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Sinusitis
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  • 1. CH2
  • 2.  Sinusinfection lasting for months or years is called chronic sinusitis. Failure of acute infection to resolve – most common cause
  • 3. PATHOPHYSIOLO GY
  • 4.  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
  • 5.  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
  • 6. PATHOLOGY
  • 7. Pollution, Chemicals, Infections LOSS OF CILIA Polypi, DNSAdenoids IMPAIRED MUCOSALTumours DRAINAGE CHANGES ALLERGY Allergy INFECTION Inadequate therapy of acute sinusitis
  • 8. BACTERIOLOGY
  • 9. Clinical Features Vague , less compared to acute sinusitis PURULENT NASAL DISCHARGE [ most common] Foul smelling – Anaerobic infection Nasal stuffiness, Anosmia
  • 10. DIAGNOSIS Xray – Mucosal thickening / Opacity CTscan [ particularly ethmoid and sphenoid] Aspiration and irrigation – Pus  confirmatory
  • 11. TREATMENT
  • 12.  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
  • 13. SURGERIES FORCHRONIC SINUSITIS
  • 14. CHRONIC MAXILLARYSINUSITIS Antral puncture and Irrigation Intranasal antrostomy – when sinus irrigation fails to resolve infection. Caldwell – Luc Operation
  • 15. 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
  • 16. 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
  • 17. CHRONIC SPHENOID SINUSITIS Sphenoidotomy Sinus entered through anterior wall Usually asso with ethmoid disease , hence external ethmoidectomy is also done
  • 18. FUNGAL SINUSITIS
  • 19. ASPERGILLUS ALTERNARIA MUCOR RHIZOPUS
  • 20. 4 Varieties of Fungal Sinusitis1. Fungal Ball2. Allergic Fungal Sinusitis3. Chronic Invasive Sinusitis4. Fulminant Fungal Sinusitis
  • 21. 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.
  • 22. 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
  • 23. 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.
  • 24.  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.
  • 25. 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
  • 26.  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.
  • 27. 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……
  • 28. CONTRAINDIATIONS 1. Inexperience and lack of proper instrumentation. 2. Endoscopy inaccessible diseases [ lateral frontal sinus disease] 3. Osteomyelitis. 4. Threatened intracranial or intraorbital complication.
  • 29. ANAESTHESIA GENERAL ANAESTHESIA Preferred. LOCAL anaesthesia with IV sedation can be used when limited work is to be done.
  • 30. POSITION Patient lies flat in supine postion with head resting on a ring or head rest.
  • 31. 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.
  • 32. 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.
  • 33. RIGHT NOSE
  • 34.  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.
  • 35. VIDEO
  • 36. Post Operative care Removal of nasal packs. Antibiotics. Antihistaminics Analgesics Nasal Irrigations. Steroid nasal sprays Endoscopic toilet Review
  • 37. 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