Sinusitis

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Sinusitis

  1. 1. Sinusitis Prepared by: Nibal Shawabkeh Supervised by: Dr. Adel Adwan 1
  2. 2. 2 They are hollow, air- filled cavities that are lined by respiratory mucosa “ pseudostratified ciliated columnar epithelium” Sinuses
  3. 3. 3  There are four pairs of paranasal sinuses;  The frontal sinuses are located above the eyes, in the frontal bone  The maxillary sinuses are located in the cheekbones, under the eyes.  The ethmoid sinuses(6 – 10 per side), also called ethmoid labyrinth are located between the eyes and the nose.  The sphenoid sinuses(2) are located in the body of sphenoid bone, behind the nose and the eyes. THE PARANASAL SINUSES
  4. 4. 4  Exact function unknown.  Resonators of the voice. Reduce the weight of the skull. Protect the eye Increasing the olfactory surface area. Function Development of sinuses 1. The ethmoid and maxillary sinuses are present at birth. 2. The frontal sinus develops about the seven year of age . 3. The sphenoid about the fifth year.
  5. 5. Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, RHINOSINUSITIS is now the preferred term for this condition. 5 Sinusitis Definition
  6. 6. Pathophysiology:  The sinuses are lined by respiratory epithelium mucosa. Superficial viscous layer and underlying serous layers.  Normal function depends on  Patent Ostia  Ciliary Function  Quality Of Mucosa. 6  The most important pathological process:  Mucosal edema resulting from a viral rhinosinusitis→obstruction of natural ostia → hypooxygenation → acidosis → vasodilation → increased secretion by goblet cells → ciliary dysfunction with poor mucous quality → retention of secretion and predisposition to bacterial infection.
  7. 7. Risk factors:  1. The common cold: major predisposing factor at all ages.  2. Cystic fibrosis.  3. Immunodeficiency, HIV infection.  4. Nasogastric or nasotracheal intubation.  5. Immotile cilia syndrome.  6. Nasal polyps.  7. Nasal foreign body.  8. Cold air.  9. Tumor.  10. Rhinitis Anything that blocks mucus from exiting the sinuses predisposes them to inflammation. 7
  8. 8. Etiology: Ostial obstruction Non-ostial obstruction Direct extension 8
  9. 9. Ostial obstruction:  Inflammation  - URTI  - Allergy  Mechanical  - Septal deviation  - Turbinate hypertrophy  - Polyps  - Tumors  - Adenoid hypertrophy  - Foreign body  - Congenital abnormalities i.e. cleft palate 9
  10. 10. Non-ostial obstruction:  Immune  - Wegener's granulomatosis  - Lymphoma, leukemia  - Immunosuppressed patients (e.g. neutropenics, diabetics, HIV)  Systemic  Cystic fibrosis  Immotile cilia syndrome (Kartagener's)  Triad of:  1. Sinusitis  2. Bronchiectasis  3. Situs inversus 10
  11. 11. Direct extension: Dental Infection Trauma Facial fractures 11
  12. 12. Bacteria causing sinusitis include: 1. S. pneumoniae 2. Nontypable H. influenzae 3. Maroxella catarrhali 4. Less commonly: S. aureus, other streptococci, and anaerobes.  Indwelling nasogastric and nasotracheal tubes predispose to nosocomial sinusitis, which is often caused by gram-negative bacteria (Klebsiella and Pseudomonas).  Antibiotic therapy predisposes to infection with antibiotic-resistant organisms.  Sinusitis in neutropenic and immunocompromised persons may be caused by Aspergillus and the Zygomycetes (e.g., Mucor, Rhizopus). 12
  13. 13. Fungal sinusitis is divided into: 1. Invasive: it is usually caused by Mucor, it has a very high mortality rate because it causes  destruction and necrosis to the bone and may reach the brain. It occurs in immunocompromised patients 2. Non-invasive 13
  14. 14. Classification According to duration: Acute < 1 month. Subacute 1-3 months. Chronic > 3 month. 14
  15. 15. Acute suppurative sinusitis Definition:  Acute infection and inflammation of the paranasal sinuses.  Clinical diagnosis requiring at least 2 major symptoms or 1 major symptom and 2 minor symptoms  Major symptoms  Facial pain/ pressure  Facial fullness/ congestion  Nasal obstruction  Purulent/ discolored nasal discharge  Hyposmia/ anosmia  Fever 15  Minor symptoms  Headache  Halitosis  fatigue  Dental pain  Cough  Ear pressure/ fullness
  16. 16. Acute suppurative sinusitis Etiology:  Viral vs. bacterial  Children are more prone to a bacterial etiology than adults, but viral is still more common  Maxillary sinus most commonly affected  Must rule out fungal causes (mucormycosis) in immunocompromised hosts (especially if painless, bloodless mucosa on examination)  Organisms:  Viral (most common): rhinovirus, influenza, parainfluenza  Bacterial: S. pneumoniae (35%), H. influenzae (35%), M. catarrhalis, anaerobes (dental) 16
