Acute Sinusitis

ACUTESINUSITI

S

-Anira Iqbal

Batch 2011

EMBRYOLOGY• Begin to develop in 3 r d fetal month• As outpouchings of mucous

membranes of Superior and Middle Meatus

• 2 processes – Primary pneumatization Secondary

pneumatization• Primary – Differential growth

Diverticular pouches/recesses expansion of wall itself to elaborate air space

• Secondary – Expansion outside wall occupies space within craniofacial bones

Sinus Development Primary pneumatizn

Secondary pneumatizn

Remarks

Maxillary From middle meatus

invaginating into maxilla

10 weeks iu 5 months IU At birth-Clinically significant(4-8ml),Radio. Identifiable

Reaches final size by 15 y

Sphenoidal Recess b/w conchae of sphenoidal bone and sphenoidal body

4 th month IU 6-7 y/o Absent at birth7 y/o- reaches sella turcica15 y – fully devVaried degrees of pneumatization in adults

Ethmoidal From Sup and Mid meatus to nasal capsule

4 th month IU 2 y Can be identified at birth. Fully dev by 20y

Frontal Frontal recess of middle meatus

4 th month IU 6 mo V.Small at birth. Slow pneumatizationFully dev by 20y.

OSTEOMEATAL COMPLEX

• Common channel that links frontal sinus, ant. and middle ethmoid sinus, and max sinus to middle meatus allows air flow and mucociliary drainage needs to be patent for drainage of secretions in sinusitis

ACUTE SINUSITIS• Acute (<4 wks) inflammation of sinus mucosa • Max.>Ethmoid>Frontal>Sphenoid• >1 sinus involved mostly – Multisinusitis• All the sinuses of 1 side – Pansinusitis unilateral• All the sinuses of both sides – Pansinusitis bilateral

Can be of 2 types :1. Open – Exudate escapes from sinus through natural

ostia2. Closed – Exudate cannot escape - more severe – greater risk of complications

ETIOLOGYEXCITING CAUSES1. Nasal infections - Nasal mucosa Sinus mucosa MCC – Viral >

Bacterial>>Fungal2. Swimming/Diving – Infected water Ostia of sinuses - Chlorine Chemical

inflammation3. Trauma – Compound # or penetrating injuries

infection4. Dental infection – Molar/Premolar infection/extraction

Max. sinus

PREDISPOSING CAUSES Local GeneralLOCAL1. Obstruction to sinus ventilation and drainage• Nasal packing• DNS• Hypertrophic turbinates• Allergy – oedema of sinus ostia• Nasal polypi• Benign/Malignant neoplasm2. Stasis of secretions in nasal cavity• Cystic fibrosis – high viscosity of secretions• Enlarged adenoids - obstruction• Choanal atresia - obstruction

GENERAL1. Environment – cold, wet - atm. pollution, smoke, dust,

overcrowding

2. Poor general health – recurrent attacks of exanth. Fevers

- nutritional deficiencies - Systemic disorders (Diabetes) - Immunodeficient

BACTERIOLOGY• Streptococcus pneumoniae• Hemophilus influenzae• Moraxella catarrhalis• Streptococcus pyogenes• Staphylococcus aureus• Klebsiella pneumoniae• Anaerobic org. – Dental infections

PATHOLOGY Infection Acute Inflammation of sinus mucosa

Hyperemia Exudation (serous mucopurulent/purulent) Outpouring of PMNs Increased activity of serous and mucus glands severe infection destruction of mucosal lining

If failure of ostium to drain EmpyemaIf destruction of bony walls complications

• Mild/Non suppurative – less virulent, good immunity, drainage

• Severe/Suppurative

ACUTE MAXILLARY SINUSITIS

• ‘Antrum of Highmore’

