rhinosinusitis

Rhinosinusitis

by : Sameer S. Sawaed - MD

• Inflammation of the mucous membrane of

nose and paranasal sinuses

• since the nasal cavity & sinuses have the same

MM, so any pathological changes affecting the

nasal mucosa can spread to the paranasal

sinuses.

• The paranasal sinuses are a group of air containing spaces that surround the nasal cavity

• Each sinus is name for the bone in which it is located:

Maxillary (one sinus located in each cheek)

Ethmoid (approximately 6-12 small sinuses per side, located between the eyes)

Frontal (one sinus per side, located in the forehead)

Sphenoid (one sinus per side, located behind the ethmoid sinuses, near the middle of the skull)

• The ethmoid and maxillary sinuses are present at birth.

• The frontal & sphenoid sinuses are not … they will develop later

Ethmoid sinuses

As u go posteriorly become:

• Larger

• Less in no.

Sinuses have small orifices (ostia) which open into recesses

(meati) of the nasal cavities.

• Meati are covered by turbinates (conchae).

• Turbinates consist of bony shelves surrounded by erectile soft

tissue.

• There are 3 turbinates and 3 meati in each nasal cavity

(superior, middle, and inferior).

The drainage of the sinuses

• Frontal, maxillary, anterior ethmiod middle meatus

• Posterior ethmoid superior meatus

• Sphenoid sphenoethmoidal recess

• Solid facial skeletal elements surrounding the nose are invaded

by respiratory mucosa and subsequently pneumatized.

• Begins in 3rd- 4th month of fetal life and further development

takes place after birth

• The Ethmoid sinuses are present at birth, reach adult size by

age 12.

• The Maxillary present at birth.

• Frontal sinus rarely present at birth; usually not visible until

age 2, great variability in size; congenitally absent in 5%

• Sphenoid sinuses are rarely present at birth, usually seen

around age 4.

1. Sinuses are normally sterile, but their proximity to

nasopharyngeal flora allows bacterial and viral

inoculation following rhinitis.

2. Diseases that obstruct drainage can result in a

reduced ability of the paranasal sinuses to function

normally. The sinus ostia become occluded, leading to

mucosal congestion.

3. The mucociliary transport system becomes

impaired, leading to stagnation of secretions and

epithelial damage, followed by decreased oxygen

tension and subsequent bacterial growth.

Why pain ??

Air trapped within a blocked sinus, along with pus or

other secretions may cause pressure on the sinus wall that

can cause the intense pain of a sinus attack.

• Acute Rhinosinusitis … up to 4 weeks

• Sub acute Rhinosinusitis … 4 to 12 weeks

• Chronic Rhinosinusitis .. > 12 weeks

• Recurrent acute Rhinosinusitis

o It is an inflammatory condition of one or more

of the para-nasal cavities

o Lasts up to 4 weeks

o Can range from acute viral rhinitis (common

cold) to acute bacterial rhino-sinusitis

• lasts 4-12 weeks

• Sub-acute rhino-sinusitis usually involves one

or two pairs of the paranasal cavities.

• It is the inflammatory and infection that

concurrently affects the nose and para-nasal

sinuses

• Lasts for longer than 12 weeks

• 4 or more recurrences of acute disease within a 12-

month period,

• With resolution of symptoms between each episode

lasts greater than 2 months .

• In most cases, each episode lasts for at least 7 days

• URTI

• Cold weather

• Day care attendance

• Smoking in the home

• Anatomic abnormalities (nasal polyps, ciliary disorder, septal deviation, concha bullosa, turbinate hypertrophy, tumors, congenital abnormalities i.e. cleft palate)

• Immunesupressed

• Direct extension: dental infection, facial fractures

• Inflammatory disorder:

– Wegener's Granulomatosis

– Sarcoidosis

• Mucosal disorder

– CF

– Allergic Rhinitis and other hyperreactivity

– Samter syndrome

• Asthma

• Nasal Polyps

• Aspirin intolerance .