  17. 17. Acute suppurative sinusitis Management:  Anterior rhinoscopy  x-ray/ CT scan not recommended unless complications are suspected (i.e. sub-periorbital abscess or intracranial) spread – Pitt's Puffy tumor.  Symptoms improving within 5 days: symptomatic relief "such as decongestant" and expectant management. 17
  18. 18. Acute suppurative sinusitis Management: cont.  Moderate symptoms that worsen or persist beyond 5 days:  institute an intranasal corticosteroid spray and continue for 14 days if symptomatic relief is noted within 48 hours.  Severe symptoms that worsen or persist beyond 5 days and refractory to intranasal corticosteroid (INCS):  Augmentin (Drug of choice) or clarithromycin therapy ± INCS ± referral to a specialist or if there is a late complication.  Surgery if medical therapy fails: 1. FESS 2. Antral washout 18
  19. 19. Acute suppurative sinusitis Complications:  Consider hospitalization if any of the following are suspected:  1. Orbital (Chandler's classification)  a. Periorbital cellulitis  b. Orbital cellulitis  c. Subperiosteal abscess  d. Orbital abscess  e. Cavernous sinus thrombosis (The most important sign is pulsating proptosis)  2. Intracranial  a. Meningitis  b. Abscess 19  3. Bony  a. Subperiosteal frontal bone abscess (Pott's Puffy tumor)  b. Osteomyelitis  4. Neurologic  a. Superior orbital fissure syndrome (CN III/IV/VI palsy, immobile globe, dilated pupils, ptosis)  b. Orbital apex syndrome (as "a" above plus neuritis, papilledema, decreased acuity)
  20. 20. Pott’s puffy tumors:  Characterized by an osteomyelitis of the frontal bone with frontal breakthrough.  This results in a swelling on the forehead.  The infection can also spread inwards, leading to an intracranial abscess.  Although it can affect all ages, it is mostly found among teenagers and adolescents. 20
  21. 21. Chronic sinusitis Definition: Inflammation of the paranasal sinuses lasting > 3 months. 21
  22. 22. Chronic sinusitis Etiology:  Can result from any of the following:  - Inadequate treatment of acute sinusitis  - Untreated nasal allergy  - Allergic fungal rhinosinusitis  - Anatomic abnormality e.g. deviated septum (predisposing factor)  - Underlying dental disease  - Ciliary disorder e.g. cystic fibrosis, Kartagener's  - Chronic inflammatory disorder e.g. wegener's  Organisms:  - Bacterial: S. pneumonia, H. influenza, M. catarrhalis, S.pyogenes, S.aureus, anaerobes  - Fungal: Aspergillus 22
  23. 23. Chronic sinusitis Clinical features: (similar to acute, but less severe)  Chronic nasal obstruction  Purulent nasal discharge  Pain over sinus or headache  Halitosis  Yellow-brown post-nasal discharge  Chronic cough  Maxillary dental pain 23 Sinobronchial syndrome: Post nasal drip in chronic sinusitis causing lower respiratory tract symptoms such as chronic cough Allergic fungal rhinosinusitis is a chronic sinusitis affecting mostly young, immunocompetent, atopic individuals. Treatment options include FESS ± intranasal topical steroids, antifungals and immunotherapy.
  24. 24. Chronic sinusitis Diagnosis:  Cultures of the nasal mucosa in not useful.  Sinus aspirate culture is the most accurate diagnostic method but is not practical or necessary.  Transillumination: show evidence of fluid, difficult to perform in children and is not reliable. 24
  25. 25. 25 Conventional Radiographs, 4 views: 1. Water's view (Occipitomental view): "with opened mouth" Shows maxillary sinuses, frontal sinuses, anterior ethmoidal sinuses & via the mouth, the sphenoidal sinuses. Best for maxillary sinuses. 2. Caldwell view (Occipitofrontal view): Shows frontal, maxillary & anterior ethmoidal sinuses. Best for frontal sinuses.
  26. 26. 26 3. Lateral soft tissue view: Shows adenoids, sphenoidal sinuses & sella turcica. Lateral soft tissue view of the neck and upper thoracic region is ordered if there is suspicion of foreign body. 4. Submentovertical view (bucket-handle): Shows ethmoidal sinuses.
  27. 27. 27 Signs of sinusitis on X ray: 1. Air-fluid level 2. Sinus opacity or clouding 3. Mucosal thickening, but it is not specific for sinusitis, it may occur in simple rhinitis. CT: The gold standard for sinuses. MRI
  28. 28. Chronic sinusitis Treatment:  Antibiotics for 3 to 6 weeks for infectious etiology  Augmentin (40-50 mg/kg/day), amoxicillin is the best in children (80-90 mg/kg/day), macrolide (clarithromycin), fluoroquinolone (levofloxacin), clindamycin, Flagyl TM  Topical nasal steroid, saline therapy  Surgery if medical therapy fails or fungal sinusitis  Removal of all diseased soft tissue and bone, post-op drainage and obliteration of pre-existing sinus cavity  FESS 28
  29. 29. Chronic sinusitis Complications: 1. Polyps 2. Mucocele (frontal and ethmoid) 29
  30. 30. End of Lecture March 2014 30

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