Chronic sinusitis is a chronic inflammation of mucous membranes of paranasal sinuses by which irreversible degenerative changes have occurred. Almost invariably succeeds acute sinusitis which did not receive adequate treatment, or it can also develop following a cold or tooth infection.
It occurs when the self-cleansing mechanism of nose and paranasal sinuses gets impaired. Most involved sinusitis is maxillary sinus with duration of symptoms is more than 3 months.
Etiology
Causes of chronic sinusitis are:
Infection of pharynx, nose and molar teeth
Trauma to the sinuses and barotraumas
Local factors include deviated nasal septum, allergy and nasal polypi
Also includes, chest conditions, such as asthma, chronic bronchiectasis, and chronic bronchitis, responsible for chronic sinusitis.
Chronic sinusitis according to histological changes in the sinus mucosa as follow:
1. Atrophic Sinusitis
Main changes take place in afferent vessels leading to cellular response at and around the arterioles and arteries, later the vessel wall itself becomes thickened and contracted causing endarteritis and thrombosis. In this condition, there is much less edema present as this is primarily a condition that affects the horse’s lower jaw. Hypertrophic and atrophic coexist in the same sinus, the condition causing atrophy at one location and polypoidal hypertrophy at the other place.
2. Hypertrophic Sinusitis
It is characterised mainly by the fact that inflammation is chiefly of the efferent vessels and of the lymphatics. Recurrent stresses take place, which result in changes of the venous and lymphatic flow and organization lead to the formation of oedema and polypoidal mucus membranes, polyps, oedema of periosteum and osteoporosis.
3. Papillary Sinusitis
Occurs when metaplasia of ciliated columnar epithelium to stratified squamous type and throughout the papillary hyperplastic epithelial cells or stroma may be seen inflammatory cells. It is a viral infection.
4. Follicular Sinusitis
Small follicles are seen in the mucous membranes of the sinuses.
5. Glandular Sinusitis
Increase markedly in the submucosal tissue lining of sinuses.
What Kind of Surgery is Done for Chronic Sinusitis?
There are different types of surgery including minimally invasive techniques using endoscopes to remove blockages such as polyps or infected tissue, or to improve drainage in the sinuses. Here are some surgical procedures for chronic sinusitis:
Functional Endoscopic Sinus Surgery
Functional endoscopic surgery is a procedure to re-establish the drainage of the natural ostia and to restore ventilation and mucociliary clearance.
It is based on the principle that clearing the blocked ostium will restore the mucociliary clearance and the diseased mucosa normalizes.
Equipment Used for FESS
4 mm 0-degree endoscope
Angled endoscopes: 30◦, 45◦, 70◦
Camera
Display screen
Light source
Indications for Endoscopic Sinus Surgery
Chronic Sinusitis
Nasal Polyps
Sinus Tumors
Anatomical Abnormalities
Procedure
First stack system positioned infront of surgeon. Usually done under general anesthesia, some surgeons prefer local anesthesia especially is unfit patients. Decongestion is done in the observation room with pledgets or nasal patties.
Patient lies in supine position with head on a ring and head end can be elevated to 15 – 30 degrees.
The two techniques are:
Stammberger’s technique (anterior to posterior): Surgery is done from uncinate process towards sphenoid sinus.
Wigand’s technique (posterior to anterior): Surgery starts from sphenoid sinus and proceeds anteriorly.
The pledgets/patties soaked in 4% xylocaine adrenaline are removed and a thorough endoscopic examination is done with the three passes.
First pass, between the septum and inferior turbinate up to choana to visualize the nasopharynx and Eustachian tube.
In second phase, it passes through middle meatus.
In third phase, between the superior turbinate and the septum up to the visualization of sphenoid ostia.
Local infiltration using 2% lignocaine adrenaline given on the axilla of middle turbinate, septum, uncinate process, middle turbinate and lateral wall.
Uncinate process is identified and the uncinectomy is done.
Maxillary ostia are identified, widened and the maxillary sinus is cleared.
