Книга_4440_Библиотеки_им_академика_М_И_Перельмана

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4.1 Presentation/History/Symptoms ofNasal andPNS Disorders

169

a b c d e

Fig. 4.3 Sites of hemicranial headache (a) CH, (b) Paroxysmal hemicrania, (c) SUNCT, (d) Hemicrania continua, (e) Migraine

Table 4.12 Presentation of trigeminal autonomic cephalgia

Trigeminal autonomic cephalalgias (TACs)—Trigeminal autonomic cephalalgias, or TACs, are a group of primary headaches characterized by pain that occurs on one side of the head or face. TACS are often accompanied by a small number of symptoms that may last for a short period of time on the same side of the head, such as teary eyes, nasal congestion and, in some cases, disrupted nerve pathways such as facial tics or paralysis. The International Headache Society’s (IHS) classication includes cluster headache, paroxysmal hemicrania and short-lasting, unilateral, neuralgiform headache attacks with conjunctival injection and tearing (SUNCT). Hemicrania continua, although classied separately, is thought to be related to TACs

Cluster headache—Cluster headache (CH) is a primary headache disorder that consists of severe headaches occurring on one side of the head that may be associated with red or teary eyes, runny or stuffy nose, ushing or sweating of the face and/or a sense of restlessness and agitation. The term ‘cluster’ refers to the recurrence of headache attacks in a series (cluster periods) lasting for weeks or months, separated by periods of remission lasting for months or years

Hemicrania continua—Hemicrania continua is a primary chronic daily headache marked by continuous, uctuating pain that varies from mild to moderate severity with occasional attacks of severe pain. This always occurs unilaterally (on one side of the head/face) and is superimposed with additional debilitating symptoms, such as watery or red eyes, blocked nasal passages and runny nose. However, some individuals with hemicrania continua report bilateral pain (that is, pain on both sides of the head/face) or ‘ice-pick’ pain. Hemicrania continua headaches are typically diagnosed when a patient has had a one-sided daily or continuous headache of moderate intensity with occasional short, piercing head pain for more than 3months without shifting sides or pain-free periods. This type of headache only responds to indomethacin

Paroxysmal hemicrania—This rare form of headache occurs primarily in adults with patients reporting severe throbbing, claw-like, or boring pain, usually on one side of the face; in, around or behind the eye; and occasionally reaching the back of the neck. Episodes of paroxysmal hemicrania typically occur from 5 to 40 times per day and last 2–30min. Along with attacks, the headache may cause episodes of redness or tearing of the eye, runny or stuffy nose, sweating or ushing of the face on the same side of the headache pain (called unilateral cranial autonomic symptoms), and certain movements of the head or neck or external pressure to the neck may trigger these headaches in some patients

(continued)

170

Table 4.12 (continued)

SUNCT headache—(Short-Lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing)— It is a rare disorder that primarily affects men over the age of 50. This condition is marked by bursts of moderate to severe burning, piercing or throbbing pain, usually on one side of the head and around the eye or temple. The pain usually peaks within seconds of onset and may follow a pattern of increasing and decreasing intensity. Typical nervous system responses include watery eyes, reddish or bloodshot eyes caused by dilation of blood vessels (conjunctival injection), nasal congestion, runny nose, sweating, swelling of the eyelids and increased pressure within the eye on the affected side of the head. Blood pressure may also rise during the attacks, and movement of the neck may trigger these headaches

Cervicogenic headache—A cervicogenic headache occurs as a symptom of a bone, disc and/or soft tissue disorder of the cervical spine. These secondary headaches are essentially ‘referred pain’, meaning that while the pain is perceived to be coming from the head, it is actually coming from a source in the neck. Those suffering from cervicogenic headache often report tenderness or a reduced range of motion in their neck, or a worsening headache associated with neck movement (however, the headache itself may or may not be associated with neck pain). The headaches typically occur on one side of the head, and the pain may radiate from the neck or back of the head up to the front of the head or behind the eye. There is also the possibility that cervical spondylosis, or age-related wear and tear affecting the spinal discs in the neck, may cause this type of headache

