5th year At Medical school

1. Rhinosinusitis
Hatlan ALHatlan

2. Paranasal Sinuses

3. Rhinosinusitis?
• Symptomatic inflammation of the nasal cavity
and paranasal sinuses..
• The term "rhinosinusitis" is preferred to
"sinusitis" since inflammation of the sinuses
rarely occurs without concurrent
inflammation of the nasal mucosa.

4. Classifications
• Based on patient history and a limited physical
examination , and which the treatment
depends on , Rhinosinusitis is classified into :
1. Acute
2. Recurrent acute
3. Subacute
4. Chronic

5. General Symptoms of Rhinosinusitis
• The symptoms of rhinosinusitis can be
classified generally into :
1. Major symptoms :
A. Facial pain/pressure/fullness
B. Nasal obstruction/blockage /congestion
C. Nasal or postnasal discharge/purulence
D. Hyposmia/anosmia
E. Fever (in acute rhinosinusitis only)

6. General Symptoms of Rhinosinusitis
2.Minor symptoms :
A. Headaches
B. Fever (other than acute rhinosinusitis)
C. Halitosis
D. Fatigue
E. Dental pain
F. Cough
G. Ear pain/pressure/fullness

7. Classifications Again
AdditionsHistory +
Examination
DurationType
Fever + Facial pain
not constitute in
absence of other
nasal symptoms
1- Two or more
major
2-One major with
two or more minor
Up to 4 weeksAcute
Same4 or more episodes
per year lasts 7
days no intervening
signs or symptoms
Recurrent acute
Complete
resolution after
effective medical
therapy.
Same4 weeks to 12
weeks
Subacute
Same as acute
(facial pain)
SameMore than 12
weeks
Chronic

8. Acute Rhinosinusitis
• Acute rhinosinusitis (ARS): is defined as
symptomatic inflammation of the nasal cavity
and paranasal sinuses lasting less than four
weeks.
• It’s further classified into acute viral or acute
bacterial rhinosinusitis.

9. Epidemiology
• It affects 30 million a year in US.
• About 1 in 7 people will have it once a year in
the western countries.
• Higher in women(20.3%), compared with
(11.5%) in men , more in 45-74 years.
• Total costs from medications, outpatient and
emergency room visits, and ancillary tests and
procedures, are estimated at $3 billion per
year.

10. Pathophysiology
• Majority are due to viral infections , with
bacterial only in 0.5 to 2.0% of the cases.
• (Rhinovirus, Influenza virus, Parainfluenza virus)
• The viral infection starts with :
1. Inoculation via direct contact (conj+nas.muc)
2. Viral replication in nasal secretions 8-10 hrs.
3. Spreads to the paranasal sinuses by systemic or
direct routes(nose blowing intranasal
presssure).

11. Pathophysiology
4. Inflammation follows sinonasal
hypersecretion and increased vascular
permeability transudation of fluid into
the nasal cavity and sinuses.
5.Direct toxic effects by the virus impairs the
cilia clearance function.
6.Mucosal edema, copious thickened secretions,
and ciliary dyskinesia .

12. Pathophysiology
• Acute bacterial infection is usually a complication
of viral .
• Other predisposing factors are :
1. allergy
2. Mechanical obstruction of the nose,
3. Swimming
4. Intranasal cocaine use
5. Impaired mucociliary clearance
6. Immunodeficiency

13. Diagnosis
• The diagnosis of acute rhinosinusitis (ARS) is
based upon clinical signs and
symptoms.(table)
• Diagnostic testing is not indicated in initial
evaluation.
• Highly symptoms :
1. Purulent rhinorrhea
2. Nasal congestion and facial pain/pressure

14. Diagnosis
Suggestions of bacterial infections ?
1. Persistent symptoms or signs of ARS lasting
10 or more days without evidence of clinical
improvement.
2. Onset of severe symptoms or signs of high
fever(>39°C )purulent nasal discharge or
facial pain 3-4 consecutive days (viral 24-48
hrs)
3. Onset with worsening symptoms or signs
(new fever +Headache+ etc..) 5-6 days after
improvement.

15. Bacterial
1) Streptococcus pneumoniae & haemophilus
influenza are the commonest
2) Gram –ve bacilli
3) Anaerobic organisms are common in
sinusitis due to dental cause
4) Moraxella catarrhalis and H.influenza are
common in pediatric sinusitis

16. Physical Examination
• Physical examination should encompass the
usual evaluation for
1. Respiratory infection, including assessment
of vital signs, eyes, ears, pharynx, teeth, sinus
tenderness, lymph nodes, and chest.
2. Pain localized to the sinuses when the
patient is asked to bend forward(more
reliable)
3. Pain provoked by direct percussion in the
diagnosis of rhinosinusitis (less reliable)

17. Physical Examination
• Nasal speculum AS anterior rhinoscopy.
findings may include:
1. Diffuse mucosal edema
2. Narrowing of the middle meatus
3. Inferior turbinate hypertrophy
4. Copious rhinorrhea or purulent discharge.

