Transcript Chronic Sinusitis

Definition
Chronic inflammation of the mucosal lining of
one or more paranasal sinuses, usually caused by
anatomical / pathological obstruction to its
drainage, and is characterized by chronic
postnasal mucopurulent discharge with or without
recurrent headache / facial pain. (more than
1month).
Types
 Open / Close
 Unilateral / bilateral
 Single sinus / multi-sinusitis / pan-sinusitis
 Anterior group / posterior group
 Suppurative / Hypertrophic
Osteomeatal complex : before and after fess
Mucociliary function
Etiopathogenesis
 Usually Rhinogenic. Other routes- rare.
 Unresolved acute sinusitis
 Any form of rhinitis
Mucosal odema in
OMC
Pathological obstruction
 Any anatomical variation
obstruction
Anatomical
 Stagnation and secondary chronic sinusitis
Infective / reactive
rhinitis
Mucosal odema/
polyp formation
Pathological
mucous/
mucociliary
dysfunction
Mechanical: DNS,
anatomical
variations in the
MM/ OMC, etc.
Anatomical
obstruction
Pathological
obstruction
Impaired drainage of
sinuses in the MM/ OMC
Stagnation and
secondary infection
Chronic sinusitis
Pathogenesis :
 Mucosal odema
 Mechanical obstruction (anatomical)
 Mucous- thick
 Primary mucociliary dysfunction
Anterior ethmoids is the key area for causation of
chronic anterior group sinusitis because
 Ostiomeatal complex is situated within it
 Acts as reservoir of infection
Types & Mucosal changes
 Open/ closed type
 Mucosal changes:
 Hyperemia
 Hypertrophy
 Increased mucosal glands
 Polypoidal changes
 Mucopurulent secretions
 Microabscesses
 Fibrosis, hyalinization
 Atrophy, squamous metaplasia, granulations
Bacteriology
 Mixed infection
 Streptococcus pneumoniae, Hemolyticus, Staph
aureus, gram negative bacteriae,etc.
 Anaerobic infection> fowl smelling discharge
Clinical features:
Symptoms
 Mucopurulent/ purulent post nasal discharge
 Cachosmia- anaerobic
 Headache/ facial pain- depending on the site and
type- usually dull aching.
 Nasal obstruction
 Aural and throat symptoms
Clinical features: Signs
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Discharge in the MM on anterior rhinoscopy
Mucosal changes in the MM
Discharge in MM/ SM on posterior rhinoscopy
Tenderness in acute excerbations
Postural/ Transillumination tests
Prominent lateral pharyngeal band
Investigations
 Plain radiographs “Water’s”
 Mucosal thickening, haziness, opacity, polyp
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CT scan of OMC/ paranasal sinuses (coronal cuts)
X-ray nasopharynx in children
Diagnostic nasal endoscopy
Allergic tests if suspected
Proof puncture for maxillary sinus
Culture and sensitivity- rarely done
Fungal culture of cheesy discharge, if present
CHRONIC
Sinusitis
Endoscopic appearance of mucosal
changes in CHRONIC sinusitis
Treatment: Medical
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Antibiotics
Nasal decongestants- topical/ systemic
Antihistaminics
Analgesic-antiinflammatory
Medicated steam inhalation
Alkaline nasal douches
Steroid nasal spray/ short course of systemic
steroids
 Antiallergy treatment
Treatment: Surgical
 When refractory to medical treatment
 Surgery for predisposing causes like DNS,
polyp, etc.
 Surgical procedure depends on the sinus
involved
 All sinuses may be surgically
accessed endoscopically
Chronic maxillary
sinusitis
Surgical options
 Antral puncture
 Intranasal antrostomy
 Caldwel-Luc operation
 FESS (Functional endoscopic sinus surgery)
•Opening through canine fossa
•Counter opening into inferior meatus
•Radical mucosal debridement
CALDWELL LUC SURGERY
Chronic ethmoiditis
 Intranasal ethmoidectomy
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Blind & dangerous
 Trans-antral ethmoidectomy
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Via Caldwel-Luc operation
 External ethmoidectomy (Howarth operation)
 Endoscopic ethmoidectomy (FESS)
Chronic frontal sinusitis
 External frontoethmoidectomy (Lynch-Howarth
operation)
 Osteoplastic operation
 Obliteration of frontal sinus
 Endoscopic frontal sinusostomy
Chronic sphenoidal sinusitis
 Intranasal sphenoethmoidectomy
 External sphenoethmoidectomy
 Endoscopic sphenoidotomy
Functional endoscopic
sinus surgery (FESS)
 Uncinectomy (infundibulotomy)
 Middle meatal antrostomy
 Frontal recess clearance
 Anterior ethmoidectomy