Download - Air Sinuses
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AIR SINUSES
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Topics covered
What is sinus?
Classification History Development Classification PNS
Functions
MAXILLARY SINUS FRONTAL SINUS ETHMOID SINUS SPHENOID SINUS
Blood supply
Lymphatic drainage
Nerve supply
Microcsopic anatomy Osteomeatal complex
Drainage of sinus
Sinusitis
Predisposing factors
Causes
Types
Pathology
C/F
Routes of spread
Complications
Diagnosis
Surgical intervention
D/D
Prevention
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a hollow, cavity, recess, or pocket ,such as air-filled cavity in a dense portion of a skull bone
a large channel containing blood
a tract or fistula leading to a cavity which maybe filled with pus
a channel permitting the passage of blood orlymph that is not a blood vessel or lymphaticvessel, such as the sinuses of the placenta.
What is a sinus?
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Classification
Sinus
Bloodfilled
Airfilled
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Air sinus is an aircontaining space within abone
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PARANASAL SINUSES
4 paired sets of air-filled cavities ofcranio-facial complex surrounding theeyes and nose & are lined with mucus-
producing membranes.
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PARANASAL SINUSES
Each sinus is named after the bone itresides in
Frontal
Ethmoidal
Maxillary
Sphenoidal
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History Galen (2oo) described the
presence of the ethmoid air cells.
descriptions of the maxillarysinuses by Leonardo da Vinci(1489)
the sphenoid sinuses by GiacomoBerengario da Carpi (1521)
the frontal sinuses by Coiter(16th century)
The first modern and accuratedescriptions by Austriananatomist Emil Zuckerkandl.
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Mesenchyme Tissue
Ethmoidoturbinal -> middle, superior,and supreme turbinates
Maxilloturbinal outgrowth -> inferiorturbinate
development of - agger nasi cells
uncinate processethmoid infundibulum
sinuses then begin to develop
NORMAL DEVELOPMENT
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Sinuses start as small sacs aroundnasal meatus and ressesses
Grow -> invading bone -> forming airsinuses & cells
NORMAL DEVELOPMENT
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Maxillary At birth -> 3 yrs
Frontal 2 - 9 yrs
Sphenoids 6 7 yrs
Ethmoids At birth -> puberty
All fully developed by age 17-18
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AIR SINUS
ANTERIOR POSTERIOR
FRONTAL MAXILLARYANT.
ETHMOIDALSPHENOIDAL
POST
. ETHMOIDAL
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Functions of para nasal sinuses
Not definitely known! but speculated:
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Functions of para nasal sinuses
Lightening the skull. Add resonance to speech Humidifying and warming inspired air
Regulation of intranasal pressure Increasing surface area of olfaction Contribute to facial growth Act as airbags in trauma - Absorbing
shock Possibly controls immune system?
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MAXILLARY SINUS
Largest PNS
Paired
Pyramidal in shape
Capacity 30 ml
Base pointing tolateral wall of nose
Apex laterally inzygomatic process
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Relations Maxillary sinus
Ant acia sur ace omaxilla
Post infratemporal &pterygopalatine fossa
Medial- middle & inferiormeatus
Floor- alveolar& palatine
Roof- floor of orbit
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Important to dentist
.bc of proximity of teeth and theirassociated structures
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FRONTAL SINUS
Resides in frontalbone
2 nd largest
Assymmetrical
Usually paired-sometimes 1, 3 ornone!
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Relations Frontal sinus
Ant- skin over theforehead
Inf- orbits & its cont
Post- meningeal andfrontal lobe of brain
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Ethmoid sinus
within the ethmoidallabyrinth of the lateralmass of ethmoid bone
divided into1. Anterior2. Middle
3. Posterior groupsaccording to the areaof drainage
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Ethmoid sinus - Relation
lies b/w the upperpart of nasal cavity&orbits (2) and isseparated from the
orbit by a thinorbital plate ofethmoid laterally.