• Viral (10-15%) - Rhinovirus (most common viral sinusitis cause), Influenza, Parainfluenza, Adenovirus

• Bacterial

– Acute Sinusitis: S.Pneumoniae, H.Influenzae, Moraxella, Streptococcus Pyogenes

– Chronic Sinusitis:

• Anaerobes (>50%)

– Bacteroides, Anaerobic Gram Positive Cocci, Fusobacteriumspecies

• Other less common causes

– Staphylococcus aureus, Hemophilus Influenzae, Pseudomonas aeruginosa, Escherichia coli, Beta-hemolytic Streptococcus, Neisseria causes

• Fungal (Immunocompromised or DM)

Aspergillus, Mucormycosis…

Allergic Rhinitis

• Hypersensitivity of the nasal mucosa due to

exposure to allergens

• Acute & seasonal or

• chronic & perennial

Definition

What happens in allergic rhinitis?

1. Exposure to allergen

2. IgE production by the body

3. Formation of allergen IgE complex

4. Binding of the complex to mast cells

5. Degranulation of the mast cells and release of

inflamatory mediators including histamine.

6. Vasodilation

7. Increase in capillary permability.

Symptoms:

Nasal obstruction with sneezing

Clear rhinorrhea (containing increased eosinophils)

Itching of eyes with tearing

Frontal headache and pressure

Signs:

Mucosa edematous, pale or violet in color

Allergic salute transverse nasal skin crease from rubbing the nose

Clinical features

Allergic salute

Allergic Rhinitis

Allergic Rhinitis

2 Types:• Seasonal (summer, spring, early autumn)

– Tree pollens, grass pollens, mold spores– Lasts several weeks– Disappears and recurs following year at the same time

• Perennial– Inhaled: house dust, wool, feathers, foods, tobacco, hair– Ingested: wheat, eggs, milk, nuts occurs intermittently for years with no pattern or may be constantly present

Types

• Chronic sinusitis

• Polyps (swollen edematous nasal mucosal

tissue, they can cause complete nasal

obstruction)

• Serous otitis media

Complications

Diagnosis

• History (atopy & family history)

• Physical examination:

1. Redness ,swelling of the mucosa (particularly

the turbinates) & mucoid discharge.

2. Check for structural anomalies (septal deviation

or nasl polyps).

• Sensitivity test for specific allergen (skin prick tests)

1. Identification and avoidance of allergen

2. During the acute attack:

1. Antihistamine (systemic or intranasal)

2. Local steroids

3. Decongestant (ephedrine)

3. Sodium cromoglycate (mast cell stabilizer used as prophyaxis)

4. Desensitization (we keep exposing the body to gradually increased amounts of allergen until the body fails to produce IgE as a result to exposure).

Treatment

Allergic Rhinitis

Vasomotor Rhinitis

• Very common

• Non-inflammatory, non-allergic rhinitis

• Characterized by a combination of symptoms that

includes nasal obstruction and rhinorrhea

• Vasomotor rhinitis is a diagnosis of exclusion reached

after taking a careful history, performing a physical

examination, and, in select cases, testing the patient with

known allergens

• 2 types ; eosinophilic & non-eosinophilic (according to

the number of eosinophils found in the nasal secretion)

Definition

• Temperature change

• Alcohol, dust, smoke

• Stress, anxiety, neurosis

• Endocrine – hypothyroidism, pregnancy,

menopause

• Parasympathomimetic drugs

Causes

Symptoms:

• Chronic intermittent nasal obstruction

• Rihinorhea (thin, watery)

Signs:

