Slides prepared and compiled by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate ENT students in the field of otorhinolaryngology. A clear and concise explanation of the basic concepts in the subject matter concerned. He is the Head of department with a sound knowledge in the field of ENT to teach both undergraduate and postgraduate ENT students

1. Rhinosinusitis: clinical features
and diagnosis
Dr. Krishna Koirala
2020-05-25

2. • Rhino-sinusitis: inflammation of lining mucosa of nose & paranasal sinuses
• Acute: infection lasting < 4 weeks
• Sub acute: infection lasting 4 to 12 weeks
• Chronic: infection lasting > 12 weeks
• Recurrent acute (RARS): > 3 episodes of rhinosinusitis in 6 months or > 4
episodes in a year, each episode lasting for 7-10 days, without persistent
symptoms in between
Definitions

3. Types of sinusitis
• Acute / sub acute / chronic / recurrent
• Open / Closed (depending on its drainage)
• Unilateral / bilateral
• Maxillary / frontal / ethmoidal / sphenoidal
• Single / multi / pan-sinusitis
• Anterior / posterior group
• Suppurative / hypertrophic
• Bacterial / fungal / allergic / occupational

4. Etiology
• Rhinogenic: commonest (85%), following any form of rhinitis
• Dental: maxillary sinusitis, root abscess, dental procedures
• Trauma:
– R.T.A., swimming, diving, F.B., barotrauma
– Iatrogenic: nasal packing, septal surgery
• Hematogenous : rare

5. • Mucosal edema: viral, bacterial, allergic, irritant, vasomotor,
barotrauma
• Mechanical obstruction: DNS with spur, polyp, hypertrophic turbinate,
concha bullosa, paradoxical middle turbinate, Haller cell, large bulla
ethmoidalis, agger nasi, uncinate anomaly, nasal tumours, foreign
body, nasal packing
Predisposing factors

6. • Mucous abnormality: Young’s syndrome, cystic fibrosis, mucoviscidosis,
dehydration
• Mucociliary dysfunction: Kartagener’s syndrome, viral, bacterial,
allergic, smoking, pollutants, hypoxia, dry air, extremes of temperature,
synechiae
• Miscellaneous: Poor health, immunodeficiency, diabetes, nutritional
deficiency

9. Bacteriology
• Acute sinusitis
− Streptococcus pneumoniae
− Hemophilus influenzae
− Moraxella catarrhalis
− Staphylococcus aureus
− Neisseria
• Chronic sinusitis
−Staph. Aureus
−Streptococcus
−H. influenzae
−Bacteroides
−Pseudomonas

10. Progress
• Severity and resolution depends on
– Open / closed
– Virulence of the organism
– Host resistance
– Treatment received

11. • Ostio-meatal complex is key
area for causation of infection
in anterior group of sinuses
• Pathological variants of ostio -
meatal complex play a major
role in causation of sinusitis
due to reduced ventilation and
drainage of sinuses

12. Clinical features of Rhinosinusitis
• Symptoms
− Nasal discharge : mucoid / purulent / blood-stained
− Nasal obstruction with hyposmia / anosmia
− Headache and facial pain
− Cheek / eyelid congestion and swelling
− Hawking, sore throat, dry irritating cough
− Earache: associated Eustachian tube dysfunction
− Constitutional: fever, malaise, body ache

13. Location of facial pain in Rhinosinusitis
• Maxillary sinusitis
− Cheek, upper jaw, forehead that increases on bending forward
• Frontal sinusitis
− Forehead that increases during morning and decreases by late
afternoon (office headache)
• Anterior Ethmoid: nasal bridge and peri-orbital, more on eye movement
• Posterior Ethmoid : deep seated retro-orbital
• Sphenoid : vertex, occipital, retro-orbital pain

14. Signs of Rhinosinusitis
• Congested and edematous nasal mucosa
• Nasal discharge (anterior and posterior rhinoscopy)
−Middle meatus: frontal, maxillary, anterior ethmoid
−Superior meatus: posterior ethmoid, sphenoid
• Tenderness over the paranasal sinuses
• Postnasal drip, granular pharyngitis
• Cheek swelling in maxillary sinusitis
• Lid edema in ethmoid & frontal sinusitis