Below is the part of
maxillary airsinus(4)and superiorly isthe anterior part offrontal sinus (1)
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Sphenoid Sinus
Resides in body ofsphenoid
May be single orpaired
Assymmetrical Not present at birth
Lies below to sella
tursica Related tooptic tract, chiasma,internal carotid artery
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Sphenoid Sinus - Relation
Pituitary gland liesabove the sphenoidsinus
Optic nerve andinternal carotidarteries traverse itslateral wall
The nerve ofpterygoid canal liein the floor of thesinus
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Blood supply
Ethmoid -
Sphenopalatine art
Ant & posterior
ethmoidal artery
Maxillary -
facial, infra orbital,greater palatine art
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Blood supply
Sphenoid sinus
post ethmoidal art
Frontal
Supra orbital art
ant ethmoidal
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Lymphatic drainage
ANTERIORMaxillary
Frontal
Ethmoid- ant,middle
submandibularnodes
SUBMANDIBULAR
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Lymphatic drainage
POSTERIOR
Post ethmoidSphenoid
retropharyngeal nodes
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NERVE SUPPLY
Maxillary- infra orbitalalveolar nerves (ant, middle, post sup)
Frontal - Supra orbital nervetraversing the floor of
the sinus
Ethmoid - Ant and post ethmoidal nerves.Orbital br of pterygopalatine ganglion
Sphenoid - post ethmoidal nerve
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MICROSCOPICANATOMY
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Lined by mucusmembrane
Ciliated columnarepithelium
Goblet cellssecretes mucus
Cilia are marked
near ostia
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Cilia 9+2
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epithelial lining has acilium - relatively longstructure -> push sinus
mucus.
mucociliary clearance isprogrammed , so mucus
moves along in a specificpattern.(About ltr per 24 hr !)
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The sinus doesnot drain by gravity - it is anactive process.
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Ostiomeatal complex
All sinus open into middle meatus exceptpost ethmoid & sphenoid sinus
The openings of the sinus ostia into themiddle meatus are close together andform the ostio-meatal complex
Functional reln between the space andthe ostia that drain into it
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This is a key area
because pathology inthis region caninterfere withventilationand mucociliaryclearance of thesinuses. Prolongedobstruction of theseostia during prolonged
nasotrachealintubation can lead onto chronic sinusitis
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Ostium: opening within themaxillary sinus
Uncinate process: sickleshaped bone extension ofthe medial wall
Infundibulum: the canal
like structure
Hiatus semilunaris: slit likeair space
Bulla ethmoidalis: largest
ethmoidal bulla
Middle meatus: wherehiatus semilunaris opens
ostium
infundibulumB E
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1) SS sphenoethmoid recess
2) FS infundibulum of middle
3) Ant ES / infundibularinfundibulum of middle
4) middle ES / Bullar sinus ethmoid bulla of middle
5) MS middle meatus
(posterior ethmoid cells superior)
DRAINAGE OF SINUSES
SS
FS
ES
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One other structure
empties into the nasalcavity and the is the
nasolacrimal duct.
This duct carries awayextra tears.
when the drainagepores are closed off dueto irritation, they fill upand cause pressure
which can then causeheadaches (sinusheadaches).
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APPLIED ANATOMY
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Paranasal sinuses are joined to nasalcavity via small orifices called Ostia
Ostia easily blocked -> drainage ofmucus is disrupted
Sinusitis may result
Latin word SINUO = bend, wind, curve
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SINUSITIS
It is a condition of infection orinflammation of PNS, which may or may
not be a result of infection, frombacterial, viral, fungal, allergic or
autoimmune issues.
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Maxillary > ethmoid > frontal > sphenoid
All sinuses affected
Pansinusitis
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Predisposing factors
Allergies
Asthma
DNS Small sinus ostia
Smoking
Nasal polyps
Cystic fibrosis -thick mucus
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Mallus.
