Chronic Sinusitis
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Transcript Chronic Sinusitis
Chronic Sinusitis
Brig Mirza Khizar Hameed
Definition
Inflammation of the Paranasal Sinuses
lasting > 3 months
Etiology
Anatomical variations
Deviated Nasal Septum
Concha Bullosa
Bulla Ethmoidalis
Underlying diseases
Cystic Fibrosis
Ciliary Dyskinesia
Immuno-deficiency
Granulomatous diseases
Microbiology
Anaerobes
Staphylococcus aureus
Streptococcus
H. Influenzae
M. catarrhalis
Pathophysiology
Obstruction of Osteomeatal complex
region
Impaired mucociliary clearance
↓
Stagnation & pooling of secretions
Infection Vicious cycle
Symptoms
Chronic nasal obstruction
Purulent post nasal discharge
Pain over sinuses/ Headache
Halitosis
Chronic cough
Physical signs
Purulent Nasal discharge
Anatomical anomalies
Transillumination ?
Investigations
X-ray PNS
CT Scan PNS
Proof puncture/ Sinus lavage
Sinus aspirate/ Pus swab for C/S
Treatment
Antibiotics – Ciprofloxacin, Augmentin,
Clarithromycin, Cefuroxime, Clindamycin,
Metronidazole
Decongestants
Antihistamines
Steroid Nasal Drops/ Sprays
Surgery- To provide drainage & ventilation
Operative procedures on
Sinuses
Maxillary Sinusitis
Antral Washout
Inferior Meatal Antrostomy
Caldwell-Luc’s Operation
FESS
1. Antral Washout
Puncturing medial wall of sinus for pus
aspiration and irrigation of sinus
Indications
- Ch sinusitis refractory to treatment
Contraindications
- Age < 3 yrs
- Hypoplastic maxilla with thick bony walls
- Acute maxillary sinusitis untreated by antibiotics
Tilley Lichwitz Trocar & Cannula
Higginson Syringe
Trocar directed towards I/L tragus
Complications
Hemorrhage
Pain & swelling of cheek
Perforation of orbital floor
Vasovagal shock
Air embolism
2. Inferior Meatal Antrostomy
A window is created in
medial wall of Maxillary
antrum by perforating it
in the Inferior meatus
with Tilley’s Antrum
Harpoon & enlarged
(1.5-2 cm) with Myle’s
perforator
Complications
Hemorrhage
Injury to Naso-lacrimal duct
Perforation of orbital floor
3. Caldwell-Luc’s Surgery
Anterior wall of the Maxillary sinus is entered
through a Sub-labial incision
A window is created in the medial wall
through Antrostomy
Indications
- Ch sinusitis refractory to treatment
- Repair of Oro-antral fistula
- Reccurrent AC polyp
- Blow out fracture of floor of orbit
- Approach to ethmoids/ PPF
Sublabial Incision
Hole made in anterior wall followed
by Inferior Meatal Antrostomy
Complications
Hemorrhage
Cheek edema
Numbness of cheek
Orbital hematoma
Trauma to teeth roots
Oro-antral fistula
Ethmoid Sinusitis
Intranasal Ethmoidectomy
External Ethmoidectomy
- Lynch Howarth procedure
- Patterson transorbital procedure
- Jansen Horgan transantral procedure
FESS
Lynch Howarth Ethmoidectomy
Patterson Ethmoidectomy
Trans-antral ethmoidectomy
Complications
Hemorrhage
Injury to Lamina papyracea Periorbital
hematoma, proptosis, visual loss
Injury to Medial palpebral ligament
CSF leak
Meningitis
Mucocoele formation
Frontal Sinusitis
Trephination
Osteoplastic flap procedure
- Coronal incision
- Brow incision
FESS
Frontal sinus trephination
Osteoplastic flap procedure
Complications
Hematoma
Frontal depression
CSF leak
Meningitis
Mucocoele formation
Osteomyelitis
Sphenoid Sinusitis
Trans-nasal trans-septal approach
Sublabial trans-septal approach
External ethmoidectomy approach
FESS
FESS
Indications
- Ch sinusitis refractory to treatment
- Nasal polyps
- Fungal sinusitis
- Antro choanal polyp
- Fronto-ethmoidal mucocoele
- Repair of CSF leak
- DCR
- Orbital decompression
Functional Endoscopic Sinus Surgery
Uncinectomy (Infundibulotomy)
Bullectomy & Anterior ethmoidectomy
Middle meatal antrostomy
Perforation of basal lamella
Posterior ethmoidectomy
Sphenoid sinus exploration
Skull base disease clearance
Frontal recess exploration
Complications
Major
Major epistaxis
Orbital hematoma
Diplopia
Blindness or visual acuity
Internal carotid injury
Intracranial hemorrhage
CSF leak / Meningitis
Pneumocephalus
Anosmia
Nasolacrimal duct trauma
Minor
Minor epistaxis
Hyposmia
Adhesions (synechiae)
Headache
Periorbital echhymosis
Periorbital hematoma
Dental / facial pain
Fungal Sinusitis
Definition
Inflammation of the sinuses due to a
fungus
Classification
Non Invasive Fungal Sinusitis
- Allergic
- Fungus Ball (Mycetoma)
Invasive Fungal Sinusitis
- Acute
- Chronic
Allergic Fungal Sinusitis
Most common form
Warm humid climate
Among younger, immuno-competent, atopic
Hypersensitivity reaction to inhaled fungus
organism
Presents with Nasal polyps & thick greenish
mucus
Investigations
Total IgE -
CT Scan PNS- Sinus filled with high signal
intensity soft tissue with calcium deposits,
thinning/ pressure bony erosion & remodelling
Histology of greasy mucous- branching, non
invasive fungal hyphae, eosinophils & CharcotLeyden crystals
Treatment
Surgical clearance of sinuses
Topical Steroids
Antihistamines
Immunotherapy
? Antifungal
Fungus Ball (Mycetoma)
Older individuals, usually females
Immunocompetent
Asymptomatic/ Cacosmia/ Chronic sinusitis
Fungal mass limited to one sinus
CT Scan- Hyperdense mass with punctate
calcifications
Fungus Ball- Treatment
Surgical clearance
? Anti fungal
Acute Invasive Fungal Sinusitis
Most lethal form
Immunocompromised/ Diabetics
Caused by Mucorales, Aspergillus,
Fusarium, Phaeohyphomycosis
Angio invasion, hematogenous spread
Local necrosis, orbital & intracranial spread
Fever, pain, nasal congestion, epistaxis,
proptosis, headaches, seizures
AIFS- CT Findings
Unilateral nasal soft tissue thickening
Bony erosions
Unilateral involvement of PNS
Proptosis
Cavernous sinus thrombosis
Acute Invasive Fungal Sinusitis - CT
Unilateral ethmoid involvement with bone destruction,
intraorbital spread and proptosis
AIFS- Treatment
Aggressive surgical debridement
Systemic anti fungal therapy
Treatment of underlying cause of
immunosuppression
Chronic Invasive Fungal Sinusitis
Immunocompetent with H/o Ch sinusitis
Progressin over months to years
Maxillofacial soft tissue swelling
Orbital involvement proptosis, visual loss
Intracranial extension with cranial
neuropathies, headaches seizures
CT Scan- Hyperdense mass, bone erosion
CIFS- Treatment
Aggressive surgical exenteration
Systemic anti fungal therapy
Thank you