneumococciandHaemophilus.

B.Viruses:Influenzaevirusessuchastheinfluenzaandtheparainfluenzavirus

C.Fungi:lesscommonlybyfungisuchasaspergillus.SinusitisPredisposingfactorsofARSFactorsassociatedwithARS：EnvironmentalExposuresAnatomicalfactors:

InpatientswithrecurrentARS,anatomicalvariationsincludingHallercellsandseptaldeviation,nasalpolyps,septaldeviation,andchoanalobstructionbybenignadenoidtissue,orodontogenicsourcesofinfectionsshouldbeconsidered.AllergyCiliaryimpairment:Ciliaryfunctionisdiminishedduringviralandbacterialrhinosinusitis.Exposuretocigarettesmokeandallergicinflammationhasalsobeenshowntoimpairciliaryfunction,althoughresearchisrequiredtounderstandtheseprocessesfurther.PrimaryCiliaDyskinesia(PCD)SmokingLaryngopharyngealrefluxAnxietyanddepressionDrugresistanceConcomitantChronicDiseaseEPOS2012PredisposingfactorsofCRSFactorsassociatedwithCRS：CiliaryimpairmentAllergyAsthmaAspirinsensitivity:Inpatientswithaspirinsensitivity,36-96%haveCRSwNP.ImmunocompromisedstateGeneticfactorsPregnancyandendocrinestateLocalhostfactors:

ThereisnoevidenceforacausalcorrelationbetweennasalanatomicvariationsingeneralandtheincidenceofCRSBiofilmsEnvironmentalfactorsIatrogenicfactorsHelicobacterpyloriandlaryngopharyngealreflux“Osteitis”EPOS2012InflammatorymechanismsCRSwNPorCRSsNPCRScanbetypicallydescribedasadysfunctionalhost-environmentinteractionatthesiteofinterface,whichoccursinthenoseandparanasalsinuses‘fungalhypothesis’‘staphylococcalsuperantigenhypothesis’‘immunebarrierhypothesis’biofilmsEPOS2012SymptomsandSignsofAcuteSinusitisA.GeneralSymptoms

AcuteSinusitismalaise

mildfeverheadachenasaldischargeB.LocalSymptomsandsigns:

a.astuffyorrunnynoseb.colored

discharge:fromthenosec.Painorheadache:persistentdullpainorswellingaroundtheeyesoraroundthecheekbones,orsensationofpressureinheadd.smellsbadSymptomsandSigns

AcuteSinusitisMaxillarysinusitismayinthemaxillaryareaoftheface,toothache,andfrontalheadache.Frontalsinusitiscausesfrontalpainandheadache.Ethmoidsinusitiscausepainbehindtheeyesandfrontalheadache.Sphenoidsinusitiscausepainintheoccipitalregion.RhinogenicheadacheDifferentsinusitishasdifferentheadacheSymptomsofchronicsinusitisBlockednose(nasalobstruction):

themostprominentsymptom,usuallyaOneormoreofthefollowingmayalsooccur:Runnynose:thedischargemaybegreen/yellow.Reducedsenseofsmell.Pain:

overtheaffectedsinus.However,painisoftennotamainfeatureofchronicsinusitis(unlikeacutesinusitis).Inmanycases,itismoreofafeelingoffacialfullnessormilddiscomfortratherthanpain.PhysicalExamination

Endoscopy:Purulentsecretionsornasalpolypsinthemeatus.

CTscan:tofindwhichsinuseshaveinflammation.SinusitisARSCRSDiagnosisSymptomsandhistoryEndoscopicexaminationComputerizedtomography(CT):

CTscanningispreferredastheinitialstudyofchoice.Itisextremelysensitive.SinusitisTreatmentA.

AntibioticsB.

DecongestantsC.NasalsteroidsprayD.SurgicalCareSinusitisTreatmentA.Antibiotics

a.Antibioticsareprescribedifabacterialinfectionispresentorsuspected.b.CommonlyusedantibioticsforsinusitisincludethefollowingdrugsSinusitisAmoxicillinAmpicillinamoxicillinwithclavulanicacidtrimethoprimwithsulfamethoxasoleerythromycinc.TreatmentdurationAcutesinusitis:generallyrequires10to14daysofantibiotics.Chronicsinusitis:requireslongertreatment—usually3to4weeks.B.Decongestants

Decongestantsareusedtorelievesymptoms.C.Nasalsteroidspray

Nasalsteroidspraydecreaseinflammation,especiallyifyouhaveallergiesorastructuralproblemcontributingtotheinflammation.SinusitisTreatment

D.SurgicalCare

Ifmedicaltherapyfailsorfungalsinusitis

SurgicalTreatmentRemovalofalldiseasedsofttissueandboneThenaturalopeningsfromthesinusesareenlargedtoallowdrainage.

FESS:functionalendoscopicsinussurgerySinusitisTreatment導航輔助下鼻內鏡手術美國GE公司InstaTrakENTrak3500電磁影像導航系統Thankyou!

鼻腔及鼻竇腫瘤

（目的要求：熟悉臨床表現、診斷）一、概述

1、鼻腔鼻竇良性腫瘤：主要有血管瘤、乳頭狀瘤和骨瘤。內翻性乳頭瘤是鼻良性腫瘤中值得重視的腫瘤。2、原發于鼻竇的惡性腫瘤較原發于鼻腔的多見。在鼻竇惡性腫瘤中上頜竇惡性腫瘤最多（70%左右）,且有1/3上頜竇癌伴有篩竇癌。3、鼻腔及鼻竇惡性腫瘤以鱗形細胞癌最為多見（約占80%），好發于上頜竇，多見于50-70歲之間。腺癌次之；肉瘤多見于青年人或兒童。

一、概述

4、鼻腔鼻竇惡性腫瘤的共同特點：原發性多，轉移性少；解剖部位隱蔽、早期癥狀不典型，且常伴炎癥，故易漏診和誤診！晚期可侵犯累及多個解剖部位，原發部位難判斷。二、鼻腔鼻竇內翻性乳頭瘤

(InvertingPapilloma)疾病特點：良性腫瘤；術后易復發；多次手術易產生惡性變；多發性侵襲性生長易產生組織破壞。鼻腔鼻竇內翻型乳頭瘤臨床表現：單側鼻腔發病（約90%）

癥狀：鼻塞、進行性加重；流黏膿涕帶血；頭痛和嗅覺異常；隨腫瘤擴大，相應表現；體征：外觀呈息肉樣紅或灰紅表面不平，質地較硬觸之易出血；

多原發于鼻腔側壁，可充滿鼻腔并侵入鄰近部位。鼻腔鼻竇內翻性乳頭瘤診斷：癥狀+體征影像學檢查病理學活檢確診。多部位多點切取；40歲以上，反復發生單側”鼻息肉“、術后很快復發者。治療：根治性切除術。（一）病因

黏膜上皮大面積鱗狀化生。

致癌物質

交界性腫瘤惡變三、鼻腔鼻竇惡性腫瘤（二）臨床表現：

1.鼻腔惡性腫瘤：

單側鼻腔進行性鼻塞；黏膿涕帶血或反復經常鼻出血；可有頭脹、頭痛、嗅覺喪失或減退。來自中鼻甲的惡性腫瘤2.鼻竇惡性腫瘤--上頜竇癌（上頜竇五面體結構及毗鄰關系）（1）.早期腫瘤較小，只限于竇腔內多無明顯癥狀（2）.隨著腫瘤的發展出現：膿血鼻涕面頰部疼痛或麻木感，對本病的早期診斷甚為重要。鼻塞：進行性加重磨牙疼痛或松動（3）.