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Medical and surgical
treatment of sinusitis
Dr. Krishna Koirala
Medical Treatment
• Systemic Antibiotics
• Nasal decongestants: topical & systemic
• Anti-histamines
• Analgesic-anti-inflammatory drugs
• Medicated steam inhalation & nasal douching
• Mucolytics : Ambroxol, Guaphenesin
• Anti-allergy treatment
• Hot fomentation
Antibiotics
Amoxicillin- clavulanate : 625 mg B.D. X 7 days
Ciprofloxacin: 500mg B.D. X 7 days
Doxycycline: 100 mg B.D. X 7 days
Cefadroxil: 500 mg B.D. X 7 days
Cefaclor: 500 mg T.I.D. X 7 days
Cefuroxime: 250 mg B.D. X 7 days
Cefixime: 200 mg B.D. X 7 days
Cefpodoxime: 200 mg B.D. X 7 days
Azithromycin: 500 mg O.D. X 3-5 days
Clarithromycin: 250 mg B.D. X 7 days
Nasal Decongestants
 Systemic decongestants
 Phenylephrine
 Pseudoephedrine
 Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline
Topical Decongestants
• Oxymetazoline 0.05 % : 2-3 drops BD
• Oxymetazoline 0.025 % : 2 drops BD
• Xylometazoline 0.1 % : 3 drops TID
• Xylometazoline 0.05 % : 2 drops BD
• Saline 2 % : 3 drops TID
• Saline 0.67 % : 2 drops BD
Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratadine: 10 mg OD
Levocetrizine: 5 mg OD
Ebastine: 20 mg OD
Topical:
Azelastine spray (0.1%): 1-2 puffs BD
Anti- cold preparations
Name Chlorpheniramine Decongestant Paracetamol
COLDIN 4 mg PsE 60 mg 500 mg
SINAREST 4 mg PsE 60 mg 500 mg
DECOLD 4 mg PhE 7.5 mg 500 mg
SUPRIN 2 mg PhE 5 mg 500 mg
PsE = Pseudoephedrine PhE = Phenylephrine
Fungal Sinusitis
A. Invasive (hyphae present in submucosa)
– Acute invasive or fulminant (< 4 weeks)
– Chronic invasive or indolent (> 4 weeks)
B. Non-invasive
– Allergic
– Fungal ball or mycetoma
– Saprophytic
Aspergillosis & Mucormycosis are common
Acute invasive fungal sinusitis
• Usually mucormycosis
• Predisposing factors
– Immune-compromise: AIDS, Lymphoma, Cytotoxic drugs,
chronic use of steroid, aplastic anemia
– Insulin dependent diabetes mellitus
– Long term use of broad-spectrum antibiotics
• C/F
– Unilateral nasal discharge with black crusts due to
ischaemic necrosis
– Cerebral & vascular invasion present
– Absence of significant inflammation
Black crusting
Treatment
• Remove precipitating factors
• Surgical debridement of necrotic debris
• Anti-fungal drugs
– Amphotericin B infusion for 1-2 months
– Itraconazole 100 mg BD for 6-12 months
Chronic invasive fungal sinusitis
• Significant inflammation with fibrosis & granuloma formation
• Locally destructive with minimal bone erosion
• Treatment : Debridement + Anti-fungal agents
Allergic fungal sinusitis
• Associated with ethmoid polyps & asthma
• Unilateral thick yellow nasal discharge with mucin,
eosinophils & Charcot Leyden crystals
• C.T. scan: radio-opaque mass with central area of
hyper density (due to hyphae)
• Tx: Surgical debridement + anti-histamines +
steroids (oral & topical)
Allergic fungal sinusitis
Allergic fungal sinusitis
C.T. scan coronal cuts
C.T. scan axial cuts
 Fungal ball (Mycetoma)
Refractory sinusitis with foul smelling cheesy
material in maxillary sinus
Tx: Surgical removal
• Saprophytic fungal sinusitis
– Seen after Sino-nasal surgery due to proliferation
of fungal spores on mucous crusts
Tx: Surgical removal
Surgical Treatment of
Sinusitis
Surgical Treatment Methods:
1. Antral Washout
2. Intra-nasal Inferior meatal antrostomy (INA)
3. Caldwell - Luc surgery
4. Middle meatal antrostomy
5. Functional Endoscopic Sinus Surgery (FESS)
Maxillary Sinusitis
Antral Washout (Proof puncture/antral lavage)
• Indications
– Diagnosis & treatment of chronic maxillary sinusitis
not responding to conservative medications
– Cytology/culture sensitivity of antral contents
• Contraindications
– Age < 3 yrs
– Hypoplastic maxilla with thick bony walls
– Acute maxillary sinusitis untreated by antibiotics
– Trauma to maxillary sinus or Fracture of orbital floor
– Drainage of maxillary antral hematoma
Tilley Lichtwitz Antral Trocar &
Cannula
Higginson’s Syringe
Trocar directed towards I/L tragus
Puncture done 1.25 cm behind
anterior end of inferior turbinate
Antral irrigation
• Anesthesia: L.A. for adults. G.A. for children & un-cooperative
patient
• Position: Sitting / supine
• Technique:
– Puncture lateral wall of inferior meatus with Tilley -
Lichtwitz antral trocar & cannula, just anterior to turbinate
genu, trocar directed towards tragus of ipsilateral ear, with
gentle boring action
– Advance till it hits posterior wall, then withdraw slightly.
