E.N.T 5th year, 4th lecture (Dr. Yousif Chalabi)


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The lecture has been given on Dec. 13th, 2010 by Dr. Yousif Chalabi.

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E.N.T 5th year, 4th lecture (Dr. Yousif Chalabi)

  1. 1. Inflammations of the paranasal sinuses
  2. 2. Inflammations of the paranasal sinuses <ul><li>Inflammations may be restricted to a single sinus or may be present in several (multisinusitis) or in all of one or both sides (pan sinusitis , unilateral or bilateral). </li></ul><ul><li>Acute and chronic non-specific infections occur with the production of either suppurative or non-suppurative forms. </li></ul><ul><li>A sinusitis is said to be (closed) if the contained inflammatory exudate can not escape, either through the viscosity of the exudate or through closure of the ostium by oedema. It is said to be (open) if ciliary action and overflow permit escape of the exudate. Specific infections are rare. </li></ul>
  3. 3. Acute non-specific sinusitis <ul><li>Aetiology: </li></ul><ul><li>Acute infective rhinitis, generally due to a cold or influenza. </li></ul><ul><li>2. Swimming and diving may similarly cause direct spread through the ostium. </li></ul><ul><li>3. Dental extraction or infection may cause infection to enter the maxillary antrum from a dental root. </li></ul><ul><li>4. Fractures involving the sinuses may followed by sinusitis. </li></ul>
  4. 4. <ul><li>Predisposing factors include: </li></ul><ul><li>a. Local : </li></ul><ul><li>Nasal obstruction from any cause. </li></ul><ul><li>Obstruction of the sinus ostium especially by nasal polypi, vasomotor an allergic swellings , rarely by a tumor . </li></ul><ul><li>Neighboring infection , example ( tonsillitis and adenoids). </li></ul><ul><li>Previous infection in the same sinus. </li></ul>
  5. 5. <ul><li>b. General: </li></ul><ul><li>Debilitation. </li></ul><ul><li>Mucociliary disorders. </li></ul><ul><li>Immunodeficiency. </li></ul><ul><li>Irritating atmospheric conditions. </li></ul><ul><li>Bacteriology: </li></ul><ul><li>The causative organisms are : </li></ul><ul><li>Pneumococcus, streptococcus, staphylococcus, H.Influenzae, klebsiella pneumonae. </li></ul><ul><li>E.Coli and anaerobic streptococci are associated with sinusitis of dental origin. </li></ul>
  6. 6. Acute maxillary sinusitis <ul><li>Maxillary sinusitis is the commonest of all sinus infection to present as a single clinical entity. The origin of the infection may be either nasal(90%) or dental(10%). </li></ul><ul><li>Acute maxillary sinusitis of nasal origin: </li></ul><ul><li>Pain in cheek, its frequently referred to the region of the frontal sinus, temporal region , or upper teeth. </li></ul><ul><li>Tenderness over the cheek .Its not present over the orbital roof unless a frontal sinusitis coexists. </li></ul><ul><li>Oedema of cheek is rare except in children. </li></ul><ul><li>Discharge in the middle meatus or postnasal space in (open) sinusitis. Spontaneous evacuation of the sinus content in to the nose may occur suddenly, especially on bending down. </li></ul><ul><li>Constitutional symptoms include pyrexia,malaise &mental depression. </li></ul>
  7. 7. <ul><li>Special local treatment: </li></ul><ul><li>The sinus is irrigated, by puncture through the inferior meatus ,with isotonic saline, if there is no response to medical treatment. This is repeated as necessary. </li></ul><ul><li>Intranasal antrostomy, needed urgently in closed infections failing to respond to antibiotics. </li></ul><ul><li>Acute maxillary sinusitis of dental origin: </li></ul><ul><li>There are three types: </li></ul><ul><li>Following dental extraction. </li></ul><ul><li>2.Following apical abscess. of the premolar or molar teeth. </li></ul><ul><li>3.In acute dental sac infection. </li></ul><ul><li>Treatment is by systemic antibiotics &drainage of any collection of pus, dead tooth buds are removed later. </li></ul>
