Sinusitis

1SinusitisPrepared by: Nibal Shawabkeh

Supervised by: Dr. Adel Adwan

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They are hollow, air-filled cavities that are lined by respiratory mucosa “pseudostratified ciliated columnar epithelium”

Sinuses

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There are four pairs of paranasal sinuses;

The frontal sinuses are located above the eyes, in the frontal bone

The maxillary sinuses are located in the cheekbones, under the eyes. 

The ethmoid sinuses(6 – 10 per side), also called ethmoid labyrinth are located between the eyes and the nose. 

The sphenoid sinuses(2) are located in the body of sphenoid bone, behind the nose and the eyes.

THE PARANASAL SINUSES

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Exact function unknown.

Resonators of the voice.

Reduce the weight of the skull.

Protect the eye

Increasing the olfactory surface area.

Function Development of sinuses

1. The ethmoid and maxillary sinuses are present at birth. 

2. The frontal sinus develops about the seven year of age .

3. The sphenoid about the fifth year. 

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Sinusitis is characterized by inflammation of the lining of the paranasal sinuses.

Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, RHINOSINUSITIS is now the preferred term for this condition.

Sinusitis

Definition

6 Pathophysiology:

The sinuses are lined by respiratory epithelium mucosa. Superficial viscous layer and underlying serous layers.

Normal function depends on Patent Ostia

Ciliary Function

Quality Of Mucosa.

The most important pathological process: Mucosal edema resulting from a viral rhinosinusitis→obstruction

of natural ostia → hypooxygenation → acidosis → vasodilation → increased secretion by goblet cells → ciliary dysfunction with poor mucous quality → retention of secretion and predisposition to bacterial infection.

7 Risk factors:

1. The common cold: major predisposing factor at all ages.

2. Cystic fibrosis.

3. Immunodeficiency, HIV infection.

4. Nasogastric or nasotracheal intubation.

5. Immotile cilia syndrome.

6. Nasal polyps.

7. Nasal foreign body.

8. Cold air.

9. Tumor.

10. Rhinitis

Anything that blocks mucus from exiting the sinuses predisposes them to inflammation.

8 Etiology:

Ostial obstruction Non-ostial obstruction Direct extension

9 Ostial obstruction: Inflammation

- URTI

- Allergy

Mechanical

- Septal deviation

- Turbinate hypertrophy

- Polyps

- Tumors

- Adenoid hypertrophy

- Foreign body

- Congenital abnormalities i.e. cleft palate

10 Non-ostial obstruction: Immune

- Wegener's granulomatosis

- Lymphoma, leukemia

- Immunosuppressed patients (e.g. neutropenics, diabetics, HIV)

Systemic Cystic fibrosis

Immotile cilia syndrome (Kartagener's) Triad of:

1. Sinusitis

2. Bronchiectasis

3. Situs inversus

11 Direct extension:

Dental Infection

Trauma Facial fractures

12 Bacteria causing sinusitis include:

1. S. pneumoniae

2. Nontypable H. influenzae

3. Maroxella catarrhali

4. Less commonly: S. aureus, other streptococci, and anaerobes.

Indwelling nasogastric and nasotracheal tubes predispose to nosocomial sinusitis, which is often caused by gram-negative bacteria (Klebsiella and Pseudomonas).

Antibiotic therapy predisposes to infection with antibiotic-resistant organisms.

Sinusitis in neutropenic and immunocompromised persons may be caused by Aspergillus and the Zygomycetes (e.g., Mucor, Rhizopus).

13 Fungal sinusitis is divided into:

1. Invasive: it is usually caused by Mucor, it has a very high mortality rate because it causes

destruction and necrosis to the bone and may reach the brain. It occurs in immunocompromised patients

2. Non-invasive

14 Classification According to duration:

Acute < 1 month. Subacute 1-3 months. Chronic > 3 month.

15 Acute suppurative sinusitis Definition:

Acute infection and inflammation of the paranasal sinuses.

Clinical diagnosis requiring at least 2 major symptoms or 1 major symptom and 2 minor symptoms

Major symptoms

Facial pain/ pressure

Facial fullness/ congestion

Nasal obstruction

Purulent/ discolored nasal discharge

Hyposmia/ anosmia

Fever

Minor symptoms

Headache

Halitosis

fatigue

Dental pain

Cough

Ear pressure/ fullness

16 Acute suppurative sinusitisEtiology:

Viral vs. bacterial

Children are more prone to a bacterial etiology than adults, but viral is still more common

Maxillary sinus most commonly affected

Must rule out fungal causes (mucormycosis) in immunocompromised hosts (especially if painless, bloodless mucosa on examination)

Organisms:

Viral (most common): rhinovirus, influenza, parainfluenza

Bacterial: S. pneumoniae (35%), H. influenzae (35%), M. catarrhalis, anaerobes (dental)

17 Acute suppurative sinusitisManagement:

Anterior rhinoscopy x-ray/ CT scan not recommended

unless complications are suspected (i.e. sub-periorbital abscess or intracranial) spread – Pitt's Puffy tumor.