• Mucosa & turbinates : swollen, pale between

exposure

Clinical features

• Elimination of irritant factor

• Symptomatic relief with exercise

• Parasympathetic blocker

• Steroids

• Surgery

Treatment

Acute Suppurative Sinusitis

• Acute infection and inflammation of paranasal

sinuses

Defenition

Diagnosis

Major sx

Fever

Facial pain/ pressure

Facial fullness

Nasal obstruction

Nasal dicharge

Hyposmia/ anosmia

Minor sx

Headache

Fatigue

Ear pressure/ fullness

Halitosis

Dental pain

Cough

At least 2 major symptoms or 1 major and 2 minor symptoms

• Viral: Rhinovirus, Influenza, Parainfluenza

• Bacterial: Streptococcus Pneumoniae,

Haemophilus Influenzae, Moraxella catarhalis,

anaerobes

Etiology

Sudden onset of :

• Facial pain or pressure

• Nasal blockage & or nasal discharge/ posterior nasal drip

• Hyposmia

Signs more suggestive of a bacterial etiology:

• Erythematus nasal mucosa

• Mucopurulent discharge

• Pus originating from middle meatus

• Presence of nasal polyps of a deviated septum

Acute viral rhinsinusitis lasts < 10 days.

Clinical features

• History & PE

• Anterior rhinoscopy

• X-ray/ CT scan not recomnded unless

complications are suspected

Diagnosis

• Symptoms relieved within 5 days symptomatic

relief and expectant management

• Moderate symptoms that worsen or persist

beyond 5 days intranasal corticosteroid spray

• Severe symptoms that worsen or persist beyond 5

days and refractory to intranasal corticosteroid

Clarythromycin, INCS , referral to specialist

• Surgery if medical treatment fails

Management

Chronic Sinusitis

• Inflammation of the paranasal sinuses lasting

>3months

Defintion

• Inadequate treatment of acute sinusitis

• Untreated nasal allergy

• Allergic fungal rhinosinusitis

• Anatomic abnormality e.g. deviated septum

• Underlying dental disease

• Cilliary disorder e.g. CF

• Chronic inflammatory disorder e.g. wegener’s

Etiology

• Bacterial: S. Pneumoniae, H. Influenzae, M.

catarhalis, S.pyogenes, S.auereus, anaerobes

• Fungal: Aspergillus

Organisms

• Chronic nasal obstruction

• Purulent nasal discharge

• Headache & Pain over sinuses

• Halitosis

• Yellow-brown post-nasal discharge

• Chronic cough

• Maxillary dental pain

Clinical features

• Antibiotics for 3 to 6 weeks for infectious etiology

– Augmented penicillin (Clavulin™)

– Macrolide (clarithromycin)

– Fluoroquinolone (levofloxacin)

– Clindamycin, FlagyjTM

• Topical nasal steroid, saline spray

• Surgery if medical therapy fails or fungal sinusitis

• Surgical Treatment

– Removal of all diseased soft tissue and bone

– Post-op drainage

– Obliteration of pre-existing sinus cavity

• FESS: functional endoscopic sinus surgery

Treatment

• Benign to potentially fatal

• The incidence of complications from both acute and

chronic rhinosinusitis has decreased as a result of the

use of antibiotics.

• Complications can be divided into 3 categories:

– Orbital

– Intracranial

– Bony

Complications

• Most commonly involved in complicated sinusitis.

• Orbital extension is usually the result of ethmoid

sinusitis.

• Children are more prone to orbital complications,

probably secondary to high incidence of URI and

sinusitis.

Orbital complications

• Uncommon but devastating.

• 2 major mechanism:

–Direct extension.

–Retrograde thrombophlebitis via valveless

diploe veins.

* Frontal sinus is rich in diploe veins

especially during adolescence

IC complications

• Meningitis Sphenoid, ethmoid

• Epidural abscess Frontal

• Subdural abscess Frontal

• Intracerebral abscess Frontal

• Superior sagittal sinus thrombosis Frontal

• Cavernous sinus thrombosis Sphenoid, ethmoid

– Proptosis

– Chemosis

– Opthalmoplegia

Complications

X-ray