Remove trocar & wash the sinus with saline at 370 C with
patient leaning forwards & saying k k.
– Wash till clear fluid comes , then remove the cannula.
1. Hemorrhage ( Lateral Sphenopalatine artery)
2. Pain & swelling of cheek (breach of anterior wall)
3. Orbital damage (perforation of orbital floor)
4. Perforation of posterior wall (maxillary artery injury)
5. Vasovagal shock
6. Fatal air embolism
Complications
Intranasal antrostomy (INA)
• Region of antral puncture
in inferior meatus
perforated with Tilley's
antral harpoon
• Antrostomy enlarged with
Tilley's antral burr or
Myle’s nasoantral
perforator
Caldwell – Luc Surgery
George Caldwell, 1893, New York
Henri Luc, 1897, Paris
Indications
• Chronic refractory maxillary sinusitis
• Antrochoanal polyp (recurrent)
• Oro-antral fistula closure
• Biopsy of suspicious neoplasm of maxillary antrum
• Foreign body removal from maxillary antrum
• Orbital floor decompression
• Fungal maxillary sinusitis
• Elevation of orbital floor fractures
• Ethmoidectomy (trans-antral)
• Route to pterygo- palatine fossa (Vidian nerve, Max Artery)
• Dental / dentigerous cyst (maxillary antrum) removal
Exposure of incision site
Incision
4 cm long, sub-labial,
horizontal incision
made 3 mm above &
parallel to the gingival
margin, from lateral
incisor to 2nd molar
tooth.
Incision deepened till the periosteum
Surgical Treatment Methods:
1. Antral Washout
2. Intra-nasal Inferior meatal antrostomy (INA)
3. Caldwell - Luc surgery
4. Middle meatal antrostomy
5. Functional Endoscopic Sinus Surgery (FESS)
Maxillary Sinusitis
Anterior wall broken with osteotome
Hole made in anterior wall
Suction of maxillary sinus contents
Inferior meatal antrostomy
Packing of maxillary sinus
Packing of sinus & nose
Closure of incision
• Facial: Cheek edema, ecchymosis, subcutaneous
emphysema, infraorbital nerve paresthesia
• Orbital: Hematoma, extraocular muscle trauma,
diplopia, globe trauma, blindness
• Oral: Trauma to teeth roots, Superior alveolar nerve
damage, Dental anesthesia, Oroantral fistula
• Vascular: Internal maxillary artery injury
Complications
Ethmoid Sinusitis
Surgical Treatment Methods
1. Intra-nasal endoscopic ethmoidectomy
2. Extra-nasal Ethmoidectomy
a. Lynch Howarth procedure
b. Patterson trans-orbital procedure
c. Trans-antral (Jansen Horgan procedure)
3. Functional Endoscopic Sinus Surgery ( FESS)
Lynch Howarth ethmoidectomy
Patterson’s ethmoidectomy
Trans-antral ethmoidectomy
• Caldwell – Luc surgery
done to reach maxillary
antrum
• Ethmoid cells
approached via postero
–supero - medial angle
of maxillary antrum
Surgical Treatment Methods
1. Trephination of frontal sinus
2. Modified Lothrop procedure
3. Osteoplastic Flap surgery
4. Functional Endoscopic Sinus Surgery
Frontal Sinusitis
Frontal sinus trephination
• 2 cm incision made 1 cm below the medial end of
eyebrow & deepened up to bone
• Frontal sinus floor opened by drilling with burr
• Opening enlarged with Citelli’s punch forceps to drain
pus
• Drainage tube inserted inside frontal sinus cavity
& sutured in place
• Regular lavage of the frontal sinus done through
drainage tube for 48-72 hours post-operatively
Osteoplastic flap procedure
Osteoplastic flap procedure
Lothrop Procedure
Removal of frontal sinus (inferior septum + floor) +
