13f bihuler pf - clin.au.dk · • akut rhinosinuitis • kronisk rhinosinuitis – nasal stenose...
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Bihulernes sygdomme
Per Friis Overlæge, Øre-,næse- og halsafdeling H
Speciale: næse- og bihulekirurgi
Inflammatoriske næselidelser
• Allergisk rhinit
– Nasalstenose – Sekretion (vandigt) – Kløe – Nysen – Lugtesans – (Tryk over bihuler)
• Akut rhinosinuitis • Kronisk rhinosinuitis
– Nasal stenose – Sekretion – Tryk over bihuler – Lugtesans
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+ Detumescerende væske (Kokain og adrenalin)
Terminologi
• Sinuitis acuta • Sinuitis chronica • Polypi cavi nasi
Rhino-sinuitis
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Klinisk definition på rhinosinuitis Voksne
Inflammation af næse og bihuler Ø Karakteriseret af to eller flere symptomer
Ø En skal være enten nasalstenose eller sekretion ± ansigtssmerter ± lugtesans og enten Endoskopi-fund og/eller ct-skannings fund
Rhinosinuitis Varighed af symptomer
Akut: < 12 uger (med fuldstændig svind af symptomer) Kronisk : > 12 uger (uden ophør af symptomer)
Med og uden polypper
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Rhino-sinosinuitis Patogenese
Osteomeatal Complex
Rhino-sinuitis
– FOKUS PÅ PATIENTENS KLAGER. • Nasal obstruktion • Nasal sekretion • Smerter eller tryk • Lugtesans
Rhino-sinuitis acuta
Årsag • Kataralsk infektion > aflukning af afløb
til næse > sekret retention. • Odontogene
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Rhino-sinuitis acuta
Rhino-sinuitis acuta
H.influenzae • Pneumokokker • Beta-hæm strep • Staf aureus • Anærobe bakterier
Rhino-sinuitis acuta Diagnose • Anamnese • Ømhed evt ødem over
sinus • Anterior rhinoskopi • Nasal endoskopi • Punktur • Podning • CT
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Rhino-sinuitis acuta Ct-bihuler
Rhino-sinuitis acuta
Differential diagnoser • Almindelig forkølelse • Allergisk rhinitis • Nasal polypose
Rhino-sinuitis acuta
Behandling • Detumenscerende næsespray • Saltvands skylning af næsekaviteterne • Penicillin ved tp. forhøjelse og/eller
påvirket almen tilstand • Proetz sugning ved ethmoiditis (?) • Kæbehuletubulation/punktur
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Sinuitis odontogenica
Årsag • Apikal parodontitis • Tandekstraktion (molar)
Symptomer • Som ved akut rhinosinuit • Dog unilateral
Sinuitis odontogenica
Diagnose • Som ved akut sinuit • Suppleret med tandfilm eller ortopan Behandling • Tandlæge • Plus behandle sinuitten som vanligt • FESS
Rhino-sinuitis chronica
Definition: Symptomer > 12 uger
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Rhino-sinuitis chronica Disponerende faktorer
• Muco-ciliær svækkelse • Infektioner • Allergi • Anatomiske variationer • Næsepolypper • Medfødt (Immundefekt,Kartageners
syndrom) • Miljø
Rhino-sinuitis chronica
Symptomer • Som ved akut sinuit, dog ofte mildere Diagnose • Som ved akut sinuit • Ofte suppleret med CT
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CRP
CRS
Case: CRS Mand 60 år ensidig symptomer
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Case 1: CRS
Case 1: CRS
Behandlings-princip Rhinosinuitis chronica
• Behandel ætiologi – Undgå allergen – Antibiotika – Kirurgi (FESS)
• Svæk inflammation – Steroide (lokal) – Immunoterapi – Leukotrien receptor antagonister – Makrolider – ?
