AAO-HNSF Primary Care Otolaryngology Handbook

RHINOLOGY, NASAL OBSTRUCTION, AND SINUSITIS

purulent nasal discharge for at least three consecutive days. Treatment similarly consists of amoxicillin with or without clavulanate with close observation. For persistent illness, some children will benefit from adenoidectomy, and occasionally sinus aspiration or even surgery may be required. Rarely, sinus infection can spread into the peri- and intraorbital tissues, as described above. If an abscess develops with visual change, proptosis , or loss of normal eye movement, urgent surgical drainage is required to prevent loss of vision. A diagnostic CT scan is required in suspected cases. These abscesses can often be drained successfully through an endoscopic approach, but an external incision (just medial to the medial canthus) may be required. Fungal Sinusitis Although fungal elements are commonly found in the nasal cavity of normal patients, some patients develop a sensitivity or immunoreactivity to fungi, resulting in allergic fungal sinusitis . This allergic disorder to fungi can result in severe symptoms of chronic sinusitis and significant inflammation in the sinonasal mucosa caused by a preponderance of eosinophils. Effective treatment requires surgery to remove the offending fungal mucin. Fungal spores can also get trapped in a sinus, where they germinate and fill the sinus with debris, forming a “fungal ball” or mycetoma . Typically, mycetomas do not cause a significant inflammatory response, and they are easily cured by surgical removal. If a patient is immunocompromised or has diabetes, certain fungal infec- tions (e.g., mucormycosis ) can become “invasive,” resulting in destruc- tion of the sinus with erosion into the orbit or brain. These invasive fungal infections constitute an ear, nose, and throat (ENT) emergency, since they are life threatening and can advance quite rapidly (see Chapter 3, ENT Emergencies, for more details). Nasal Obstruction Nasal obstruction is another complaint seen regularly in the ENT office setting. A frequent cause of nasal obstruction is septal deviation (Figure 8.4). These patients often present with histories of nasal obstruction, possibly complicated by sinusitis and headaches. There may be a history of nasal trauma. Patients may also snore and have obstructive sleep apnea syndrome.

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