superior part of nasal septum
Sphenoid sinus
Surgical Treatment Methods
1. Trans-nasal trans- septal approach
2. Sublabial trans- septal approach
3. External ethmoidectomy approach
4. Endoscopic intra-nasal approach
5. Functional Endoscopic Sinus Surgery
Sublabial trans-septal approach
External ethmoidectomy approach
Endoscopic approach
Functional Endoscopic
Sinus Surgery
FESS
Anatomy of lateral wall
Steps of FESS
1. Uncinectomy (Infundibulotomy)
2. Anterior ethmoidectomy
3. Middle meatal antrostomy
4. Perforation of basal lamella
5. Posterior ethmoidectomy
6. Sphenoid sinus exploration
7. Skull base disease clearance
8. Frontal recess exploration
Steps of F.E.S.S.
Left nasal cavity
Left middle meatus
Incision on uncinate process
Uncinate process removed
Opening of bulla ethmoidalis
Bulla ethmoidalis removed
Natural & accessory ostia exposed
Middle meatal antrostomy done
Opening made on basal lamella
Basal lamella removed
Posterior ethmoidectomy done
Anterior sphenoid sinus wall
Interior of sphenoid sinus
Skull base clearance done
Frontal recess opened
Final FESS cavity
Surgical Navigation ( Image Guided surgery)
Complications of FESS
Major (1%)
• Major epistaxis
• Orbital hematoma
• Diplopia
• Blindness or ed visual acuity
• Internal carotid injury
• Intracranial hemorrhage
• CSF leak / Meningitis
• Pneumocephalus
• Anosmia
• Nasolacrimal duct trauma
Minor (7%)
• Minor epistaxis
• Hyposmia
• Adhesions (synechiae)
• Headache
• Periorbital echhymosis
• Periorbital hematoma
• Dental / facial pain

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Treatment of sinusitis

  • 1. Medical and surgical treatment of sinusitis Dr. Krishna Koirala
  • 2. Medical Treatment • Systemic Antibiotics • Nasal decongestants: topical & systemic • Anti-histamines • Analgesic-anti-inflammatory drugs • Medicated steam inhalation & nasal douching • Mucolytics : Ambroxol, Guaphenesin • Anti-allergy treatment • Hot fomentation
  • 3. Antibiotics Amoxicillin- clavulanate : 625 mg B.D. X 7 days Ciprofloxacin: 500mg B.D. X 7 days Doxycycline: 100 mg B.D. X 7 days Cefadroxil: 500 mg B.D. X 7 days Cefaclor: 500 mg T.I.D. X 7 days Cefuroxime: 250 mg B.D. X 7 days Cefixime: 200 mg B.D. X 7 days Cefpodoxime: 200 mg B.D. X 7 days Azithromycin: 500 mg O.D. X 3-5 days Clarithromycin: 250 mg B.D. X 7 days
  • 4. Nasal Decongestants  Systemic decongestants  Phenylephrine  Pseudoephedrine  Topical decongestants  Xylometazoline  Oxymetazoline  Saline
  • 5. Topical Decongestants • Oxymetazoline 0.05 % : 2-3 drops BD • Oxymetazoline 0.025 % : 2 drops BD • Xylometazoline 0.1 % : 3 drops TID • Xylometazoline 0.05 % : 2 drops BD • Saline 2 % : 3 drops TID • Saline 0.67 % : 2 drops BD
  • 6. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratadine: 10 mg OD Levocetrizine: 5 mg OD Ebastine: 20 mg OD Topical: Azelastine spray (0.1%): 1-2 puffs BD
  • 7. Anti- cold preparations Name Chlorpheniramine Decongestant Paracetamol COLDIN 4 mg PsE 60 mg 500 mg SINAREST 4 mg PsE 60 mg 500 mg DECOLD 4 mg PhE 7.5 mg 500 mg SUPRIN 2 mg PhE 5 mg 500 mg PsE = Pseudoephedrine PhE = Phenylephrine
  • 8. Fungal Sinusitis A. Invasive (hyphae present in submucosa) – Acute invasive or fulminant (< 4 weeks) – Chronic invasive or indolent (> 4 weeks) B. Non-invasive – Allergic – Fungal ball or mycetoma – Saprophytic Aspergillosis & Mucormycosis are common