18. Diagnostic Tests
• Microbiologic culture :
• Viral culture of nasal secretions is impractical
and unnecessary, given the self-limited nature
of AVRS
• Bacterial culture of material from blind swabs
of the nasal cavity or from purulent nasal
secretions is not recommended, as results are
not reliable.

19. Diagnostic Tests
• Endoscopy :
• Indicated in intracranial extension or other
serious complications , better tolerated than
the classic antral puncture.
• Corner stone with biopsy in early diagnosis of
Acute fulminant invasive fungal rhinosinusitis
(IFRS).

20. • Endoscopic image of purulent drainage from the middle meatus in a
patient with acute bacterial rhinosinusitis.

21. Diagnostic Tests
• Radiologic studies:
• Indicated in complicated cases mainly .
• These signs of complications , which needs
urgent referral and imaging :
1. High fevers (>39°C or 102°F)
2. Severe headache
3. Abnormal vision (diplopia, blindness)
4. Change in mental status
5. Periorbital edema

22. Diagnostic Tests
• CT is the modality of choice :
• A CT scan with contrast is indicated for
suppurative complication such as orbital
cellulitis or intracranial infection.
• Noncontrast CT scan is for evaluation of
recurrent or treatment-resistant sinusitis.
(Ability to discern bony and soft tissue detail)

23. Diagnostic Tests
• Common findings CT :
1. Air-fluid levels
2. Mucosal edema
3. Air bubbles within the sinuses.
• However , it cannot distinguish viral from
bacterial, only in diagnosis in the disease.

24. CT

25. CT

26. Diagnostic Tests
• Other modalities :
• MRI used with CT when extra sinus
complications is suspected, mainly by ABRS.
• Ultrasound is of limited value.

27. Managements
• Managements goals :
1. Eradicate the infection
2. Decrease the severity and duration of
symptoms
3. Prevent complications.

28. Managements
• Symptomatic Treatment:
1. Humidification/vaporizer
2. Warm compressor
3. Adequate hydration
4. Smoking cessation
5. Balanced nutrition
6. Analgesia

29. Managements
• Antimicrobial Therapy
• Choice of antibiotic depends on whether the
sinusitis is acute, chronic, or recurrent.
• Use of antibiotics in ARS is mainly for ABRS.
• Penicillins+ cephalosporins+ macrolides seem
to be equally efficacious.

30. Managements
• Surgical choice:
• Recurrent or persistent sinusitis and presence
of complications with failure of treatment
may require surgical therapy.
• Functional endoscopic sinus surgery (FESS) has
revolutionized the treatment of sinusitis in
recent years. The therapeutic benefits of FESS
have helped a large number of patients with
chronic sinus disease.

31. FESS

32. FEES Complications
1) orbital:
a) Injury to orbital fat & muscles
b) Orbital haematoma lead to optic nerve
compression & blindness
c) Optic nerve injury and blindness
2) intracranial:
a) CSF leak
b) Brain tissue nasal herniation
(from the lecture)

33. Sinusitis Complications
1. Local Complications
2. Orbital Complications (Most Common)
3. Intracranial Complications
4. Systemic Complications

34. Complications
• Local complications
1. Mucoceles are chronic epithelial cysts that
develop in sinuses in the presence of either
an obstructed sinus ostium or minor salivary
gland duct.
2. Osteomyelitis (more with frontal , called Pott
puffy tumor presenting subperiosteal
abscess)

35. Complications
• Orbital complications:
• The most common , direct spread through thin bone of
ethmoid or frontal or by thrombophlebitis of the
ethmoid veins.
• 5 groups (Chandlr’s classifications):
1. Inflammatory edema (preseptal cellulitis).
2. Orbital cellulitis with diffuse orbital edema
3. Subperiosteal abscess beneath the periosteum
4. Orbital abscess with chemosis, ophthalmoplegia, and
decreased visual acuity
5. Cavernous sinus thrombosis with rapidly progressive
bilateral chemosis, ophthalmoplegia, retinal
engorgement, and loss of visual acuity.
• Ttt :sinus drainage and intravenous antibiotics,

36. Complications
• Intracranial complications
1. Subdural abscess is the most common,
2. Cerebral abscesses
3. Infarction
Treated by surgical drainage both cranium+sinus
• Systemic complications:
1. Sepsis
2. Multisystem organ failure

37. Complications

38. Complications

39. Complications

40. Thanxxxxxxxxx