Clearance of the anterior ethmoids beginning with the bulla ethmoidalis then done.
Posterior ethmoids are then cleared after removal of the basal lamella and cleared.
If there is involvement of the frontal sinus, then the frontal recess is cleared. If there is isolated frontal sinus involvement, it can be accessed without removing the bulls, called as the intact bulla technique.
Sphenoid sinus can then be approached via the inferomedial aspect of the most posterior ethmoid cell.
It can also be approached medially by identifying its ostium around 1.5 cm above the roof of the nasopharynx.
After completion of surgery and achieving hemostasis, nasal packing is done.
Balloon Catheter Sinuplasty (BCS)
Ballon Sinuplasty is a minimally invasive procedure used to treat chronic sinusitis. It includes use o a ballon catheter to dilate the sinus openings, improving drainage and airflow.
Balloon sinuplasty is a medical treatment that is employed by ear, nose, and throat surgeons to open blocked sinus, especially the sinusitis patients who do not respond to drugs.
The United States Food and Drug Administration approved this endoscopic, catheter-based procedure for chronic sinusitis in 2005. It employs the use of a balloon inflated over a wire catheter in order to open up the sinuses passages. It therefore helps to regain normal drainage because when filled the balloon stretches the sinus opening and therefore the walls of the passageway.
Indications:
Chronic Sinusitis
Nasal Obstruction
Procedure:
Patients undergo imaging such as CT scan to assess the sinus anatomy.
Performed under local anesthesia, sometimes with sedation.
An endoscope is inserted into nasal passage with small balloon catheter which is threaded into the blocked sinus cavity.
Balloon is inflated to widen the sinus opening and the balloon is deflated, removed left the passage open.
Frequent Asked Questions (FAQs)
Q1. What are the different types of sinus surgery?
Ans. Here are some different types of sinus surgery:
Functional endoscopic sinus surgery (FESS)
Turbinate surgery
Balloon sinus dilation
Adenoidectomy
Q2. What is the conservative treatment for chronic sinusitis?
Ans. Chronic sinusitis with polyps should be treated with topical nasal steroids. If severe or unresponsive to therapy after 12 weeks, a short course of oral steroids can be considered. Leukotriene antagonists can be considered.
Q3. What are the differences between Functional Endoscopic Sinus Surgery (FESS) and balloon sinuplasty?
Ans. FESS is a more traditional approach that involves the endoscopic removal of obstructive tissue and polyps to restore sinus drainage. In contrast, balloon sinuplasty is a less invasive technique that utilizes a balloon to dilate the sinus openings without extensive tissue removal. Both techniques aim to improve sinus drainage, but their applications may vary based on the severity and anatomy of the sinus disease.
Q4. What are the potential complications and considerations during the post-operative period for sinus surgery?
Ans. Potential complications include bleeding, infection, and cerebrospinal fluid leaks, although these are relatively rare. Post-operative care involves monitoring for signs of complications, managing pain, and ensuring proper nasal hygiene. Medical students should be aware of the importance of follow-up evaluations to assess healing and address any complications early. Educating patients on signs of complications is also a vital part of post-operative care.
4 Nov 2024
Important Topics for Radiology
Radiology is a study of medical technology, it is a important discipline included in the MBBS typically introduced in the later years of medical training. It covers various imaging techniques used to diagnose and manage diseases, including X-ray, ultrasound, computed tomography, positron emission tomography, nuclear medicine and magnetic resonance imaging.
Radiology serves as a critical link between clinical medicine and diagnostic image technology helping medical professionals to visualize internal structures and identify pathological conditions.
A strong grip in radiology for medical students is important, as it aids in accurate diagnosis, treatment/management planning and monitoring of diseases progression with stages.
The radiology curriculum in MBBS covers topics like principles of imaging modalities, anatomy in imaging, interpretation of radiographs, advanced imaging techniques, radiation safety, and the role of radiology in various clinical scenarios, including trauma, oncology, and pediatric care.