  8. 8. <ul><li>Diffrential diagnosis of acute sinusitis </li></ul><ul><li>Pain of dental origin. </li></ul><ul><li>Migraine. </li></ul><ul><li>Trigeminal neuralgia. </li></ul><ul><li>Neoplasms of sinuses. </li></ul><ul><li>Erysipelas. </li></ul><ul><li>Temporal arteritis. </li></ul><ul><li>Herpes zoster. </li></ul>
  9. 9. Principles of treatment of acute sinusitis <ul><li>Treatment of the infections. Systemic penicillin is nearly always effective. </li></ul><ul><li>Ampicillin & flucloxacillin will cover most organisms. </li></ul><ul><li>In infection of dental origin Metronidazole should be added. </li></ul><ul><li>2. Treatment of the pain: </li></ul><ul><li>Analgesics. </li></ul><ul><li>Local heat as by hot water bottle, or steam, short wave diathermy is often comforting & it must not be used in acute stage. </li></ul><ul><li>3- Establishment of drainage may be affected by : </li></ul><ul><li>Decongestant solutions such as 0.5 or 1% ephedrine in NS used either as drops or spray. </li></ul>
  10. 10. Acute frontal sinusitis <ul><li>Usually associated with an infection of the homolateral anterior ethmoidal cells , and often of the maxillary sinus . </li></ul>
  11. 11. Acute frontal sinusitis <ul><li>Clinical features : </li></ul><ul><li>1- frontal head ache may be severe . </li></ul><ul><li>Its usually periodic , in that it starts soon after waking and subsides in the afternoon </li></ul><ul><li>2- extreme tenderness to pressure on the orbital roof , at a point internal to the supra orbital notch . Percussion of the anterior sinus wall is painful. </li></ul><ul><li>3-oedema of the upper lid is not uncommon . </li></ul><ul><li>4-discharge is seen in the high anterior portion of the middle meatus when the infection is open . </li></ul>
  12. 12. Acute ethmoiditis <ul><li>Though very commonly involved with either sinuses an infection of the ethmoidal labyrinth seldome produces a separate clinical entity in the adult . </li></ul><ul><li>Clinical features : </li></ul><ul><li>1-pain between the eyes . Accompanied by frontal head ache . </li></ul><ul><li>2- discharge in the middle and superior meatus from the ostia of the anterior and the posterior group of cells . </li></ul><ul><li>Treatment :usually non is necessary . The treatment of any acute infection in the larger sinuses commonly procures resolution in the ethmoids </li></ul>
  13. 13. Chronic sinusitis <ul><li>Definition :long standing infection of the sinus. </li></ul><ul><li>change of the mucosa over this time may be irreversable </li></ul><ul><li>Continuation of infection is inhanced if there is obstruction of the ostia </li></ul>
  14. 14. Chronic sinusitis <ul><li>Classification ; </li></ul><ul><li>Chronic non specific </li></ul><ul><li>Simple infective chronic sinusitis </li></ul><ul><li>Mixed infective & vasomotor chronic sinusitis </li></ul><ul><li>Simple chronic suppurative sinusitis </li></ul><ul><li>Chronic specific </li></ul><ul><li>TB & Syphilitic infection </li></ul><ul><li>Fungus infection </li></ul>
  15. 15. Chronic sinusitis <ul><li>Predisposing factor for chronic sinusitis </li></ul><ul><li>Nasal : blockage </li></ul><ul><li>adenoid hypertrophy </li></ul><ul><li>deviated nasal septum </li></ul><ul><li>nasal polyposis </li></ul><ul><li>enlarged inferior turbinate </li></ul><ul><li>recurrent acute infection </li></ul><ul><li>irritation: gases </li></ul><ul><li>Teeth : root infection </li></ul><ul><li>dental abscesses </li></ul>