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Endoskopisk teknik • Akut og kronisk rhino-sinuitis • Nasal polypose • Odontogen sinuitis • Antrochoanal polyp • Choanal-atresi (nyfødte) • Schneiders papillom • Epistaxis (ligering a. sphenopalatina) • Cerebrospinal væske leak • DCR (Tårevejs-kirurgi) • Benign/malign tumor • Hypofyse-kirurgi. • Skull-base kirurgi
Case 2: CRS
50 årig kvinde, Tryk og smerte i pande venstre side Nasalstenose Forværring ved forkølelse Nasalsekretion Effekt af nasal-steroid
Ct-bihuler axial
Case 2: CRS
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Ct-bihuler axial
Case 2: CRS
Ct-bihuler axial
Case 2: CRS
Ct-bihuler coronal
Case 2: CRS
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Ct-bihuler coronal
Case 2: CRS
Ct-bihuler coronal
Case 2: CRS
Ct-bihuler saggital
Case 2: CRS
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Ct-bihuler saggital
Case 2: CRS
Ct-bihuler saggital
Case 2: CRS
Case 2: CRS
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Case 2: CRS
Case 2: CRS
Case 2: CRS
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Case 2: CRS
Case 2: CRS
Case 2: CRS
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Polypi cavi nasi
• Blege, glatte, stilkede og væskefyldte strukturer.
• Årsager Ø Ukendt Ø ‘Samters triade’ (astma, NSAID, polypose) Ø Cystisk fibrose Ø Kartageners syndrom (Primær
ciliedyskinesi)
Polypi cavi nasi
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Nasal polypper
Nasal polyp
Polypi cavi nasi
Symptomer • Nasalstenose, dobbeltsidig • Retronasal sekretion • Påvirket lugtesans • Trykken, (smerter)
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Polypi cavi nasi Diagnose • Nasal endoskopi • Biopsi • CT før FESS
Polypi cavi nasi
Behandling • Lokal steroid • Systemisk steroid • Evulsio • FESS
Komplikationer til rhino-sinuitis Simple • Tubaokklusion • Otitis media serosa • Otitis media acuta • Kronisk rhinitis • Pharyngitis • Laryngitis • Tracheitis, bronchitis • Neuritis vestibularis
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Orbitale komplikationer
• Oedema orbitae • Subperiosteal absces (ethmoiditis
acuta) • ”phlegmone orbitae”, abscessus orbitae
Orbitale komplikationer
Diagnose: Subperiostal absces ved ethmoiditis acuta.
Orbitale komplikationer
Behandling • Penicillin megadoser • Detumenscerende næsespray/dråber • Ethmoidektomi • Drænage af sinus frontalis
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Intrakranielle komplikationer
Udgår fra sinus frontalis, ethmoidalis og sphenoidalis. • Meningitis • Epidural/subdural absces • Hjerneabsces
Intrakranielle komplikationer
Behandling • Penicillin megadoser • Drænage fra bihuler • Drænage fra absces (neurokirurg)
Mukocele sinus frontalis Cysteligende proces der vokser ekspansivt. Årsag • Aflukning af ductus nasofrontalis Diagnose • Nasal endoskopi • CT Behandling • Åbning af ductus nasofrontalis (FESS)
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Mucocele
Mucocele FESS-CAS
Mucocele
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Mucocele
Mucocele
Benigne tumorer
• Choanal polyp • Invert papillom • osteom
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Koanal polyp dreng, 10år
Koanal polyp
Koanal polyp
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Koanal polyp
Case
• 35 årig kvinde • Gennem år smerter/tyk over pande • Ensidig nasalstenose • Ingen nasal sekretion
Osteom
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Osteom
Osteom
Maligne tumorer
Ses hyppigst i sinus maxillaris • 2/3 planocellulære carcinomer • Adenocarcinom (træstøv) • Sarkomer (malignt lymfom) • Malignt melanom
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Maligne tumorer Symptomer • Få og snigende • Nasalstenose (ensidige) • Blodigt sekret • Pus • Smerter • Tåreflod • Protesen passer ikke • Dobbeltsyn
Maligne tumorer Diagnose • Biopsi, CT Behandling • Operation • Strålebehandling • Kemoterapi (lymfom) Prognose • 40-45% 5 års overlevelse for carcinomer
Kvind 60 år, strålebehandlet adenokarcinom
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Kvind 60 år, strålebehandlet adenokarcinom
Mand 61 år, adenokarcinom
Sarcom
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Sino-nasal-cancer Opereret + stråle
Sino-nasal cancer Opereret + stråle
Rhinolikvoré
• Case: – 7 årig dreng – 2 meningitter – pneumokokker – Serøs væske fra næse – Stikset positiv for sukker
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Rhinolikvoré
Rhinolikvoré
Rhinolikvoré
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Rhinolikvoré
Rhinolikvoré
Rhinolikvoré
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Rhinolikvoré
Rhinolikvoré
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Arterie ethmoidale anterior