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- 2. • hollow, air-filledcavities in skull that are lined by a mucous membrane. • known as the paranasal sinuses because of their formation from the nasal mucosa and their continued communication with nasal fossas. PARANASAL SINUS Anterior Sinus Anatomy Lateral Sinus Anatomy
- 3. 3 Purpose of sinuses • Humidifyingand warming inspired air • Regulation of intranasal pressure • Increasing surface area for olfaction • Lightening the skull • Resonance • Absorbing shock • Contribute to facial growth Development of sinuses • Aerated at birth • Maxillary sinuses • Age 6-7 • Frontal /sphenoidal sinuses • Puberty- approx 17-18 yrs • Ethmoid
- 4. 4 Maxillary Sinuses • Largestsinuses • 3.5 cm high • 2.5 – 3 cm wide • Within maxilla • Above upper teeth • Paired & symmetric • Communicates with middle nasal meatus
- 5. 5 Frontal Sinuses • Secondlargest sinuses • 2 – 2.5 cm • Normally: • Between tables of vertical plate in frontal bone • Can extend beyond frontal bone inot the orbital plates • Rarely symmetrical & Number varies (occassionally absent) • Drain into middle nasal meatus
- 6. 6 Sphenoid Sinuses • Belowsella turcica • Extends between dorsum sellae and post clinoid processes • Can be single or paired • Usually no more than two • Drains into sphenoethmoidal recess of nasal cavity
- 7. 7 Ethmoid Sinuses • Withinlateral masses of ethmoid bone • Three groups: • Anterior, middle & posterior • Anterior & middle • 2-8 cells • Drains into middle nasal meatus • Posterior • 2-6 cells • Drain into superior nasal meatus
- 8. 8 Osteomeatal complex – coronal view •Pathways of communication • Frontal, ethmoid and maxillary • 2 key passageways • Infundibulum • Middle nasal meatus
- 9. Rhino-sinusitis: inflammation oflining mucosa of nose & paranasal sinuses TASK FORCE CLASSIFICATION Acute: infection lasting < 4 weeks Sub acute: infection lasting 4 to 12 weeks Chronic: infection lasting > 12 weeks Recurrent: > 3 episodes in 6 months or > 4 episodes per year with asymptomatic intervals of > 10 days
- 10. • Acute Rhinosinusitis(< 4 weeks duration) Viral Rhinosinusitis (VRS) Acute Bacterial Rhinosinusitis (ABRS) Acute invasive fungal rhinosinusitis • Subacute Rhinosinusitis (4 to 12 weeks duration) • Chronic Rhinosinusitis (> 12 weeks duration) With Polyps Without Polyps Allergic fungal rhinosinusitis • Recurrent Acute Rhinosinusitis (3 episodes in 6 months or 4 or > 4 episodes of acute rhinosinusitis in 1 year) CLASSIFICATION
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- 12. 12 PREDISPOSING FACTORS Viral/ BacterialURI Allergic rhinitis Cigarette smoke exposure Immune Deficiency Cystic Fibrosis, Ciliary Dysfunction Abnormality of phagocyte function GER, Cleft Palate Nasal Polyp, Nasal Foreign body Immunosuppression/ Immunodefiency Lymphopenia Nasotracheal Intubation Nasogastric tube CHRONIC SINUSITIS SEVERE FUNGAL INFECTION SINUSITIS WITH MDR BUGS OF ICU
- 13. • Trauma • Physicalstigmata such as deviated nasal septum and synechia. • Swimming and diving: Infected water and high content of chlorine gas (chemical inflammation) enters the sinuses. • Barotraumas. • Dental infections and extraction of upper molars and premolars: Periapical dental abscess may burst into the sinus Root of a tooth, during extraction, may be pushed into maxillary sinus. 13
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- 15. LANZA &KENNEDY CRITERIAFOR SINUSITIS- DIAGNOSIS MAJOR MINOR Purulent nasal discharge Headache Purulent postnasal drip Ear pain/ fullness Nasal congestion/ obstruction Halitosis Facial congestion Dental Pain Facial pressure/ pain Cough Hyposmia / anosmia Fever(subacute) Fever (acute) Fatigue 15