  16. 16. Management <ul><li>Diagnosis : </li></ul><ul><li>Radiography: </li></ul><ul><li>if it is clear, it excludes hypertrophic but not atrophic </li></ul><ul><li>thickening of mucosa: uniforn </li></ul><ul><li>polypoidal (opacified sinus) </li></ul><ul><li>fluid level: signifies infection </li></ul><ul><li>Antroscopy * direct vision </li></ul><ul><li>* biopsy </li></ul><ul><li>* operative treatment </li></ul>
  17. 20. <ul><li>Treatment : </li></ul><ul><li>Maxillary sinus is the most commonly affected .if all sinuses are infected , treatment of maxillary sinus often allow spontanous resolution of other sinuses </li></ul><ul><li>Provition of drainage by </li></ul><ul><li>decongestant </li></ul><ul><li>antrum puncture & lavage </li></ul><ul><li>conservative surgery ( antrostomy ) </li></ul><ul><li>radical surgery ( removal of lining mucsa) </li></ul><ul><li>Systemic antibiotics </li></ul><ul><li>Correction of predisposing factors </li></ul>
  18. 23. <ul><li>Indication for surgery </li></ul><ul><li>to control infection </li></ul><ul><li>to remove polypi </li></ul><ul><li>to remove other manifestation of vasomotor or allergic </li></ul><ul><li>component which includes: </li></ul><ul><li>* rcurrent non_secreting cysts </li></ul><ul><li>* collection of thick , gluey, mucoidal material which may completely fill the sinus </li></ul><ul><li>Operative procedures : </li></ul><ul><li>intranasal polypectomy </li></ul><ul><li>external fronto_spheno_ethmoidectomy </li></ul>
  19. 24. <ul><li>Chronic maxillary sinusitis </li></ul><ul><li>* irrigation by repeated puncture. </li></ul><ul><li>* intranasal antrostomy : failure of resolution after irrigation </li></ul><ul><li>short duration </li></ul><ul><li>* sublabial antrostomy ( Caldwell_luc operation) </li></ul><ul><li>if above methods have failed </li></ul><ul><li>long standing cases </li></ul>
  20. 26. Sinusitis in children <ul><li>Aetiology: </li></ul><ul><li>systemic factors allergy </li></ul><ul><li>Ab dificiency </li></ul><ul><li>mucoviscidosis </li></ul><ul><li>heredity </li></ul><ul><li>environmental factors dietary deficiency </li></ul><ul><li>social deprivation </li></ul><ul><li>lack of exercise </li></ul><ul><li>lack of ventilation </li></ul><ul><li>local causes : intranatal </li></ul><ul><li>neonatal </li></ul><ul><li>older children </li></ul><ul><li>clinical causes : repeated cold </li></ul><ul><li>influenza </li></ul><ul><li>dental sac infection </li></ul><ul><li>adenoids </li></ul><ul><li>inborn errors of cilial structure </li></ul>
  21. 27. <ul><li>Sinusitis in children </li></ul><ul><li>pathology : maxillary & ethmoidal sinus are usual sites </li></ul><ul><li>after 10 years the condition is similar to that in adult </li></ul><ul><li>non suppurative cases are more common </li></ul><ul><li>Clinical features </li></ul><ul><li>acute sinusitis: features more pronounced than in adult </li></ul><ul><li>oedema of eyelids & cheeks </li></ul><ul><li>chronic sinusitis: chronic nasal obstruction associated with nasal discharge </li></ul><ul><li>mouth breathing </li></ul><ul><li>snoring </li></ul><ul><li>coughing </li></ul><ul><li>early morning vomiting </li></ul><ul><li>apathetic & dull </li></ul>
  22. 28. <ul><li>Sinusitis in children </li></ul><ul><li>Diagnosis ; radiography </li></ul><ul><li>proof puncture ( under GA) </li></ul><ul><li>Difrential diagnosis :foreing body </li></ul><ul><li>Treatment : acute:non operative </li></ul><ul><li>chronic :antiallergic </li></ul><ul><li>decongestant nasal drops </li></ul><ul><li>intermitent irrigation(polythine tube) </li></ul><ul><li>infected tonsils& adenoid </li></ul><ul><li>dental causes treatnent </li></ul>