Important Topics in Radiology
In the NEET-PG examination 10- 15 questions are asked, while in the INI-CET there are about 15-20 questions that are based on the Radiology Subject.
These competitive exams mainly cover the extent of the candidates’ knowledge about medical imaging procedures, diagnosis diagnostic accuracy principles and role of radiology in clinical practice.
Acquaintance of subject weightage, typical examination formats, areas of significant potential for high yield and general study strategies can greatly help to improve conceptual understanding of Radiology exam.
Intraparenchymal and intraventricular bleed Abdominal Trauma-FAST
CECT liver lacerations
Splenic injury Acute Abdomen-Acute Pancreatitis
Small and large Intestinal obstruction and Volvulus
X-Rays
Concepts of Kilovolt Peak (KVP) and Milliampere-Seconds (MAS)
KVP (Kilovolt Peak): Refers to the maximum voltage applied across the X-ray tube, influencing the quality and penetrability of the X-ray beam. Higher KVP results in better image quality with less radiation exposure.
MAS (Milliampere-Seconds): Indicates the quantity of X-ray exposure, combining the current (mA) and the duration (s) of the exposure. It affects the density and contrast of the image.
Schizophrenia is a serious mental illness that impacts about 1% of the global population. It is characterized by symptoms such as hallucinations, delusions, disorganized speech, and severely disorganized behavior. Additionally, individuals may experience negative symptoms, including diminished emotional expression, lack of motivation (avolition), and cognitive impairments.
Excessive dopamine is found in schizophrenics. Drugs that increase or decrease dopamine are known to worsen or make schizophrenia better.
Schizophrenia’s pathophysiology involves multiple molecular and neural circuit changes, though it’s unclear whether these are direct causes or adaptations to underlying dysfunctions. No current model fully explains all observed changes.
Neurotransmitter imbalances, particularly involving dopamine, serotonin, glutamate, and GABA, are central to schizophrenia. The connection between dopamine and schizophrenia was highlighted by the discovery that D2 receptor blockers can alleviate psychotic symptoms. Four key dopamine pathways—mesolimbic, mesocortical, tuberoinfundibular, and nigrostriatal—play distinct roles. Excessive dopamine in the mesolimbic pathway is linked to positive symptoms, while reduced dopamine in the mesocortical pathway may lead to negative symptoms and cognitive deficits. The nigrostriatal pathway is associated with motor side effects of antipsychotics, and the tuberoinfundibular pathway relates to hyperprolactinemia.
Recent research in cognitive neuroscience has shown that mesostriatal dopamine neurons respond to “reward prediction error,” helping assign significance to stimuli. In schizophrenia, dysregulated firing of these neurons can lead to misattribution of importance to irrelevant stimuli, contributing to delusions and hallucinations.
The relationship between dopamine and schizophrenia is complex, as evidenced by the delay between D2 receptor blockade and clinical response to antipsychotics, suggesting secondary neurochemical mechanisms are also at play. Additionally, the interplay among dopamine, glutamate, and GABA is critical for regulating cortical circuits, with postmortem studies indicating alterations in these microcircuits. This has prompted exploration of targeting glutamate and GABA pathways for improved treatment options.
Stages of Schizophrenia
Phase 1: Initial diagnosis for the earliest signs of schizophrenia.
Phase 2: These are the periods between exacerbations of symptoms, which are relatively calm, but may be deteriorating.
Phase 3: Exacerbation or relapse with increased use of resources.
Major Types of Schizophrenic Disorders
Disorganized Schizophrenia: Personality is severely disorganized, which includes hallucinations, inappropriate behavior and regression.
Catatonic Schizophrenia: Acute stupor and sudden loss of animation that alternates with periods of excitement and over activity.
Paranoid Schizophrenia: Suspicious of everyone and ideas of persecution or grandeur.
Undifferentiated Schizophrenia: Prominence of psychotic symptoms from more than one subtype or that does not meet the criteria for any subtype.
