Sinonasal tract pathology
What is it?
The nasal passages are two symmetrical hollow structures divided by an osteo-cartilaginous septum joint with some cavities in the thickness of the bones of the facial massif called paranasal sinuses (we distinguish the maxillary, frontal, ethmoidal and sphenoidal sinuses) and occupied by three horn-shaped formations called turbinates. They constitute the first part of the respiratory tract, also contributing to the functions of humidification and heating of the inhaled air, odor perception, defense against external pathogens, middle ear drainage and voice resonance. Anatomic and functional alterations of these structures, such as deviation of the nasal septum, may result in a deficit of these functions, and predisposition to nasal-sinus inflammation. In fact, the most frequent pathologies of this area are inflammatory ones, in particular acute or chronic rhinosinusitis, with a wide spectrum of symptoms, severity and quality of life involvement. The causes of these diseases are varied and often multifactorial, including infectious etiologies (bacterial, viral, fungal), allergic, dysimmune or the already mentioned anatomical alterations. Chronic nasosinusal inflammation can lead to the development of benign inflammatory neoformations called nasal polyps, which contribute to the worsening of the picture of nasal obstruction.
Which are the symptoms?
In cases of respiratory obstruction due to anatomical alterations, such as deviation of the nasal septum, the patient complains of the need to breathe through the mouth, snoring at night, difficulty in practicing sports; there is also a predisposition, precisely because of a reduced ventilation capacity, to the development of nasosinusal inflammatory diseases. Signs and symptoms of the latter depend on the type of pathology, as well as on the quality and timeliness of their treatment: milder forms, such as acute viral rhinosinusitis (commonly referred to as colds) are generally characterized by nasal respiratory obstruction, presence of abundant seromucous secretions, sinus headache (with localization in the maxillary, frontal, medial portion of the orbit or vertex), blocked ear, hyposmia (reduced sense of smell) and rhinolalia (nasal voice). More severe forms may result in fever, very intense headache, purulent nasal discharge, erosion of bone structures, and systemic lesion. Neoplastic forms are characterized by a wide variety of signs and symptoms, which are, however, often completely nonspecific (nasal obstruction, recurrent nosebleeds, lymphadenopathy, etc.).
- Nasal respiratory obstruction
- Nasal secretions
- Pharyngeal discharge
- Sinus headache
- Auricular ovation
- Decreased sense of smell
- Fever
- Epistaxis
How is it diagnosed?
The first step for a correct diagnosis of nasal pathology is based on an adequate anamnestic collection: previous episodes, type, mode of appearance, duration and evolution of symptoms, any therapy already established. It is necessary to underline the existence of some alarm bells (particularly serious symptoms, high fever, systemic lesion, neoplastic suspicion) that make a correct diagnostic and therapeutic investigation not deferable. Objective examination is of fundamental importance, and generally consists of an anterior rhinoscopy and nasal endoscopy using optical fibers, which allow to evaluate the state of the mucosa, presence of secretions and their quality, and localization of inflammatory or neoplastic processes
The first-line radiologic examination for most nasosinus pathologies is CT (computed tomography) of the facial massif without contrast medium. The use of contrast medium or the use of MRI is generally limited to individual cases. Blood tests can be indicative of the severity of a phlogistic process, while rhinomanometry allows to objectify nasal respiratory obstruction and to better define its characteristics in functional forms. In some cases it may be useful to consult other specialists, for example, allergy specialist consultation for seasonal rhinitis.
Suggested exams
How is it treated?
Treatment of nasosinus pathology depends on the cause and severity of the condition. Some pathological processes of mild severity (common cold) tend to resolve spontaneously and do not require a specific therapy; in the case of an anatomical alteration, such as deviation of the nasal septum, only surgery can resolve the symptom; in acute bacterial infectious forms, antibiotic therapy is generally necessary, possibly in combination with corticosteroids, while the surgical option is limited to the most aggressive, relapsing or chronic inflammatory-infectious forms; some chronic pathologies, such as polypoid rhinosinusitis, require treatment with topical/systemic corticosteroids or new biological drugs (e.g., dupilumab, mepolizumab); finally, in the case of neoplastic lesions, a multidisciplinary discussion is necessary to determine the best treatment, which generally consists of one or more approaches among surgical, chemotherapeutic and radiotherapeutic ones.
The most frequent nasosinus surgeries are septoplasty (remodeling of the nasal septum), inferior turbinoplasty (reduction of the size of the nasal turbinates) and functional endoscopic sinus surgery (functional endoscopic sinus surgery or FESS), which consists in opening the obstructions of the paranasal sinuses to ensure better ventilation and resolution of inflammation.
Suggested procedures
Where do we treat it?
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