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Sinusitis
- 2. Sinusitis -Inflammation of mucosa of one or more PNS Pan Sinusitis – all sinuses involved Multi Sinusitis – more than one sinus involved MC – Maxillary, 2nd – Ethmoid, Frontal and Sphenoid (rare alone, mainly as pan sinusitis) Acute Sinusitis – if < 4 weeks Subacute Sinusitis – 4 weeks to 3 months Chronic Sinusitis – persistant for > 3 months due to incomplete resolution of acute stage, destruction of respiratory epithelium (cilia) – inadequate drainage of secretions – mucosal oedema – polypoidal changes Open Sinusitis – drainage of secretions, patent ostia Closed Sinusitis – no drainage, blocked ostia, more severe
- 3. Infection –Nasal infection, adenotonsillitis, dental infection (maxillary sinus) – upper molar and premolar Persistant infection – chronic sinusitis MC cause – viral infection initially (Rhinovirus, Parainfluenza virus), followed by becterial infection (H.Influenzae-mc, pneumococci, streptococci) Mechanical obstruction – DNS, Hypertrophied turbinates, nasal polyp, tumours, nasal packing Decreased mucociliary clearance – cystic fibrosis, kartagener’s syndrome, young’s syndrome Allergic rhinitis – chronic sinusitis Trauma - # or penetrating injuries
- 4. Iatrogenic –rhinitis medicamentosa, aspirin intolerance, drug induced Granulomatous diseases – TB, leprosy, syphilis, rhinoscleroma, rhinosporidiosis Hormonal – pregnancy, puberty, menstruation, honeymoon, emotions, stress VMR Immunodeficiency and nutritional deficiency Enviromental – cold and wet climate, smoke, dust, swimming and bathing in pond with high chlorine content, contaminated pond Idiopathic
- 5. C/F –localised headache Pain over cheeks radiating to teeth, aggravating on bending forward, straining, chewing, coughing – Maxillary Sinusitis Pain between and behind the eyes, over bridge of nose aggravated by movement of eye ball – Ethmoidal Sinusitis Frontal headache starts in the morning, peaks in the afternoon then subsides (office headache) to again increase at time of sleep (diurnal) – Frontal Sinusitis Pain over the vertex or occiput radiating to the temporal/mastoid region – Sphenoidal Sinusitis Purulent nasal discharge in middle meatus – ant sinuses/ superior meatus – post sinuses/ foul smelling – dental infection
- 6. Nasal blockage Loss of smell Affects vocal resonance Fever, general malaise, bodyache Post nasal discharge Nocturnal cough – children Children – ethmoidal sinusitis more common as relatively large ethmoids, swelling of cheeks Altered taste
- 7. Signs Flushingand swelling of cheeks and lower eyelid – Maxillary sinusitis Oedema of lids – puffy and swollen, swelling of inner canthus – Ethmoidal sinusitis Swelling of upper eyelid and orbital swelling – Frontal Sinusitis Tenderness – canine fossa (maxillary), inner canthus (ethmoidal), floor or anterior wall of frontal bone (frontal) Associated dental infection - maxillary Postural test – on bending down discharge in nose – frontal, on bending head to the opposite side - maxillary
- 8. Diagnosis DNE– oedema of middle turbinate, OMC X Ray PNS – fluid level, opacity – Waters view, Caldwel view, Pierre view CT Scan OMC/PNS Transillumination tests D/D – TM Neuralgia (Costen’s syndrome), Trigeminal neuralgia, Dental neuralgia (caries), Migraine, Temporal arteritis, Herpetic neuralgia, Neoplasms, Brain stem lesions Complications – Chronic sinusitis, middle ear, pharyngeal infections, osteomyelitis, orbital cellulitis, optic nerve damage
- 9. Treatment Medical Bed rest Treat the dental infection Antibiotics – Ampicillin, Amoxycillin, Erythromycin, Doxycycline, Amoxyclav (for H influenzae) , metronidazole ( for anaerobes) for 10 – 21 days Nasal decongestant drops and systemic decongestants Steam inhalation with inhalant capsules Nasal irrigation with saline Analgesics and anti inflammatory Hot fomentation
- 10. Surgical Minimalrole – only if medical treatment fails Drainage of pus Antral lavage – maxillary sinusitis Trephination of frontal sinus – frontal sinusitis – 2 cm horizontal incision supero medial aspect of eyebrow Perforation of anterior wall of sphenoid sinus – sphenoidal sinusitis
- 11. Etiology –allergy, dusty enviroment, fungal infection C/F Less severe headache, dull but persistant/ heavy head Nasal obstruction – persistant and more at night – polypoidal changes Foul smelling purulent nasal discharge/ viscid mucoid nasal discharge/ mucopurulent Loss of taste Reduced sense of smell Post nasal discharge – hawking sensation Nasal bleed Halitosis