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- 17. • Viruses: Common viruses:Rhinovirus (most common in adults) and parainfluenza viruses. Other viruses: Adeno virus, picorna virus and its sub groups such as rhinovirus, coxsackie, and ECHO viruses. Respiratory syncytial virus (RSV) and influenza virus: More destructive to respiratory cilia. • Transmission: Airborne droplets. • Incubation period: 1- 4 days • Duration: Lasts for 2-3 weeks. COMMON COLD OR VIRAL RHINOSINUSITIS (VRS)
- 18. 18 VIRAL RHINOSINUSITIS Inflammation & Edemaof nasal mucosa block sinus drainage and Impair mucociliary clearance SINUSITIS Nose blowing propel nasal secretion & nasopharyngeal bacteria into Sinus Cavity
- 19. • No approvedtreatment. • Efficient in symptom control: Antihistamines: Oral decongestants: Ipratropium bromide nasal spray: It reduces rhinorrhea. Topical decongestants • Analgesics: Aspirin causes increased shedding of viruses. • Others: Chicken soup. • Antibiotics have no role in VRS. • General: Bed rest and plenty of fluids are encouraged. Treatment
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- 21. 21 TYPE OF SINUSITISDURATION OF EACH EPISODE SYMPTOMS IN BETWEEN EPISODES ACUTE BACTERIAL SINUSITIS < 30 DAYS COMPLETE RESOLUTION SUB-ACUTE BACTERIAL SINUSITIS 30- 90 DAYS COMPLETE RESOLUTION RECURRENT ACUTE BACTERIAL SINUSITIS EACH EPISODE <30 DAYS @ INTERVAL OF 10 DAYS COMPLETE RESOLUTION CHRONIC SINUSITIS > 90 DAYS PERSISTENT RESIDUAL RESPIRATORY SYMPTOMS (Cough, Rhinorrhea, Nasal Blockage) ACUTE SINUSITIS SUPERIMPOSED TO CHRONIC SINUSITIS ___ NEW RESPIRATORY SYMPTOMS IN PATIENT WITH RESIDUAL RESPIRATORY SYMPTOMS
- 22. 22 ETIOLOGY ACUTE SINUSITIS Common ● S.Pneumonia(30%) ● H. Influenza (20%) ● M. Catarrhalis (20%) Uncommon ● S.Aureaus ● Other streptococci ● Anaerobes CHRONIC SINUSITIS ● H. Influenza ● α & β hemolytic streptococci ● M.Catarrhalis ● S.Pneumoniae ● Coagulase negative staphylococci
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- 24. SINUS MAXILLAR Y SINUSITIS FRONTAL SINUSTIS ETHMOID SPHENOID SYMPTOMDENTAL PAIN UPPER JAW OFFICE HEADACHE BRIDGE OF NOSE, MEDIAL CANTHAL OCCIPUT O/E TENDERNE SS ON TAPPING ANTERIOR WALL FLOOR OF FRONTAL SINUS TENDERNESS NEAR MEDIAL CANTHUS POSTNASAL DRIP ENDOSCOPY MUCUS IN MIDDLE MEATUS MUCUS IN MIDDLE MEATUS MUCUS IN MIDDLE MEATUS SPHENOETHM OID RECESS COMPLICATION ORBITAL CELLLITIS OSTEOMYELITI S, MENINGITIS, ABSCESS CAVERNOUS SINUS THROMBOSIS VISUAL DETEORIRATIO N TREATMENT ANTRAL LAVAGE TREPHINATION EXTERNAL ETHMOIDECTO MY 24
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- 26. • S. aureus, •Coagulase-negative staphylococcus, • Anaerobic, and • Gram-negative bacteria CHRONIC RHINOSINUSITIS
- 27. PREDISPOSING FACTORS • SYSTEMIC •Immune Deficiency- IgA, Ig G • Cystic Fibrosis- Highly viscous mucus secretion – impaired mucociliary clearance • Ciliary Dysfunction • Abnormality of phagocyte function • Asthma • LOCAL • Odontogenic • Anatomical abnormalities • GERD • ENVIRONMENTAL • Super antigens • Biofilm • Air pollution &smoking • Microbes 27
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- 29. 29 DIAGNOSIS HISTORY Persistent symptoms ofURTI Physical findings RADIOGRAPHIC STUDIES Opacification Mucosal Thickening Air-Fluid level OTHER Transillumination of sinus cavity Sinus aspirate culture Nasal Endoscopy ANTERIOR RHINOSCOPY
- 30. 30 Technical Considerations • Radiographicdensity is critical • Overpenetration diminishes or obliterates pathology • Underpenetration can simulate pathology • Small focal spot • Clean screens • Perfect film/screen contact • No high contrast
- 31. 31 Lateral Projection • All4 sinuses • Sphenoid of primary interest • No rotation • SI orbital roofs, mandibular rami • Close beam restriction • Clear air-fluid levels