Primary stabbing/ice-pick headache—Primary stabbing headaches, commonly called ‘ice-pick’ headaches, are short, stabbing and extremely intense headaches that generally last for only seconds and are common in patients with migraine. Other common names for stabbing headaches include ice-pick pains; jabs and jolts; needle-in-theeye syndrome; ophthalmodynia periodica; and sharp short-lived head pain. Symptoms of primary stabbing headache include single or multiple stabs of pain that occur seemingly out of nowhere. These stabs can last seconds (many lasting under 3s), and the stabs can move from one area to another on either the same side of the head or the opposite side. If the stabs occur only in one place, it is important to evaluate to exclude any structural changes or injury to a nerve at that site. At most, primary stabbing headaches occur only a few times a day but may occur more frequently in rare cases

4 History andExamination ofNose andPara Nasal Sinuses

• Type of headache – Continuous—Refractory error,

sinusitis, Schluder’s neuralgia

– Intermittent—CH, tension head-

ache, occipital neuralgia, migraine, Tolosa-Hunt syndrome

• Nature of headache – Throbbing or pulsatile—Migraine,

sphenoid sinusitis, ice-pick pain

– Dull, tightening—Refractory

errors, tension headache – Piercing or stabbing—CH – Burning headache—CH – Sharp and shearing—Tolosa-Hunt

syndrome – Electric shock Jolts—Occipital

neuralgia – Constricting—Tension headache

• Aggravating and relieving factors (Table4.13)

• Associated symptoms or history/of

headache

– General associated symptoms/his-

tory of headache

Aura (sensitivity to light and sound)—Migraine Nausea and vomiting—Migraine

Physical exertion—(Exertional

headache)

Hunger—Hunger headache Hangover—Post-alcohol head-

ache

Fatigue

Having a cold or u—URI

Head trauma Eye strain or staring at a com-

puter for too long Using too much headache medicine, also known as rebound

headache

Alcohol, particularly red wine Certain foods, such as processed meats that contain nitrates Changes in sleep or lack of sleep Poor posture—Occipital headache Pent up anger—Tension headache

4.1 Presentation/History/Symptoms ofNasal andPNS Disorders

Table 4.13 Aggravating and relieving factors of headache

Aggravating factors Relieving factors Diagnosis Loud sounds, bright or ashing lights, specic

odours, certain foods, changes in weather

conditions, lack of sleep, hormonal changes,

skipping meals, dehydration No trigger Applying xylocaine in nose Cluster headache (CH) Sit upright, stand, cough, sneeze, strain,

engage in physical activity Bending forward, URI Antibiotic treatment Maxillary sinusitis URI Applying xylocaine agent

Increase in evening, stress Rest Tension headache More in morning, sleep Sitting or upright posture,

Rest Migraine

Lie down Intracranial hypotension

Sluder’s neuralgia, septal spur between the septum spur and lateral wall

Frontal sinusitis evening

171

Stress—Tension headache Decrease vision—Migraine, low blood sugar, retinal migraine Loss of vision—Retinal migraine

– Associated symptoms with specic

types of headaches

Associated symptoms with occipital headache pain with movement of neck, trauma to head, diabetes, neck tension (occipital neuralgia) Associated symptoms with retro-orbital pain (pain in, around and behind eye), ear discharge and diplopia—Gradenigo’s syndrome due to petrositis causing abducent nerve palsy U/L retro-orbital pain with autonomic features—CH Associated symptoms hemicranial headache URI—Pan sinusitis DNS with septal spur—Sluder’s neuralgia Aura with nausea, vomiting—Migraine Associated symptoms with frontal headache Burning and tearing of the eyes Diplopia—Ocular migraine Runny nose

Frequent sneezing Jaw pain Nausea with or without vomiting Dizziness

(f) Orofacial pain: Orofacial felt in any part

of the face, including the mouth and eyes. Although most causes of facial pain are harmless and normally due to an injury or infection, in some cases facial pain may also be the result of a serious medical condition (Fig. 4.35). The patients with facial pain may be presented as follows:

• Presentation of orofacial pain – Short periods of stabbing, shooting

and tingling pain

– Pain during activities like brushing

your teeth, washing your face, shaving or putting on make-up

– Pain that can last a few seconds up

to several minutes

– Recurrent attacks, followed by

periods of lull

– Pain generally on one side of your

face

– Frequent, worsened attacks over

time

– Pain mostly in your cheek, jaw,

teeth, gums and lips

• Periodicity of pain—The facial pain

can be continuous or episodic (Table4.14).

