Sinusinfection lasting for months or years is called chronic sinusitis. Failure of acute infection to resolve – most common cause
Acute Infection Destroys normal ciliated epithelium Impairs drainage from sinus Pooling and stagnation of secretions Persistence of infection Mucosal changes – loss of cilia , edema ,polyp formation
Destruction of mucosa and healing occurs simultaneously Thickening of mucosa Polypoidal Atrophy[ hypertrophic sinusitis] [ atrophic sinusitis]Surface epithelium – Desquamation Regeneration/ MetaplasiaSubmucosa – lymphocytic , plasma cells infiltration with /without micro abscesses, granulations , fibrosis or polyp formation
Pollution, Chemicals, Infections LOSS OF CILIA Polypi, DNSAdenoids IMPAIRED MUCOSALTumours DRAINAGE CHANGES ALLERGY Allergy INFECTION Inadequate therapy of acute sinusitis
Clinical Features Vague , less compared to acute sinusitis PURULENT NASAL DISCHARGE [ most common] Foul smelling – Anaerobic infection Nasal stuffiness, Anosmia
DIAGNOSIS Xray – Mucosal thickening / Opacity CTscan [ particularly ethmoid and sphenoid] Aspiration and irrigation – Pus confirmatory
Identify the etiology which obstruct sinus drainage and ventilation Work up for Nasal allergy may be required Culture and sensitivity – Antibiotic selection Initial treatment – Conservative [ Antibiotics, decongestants, antihistaminics, and sinus irrigations] SURGERIES – for free drainage and ventilation
SURGERIES FORCHRONIC SINUSITIS
CHRONIC MAXILLARYSINUSITIS Antral puncture and Irrigation Intranasal antrostomy – when sinus irrigation fails to resolve infection. Caldwell – Luc Operation
CHRONIC FRONTAL SINUSITIS Intranasal drainage operations[ Correction of DNS, removal of a polyp or Iintranasal ethmoidectomy, provide drainage through the frontonasal duct.] External frontoethmoidectomy Trephination of frontal sinus Osteoplastic flap operation
CHRONIC ETHMOID SINUSITIS Intranasal ethmoidectomy- ethmoid air cells & the diseased tissue is removed between the middle turbinate and the medial wall of orbit by intranasal route. External ethmoidectomy – Medial orbital incision
CHRONIC SPHENOID SINUSITIS Sphenoidotomy Sinus entered through anterior wall Usually asso with ethmoid disease , hence external ethmoidectomy is also done
Fungal ball Due to implantation of fungus in otherwise healthy sinus CT – hyper dense area with no evidence of bone erosion or expansion. Maxillary > Sphenoid> Ethmoid> Frontal Surgical removal of fungal ball & adequate drainage of sinus.
Allergic Fungal Sinusitis Allergic reaction to causative fungus Presents with Sinu- nasal polyposis & Mucin [ Eosinophils, CL crystals, fungal hyphae] CT - Mucosal thickening with hyperdense areas - Bone erosion - Expansion of sinus but no fungal invasion into mucosa. Treatment – endoscopic surgical clearance , drainage ventilation + pre- & post-operative steroids
CHRONIC INVASIVE SINUSITIS Fungal invasion into sinus mucosa Presents with chronic rhinosinusitis, may present with intracranial or intraorbital invasion. CT – mucosal thickening, opacification of sinus, bone erosion, expansion. Histopatho – submucosal fungal invasion + granulomatous reaction with multinucleated giant cells.
Treatment – Surgical removal of involved mucosa, bone and soft tissues followed by IV Amphotericin B upto 2-3g followed by Itraconazole for 12 months or more monitored by serial CT/MRI scans.
Fulminant Fungal Sinusitis Acute presentation Immunocompromisation /Diabetes Mucor , Aspergillus Mucor – Rhinocerebral disease - Due to invasion of BV ischemic necrosis black eschar involving inf. Turbinate , palate or sinus. - Spreads to face , eyes, skull base and brain Treatment – Surgical debridement of necrotic tissue and IV Amphotericin B Aspergillus – no eschar
Minimally invasive Does not require skin incisions / removal of intervening bone to access the disease. Ventilation and drainage of the sinuses is established preventing the nasal and sinus mucosa & its mucociliary clearance function.
INDICATIONS 1. Chronic bacterial sinusitis unresponsive to medical treatment 2. Recurrent acute bacterial sinusitis. 3. Polypoid rhinosinusitis 4. Fungal sinusitis with fungal ball/nasal polypi. 5. Antrochoanal polyp. 6. Mucocoele of frontoethmoid/ sphenoid sinus……
CONTRAINDIATIONS 1. Inexperience and lack of proper instrumentation. 2. Endoscopy inaccessible diseases [ lateral frontal sinus disease] 3. Osteomyelitis. 4. Threatened intracranial or intraorbital complication.
ANAESTHESIA GENERAL ANAESTHESIA Preferred. LOCAL anaesthesia with IV sedation can be used when limited work is to be done.
POSITION Patient lies flat in supine postion with head resting on a ring or head rest.
TECHNIQUES Stammberger’s Technique[ Anterior to posterior] - Starts from uncinate process proceed backwards to sphenoid sinus. Wigand’s Technique[ Posterior to Anterior] - Starts at sphenoid sinus and proceeds anteriorly along the base of skull and medial orbital wall.
Steps Of Operation…1. Remove the pledgets of cotton kept for nasal decongestion and topical anaesthesia.2. Inspect the nose with 4mm 0degree endoscope .3. Inject submucosally 1% lignocaine with 1:100000 adrenaline under endoscopic control.
Uncinectomy Identification and enlargement of maxillary ostium Bullectomy Penetration of basal lamella and removal of posterior ethmoidal cells. Clearance of frontal recess and frontal sinusotomy Sphenoidotomy Nasal packs.
Post Operative care Removal of nasal packs. Antibiotics. Antihistaminics Analgesics Nasal Irrigations. Steroid nasal sprays Endoscopic toilet Review
COMPLICATIONS MAJOR MINOROrbital haemorrhage Periorbital ecchymosisLoss of vision Periorbital emphysemaDiplopia EpistaxisCSF Leak Post-op sinusitis,rhinitisMeningitis AdhesionsBrain abscess Exacerbation of asthmaMassive h’ge req. trnsfusion HyposmiaIntrcranial haemorrhage Dental painanosmiaInjury to ICA