- 32. 32 CALDWELL • Occipitofrontal -15-20 caudally •Frontal ðmoid air cells • Air fluid levels • Close beam restriction
- 33. 33 WATER’S • OCCIPITOMENTAL VIEW • Maxilla& orbit • Frontal • Sphenoid • Zygoma • Nasal bone • Clear air-fluid levels
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- 35. 35 Open Mouth Watersfor Maxillary / sphenoid sinuses • Petrous ridges below maxillary sinuses • No rotation • Maxillary sinuses • Close beam restriction • Clear air-fluid levels • Sphenoid sinuses through open mouth
- 36. 36 Basillar View forethmoidal and sphenoidal sinuses • No tilt or rotation • Anterior frontal bone SI over mental protuberance • Mandibular condyles anterior to petrous pyramids • Clear air-fluid levels
- 37. 37 ACUTE SINUSITIS CHRONICSINUSITIS The use of CT should be reserved for patients who (1) Present with severe unilateral maxillary pain, facial swelling, and fever (2) Have not responded to antibiotic therapy
- 38. RADIOLOGICAL INVESTIGATIONS • CTScan • MRI 38
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- 44. ACUTE BACTERIAL SINUSITIS •Saline irrigation/ nasal douching • Antibiotic- penicillin/ cephalosporins/ macrolide • Antihistamines • Intranasal corticosteroids • Decongestants- oral/ topical • Surgical – associated complication 44
- 45. 45 Conditions Requiring ActionBefore Seven Days • Fever >102 degrees F and a documented history of sinusitis • Upper teeth pain (not of dental origin) with any of nasal findings • Severe symptoms should be considered for treatment before 7 days. • Known anatomical blockage (e.g., chronic nasal polyps, severely deviated septum, recurrent sinusitis) may need immediate treatment
- 46. 46 • Amoxicillin (45mg/Kg/d) • TMP-SMX in child with penicillin allergy • Amoxi-Clav (80-90 mg/kg/d) in patient not responding to amoxicillin in <72 hrs 1st Line • Macrolide (Azithromycin, Clarithromycin) • Fluoroquinolone (Levofloxacin, Ofloxacin, Moxyfloxacin) • cefdinir, cefuroxime, and cefpodoxime 2nd Line ANTIBIOTICS Recommended Course of antibiotic is 7 days after resolution of symptoms Parenteral antibiotic is recommended for (1) Severe Sinusitis (2) Sinusitis with complication
- 47. 47 Failure or NoResponse in 3 to 4 Weeks • Consider referral to ENT or Allergy for further workup Referral to ENT • Need for microbiology diagnosis • Complications such osteomyelitis, periorbital infections or facial cellulites • Polyps • Treatment failures Nasal steroid spray selected cases of recurrent sinusitis especially in the presence of an allergy or inflammation Referral to Allergy • Recurrent episodes, may be allergic greater than 30% of the cases • Polyps • Treatment failures • Seasonal pattern to the occurrence of sinus symptoms
- 48. 48 CHRONIC OR RECURRENT SINUSITIS Referralto ENT Surgical intervention Balloon Sinuplasty Functional Endoscopic Sinus Surgery (FESS) Caldwell-Luc Radical Antrostomy
- 49. FUNGAL SINUSITIS • NONINVASIVE • FUNGAL BALL • ALLERGIC FUNGAL • INVASIVE • ACUTE • CHRONIC • GRANULOMATOUS 49 ASPERGILLUS, RHIZOPUS, MUCOR, ALTENARIA
- 50. 50 FUNGAL BALL • Denseaccumulation of fungus and the associated debris presenting as a noninvasive mass in the sinuses. • Nasal obstruction , postnasal drip • O/E - 40% - purulent discharge from the involved sinus and 10% have polyps. • CT SCAN
- 51. 51 CT SCAN • Singleopacified sinus with a central area of high attenuation is highly suggestive of fungus ball • Centrally within the involved sinus are areas of hyperattenuation that correspond to fungal debris and punctate calcifications. • There is usually minimal or no sinus expansion, but there may be a thick osteitic bone reaction from the chronic state.