- 12. Signs Tendernesspresent Discharge in middle meatus/ superior meatus Posterior rhinoscopy – discharge in middle/ superior meatus Excoriation of nasal vestibule skin Crusting, hypertrophied turbinates Congestion of middle meatus (localised) Diagnosis DNE, CT Scan, X Ray PNS, antroscopy (maxillary sinus) X Ray PNS – opacity, thickened mucosa DNE – Discharge, polyp, accessory ostia
- 13. Complications ETobstruction, pharyngitis, dryness of throat, cough, hoarseness of voice Treatment Medical Steroid nasal spray Alkaline nasal douching Antibiotics – rare Surgical FESS – middle meatal antrostomy (maxillary), anterior/ posterior ethmoidectomy, frontal recess clearance, sphenoidectomy
- 14. Intra nasalantrostomy – maxillary sinus Caldwel luc surgery – maxillary sinus Intranasal/ External ethmoidectomy – ethmoidal sinus External fronto ethmoidectomy (Howarth’s surgery) – frontal sinus Osteoplastic flap procedure – frontal sinus Spheniodotomy – sphenoid sinus NOTE – ISOLATED FRONTAL, SPHENOIDAL SINUSITIS IS RARE
- 15. Aspergillus (mc)– fumigatus/ niger/ flavus Alternaria Mucor Rhizopus Common in immunocompromised and those with trauma (#) Predisposing factors – dry and hot climate Types Invasive - chronic invasive, fulminant fungal sinusitis Non invasive – fungal ball, allergic fungal sinusitis
- 16. Fungal ball/Mycetoma Implantation of fungi into healthy sinus No bone erosion MC – Maxillary Sinus, Sphenoidal (2nd), Ethmoidal, Frontal Thick greenish discharge visualised Diagnosis – Histopathology, CT Treatment – Surgical removal NO ROLE OF ANTI FUNGAL THERAPY
- 17. Allergic FungalSinusitis Allergic reaction to fungi Seen in young adults h/o asthma Sino nasal polyps Pan sinusitis Nasal secretions – mucin – contains eosinophils, charcot leyden crystals, fungal hyphae No invasion of sinuses, bony erosion by pressure Treatment – FESS with pre op and post op systemic steroids
- 18. Chronic invasivesinusitis Invades sinus mucosa Bone erosion by fungi Intracranial and intraorbital invasion Treatment Surgical removal of invaded mucosa Anti fungal therapy – Amphotericin B IV, Itraconazole oral
- 19. Fulminant fungalsinusitis Fungi – mucor, aspergillus Immunocompromised Widespread haemotogenous and intracranial spread/extension Mucor – invades blood vessels, ischaemic necrosis, black eschar (discolouration)of turbinates, mucosa, palate Aspergillus – tissue invasion, sepsis, no black eschar Treatment – surgical debridement of necrosed tissue Anti fungal therapy – Amphotericin B IV
- 20. Infection spreadsinto or beyond the bony walls of PNS EXTRA CRANIAL Mucocele Pyocele Osteomyelitis Orbital – Orbital cellulitis and abscess Descending infections – ASOM,CSOM, Pharyngitis, Tonsillitis, Laryngitis, Bronchitis Focal infections – Polyarthritis, Tenosynovitis, skin diseases Distant infections – Septicaemia, TSS
- 21. INTRACRANIAL Meningitis Encephalitis Brain abscess, Subdural abscess, Extradural abscess Cavernous Sinus Thrombophlebitis Ant PNS complications – mucocele, pyocele, osteomyelitis, orbital, intracranial Post PNS complications – CST, Supraorbital fissure syndrome, Orbital apex syndrome, optic neuritis
- 22. Chronic epitheliallined, oval cystic swelling of PNS containing mucus occurs as a complication of chronic sinusitis Etiology Due to permanent/chronic obstruction of sinus ostium Due to obstruction of ducts of mucus/minor salivary glands of sinus mucosa Leading to expansion of sinus and erosion of bony wall or collection of secretions in the sinus leading to retention cyst without wall erosion Any age group, mc 40-60 years Frontal (mc), Ethmoid (2nd mc), Maxillary, Sphenoid
- 23. Spread Direct– through walls of sinus – Osteomyelitis, Mucocele Venous – through subepithelial venous plexus Lymphatics – through perivascular lymphatic spread Olfactory nerve – through perineural sheath INVESTIGATIONS X Ray PNS CT Scan OMC DNE
- 24. Frontal Mucocele Due to chronic diseases of frontal sinus/recess, post surgery or traumatic fibrosis of ostia – blockage of ostia Invades superomedial wall of orbit – displaces the eye ball downwards, laterally and foarwards Invades anterior wall – swelling in forehead Invades posterior wall – displacement of dura Can occur as fronto ethmoid mucocele
- 25. C/F Supraorbitalswelling above and lateral to medial canthus Diplopia Proptosis with downward, forward and lateral displacement of eye ball Mild and dull frontal headache Swelling is cystic, non tender, egg shell cracking elicited Cystic swelling in forehead, result in fistulae formation Retention cyst – may be asymptomatic
- 26. Diagnosis XRay PNS – Cloudiness of affected sinus, loss of scalloping/outline of sinuses CT Scan OMC and PNS DNE – Swelling in region of attachment of middle turbinate Treatment FESS with frontal recess clearance External fronto ethmoidectomy (Lynch Howarth operation) Osteoplastic flap operation Asymptomatic retention cyst – no treatment required
