Estudio de la supervivencia

The patient was a 32-year-old software engineer with a long history of sinusitis, difficulty in breathing through his nose, nasal polyps, and asthma. His asthma was, to a large degree, affected by the condition of his paranasal sinuses, and hence 3 years previously, he underwent extirpative sinus surgery including a Caldwell-Luc and antral windows. He also had bilateral intranasal ethmoidectomies. In the early postoperative period, he felt better, feeling that both his allergies and his asthma were symptomatically improved. However, over the course of several years, the asthmatic symptoms worsened and his exercise tolerance decreased. He also had recurrent episodes of sinusitis and had required repeated, prolonged antibiotic therapy.

He was referred to the UCSD nasal dysfunction clinic. The only additional pertinent history was an awareness of a diminution in his sense of smell

5

years previously, with a marked increase in this loss immediately following the previous ethmoid surgery. He had no parosmia, but had had occasional phantosmias, usually a gasoline smell. Olfactory and odor identification testing indicated mild hyposmia in the left nostril and anosmia or severe hyposmia in the right nostril. Both airways were reasonably patent after decongestants. The nasal cytogram revealed significant numbers of eosinophils and a few basophilic cells. There was no evidence of infection. An IgE was

40

U/ml, which is at the upper limits of normal. The RAST inhalant screen was negative. Nasal endoscopy revealed a posterior septal deflection and an ostiomeatal complex filled with mucopus and inflammatory tissue. The nose was clearly malodorous, and the middle turbinates were strikingly absent, a consequence of the previous intranasal ethmoidectomy. The CT scan is shown in

Figures 3.7 A

to

Z.

Septoplasty and endoscopic sinus surgery were performed. At the time of surgery, the nasal cavity was filled with mucopurulent polypoid material. This material was carefully removed. Additional ethmoid sinuses were opened and drainage facilitated. The natural middle meatal maxillary sinus ostia were large, however, obstructed by polypoid tissue. This polypoid tissue was resected. The agger nasi cells surrounding the frontal sinus drainage contained mucopurulent material. These cells were resected, and the frontal sinus drainage reestablished.

The patient's postoperative recovery was uneventful. The nasal packing was removed after

3

days. Nasal irrigations with a Grossan Nasal Irrigator were initiated on postoperative day

10.

The patient was maintained on his asthmatic medicines throughout surgery and the postoperative period and was begun on intranasal steroids 3 weeks postoperatively.

His sense of smell has not returned substantially, probably because the olfactory epithelium was inadvertently destroyed at the previous sinus surgery.

Figure 3.7A1: Lateral scout film Figure 3.7A2: The Eustachian tube orifices are gone. Sphenoid sinuses, soft palate and uvula are evident

Figure 3.781: Lateral scout film. Each Figure 3.782: The posterior sphenoid sinus's

dotted line represents coronal CT scan soft palate and uvula are evident as well sliced. In this case, each slice is taken at 3

Clinical Manual of Otolaryngology

Figure 3.7Cl: One sees the frontal bone, Figure 3.7C2: The raised tissue in the nasal the bridge of the nose and the cartilaginous pharynx is probably adenoid tissue. The

nasal septum tongue base can be seen

Figure 3.701: The anterior frontal Figure 3.702: Large adenoid tissue is evident.

sinuses are now evident. The soft tissue The beginning of the epiglottis is seen. The density with pockets of air are sphenoid sinus is absent

suggestive of infection and is present in the left frontal sinus. The right frontal sinus is clear. Note the swelling of the turbinate immediately beneath the nasal bones. This is an area called the septal turbinate

Figure 3.7El: Frontal sinus infection is Figure 3.7E2: The oropharynx and the present on the left. Normal, air-filled frontal epiglottis are seen

sinus on the right

Figure 3.7Fl: Frontal sinus disease persists Figure 3. 7F2: The oropharynx and the the very beginning of the anterior superior epiglottis are seen

ethmoids is evident. The central incisor

Clinical Manual of Otolaryngology

Figure 3.7G: Frontal sinuses extending over figure 3.7H: Supraorbital frontal sinuses are

the orbits. The ethmoid sinuses can be seen. seen the proximity of the orbit, both The beginning of the maxillary sinuses are superiorly and medially to the frontal sinus. seen. The lateral maxillary incisors are Maxillary sinusitis is evident and infection

evident in the superior anterior ethmoids is also

evident on the patient's left. The same area is clear on the right

figure 3. 71: Severe ethmoid disease is Figure 3.7J: Maxillary and ethmoid sinusitis. evident. The turbinates are seen. The very Crista galli is well seen

beginning of a pneumatized Crista galli is evident

Figure 3.7K: Frontal sinuses are gone, supraorbital ethmoids persist. Maxillary and ethmoid diseases are evident. Note the normal inferior and beginnings of the middle turbinate on the patient's right side

Figure 3.7l: Maxillary and ethmoid sinus opacification is very evident. Note the thin lamina papyracea, note the normal middle and inferior turbinates. The olfactory groove just above the cribriform plate is now seen. The olfactory bulb resides in this area

Figure 3.7M: Persistent maxillary and Figure 3.7N: Persistent maxillary and ethmoid sinus disease ethmoid sinus disease. Note the deviated septum in the area of the osteomeatal complex

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Clinical Manual of Otolaryngology

Figure 3.70: Persistent maxillary and Figure 3.7P: Maxillary disease persists. This ethmoid sinus disease. Deviated septum. The is an opacified maxillary sinus. Some olfactory grooves continue. The olfactory posterior ethmoid disease is evident cleft can be seen wherein the olfactory

epithelium resides, lies immediately beneath the olfactory grooves. This is separated by a thin shell of bone, known as the cribriform plate. The cribriform contains both the horizontal and a vertical portion. These are evident in this slice

Figure 3.7Q: Persistent maxillary sinus Figure 3.7R: Persistent maxillary sinus disease. The posterior ethmoids in this disease is also shown. The posterior region seem clear ethmoids in this region are also clear

Figure 3.75: Persistent maxillary sinus disease is shown in this image as well. The posterior ethmoids in this seems clear

Figure 3. 7T: The posterior end of the maxillary sinus is seen. The posterior ethmoids are now transitioning into the sphenoid sinus. This is clear bilaterally

Figure 3.7U: Posterior choana. The middle Figure 3.7V: Large sphenoid sinus. Posterior turbinates are all but gone and all one sees choana. Note the wings of the sphenoid is the inferior turbinates. A large sphenoid

Clinical Manual of Otolaryngology

Figure 3.7W: The inferior turbinates are Figure 3.7X: The posterior choana is gone. Posterior choana is transitioning into transitioning into the nasal pharynx

the nasal pharynx

Figure 3.7Y: This is the nasal pharynx. The Figure 3.7Z: Nasal pharynx. The Eustachian Eustachian tubes lie on either side of the tubes can be seen. The back of the soft nasal pharynx palate with the uvula is seen

Figures 3.7A to Z: Coronal CT scans of a patient with sinusitis. This is a unique scan, for the right side is essentially normal and the left side is severely diseased. The contrast of the two sides is a useful learning experience.

His asthma and exercise tolerance have improved dramatically. His nose has remained clean and he has felt well. Twice daily nasal irrigation plus nasal steroids are recommended for life.

In document Universidad de Oviedo (página 94-128)