172

Table 4.14 The difference between episodic and continuous orofacial pain

Continuous pain Episodic pain Unilateral

Post-therpetic neuralgia, post-traumatic trigeminal pain, anaesthesia dolorosa Persistent dentoalveolar pain, referred pain Post-stroke pain, giant cell arthritis, chronic migraine, cancer pain, TM joint disorders, burning mouth syndrome, Persistent idiopathic facial pain, Persistent orofacial pain, dental abscess

Bilateral Mumps, B/L maxillary sinusitis

4 History andExamination ofNose andPara Nasal Sinuses

Unilateral Classical trigeminal neuralgia (type 1 and type 2) Glossopharyngeal neuralgia Episodic migraine Tension-type headache

Bilateral TM joint disorder

• Site of pain – Front of face—Sinusitis, trauma – Side of face—Dental pain, TM

joint dysfunction, facial abscess, facial cellulitis, parotid abscess, parotid cellulitis, trauma, buccal lymphadenitis, mumps

– Upper part of face (supraorbital

ridge, eyelid, Forehead, supraorbital area)—Trauma, supraorbital neuralgia

– Middle part of face (skin of upper

lip, ala, cheek, infraorbital area)— Maxillary sinusitis, facial cellulitis, dental abscess oroantral stula

– Lower part of face (lower lip, lower

jaw)—Trauma, dental abscess, furunculosis, buccal lymphadenitis

– Retro-orbital pain—Gradenigo’s

syndrome, CH, Tolosa-Hunt syndrome

• Side of pain – Unilateral—Trigeminal neuralgia,

TM joint synovitis, parotid abscess, CH, Gradenigo’s syndrome

– Bilateral—TM joint arthritis, B/L

maxillary sinusitis, mumps, B/L sinusitis

• Type of pain – Dental pain—This relates to prob-

lems with the teeth and gums, e.g. dental abscess, dental caries, etc.

– Nerve pain or neuralgia—This

relates to conditions that affect the facial nerves or trigeminal neuralgia.

– Temporomandibular pain—This

relates to the temporomandibular joint and the muscles of the jaw.

– Vascular pain—Vascular pain

occurs due to issues with blood vessels and blood ow.

– Sinus pain—It is a pain or pres-

sure in face, particularly around the nose, cheek and forehead. This is due to congestion, inammation of mucosa and collection of uid.

• Duration – Acute—Acute sinusitis, facial

trauma, facial cellulitis, furunculosis, TM joint synovitis, furunculosis

– Chronic (Fig.4.36)—TM joint dys-

function, chronic sinusitis, trigeminal neuralgia

• Onset of pain – Sudden—CH, acute sinusitis – Gradual—TM joint dysfunction,

chronic sinusitis

• Character of pain – Dull, nagging—TM joint

dysfunction – Dull aching—Infection – Shooting, stabbing, sharp, elec-

tric—Trigeminal neuralgia

• Severity of pain – Mild – Moderate—TM joint dysfunction – Severe—Trigeminal neuralgia

• Relieving and aggravating factors

(Table4.15)

4.1 Presentation/History/Symptoms ofNasal andPNS Disorders

173

Table 4.15 Aggravating and relieving factors

Relieving

Aggravating factors Brushing teeth, putting

make-up, shaving, touching teeth, eating, drinking, talking, smiling

Chewing Decrease

URI Sinusitis Chewing, clinching

teeth

factors Diagnosis Keeping still Trigeminal

neuralgia

TM joint mouth opening

No movement

dysfunction

Dental pain

• Radiation of pain – Radiating to ear—Dental pain, TM

joint dysfunction

– Radiating to head—Sinusitis, TM

joint dysfunction

– Radiating to neck—TM joint dys-

function, glossopharyngeal neuralgia

• Associated symptoms—Nasal

obstruction, facial trauma, nasal discharge, trismus, facial swelling, headache, nasal pain, DM, fever, swelling over face, bad breath, nasal obstruction, hyposmia, other pain conditions (migraine, bromyalgia), impact of pain (sleep disturbance, lack of concentration, fatigue)

Causes/differential diagnosis of facial pain (Table 4.16)

(g) Facial swelling: Facial swellings can be

caused by both minor and major medical conditions. Many causes are easily treatable. However, some are severe and require immediate medical attention.

• Site—The swelling can be localized or

generalized (Table4.17).