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- 53. 53 AFRS • Most common •Symptoms- blowing dark chunks or rubbery mucus, visual disturbance / diplopia • O/E – proptosis or telecanthus due to sinus expansion and mucocele formation.20 Intranasal examination will reveal polyposis that is unilateral in up to 50% of cases. • Inspissated yellowish mucus (allergic mucin) may be seen within the nasal cavity.
- 54. 54 • Diagnostic Criteriafor Allergic Fungal Rhinosinusitis Bent and Kuhn • Type 1 hypersensitivity confirmed by history, skin test, or serology • Nasal polyposis • Characteristic CT scan findings • Positive fungal stain of sinus contents Eosinophilic mucus without fungal invasion of sinus mucosa
- 55. 55 Fungus enters nose Triggers coombstype I & III Reaction Allergic mucin, stasis of secretion, sinus ostia obstruction
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- 57. 57 Acute invasive fungalsinusitis • Aspergillus and mucor • Immunocompromised or have diabetic ketoacidosis. • Risk factor - prolonged neutropenia. prolonged treatment with systemic corticosteroids.
- 58. 58 • fever, headache,facial pain, and swelling are rapidly followed by decreased visual acuity, other cranial nerve deficits, and facial or palatal necrosis. • Extension into the cranial vault may cause seizures, altered mental status, and then death in a matter of days. • O/E – middle turbinate most common site
- 59. 59 • Reveal areasof pallor and nonbleeding, insensate mucosa. • As the disease progresses, the nasal tissues will take on a gray to black appearance with areas of ulceration • Perineural or vascular invasion leads to areas anesthesia, mycotic thrombosis, and ischemic coagulative necrosis of tissue.
- 60. 60 Chronic invasive fungalsinusitis • Cranial nerve deficits, cavernous sinus syndrome, orbital apex syndrome, seizures, or mental status changes may develop before the diagnosis. • Diagnosis of CIFS is made by a combination of the clinical presentation and histopathologic examination.
- 61. 61 Treatment • FESS • AmphotericinB • Itraconazole • Voriconazole
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- 63. 63 COMPLICATIONS ORBITAL Periorbital & Orbital Cellulitis(Most often secondary to Acute bacterial Ethmoiditis) - IV Antibiotic - Surgical drainage of ethmoidal sinus INTRACRANIAL 1. Meningitis 2. Brain/ Epidural Abscess 3. Subdural Empyema 4. Cavernous sinus thrombosis - IV Antibiotic - Surgical drainage of Abscesses OTHER 1. Pott Puffy Tumor (Osteomyelitis of frontal bone) 2. Mucocele Surgical Drainage
- 64. 64 ORBITAL COMPLICATIONS • Mostcommonly following ethmoid sinusitis • Lamina papyracea • Osteitis or as thrombophlebitic process of ethmoidal veins.
- 65. 65 • Superior orbitalfissure syndrome- 6, 3,4 palsy • Orbital apex – optic nervand maxillary division of trigeminal
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- 69. 69 • Fever, chillsand rigors • Ophthalmoplegia • V 1 anaesthetia • CT, MRI • Antibiotics • Blood thinners • Find out source of infection and surgical management
- 70. 70 INTRACRANIAL COMPLICATIONS • Meningitis •Subdural &extradural abscess • Potts puffy tumor- frontal sinus • Intradural abscess
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- 72. 72 TAKE HOME MESSAGE •Nasal Examination is mandatory in children with persistent Upper respiratory symptoms • Diagnosis is almost clinical. • Mostly due to viral infection, so wait & watch strategy for first week of illness. • Judicious use of antibiotic. • Appropriate referral to ENT Specialist