  • 9. Acute invasive fungal sinusitis • Usually mucormycosis • Predisposing factors – Immune-compromise: AIDS, Lymphoma, Cytotoxic drugs, chronic use of steroid, aplastic anemia – Insulin dependent diabetes mellitus – Long term use of broad-spectrum antibiotics • C/F – Unilateral nasal discharge with black crusts due to ischaemic necrosis – Cerebral & vascular invasion present – Absence of significant inflammation
  • 11. Treatment • Remove precipitating factors • Surgical debridement of necrotic debris • Anti-fungal drugs – Amphotericin B infusion for 1-2 months – Itraconazole 100 mg BD for 6-12 months Chronic invasive fungal sinusitis • Significant inflammation with fibrosis & granuloma formation • Locally destructive with minimal bone erosion • Treatment : Debridement + Anti-fungal agents
  • 12. Allergic fungal sinusitis • Associated with ethmoid polyps & asthma • Unilateral thick yellow nasal discharge with mucin, eosinophils & Charcot Leyden crystals • C.T. scan: radio-opaque mass with central area of hyper density (due to hyphae) • Tx: Surgical debridement + anti-histamines + steroids (oral & topical)
  • 17.  Fungal ball (Mycetoma) Refractory sinusitis with foul smelling cheesy material in maxillary sinus Tx: Surgical removal • Saprophytic fungal sinusitis – Seen after Sino-nasal surgery due to proliferation of fungal spores on mucous crusts Tx: Surgical removal
  • 19. Surgical Treatment Methods: 1. Antral Washout 2. Intra-nasal Inferior meatal antrostomy (INA) 3. Caldwell - Luc surgery 4. Middle meatal antrostomy 5. Functional Endoscopic Sinus Surgery (FESS) Maxillary Sinusitis
  • 20. Antral Washout (Proof puncture/antral lavage) • Indications – Diagnosis & treatment of chronic maxillary sinusitis not responding to conservative medications – Cytology/culture sensitivity of antral contents • Contraindications – Age < 3 yrs – Hypoplastic maxilla with thick bony walls – Acute maxillary sinusitis untreated by antibiotics – Trauma to maxillary sinus or Fracture of orbital floor – Drainage of maxillary antral hematoma
  • 21. Tilley Lichtwitz Antral Trocar & Cannula
  • 24. Puncture done 1.25 cm behind anterior end of inferior turbinate
  • 26. • Anesthesia: L.A. for adults. G.A. for children & un-cooperative patient • Position: Sitting / supine • Technique: – Puncture lateral wall of inferior meatus with Tilley - Lichtwitz antral trocar & cannula, just anterior to turbinate genu, trocar directed towards tragus of ipsilateral ear, with gentle boring action – Advance till it hits posterior wall, then withdraw slightly. Remove trocar & wash the sinus with saline at 370 C with patient leaning forwards & saying k k. – Wash till clear fluid comes , then remove the cannula.
  • 27. 1. Hemorrhage ( Lateral Sphenopalatine artery) 2. Pain & swelling of cheek (breach of anterior wall) 3. Orbital damage (perforation of orbital floor) 4. Perforation of posterior wall (maxillary artery injury) 5. Vasovagal shock 6. Fatal air embolism Complications
  • 28. Intranasal antrostomy (INA) • Region of antral puncture in inferior meatus perforated with Tilley's antral harpoon • Antrostomy enlarged with Tilley's antral burr or Myle’s nasoantral perforator
  • 29.