River bath Oil bath
Change of weather
Humid climateSea air
Pollution
Two wheeler
Allergies from pets
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SINUSITISCause of a/c sinusitis
Virus
Bacteria
Fungus
Nose blowing
Scuba diving Foreign body
Medications
Dental infections
Trauma
Adenoids & tonsillitis
DNS , polypi ,beneign tumours
Cause of c/c sinusitis
Allergies
Fungus
Unresolved a/c sinusitis
Asthma
Temp & humidity Narrow sinuses
Defective m m
Dehydration
Poor air quality
Weak immune system Hormones & stress
Polyps & tumours
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Viral Rhinosinusitis
Most URTI are viral
Short lived, lasts less than 10 days
Sinus mucosa & nasal mucosa isinvolved
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Classification of Bacterial Sinusitis
a/c < 4 weeks Resolvecompletely
Sub a/c 4 - 12 weeks Resolvescompletely
c/c > 12 weeks
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Chronic Sinusitis
Symptoms present longer than 8 weeksin adults or 12 weeks in children
Eosinophilic inflammation or chronicinfection
Associated with positive CT scans
B t i I l d i Ch i
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Bacteria Involved in ChronicSinusitis
Role of Viruses is Unknown
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Staph aureus
Coagulase negative staphylococcus
Anerobic bacteria
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Fungal sinusitis
Patients with Diabetes orimmune defeciencies
Aspergillus - temperate
climate
mouldy work atmosphere
Mucor species
Life threatening
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Paediatric sinusitis
R/c cold , allergy
Intake of cold food
Foreign bodies in nose Influenza
Measles
Adenoids
Living in congested area, unhygeinicenv
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PATHOLOGY
Mucus membrane affected
Secretions -> purulent
Increased ciliary movement -> ineffective-> destruction
Proliferation of mm
Thickening of memb -> polyps
Infection -> submucus layer -> bone
Fibrous tissue, new bone formation
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CLINICAL FEATURES
a/c sinusitis c/c sinusitis
Vacuum headache
Systemic malaise,
bodyache, fever
MM of nose red &oedematous
Pus from correspondingoutlets
Headache
Facial fullness < bending
Fever
Hoarseness
Halitosis
Nasal obstruction
Nasal discharge - purulent
PND
Abnormalities of smell
Epistaxis
r/c sore throat
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Frontal Above eyes
< morning
Swelling ofupper eyelid
Ethmoidal Deep behindeyes
Medial canthus
Maxillary Localised toupper teeth
< noon
Lower eyelid
Sphenoidal Deep seatedcentral pain
Vertex / occiput
Blockage of frontonasal duct -> air absorbed -> hyperaemia -> HA
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Routes of spread
Dehiscences and weak bony barriers
Floor of the frontal sinuses form the roof of the orbit
(Infraorbital canal)
Thrombophlebitis via diploic veins present in the frontalbone - veins of Breschet.
Venous connections between the sinuses and the orbitdonot have any valves
The roots of the second premolar and the first upper molarare intimately related to the floor of the maxillary sinus.
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Predisposing factors forcomplications
Immunocompromised patient (e.g. HIV)
Diabetes mellitus
Irregular treatment for sinus infections
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ORBITAL COMPLICATIONS
Orbital cellulitis &abscess
Blindness compression of opticcanal
Optic neuritis
infection thru duralsheath of optic N
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INTRACRANIAL COMPLICATIONS
Meningitis thrombophlebitis
Brain abscess
Cavernus sinus thrombosis
CSF rhinorrhoea from blowing nose
Persisting HA
Defects in memory, behaviour
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Osteomyelitis
Pott's puffy tumor: oeteomyelitis of frontalbone
Fractures Mucocoele
Cysts
Fistula
Malignancies Tumours
Kartageners syndrome
OTHER COMPLICATIONS
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DIAGNOSIS
Duration of s/s
Diagnostic Nasal Endoscopy (DNE)-congestion & mucopus
CT scan Echosinography
Diagnostic proof puncture
Tissue sample for histology & culture Multiple biopsy
Transillumination maxillary & frontal
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Waters View
W i
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Waters view ( occipitomental )
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ELICITING SINUS TENDERNESS
Frontal sinuses by pressing the fingerupward beneath the medial end of thesuperior orbital margin.
Ethmoidal sinuses with the thumb inthe inner canthus of one eye and theindex finger in the other and pushingposteriorly, posterior to the lachrymalbone and squeezing.