Residual Schizophrenia: Absence of prominent psychotic symptoms but continued evidence of symptoms of symptoms such as peculiar behavior and blunted affect.
(Hebephrenic) Disorganized Schizophrenia Type
Individual has facial tics and grimaces, characteristic rises sardonic smile, flat affect with no emotion or strong feeling and in between blunt affect, Volitional affect, and labile affect. Almost all affects are oriented to time place and person.
Pathognomonic are very characteristic:
Clanging- Rhyming ‘Go to hell, bell’ (pathognomonic).
Echolalia- Repeating phrase- repeats back “When did you come?”
Neologisms- Uttering new words without any meaning.
Pathognomonic are schizophrenics until rules out.
Catatonic Schizophrenia Disorder
Presence of psychomotor retardation, thought process is slow, walking slowly and flexibility is slow. Tendency to talk as though the other person isn’t there! Its tendency is very harmful.
Sometimes rage is combined with anger catatonic excitement and grand blow up can come out with insensitivity to staff.
Increased stress is like increased catatonic excitement.
Paranoid Schizophrenia
The individuals are intelligent with inflated ego (think they are someone special).
Basically, they have severe auditory hallucinations and fear of persecution. They have such fears about safety such as CBI is after them, they being controlled by special messages through electronic media. All delusions start with a kernel of truth.
Undifferentiated Type
The individual has a lot of symptoms. They may have symptoms of all other types so that it is difficult to differentiate.
Kinesics Nonverbal Behaviors
Bizarre behaviors which are outlandish, ridiculous and abnormal but not for drawing attention like shaving of one side of moustache, rose on one side of cheeks, etc.
Symptoms of Schizophrenia
Here are some of the symptoms associated with schizophrenia:
Primary Symptoms of Schizophrenia
Delusions: False beliefs maintained against logic and contrary evidence.
Loosening of Associations: Ideas skip from one thought to another in unrelated way.
Hallucinations: False sensory perceptions in the absence of actual external stimuli.
Positive Symptoms reflect the presence of unusual behavior and related distortions in form and content of thought.
Secondary Symptoms of Schizophrenia
Disturbances in affect often blunt or flat.
Disturbances in volition inability to initiate goal-directed activity.
Disturbances/interpersonal functioning often withdrawn from others (in the extreme autism).
Increases psychomotor activity or decreased psychomotor activity.
Negative symptoms reflect the absence of normally expected behavior.
Diagnosis of Schizophrenia
The diagnosis of schizophrenia relies on two primary systems: the DSM-5-TR and the ICD-10, each with slight variations.
1. DSM-5-TR
The DSM-5-TR, published by the American Psychiatric Association (APA) in 2022, outlines the following criteria for diagnosing schizophrenia:
Symptom Presence: The patient must exhibit two (or more) of the following symptoms for a significant portion of time during a 1-month period (or less if successfully treated). At least one symptom must be one of the first three:
Delusions
Hallucinations
Disorganized speech (e.g., frequent derailment or incoherence)
Grossly disorganized or catatonic behavior
Negative symptoms (e.g., diminished emotional expression or avolition)
Functional Decline: There must be a noticeable decline in functioning in areas such as work or relationships since the onset of symptoms.
Duration: Continuous signs must persist for at least 6 months, including at least 1 month of active-phase symptoms, which may be shorter if treated. Symptoms can also be prodromal or residual, including negative or attenuated active-phase symptoms.
Exclusion Criteria: Schizoaffective, depressive, or bipolar disorders with psychotic features must be excluded. Symptoms should not be attributed to substance use, medication, or another medical condition. If a developmental disorder is present, the diagnosis requires at least 1 month of prominent delusions or hallucinations.