15. Palpation to elicit paranasal sinus tenderness
• Maxillary: over the canine fossa
• Anterior ethmoid: medial to medial canthus
• Frontal: Floor of sinus at the superomedial
aspect of the orbit or tap over its anterior
wall on the forehead

17. Transillumination test for sinuses
• Performed in a dark room.
• High-intensity light source placed inside patient’s mouth or
against the cheek (for maxillary sinus) & under medial
aspect of supra-orbital ridge (for frontal sinus)
• Trans-illumination normal : no sinusitis
• Trans-illumination absent : sinus filled with pus
• Trans-illumination dull : equivocal result

18. Postural tests for sinusitis
• Performed in acute sinusitis (active nasal discharge)
• Pus cleaned in supine position & pt sits upright
• Pus appears = frontal or ethmoid sinusitis
• Pus appears on stooping forwards = sphenoid sinusitis
• No discharge  pt lies in lateral position with affected side up
• Pus appears = maxillary sinusitis

19. Rhinosinusitis Task Force Criteria
Major Minor
1. Facial pain / pressure 1. Headache
2. Nasal obstruction 2. Fever (non-acute sinusitis)
3. Nasal discharge or 3. Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia 5. Dental pain
5. Purulence on exam 6. Cough
6. Fever (acute sinusitis) 7. Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

20. Investigations
1. Diagnostic nasal endoscopy (D.N.E.)
2. Maxillary Sinoscopy
3. X-ray of P.N.S.
4. U.S.G. of maxillary sinus (Rhinoscan)
5. C.T. scan of P.N.S.
6. M.R.I. of P.N.S.: rarely done
7. Allergic tests
8. Proof puncture (antral wash): for maxillary sinus
9. Endoscopic microswab for culture & sensitivity
10. Fungal culture: of cheesy nasal discharge

21. Diagnostic Nasal Endoscopy

22. • Patients not responding to medical therapy
• Anatomic factor preventing adequate
examination by anterior rhinoscopy
• Collection of pus from hiatus semilunaris
for culture & sensitivity
• Objective monitoring of patients
• Peri-operative nasal inspection & cleaning
Indications for D.N.E.
Pus seen in middle meatus
on doing D.N.E.

23. Maxillary sinoscopy
• Anterior sinus wall perforated directly through
canine fossa between roots of 3rd & 4th teeth
with maxillary sinus trocar & cannula
• Trocar removed and sinoscope introduced
through cannula to see inside the maxillary
sinus

24. Plain X- ray of Paranasal sinuses
• Water’s view (Occipito -mental)  maxillary sinus
• Caldwell’s view (Occipito -frontal) and lateral view
frontal
• Rhese’s view (lateral oblique) and lateral view 
ethmoids
• Base skull view (Submento -vertical) and Pierre’s view
(Occipito -mental with mouth open)  sphenoid
− Air-fluid level seen in acute sinusitis
− Mucosal thickening seen in chronic sinusitis

25. Para-nasal sinus sonography
• Bony anterior wall is seen as hyper-echoic line
• Maxillary cavity filled with air appears as hyper-
echoic hence posterior sinus margin not seen
• Fluid in sinus, cyst & mucosal thickening are
hypoechoic, so posterior sinus margin is visible
• B mode sonogram differentiates between fluid
in sinus, cyst & mucosal thickening

26. C.T. scan of Nose and PNS
• Most reliable imaging modality for sinusitis at present
• Plain axial, coronal and sagittal cuts of 3 mm
• Contrast for suspected vascular, neoplastic, inflammatory lesions
• Helps to delineate the extent of disease, define anatomical
variants and study the relationship of sinuses with
surrounding structures
• Indications:
• Recurrent acute/chronic sinusitis not responding to medical treatment
• Before endoscopic sinus surgery
• Impending complications of sinusitis

27. Plain C.T. scan Nose and PNS: Maxillary and ethmoid sinusitis

28. C.T. scan: frontal sinusitis

29. C.T. scan: sphenoid sinusitis

30. M.R.I. of P.N.S.
• Indications
−To assess the intracranial extension of
sinonasal disease, brain abscess due to
sinusitis and meningocele or encephalocele
−Malignant neoplasms of sinonasal tract
−To evaluate the orbital complications of
sinusitis