Maxillary sinus by pressing the fingeragainst the ant wall of maxilla belowthe inf orbital margin
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Surgical intervention
Trephening of the frontal sinus for a/c sinusitis through floor of the frontal sinus above the innercanthus
Antrum puncture
Intra nasal antrostomy
Caldwell-LUC operation
Balloon catheter dilation of paranasal sinus for chronicsinusitis
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D/D
Allergic rhinitis
Bronchitis
Rhinoviral infections
Upper respiratory infection Cystic fibrosis (especially in children with polyps)
HIV infection
Wegener's granulomatosis
Tumors Mucor Mycosis
Migraine
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Differentiating Sinusitis from Rhinitis
Sinusitis
Nasal congestion
Purulent rhinorrhea
Postnasal drip
Headache
Facial pain
Anosmia
Cough, fever
Rhinitis
Nasal congestion
Rhinorrhea clear
Runny nose
Itching, red eyes
Nasal crease
Seasonal
symptoms
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PREVENTION
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For sinus pain or pressure
Avoid flying when you are congested
Avoid temperature extremes
Avoid sudden changes in temperature
Avoid bending your head down
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Apply a warm, moist washcloth to yourface several times a day
Drink plenty of fluids to thin the mucus
Inhale steam 2 - 4 times per day
nasal saline several times per day
Use a humidifier?
Saline rinse - one cup of warm water +
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Saline rinse one cup of warm water +
1/4 teaspoon of non-iodized salt + teaspoon of baking soda
Discontinue eating milk
and cheese
since dairy products contribute to
mucus production in the body
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Avoid substances that dehydrate the
body - spicy foods, alcoholic
beverages, tea and coffee
Avoid excessive forceful nose-blowing
Avoid swimming or diving, which canput undue pressure on the sinuses
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Frontal sinus
Supra orbital nerve referred pain overskin of forehead upto vertex
Drains close to maxillary sinus orifice
infection spreads easily
Brain abscess in frontal lobe
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Ethmoid sinus
Fragile medial wall of orbit blindness& optic neuritis
Common in paediatric age group
Common site of # - CSF Rhinorrhoea
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Sphenoid sinus
Spread upward in front of pituitary
affects optic chiasma
disturbed vision
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Other Diseases Affecting Sinuses
MucocoeleCysts
Oro antral fistulaTumours of the sinusesBarotraumaFractures
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Mucoceles
c/c cystic lesions esp in the frontal ðmoid
result of obstruction of the sinus ostium
accumulation of secretions into anexpanding mass.
Expansion and inflammation lead toremodeling and erosion of bone, whichchanges the bony architecture significantly.
Usually contents of the mucocele are sterile
If infected, then known as mucopyocele
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Cysts
more popularly known as nasal polyp
soft and pearl-colored growths thatdevelop in the lining of the sinuses.
in singles or clustered together
by prolonged inflammation of the nasalpassages.
Symptoms of allergies and asthma canalso lead to polyp formation.