• Onset – Sudden—Haematoma, angio-

edema, anaphylaxis, drug reaction

– Gradual—Osteoma, brous dyspla-

sia, nasolabial cyst, trauma

Table 4.16 Causes of facial pain

Non-serious causes Serious causes Oral infection, an ulcer or

open sore

Oral abscess, such as a

collection of pus under the surface tissue in the mouth Skin abscess, which is a collection of pus under the skin Facial injury

Toothache

Table 4.17 Differential diagnosis of facial swelling in relation to site

Site Diagnosis Whole face

(generalized facial swelling)

Localized facial swelling Upper (third)

part of face Middle (third)

part of face

Lower (third) part of face

Lateral part of face

Middle part Orbital tumour, proptosis, maxillary

Median part of face

Allergic reaction, angioedema, preeclampsia, cellulitis, food allergy, medication (steroid, ACE inhibitor, oestrogen, etc.), bee bite, Cushing’s syndrome, anaphylaxis, hypothyroidism, superior vana cava syndrome, anasarca, panfacial fracture

Frontal osteoma, frontal mucocele, frontal bone fracture

Dental abscess, nasolabial cyst, maxillary sinusitis, furunculosis maxillary tumour, maxillary fracture, maxillary tumours

Mandible fracture, ameloblastoma, dental abscess, dentigerous cyst

Parotid swelling, hypertrophy of masseter

tumour, mandibular swelling Lip swelling, swelling over dorsum

of nose, frontal bone swelling

Herpes zoster or shingles

Migraine Sinusitis (sinus infection)

Nerve disorder (trigeminal neuralgia)

Herpes simplex virus 1 (HSV-1), sores

Parotid abscess or cellulitis

• Progression – Progressive (slow or fast)—

Haematoma, angioedema, anaphylaxis, drug reaction

– Non-progressive—Osteoma,

lymphadenopathy, hypertrophy of masseter

174

Table 4.18 Differential diagnosis of facial pain with other associated symptoms

Associated symptoms with facial swelling Diagnosis

Swollen mouth and throat, difculty breathing or swallowing, hives or rash, swelling of the face or limbs, anxiety or confusion, coughing or wheezing, dizziness, light headedness, nasal congestion, palpitations and irregular heartbeat, slurred speech

Pain Furunculosis,

Loose denture Carcinoma

Anaphylaxis

abscess, cellulitis, trauma

maxilla, trauma to maxilla

4 History andExamination ofNose andPara Nasal Sinuses

• Duration – Short (<3 months)—Haematoma,

furunculosis, mumps, acute parotitis, Abscess

– Long (>3 months)—Pleomorphic

adenoma, lipoma

• Time of onset – Congenital—Haemangioma, vas-

cular malformation

– Acquired—Haematoma, furuncu-

losis, mumps, acute parotitis, abscess, pleomorphic adenoma, lipoma, angioedema

• Associated symptoms—Facial pain,

redness, loose denture (Table4.18)

• Pre-eclampsia (high blood pressure during pregnancy)

• Fluid retention

• Angioedema (severe skin swelling)

• Actinomycosis (a type of long-term soft tissue infection)

(h) Nasal mass: There is a wide variety of

diseases that can cause or present as a nasal mass.

• Presentation of nasal mass—The common presentation of nasal masses is nasal obstruction, rhinorrhoea, hyposmia, headache, sneezing, nasal bleeding, external deformities and swelling over nose.

• Site of mass (Table4.19)

• Age of onset

– Congenital—Meningioma, menin-

goencephalocele, dermoid cyst

– Acquired—JNA, nasal polyp, nasal

tumour, rhinosporidiosis, nasolabial cyst

• Side—Nasal mass can be either unilateral or bilateral (Table4.20).

• Duration—The nasal mass can be either of short duration or long duration (Table4.21).

Common Causes of Generalized Facial Swelling

• Allergic reaction

• Allergic conjunctivitis

• Surgery

• Side effects of medication

• Cellulitis (bacterial infection of the

skin)

• Hypothyroidism

• Style

• Abscess

Table 4.19 Differential diagnosis of nasal mass

External nasal mass Nasal cavity (internal) Dorsum of nose—

meningocele, meningioma Root of nose— dermoid cyst Side of nose—brous dysplasia, nasolabial cyst Tip of nose—rhinophyma Vestibule of nose— rhinosporidiosis, furunculosis

Rhinosporidiosis, JNA, nasal polyp, inverted papilloma, nasal tumour, HIT, concha bullosa, sphenochoanal polyp