2. ICD-10
The ICD-10 specifies that the patient must demonstrate at least one of the following symptoms for a duration of 1 month or more:
Thought echo, thought insertion or withdrawal, thought broadcasting
Delusions of control, influence, or passivity; delusional perceptions
Hallucinatory voices providing a running commentary on the patient or discussing the patient among themselves
Persistent delusions that are culturally inappropriate or implausible
Alternatively, the patient may exhibit at least two of the following symptoms for 1 month or more:
Persistent hallucinations in any modality, accompanied by fleeting or half-formed delusions
Breaks or interruptions in thought leading to incoherence, irrelevant speech, or neologisms
Catatonic behavior
Negative symptoms
Significant changes in overall behavior, such as loss of interest and social withdrawal
In contrast to the DSM-5-TR, the ICD-10 categorizes schizophrenia based on key presenting symptoms into various types, including:
Paranoid schizophrenia
Hebephrenic schizophrenia
Catatonic schizophrenia
Undifferentiated schizophrenia
Post-schizophrenic depression
Residual schizophrenia
Simple schizophrenia
Schizophrenia, other
Schizophrenia, unspecified
Evaluation of Schizophrenia
Schizophrenia is primarily a Clinical diagnosis, but specific radiographic and laboratory tests are necessary to rule out other potential causes. The American Psychiatric Association Practice Guideline for the Treatment of Patients with Schizophrenia recommends the following evaluations during an initial assessment:
1. Hematology
A complete blood count (CBC) should be performed to check for anemia or signs of infection that may mimic schizophrenia symptoms. If the patient is being considered for treatment with clozapine, an absolute neutrophil count (ANC) should also be obtained.
2. Blood Chemistry Panel
This should include tests for electrolytes, renal function, liver function, and thyroid-stimulating hormone (TSH). Hypothyroidism can present with psychiatric symptoms such as depression and cognitive impairment.
3. Pregnancy Test
A pregnancy test is recommended for women of childbearing age.
4. Electroencephalogram (EEG)
An EEG may be warranted based on the neurological examination or patient medical history to rule out seizure disorders.
5. Imaging
Brain imaging tests, either a CT or MRI (with MRI being preferred), may be indicated based on neurological findings or patient medical history.
6. Genetic Testing
Chromosomal testing is suggested if indicated by the physical examination or developmental clinical history.
7. Drug Toxicology Screen
This screen may be necessary to identify substance use that could lead to psychotic symptoms.
Treatment of Schizophrenia
The treatment of schizophrenia typically involves a comprehensive approach that combines medication, psychotherapy, and supportive services. Here are the key components:
1. Medications
Antipsychotics: These are the cornerstone of schizophrenia treatment. They can help manage symptoms such as delusions, hallucinations, and disorganized thinking. There are two main categories:
Typical (First-Generation) Antipsychotics: Examples include haloperidol and chlorpromazine. These primarily target dopamine receptors but may have more side effects, such as extrapyramidal symptoms.
Atypical (Second-Generation) Antipsychotics: Examples include risperidone, olanzapine, and aripiprazole. These tend to have a lower risk of motor side effects and can also address negative symptoms.
2. Psychotherapy
Cognitive Behavioral Therapy (CBT): This can help patients manage symptoms and improve functioning by challenging distorted thoughts and developing coping strategies.
Supportive Therapy: Providing emotional support, practical assistance, and education about the mental disorders can be beneficial.
Family Therapy: Involving family members can enhance support and improve communication.
3. Rehabilitation and Support Services
Psychosocial Rehabilitation: Programs focused on social skills training, vocational rehabilitation, and community support can help individuals reintegrate into society and improve quality of life.
Case Management: Coordinated care by case managers can assist patients in accessing services and navigating the healthcare system.
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24 Oct 2024
Wearable Tech Revolutionizes Diabetes Management with Real-Time Glucose Monitoring
A new generation of wearable devices is transforming diabetes care by providing continuous, real-time glucose monitoring. These innovative gadgets, which integrate seamlessly with smartphones, allow users to track their blood sugar levels with unprecedented accuracy. The technology enables personalized insights and alerts, helping individuals manage their condition more effectively and potentially reducing the risk of diabetes-related complications. Early adoption shows promising improvements in patient adherence and overall health outcomes.