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Tumours of sinuses
BENIGN Transitional cell papilloma
- Localised ivory osteoma
- Cancellous osteoma
MALIGNANT- Squamous cell carcinoma
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Kartageners syndrome
cilia are unable to move
rare genetic birth defect
Autosomal recessive
Triad DextrocardiaBronchiectasis
Sinusitis
Primary ciliary dyskinesia /Immotile ciliary
syndrome
Afzelius syndrome /Zivert's syndrome
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HOMOEOPATHY
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MIASMATIC DIAGNOSIS
Early stage psora
R/c infection of sinus tubercular
& sycosis
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PSORA SYCOSIS SYPHILIS TUBERCULAR
Rhinitis Sinusitis
DNS,
adenoids
Deg &ulcerativecondn
Epistaxis
Nasal polyps
Narrow nostrils
a/c sympThin watery
Moist snuffleswith purulentdge
Clinkers withoffensiveness
r/c & c/cEpistaxis
PND
< morning
cold> NaturalDge
< damp
weather> Abn dge
< nght
warmth> Abn dge
< closed room
> Open air> epistaxis
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MURPHYS REPERTORY
Children - CATARRH, infants - sinuses,of
Constitutions - INFANTS, constitutions -catarrh - sinuses, of
Diseases - SINUSITIS, infection, nose
Emergency - HEADACHES, severe,migraines - sinus, headache
BBCR
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BBCR
NOSE - Internal sinuses
PHATHAK
N - Nose - sinuses
S - Sinus affections, ofBOERICKE
NOSE - Pain in - Pressing - in frontalsinuses
NOSE - Sinuses
NOSE - Sinuses - Catarrh of frontalsinuses
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COMPLETE REPERTORY
GENERALITIES - INFLAMMATION -chronic - sinusitis
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SYNTHESIS
GENERALS - HISTORY; personal -sinusitis; of recurrent
GENERALS - INFLAMMATION - Sinuses;
of GENERALS - INFLAMMATION - Sinuses;of - recurrent
GENERALS - SINUSITIS
GENERALS - SUPPRESSEDCOMPLAINTS; ailments from - sinusitis
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Rare remedies
Luffa operculata
Abroma augusta folia
Cassia sophera
Granatum
Erigeron Q
Mucor mucido
Distemberinumvaccinum
Oscillococcinum Justisia adhatoda
Berrylium mur
Oxygenium
Gallium sulph
Tungstenium
Cotyledon
sinusitisinum
Luffa operculata
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Purulent sinusitis Frontal and occipital headache Acute or chronic inflammation of the mucous membranes
in the nasal cavities Hypertrophy or atrophy of the nasal mucous membranes Violent headaches going from the forehead towards the
nape of the neck Pain in the occipital region
Frontal pains , with vertigo and muscae volitantes. Head cold , with pale or yellow nasal secretion , especiallyin the morning.
Extreme hunger with emasciation Dryness of the nasal mucus, with sticky scab formations. < dry air in the closed room.
> fresh air outdoors.
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Cassia sophera
Dull pain in temporal and frontalregions < heat > Cold applicationbandage
Desire for curd and pickles
Desire for warm food and drinks eggs,sweet
Appetite, diminished Weakness
Granatum (pomgranate) vertigo
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Granatum (pomgranate) vertigovermifuge
OscillococciniumEspecially indicated in cases of INFLUENZA in persons wherethere is a carcinomatous background in the family-anamnesis, somewhat identical to Carcinosinum.Inflammatory reactions
ll
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Berryllium mur
These people are very unsure ofthemselves. They don't know how tostand up for themselves, especially
because they think that the otherperson will leave them if they do. Sothey tend to ignore their own needs toplease others; they come across as
being kind and very easy going.
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Chest radiography showing dextrocardia withaortic arch lying on right side of trachea with
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aortic arch lying on right side of trachea withcystic bronchiectatic changes
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Sinus polyp Oroantral fistula
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R l f NO i h t d f
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Role of NO in host defence
In nasal airways, continuous production of NO- indicated by presence of gas in nasallyderived air- In Kartagener's syndrome, pts lack NO innasal air & have severe problems withrecurrent airway infection
epithelium in paranasal sinuses is a major site
of NO production and suggest a role forairway-derived NO in primary host defence
Structural theory:
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Fallopio's theory: (1600) - Reducing the load on neckmusculature which supports the head
maintenance of equilibrium and the positioning of the
head Proetz theory: remodelling of facial bones
Evolutionary theory: Evolutionary response of anthropomorphic monkeys to
shift from terrestrial environment to the aquatic one
By Hardy.
Necessity to cross large stretches of water enabledthem to develop these air filled sinus cavities
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Functional theories:
Bartholini's theory:
As organs of resonance which
added quality and resonanceto the voice
Cloquet's theory:
Paranasal sinuses contained olfactory epithelium aidingin the function of smell.
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Sinuses improves nasal function:
Embryological and histological continuity withthe nasal mucosa
Additional secretion of lytic enzymes andimmunoglobulins.
Ventilatory function:
Gaseous exchange
There is a pressure gradiant between thenasal cavity and para nasal sinuses causingairflow in to the sinus cavities
T ansill mination of sin s
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Transillumination of sinus