4.1 Presentation/History/Symptoms ofNasal andPNS Disorders

175

Table 4.20 Differential diagnoses of unilateral and bilateral nasal mass

Unilateral Bilateral Antro-choanal polyp,

haemangioma, inverted papilloma, angiomatous polyp, HIT, HMT, rhinosporidiosis, aesthesioneuroblastoma, encephalocele, squamous cell carcinoma, adenocarcinoma, rhinolith, FB, nasal tumour

Table 4.21 Differential diagnosis of acute and chronic nasal swelling

Short duration Long duration Rhinosporidiosis,

haemangioma, FB

Rhinolith, AC polyp, inverted papilloma, aesthesioneuroblastoma, HIT, HMT

Concha bullosa, HIT, HMT, ethmoidal polyp, rhinosporidiosis

• Associated symptoms—Any association with pain, bleeding, nasal obstruction, discharge, facial swelling, headache, numbness over face, sneezing, rhinorrhoea, recurrent attack of meningitis.

• Orbital symptoms: The nasal and paranasal sinuses diseases and tumours can present with orbital symptoms. The common orbital symptoms are diplopia, loss of vision, proptosis and difculty in movement of the eyes. The duration and severity of symptoms are noted.

(i) Trauma to nose

• Common presentations of trauma to the nose are external deviation, depression, laceration, loss of nose, hyponasal/hypernasal voice, epistaxis, rhinorrhea, bruising/laceration over the nose, hyposmia or anosmia.

• Type of trauma—Suicide, homicide, accidental to be noted.

• Time of onset—This is to be noted in medicolegal cases.

• Mode of onset—Either it is medicolegal or non-medicolegal.

• Other injuries to be ruled out are orbital injury, pharyngeal injury, intracranial injury, neck trauma and trauma to other parts of the body.

(j) Epistaxis (nasal bleeding):

• Presentation of epistaxis—It can be bleeding from one or both nostrils and bleeding down the back of the throat with spitting, coughing or vomiting of blood.

• Duration of bleeding

– Acute bleeding—Trauma (nose

picking commonest in children)

– Chronic bleeding—

Microaneurysm, rhinosporidiosis, JNA, angiomatous polyp, bleeding disorders

– Recurrent bleeding—Hypertension,

JNA, bleeding disorders

• Onset of bleeding

– Sudden onset—It is caused by

trauma, nose picking, hypertension, bleeding disorder, JNA and angiomatous polyp.

– Gradual onset—Rhinolith, FB in

nose, nasal tumour.

• Nature of bleeding

– Continuous—Bleeding disorders,

JNA, microaneurysm, maxillary artery tear

– Episodic—How long the episode

lasts, how the bleeding stops, nasal tumours, rhinosporidiosis, hypertension, nose picking

• Severity/amount of bleeding—It is decided by the amount of blood loss.

– Mild—Nose picking, rhinolith, FB

nose

– Moderate—Rhinosporidiosis, angi-

omatous polyp – Severe—Haemangioma – Profuse—JNA, tear in internal

maxillary artery

• Site of bleeding—This can be conrmed by asking about the direction of the ow of blood in a sitting position.

176

4 History andExamination ofNose andPara Nasal Sinuses

– Blood ow through the anterior

nares (anterior epistaxis)—It is caused by nose picking, microaneurysm and rhinosporidiosis.

– Blood trickle down in the orophar-

ynx or throat (posterior epistaxis)— It is caused by hypertension and trauma.

• Side of bleeding – Unilateral—Microaneurysm, rhi-

nosporidiosis, angiomatous polyp

– Bilateral—Nose picking, bleeding

disorders, hypertension

• Associated symptoms—H/O hyper-

tension, nose picking, bleeding disorder, nasal mass, age of patient, facial swelling, ear symptoms.

(k) Nasal regurgitation: This is dened as

food or uid that comes up into the nose during swallowing. This occurs due to incomplete closure of the velopharynx.

• Presentation/history of nasal regurgi-

tation—Nasal regurgitation, if present, strongly suggests a neurogenic process. Patient complains of food coming to the nose while swallowing, poor nutrition and recurrent nasal discharge while swallowing. In infants, velopharyngeal dysfunction, e.g. cleft palate, is a common cause of milk coming in the nose while feeding and recurrent nasal or ear infections, while in adult nasal regurgitation is due to neurological causes, trauma to palate and destructive lesions of palate.