Symptoms improving within 5 days: symptomatic relief "such as decongestant" and expectant management.

18 Acute suppurative sinusitisManagement: cont.

Moderate symptoms that worsen or persist beyond 5 days: institute an intranasal corticosteroid spray and

continue for 14 days if symptomatic relief is noted within 48 hours.

Severe symptoms that worsen or persist beyond 5 days and refractory to intranasal corticosteroid (INCS): Augmentin (Drug of choice) or clarithromycin

therapy ± INCS ± referral to a specialist or if there is a late complication.

Surgery if medical therapy fails:

1. FESS

2. Antral washout

19 Acute suppurative sinusitisComplications:

Consider hospitalization if any of the following are suspected: 1. Orbital (Chandler's classification)

a. Periorbital cellulitis

b. Orbital cellulitis

c. Subperiosteal abscess

d. Orbital abscess

e. Cavernous sinus thrombosis (The most important sign is pulsating proptosis)

2. Intracranial

a. Meningitis

b. Abscess

3. Bony

a. Subperiosteal frontal bone abscess (Pott's Puffy tumor)

b. Osteomyelitis

4. Neurologic

a. Superior orbital fissure syndrome (CN III/IV/VI palsy, immobile globe, dilated pupils, ptosis)

b. Orbital apex syndrome (as "a" above plus neuritis, papilledema, decreased acuity)

20 Pott’s puffy tumors:

Characterized by an osteomyelitis of the frontal bone with frontal breakthrough.

This results in a swelling on the forehead.

The infection can also spread inwards, leading to an intracranial abscess.

Although it can affect all ages, it is mostly found among teenagers and adolescents.

21 Chronic sinusitisDefinition:

Inflammation of the paranasal sinuses lasting > 3 months.

22 Chronic sinusitisEtiology:

Can result from any of the following: - Inadequate treatment of acute sinusitis

- Untreated nasal allergy

- Allergic fungal rhinosinusitis

- Anatomic abnormality e.g. deviated septum (predisposing factor)

- Underlying dental disease

- Ciliary disorder e.g. cystic fibrosis, Kartagener's

- Chronic inflammatory disorder e.g. wegener's

Organisms: - Bacterial: S. pneumonia, H. influenza, M. catarrhalis, S.pyogenes, S.aureus,

anaerobes

- Fungal: Aspergillus

23 Chronic sinusitisClinical features:

(similar to acute, but less severe)

Chronic nasal obstruction

Purulent nasal discharge

Pain over sinus or headache

Halitosis

Yellow-brown post-nasal discharge

Chronic cough

Maxillary dental pain

Sinobronchial syndrome: Post nasal drip in chronic sinusitis causing lower respiratory tract symptoms such as chronic cough

Allergic fungal rhinosinusitis is a chronic sinusitis affecting mostly young, immunocompetent, atopic individuals. Treatment options include FESS ± intranasal topical steroids, antifungals and immunotherapy.

24Chronic sinusitisDiagnosis:

Cultures of the nasal mucosa in not useful.

Sinus aspirate culture is the most accurate diagnostic method but is not practical or necessary.

Transillumination: show evidence of fluid, difficult to perform in children and is not reliable.

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Conventional Radiographs, 4 views:

1. Water's view (Occipitomental view): "with opened mouth" Shows maxillary sinuses, frontal sinuses, anterior ethmoidal sinuses & via the mouth, the sphenoidal sinuses. Best for maxillary sinuses.

2. Caldwell view (Occipitofrontal view): Shows frontal, maxillary & anterior ethmoidal sinuses. Best for frontal sinuses.

26 3. Lateral soft tissue view: Shows adenoids, sphenoidal sinuses & sella turcica. Lateral soft tissue view of the neck and upper thoracic region is ordered if there is suspicion of foreign body.

4. Submentovertical view (bucket-handle): Shows ethmoidal sinuses.

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Signs of sinusitis on X ray: 1. Air-fluid level 2. Sinus opacity or clouding 3. Mucosal thickening, but it is not specific for sinusitis, it may occur in simple rhinitis. CT: The gold standard for sinuses. MRI

28 Chronic sinusitisTreatment:

Antibiotics for 3 to 6 weeks for infectious etiology Augmentin (40-50 mg/kg/day), amoxicillin is the best in

children (80-90 mg/kg/day), macrolide (clarithromycin), fluoroquinolone (levofloxacin), clindamycin, Flagyl TM

Topical nasal steroid, saline therapy Surgery if medical therapy fails or fungal sinusitis

Removal of all diseased soft tissue and bone, post-op drainage and obliteration of pre-existing sinus cavity

FESS

29 Chronic sinusitisComplications:

1. Polyps

2. Mucocele (frontal and ethmoid)

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End of Lecture

March 2014