- 27. Ethmoidal mucocele Expansion of cyst towards lamina papyracea – expansion of medial wall of orbit – displacement of eyeball laterally Bulge in middle meatus of nose Rarely seen in children (anterior ethmoid) Treatment – Intranasal surgery/ external ethmoidectomy Maxillary mucocele – mainly affects floor of maxillary sinus Sphenoethmoidal mucocele – extends to retrobulbar area with pressure on optic nerve leading to exophthalmos, visual disturbance Diagnosis – CT Scan Treatment – Endoscopic sphenoidotomy/ External sphenoethmoidectomy
- 28. Can leadto – Superior orbital fissure syndrome Involvement of III, IV, V-1and VI CN Deep seated orbital pain Frontal headache/ pain over occiput/vertex Due to infection of sphenoid sinus Orbital apex syndrome Involvement of II, III, IV, V-1, V-2 and VI CN
- 29. Complication ofacute sinusitis Infection of mucocele Pain and fever Ethmoidal pyocele – seen in children Treatment – evacuation of pus and excision of diseased mucosa IV broad spectrum antibiotics
- 30. Commonly seenin ethmoid sinus infections as closely related to orbit by lamina papyracea 2nd – frontal sinus infections Can lead to orbital cellulitis, subperiosteal abscess, intra orbital abscess Inflammatory oedema of eyelids – upper lid (frontal), lower lid (maxillary), both (ethmoidal) Proptosis Lid oedema Chemosis of conjuctiva Exophthalmos Ophthalmoplegia
- 31. High gradefever – 102 to 104 F Limited eye movements Headache Partial or total visual loss Displacement of eyeball Complications – can lead to meningitis, CST Diagnosis – CT/USG Orbit Treatment Exploration and drainage of affected sinus IV antibiotics Pencillin/Vancomycin – for gram positive IIIrd gen Cephalosporins/ Metronidazole/ Clindamycin – for gram negative
- 32. Osteitis –infection of compact bone Osteomyelitis – infection of cancellous/diploic bone, infection of bone marrow Involves – Frontal Sinus (mc), Maxillary sinus (2nd mc) Etiology Suppurative sinusitis (acute infection) Trauma Surgery Thrombophlebitis of infected bone Staph aureus, streptococci, pneumococci, anaerobes F>M Frontal – adults, Maxillary – infants and children
- 33. Frontal Osteomyelitis Fever – low grade Headache Purulent discharge from infected bone Edema of upper eyelid Erosion of anterior wall – Pott’s Puffy tumour – swelling in the frontal region- soft and doughy with pus beneath the swelling, moth eaten appearance on X Ray Erosion of posterior wall – extradural abscess, intracranial spread Diagnosis – CT Treatment – exploration and drainage of frontal sinus
- 34. Maxillary Osteomyelitis MC in children and infants as anterior wall of maxilla is spongy Etiology Acute maxillary sinusitis Dental infection – children Buccal infection – infants C/F Erythema and swelling of cheeks Edema of lower eyelid Purulent nasal discharge Fever Can lead to subperiosteal abscess C/F
- 35. Can leadto fistula formation – infra orbital region, alveolus, palate, zygoma Sequestration of bone Treatment IV high dose antibiotics Drainage of abscess Removal of damaged bone
- 36. Meningitis Extraduralabscess Subdural abscess Cerebral abscess CST Etiology Sinusitis – Destruction of roof of frontal, ethmoidal, sphenoidal sinus – anterior cranial fossa Otitis Media Treatment – IV antibiotics and anti convulsive therapy
- 37. Etiology Infectionof PNS – posterior ethmoid and sphenoid Orbital complications of sinusitis Furunculosis of nose, infection of vestibule Due to valveless nature of veins of cavernous sinus – easy spread of infection C/F Abrupt onset with B/L involvement High grade fever 105 F with chills and rigor Acute ill Swollen eyelids and proptosis of eyeball Ophthalmoplegia with retinal congestion
- 38. Diminished vision Dilated and fixed pupil Papilloedema and chemosis of conjuctiva Affects III, IV, V-1 and VI CN Diagnosis CT Scan Blood culture Fundus examination – papilloedema CSF – normal Treatment IV antibiotics/ anticoagulant therapy Drainage of infected sinus Orbital decompression
- 39. Communication betweenoral cavity and maxillary sinus Etiology Dental extraction – upper premolar and molar Malignancy Granulomatous disorders Complication of acute maxillary sinusitis Trauma Surgery – Caldwel Luc Surgery C/F – passage of food and fluids from oral cavity to nose Blow of air from nose to oral cavity
- 40. Treatment Antibiotics Large fistula – surgery with flaps – palatal and buccal flaps TOXIC SHOCK SYNDROME Staph aureus (mc), Streptococci Fever Rash, desquamation of skin Hypotension Multi organ failure