• Duration

Acute—Acute palatal palsy, trauma with palatal perforation Chronic—Palatal palsy, cleft palate, bid uvula, Oral submucous brosis (OSMF)

• Mode of onset

Sudden—Acute palatal paralysis, trauma with perforation of palate Insidious—OSMF

• Age of onset

Acquired—Trauma, palatal palsy, GERD, OSMF, palatal palsy

Congenital—Cleft palate

• Associated symptoms and history— Sore throat, hoarseness of voice, shortness of breath, chest discomfort, food refusal, failure to thrive and other weakness

(l) Deformities of nose: Nasal deformities

are abnormalities in the shape or structure of the nose. In some cases, the deformity can be a result of trauma or injury; in other cases, the deformity could be something the child was born with.

• Presentation of nasal deformities— The nasal deformities can present with deformities of the dorsum of the nose (crooked nose, deviated dorsum, hump nose, depressed nose, supratip depression, saddle nose), alar deformities (collapsed ala, stenosis of anterior nares, wide ala) and columellar deformities (retracted columella, hanging columella, shorted columella).

• Types of nasal deformities—These can be depressed deformities, deviated or crooked nose deformities and hump nose deformities (Table4.22).

Table 4.22 Types of deformities of nose

Types of deformities of dorsum Denition

Deviated dorsum of nose

Crooked nose 1. Deviated upper 1/3 and lower

Concavity (depression) of dorsum of nose

Convexity dorsum of nose

Broad dorsum Broad dorsum

Deviation of the whole dorsum from the midline

2/3in opposite directions

2. Deviation of upper 1/3 of nose and lower 2/3in the same direction

3. Deviation of middle 1/3 (upper lateral cartilage) of nose

4. Deviation of lower 2/3 (cartilaginous part) of nose

5. Deviation of upper 1/3 of nose and middle 1/3 of nose

6. Deviation of lower 1/3 nose

Saddle nose Supratip deformity of nose

Hump of nose, long nose

4.1 Presentation/History/Symptoms ofNasal andPNS Disorders

177

• Sites of deformities—The site of deformities can be the whole nose, ala of nose, columella of nose and dorsum of nose.

– Deformities of dorsum of nose

Deviated nose—When a whole dorsum is deviated from midline to one side, it is called as deviated nose. Crooked nose—When a part of dorsum is deviated to one side and rest to another side, it is called crooked nose. Saddle nose—When whole bony and cartilaginous dorsum is depressed, giving concave appearance is known as a saddle nose. Humped nose—A part of nasal dorsum is elevated. Tensed nose—It is dened as excessive growth of the quadrilateral cartilage or bony framework resulting in a high nasal dorsum with anterior and sometimes inferior displacement of the nasal tip cartilages. In tension nose, the anterior septal angle is upper than the tipdening point. Supratip depression—Dorsum of nose cephalad to tip of nose is depressed caused by post-SMR fracture dislocation of septal cartilage.

– Deformities of base of nose—Nasal

base is dened as an imaginary line between the two most lateral points where alae nasi attach to face. Nasal width deformities—Pinched nose (narrow nostril width) and wide nose (increased nasal width). Nostril shape deformity—Nasal outline, alar base position, nostril outline, nostril axis and columellar angle

– Deformities of tip of nose

Loss of nasal tip support and denition

Shortened (vertical) nasal length Overrotation of the nasal tip Retrusion of the nasal spine and caudal septum Depression of supratip of nose Overhanging columella Retrusion of columella Alar collapse

• Associated symptoms—Nasal obstruction, allergic symptoms, nasal discharge, headache, post-nasal drip, headache, recurrent URI, psychiatric disorder

Presentation/clinical features/chief complaints of complications of Paranasal sinus infections

(Table4.23)

D/D of infective diseases of the sinus on the basis of symptoms (Table

4.24)

Table 4.23 Symptoms of complications of sinusitis

Symptoms and signs Diagnosis Swollen upper lid in frontal sinusitis

Swollen lower lid in maxillary sinusitis Swollen both in the ethmoid sinus

Ethmoid—push the eyeball forward, downward and laterally Frontal—abscess present above and behind the medial canthus pushes the eyeball downward and laterally Maxillary sinus—displace epstein bar virus (EB) upward and forward

Oedema of the lid, exophthalmos, chemosis of conjunctiva, restricted movement of eyeball, partial or complete loss of vision, fever