• Largest• MC Sinus infected –

drainage pattern• Pyramidal• Base – Lat. Wall of

nose• Apex – Zygomatic

process of maxilla• *Floor* - Rel. to

molars and premolars extraction oroantral fistula

• Capacity – 15 ml

ETIOLOGY1. MCC – Viral rhinitis2. 2 n d MCC – Bacterial invasion3. Diving/swimming4. *Dental infections* - Periapical dental abscess Tooth extraction5. Trauma – Compound # Penetrating injuries Gunshot wounds

CLINICAL FEATURES1. Due to toxemia – Fever Body ache Malaise2. Headache – Forehead ( ~ Frontal)3. Pain – Over upper jaw/referred to

gums/teeth/ipsilateral supraorbital region (~frontal) - aggravated by stooping/coughing/chewing - worse if head upright, relieved if supine4. Tenderness5. Redness and oedema of cheek – children – thinner

bone6. Nasal discharge – Ant. Rhinoscopy/nasal endoscopy

pus/mucopus in MM red swollen mucosa7. Postnasal discharge – Post. Rhinoscopy/Nasal

endoscopy Pus on upper soft palate

DIAGNOSIS• Transillumination test - Affected sinus Opaque

• X-rays – Water’s view (Occipito-mental view) – Air fluid level or opacification

• CT Scan

COMPLICATIONS1. Subacute/Chronic sinusitis2. Frontal sinusitis – Oedema obstruction of OMC

obstruction of frontal sinus drainage pathway3. Osteitis/Osteomyelitis of maxilla4. Orbital cellulitis/abscess – Spread of infection a. direct – roof of

maxillary sinus b. indirect –

ethmoid sinus

ACUTE FRONTAL SINUSITIS

• B/w inner & outer table of frontal bone, above & deep to supraorbital margin

• Thin bony septum b/w the 2 asymmetric sinuses

• Drainage ostium frontal recess (hourglass structure) infundibulum Middle meatus

• Gravity heals faster

ETIOLOGY1. Viral rhinitis2. Bacterial invasions3. Diving/Swimming4. Trauma5. Ipsilateral Maxillary/Ethmoid sinusitis

CLINICAL FEATURES1. Frontal headache – Medial brow area ‘Office Headache’ – Comes up

on waking Gradually increases Peak at mid-day Subsides

2. Tenderness – Tapping - Pressure upwards on floor of frontal

sinus3. Oedema of upper eyelid4. Nasal discharge – Nasal endoscopy – vertical streak

of mucopus high up in anterior part of middle meatus

• X- ray – Water’s view

DIAGNOSIS

• CT Scan

COMPLICATIONS1. Orbital cellulitis2. Osteomyelitis of frontal bone and fistula formation3. Meningitis4. Extradural abscess5. Frontal lobe abscess6. Chronic frontal sinusitis

ACUTE ETHMOID SINUSITIS

• 3 to 18 in no.• B/w U 1/3 Lateral

nasal wall & medial wall of orbit

• V. low capacity• Ant. Group MM• Post. Group SM

ETIOLOGY• Infection of other sinuses

Clinical Features1. Pain – bridge of nose – medial and deep to eye - aggravated by movements of eyeball - ‘Spectacle tenderness’2. Oedema of lids3. Inc lacrimation4. Nasal discharge – Ant group pus in MM Post group pus in SM

spreads over post pharyngeal wall

COMPLICATIONS1. Orbital cellulitis and abscess2. Optic Nerve Visual deterioration blindness3. Cavernous sinus thrombosis4. Extradural abscess5. Meningitis6. Brain abscess

• X-ray – Caldwell ’s view (Occipito-frontal view)

• CT Scan

ACUTE SPHENOID SINUSITIS

• Ostium high up in ant wall Sphenoethmoidal recess SM

ETIOLOGY• Isolated involvement – rare• + Pansinusitis/Post. Ethmoidal sinusitis

Clinical Features1. Headache occiput/vertex - maybe referred to mastoid2. Postnasal discharge – Posterior rhinoscopy pus

on roof and post. Wall of NP

• X-ray – Lateral view• CT Scan

THANK YOU!