  • 30. Caldwell – Luc Surgery George Caldwell, 1893, New York Henri Luc, 1897, Paris
  • 31. Indications • Chronic refractory maxillary sinusitis • Antrochoanal polyp (recurrent) • Oro-antral fistula closure • Biopsy of suspicious neoplasm of maxillary antrum • Foreign body removal from maxillary antrum • Orbital floor decompression • Fungal maxillary sinusitis • Elevation of orbital floor fractures • Ethmoidectomy (trans-antral) • Route to pterygo- palatine fossa (Vidian nerve, Max Artery) • Dental / dentigerous cyst (maxillary antrum) removal
  • 33. Incision 4 cm long, sub-labial, horizontal incision made 3 mm above & parallel to the gingival margin, from lateral incisor to 2nd molar tooth.
  • 34. Incision deepened till the periosteum
  • 35. Surgical Treatment Methods: 1. Antral Washout 2. Intra-nasal Inferior meatal antrostomy (INA) 3. Caldwell - Luc surgery 4. Middle meatal antrostomy 5. Functional Endoscopic Sinus Surgery (FESS) Maxillary Sinusitis
  • 36. Anterior wall broken with osteotome
  • 37. Hole made in anterior wall
  • 38. Suction of maxillary sinus contents
  • 43. • Facial: Cheek edema, ecchymosis, subcutaneous emphysema, infraorbital nerve paresthesia • Orbital: Hematoma, extraocular muscle trauma, diplopia, globe trauma, blindness • Oral: Trauma to teeth roots, Superior alveolar nerve damage, Dental anesthesia, Oroantral fistula • Vascular: Internal maxillary artery injury Complications
  • 44. Ethmoid Sinusitis Surgical Treatment Methods 1. Intra-nasal endoscopic ethmoidectomy 2. Extra-nasal Ethmoidectomy a. Lynch Howarth procedure b. Patterson trans-orbital procedure c. Trans-antral (Jansen Horgan procedure) 3. Functional Endoscopic Sinus Surgery ( FESS)
  • 47. Trans-antral ethmoidectomy • Caldwell – Luc surgery done to reach maxillary antrum • Ethmoid cells approached via postero –supero - medial angle of maxillary antrum
  • 48. Surgical Treatment Methods 1. Trephination of frontal sinus 2. Modified Lothrop procedure 3. Osteoplastic Flap surgery 4. Functional Endoscopic Sinus Surgery Frontal Sinusitis
  • 50. • 2 cm incision made 1 cm below the medial end of eyebrow & deepened up to bone • Frontal sinus floor opened by drilling with burr • Opening enlarged with Citelli’s punch forceps to drain pus • Drainage tube inserted inside frontal sinus cavity & sutured in place • Regular lavage of the frontal sinus done through drainage tube for 48-72 hours post-operatively
  • 53. Lothrop Procedure Removal of frontal sinus (inferior septum + floor) + superior part of nasal septum
  • 54. Sphenoid sinus Surgical Treatment Methods 1. Trans-nasal trans- septal approach 2. Sublabial trans- septal approach 3. External ethmoidectomy approach 4. Endoscopic intra-nasal approach 5. Functional Endoscopic Sinus Surgery
  • 59. FESS
  • 61. Steps of FESS 1. Uncinectomy (Infundibulotomy) 2. Anterior ethmoidectomy 3. Middle meatal antrostomy 4. Perforation of basal lamella 5. Posterior ethmoidectomy 6. Sphenoid sinus exploration 7. Skull base disease clearance 8. Frontal recess exploration
  • 67. Opening of bulla ethmoidalis
  • 69. Natural & accessory ostia exposed
  • 71. Opening made on basal lamella
  • 79.
  • 80. Surgical Navigation ( Image Guided surgery)
  • 81. Complications of FESS Major (1%) • Major epistaxis • Orbital hematoma • Diplopia • Blindness or ed visual acuity • Internal carotid injury • Intracranial hemorrhage • CSF leak / Meningitis • Pneumocephalus • Anosmia • Nasolacrimal duct trauma Minor (7%) • Minor epistaxis • Hyposmia • Adhesions (synechiae) • Headache • Periorbital echhymosis • Periorbital hematoma • Dental / facial pain