Same as orbital abscess Orbital

Caused by sphenoid sinusitis presented as deep-seated orbital pain, headache, progressive loss of function of sixth, third and fourth cranial nerves

SOF syndrome symptoms+involvement of Optic nerve and V2 nerve

Fever with chills and rigours Eyelids are swollen with chemosis and proptosis of eyeball Pupil dilated and xed Optic disc shows congestion Cranial nerve sixth, third and fourth

Preseptal cellulutis

Subperiosteal abscess

Orbital cellulitis

abscess Superior

orbital ssure syndrome

Orbital apex syndrome

Cavernous sinus thrombosis

178

Table 4.24 Differential diagnosis of infective diseases of nose

Type of sinusitis Symptoms Acute maxillary sinusitis Frontal headache, facial pain

Nasal discharge, post-nasal discharge, constitutional symptoms Acute frontal sinusitis Frontal headache over frontal sinus. Nasal discharge, oedema of eyelid Acute ethmoidal sinusitis Pain over nasal bridge, nasal discharge Acute sphenoidal sinusitis Pain over vertex or occiput, post-nasal discharge Pan sinusitis Hemicranial headache, nasal discharge Allergic fungal sinusitis Nasal obstruction, ipsilateral facial pain

Thick yellow/brown nasal discharge with intermittent cork-like fragments Invasive fungal rhinosinusitis Fever, facial pain or numbness, facial swelling, nasal discharge, headache, mental

status change, visual disturbance Rhinocerebral mucormycosis/

rhino-orbital mucormycosis

Pan sinusitis Pain around eye, cheek or nose, sore throat fever, bad breath, headache, nasal

Chronic maxillary sinusitis Pressure in the face (forehead, nose and face) post-nasal drip, nasal discharge, nasal

Chronic frontal sinusitis Nasal discharge, frontal headache, reduced ability to smell, poor breath Frontal pyocele/mucocele Pain, swelling, proptosis, lateral displacement of the eyeball, vertical diplopia, ptosis,

Pyocele/mucocele in the posterior ethmoid

Pyocele/mucocele in anterior ethmoid

Sphenoid sinus pyocele Slowly progressive cranial neuropathies (oculomotor and V nerve are common),

Maxillary sinus pyocele/ mucocele

Present in immunocompromized individuals, one-sided facial swelling, headache, black

lesion (hard palate, soft palate, middle turbinate), fever, facial pain, black colour scab,

visual problem, shortness of breath, dark vomitus, cough, ank pain, exophthalmos

discharge, post-nasal drip

obstruction, morning cough

loss of vision, pott’s puffy tumour (uctuant mass over the forehead) anterior orbital

rim where it may be palpated as a rm, rubbery, nontender mass that produces

fullness of the upper eyelid and displaces the globe downward and outward

Loss of vision, proptosis and limitation of movement of the eye, isolated or multiple

ocular motor nerve paresis

Proptosis, eye pain, lateral displacement of the globe and limitation of adduction of

eye

diplopia, atypical facial pain, paraesthesia, B/L slow progressive loss of vision, visual

eld defects, altered pittutary or hypothalamic function

Facial swelling inferior to orbit, infraorbital anaesthesia, upward displacement of

eye, diplopia on attempted downward gaze, epiphora

4 History andExamination ofNose andPara Nasal Sinuses

4.2 Examination ofNose andParanasal Sinuses

4.2.1 Examination ofNose

4.2.1.1 Functional Examination ofNose

1. Examination of the external nose:

(a) General inspection of nose: It begins

with an overall inspection of the nose. It is done to evaluate the type, size, shape, deformity, deviation of nose, colour and texture of the skin of nose.

• Type of nose—It varies in different ethnic groups and geographical areas group (Fig.4.4).

• Shape of nose—The external nose is said to have a pyramidal shape but it varies (Fig.4.5).

• Size of nose—Average male has a nose size of 2.2in., while the average female nose size is 2in. The nose is classied into small, medium and tall (Fig.4.6).

• Overlying skin of nose—Normally, the skin over the bony part of the nose is thin, and overlying the cartilaginous part is thicker with many sebaceous glands. This skin extends into the vestibule of the nose via the nares.

– Type of skin—Thick or thin,

Fitzpatrick type, sebaceous

– Discolouration

Redness—Rosacea, acne, skin irritation, windburn, allergic contact dermatitis Hyperpigmentation—Melasma (due to hormonal changes in the body)

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