Transcript Acute and Chronic Sinusitis - The Medical Post | Trusting

Rhino-Sinusitis:
Clinical Features,
Diagnosis & Medical
Treatment
Dr. Vishal Sharma
Definitions
Rhino-sinusitis: inflammation of lining mucosa
of nose & paranasal sinuses
Acute: infection lasting < 4 weeks
Sub acute: infection lasting 4 to 12 weeks
Chronic: infection lasting > 12 weeks
Recurrent: > 3 episodes in 6 months or > 4
episodes per year with asymptomatic
intervals of > 10 days
Types of Sinusitis
• Acute / sub acute / chronic / recurrent
• Open / Closed (depending on its drainage)
• Unilateral / bilateral
• Maxillary / frontal / ethmoidal / sphenoidal
• Single sinusitis / multi-sinusitis / pan-sinusitis
• Anterior group / posterior group
• Suppurative / hypertrophic
• Bacterial / fungal / allergic / occupational
Etiology
• Rhinogenic: commonest (85%)
– following any form of rhinitis
• Dental: for maxillary sinusitis
– root abscess, dental procedures
• Trauma:
– R.T.A., swimming, diving, F.B., barotrauma
– Iatrogenic: nasal packing, septal surgery
• Hematogenous: rare
Predisposing factors
• Mucosal odema: viral, bacterial, allergic, irritant,
vasomotor, barotrauma
• Mechanical obstruction: D.N.S. (spur), polyp,
hypertrophic turbinate, concha bullosa,
paradoxical middle turbinate, Haller cell, large
bulla ethmoidalis, agger nasi, uncinate anomaly,
nasal tumour, foreign body, nasal packing
• Mucous abnormality: Young’s syndrome, cystic
fibrosis, mucoviscidosis, dehydration
• Mucociliary dysfunction: Kartagener’s
syndrome, viral, bacterial, allergic, smoking,
pollutants, hypoxia, dry air, extremes of
temperature, synechiae
• Miscellaneous: Poor health, immunodeficiency,
diabetes, nutritional deficiency
Bacteriology
Acute sinusitis
Chronic sinusitis
 Streptococcus
 Staph. Aureus
pneumoniae
 Streptococcus
 Haemophilus influenzae
 Moraxella
 Staphylococcus aureus
 Neisseria
 H. influenzae
 Bacteroides
 Pseudomonas
Progress
Severity and resolution depends on
– Open / closed
– Organism virulence
– Host resistance
– Treatment received
Ostio-meatal complex is key area for causation
of chronic anterior group sinusitis
Pathological variants
of ostio-meatal
complex
Concha bullosa
Concha bullosa
Paradoxically curved M.T.
Paradoxically curved M.T.
Medialized uncinate process
Large bulla ethmoidalis
Haller cell
Agger nasi cell
Nasal Septal Spur
Nasal Septal Spur
Mucosal disease
Symptoms
• Nasal discharge: mucoid / purulent / blood-stained
• Nasal obstruction with hyposmia / anosmia
• Headache / facial pain
• Cheek / eyelid congestion + swelling
• Hawking, sore throat, cough
• Earache: associated Eustachian tube dysfunction
• Constitutional: fever, malaise, body ache
Location of facial pain
Maxillary: cheek, upper jaw, forehead (supra-orbital)
that es on bending forward
Frontal: forehead that es during morning & es by
late afternoon (Office headache)
Anterior Ethmoid: nasal bridge & peri-orbital, es
with eye movement
Posterior Ethmoid: retro-orbital
Sphenoid: vertex, occipital, retro-orbital
Signs
• Congested & edematous nasal mucosa
• Nasal discharge (anterior & posterior rhinoscopy):
middle meatus: frontal, maxillary, anterior ethmoid
superior meatus: posterior ethmoid, sphenoid
• Paranasal sinus tenderness present
• Postnasal drip, granular pharyngitis
• Cheek swelling: in maxillary sinusitis
• Lid edema: in ethmoid & frontal sinusitis
Para-nasal sinus tenderness
Para-nasal sinus tenderness
• Maxillary: palpate
over canine fossa
• Anterior ethmoid:
palpate medial to
medial canthus
• Frontal: palpate floor
of sinus or tap over its
anterior wall
Para-nasal sinus tenderness
Sinus trans-illumination test
Sinus trans-illumination test
• Performed in a dark room. High-intensity light
source placed inside patient’s mouth or against
the cheek (for maxillary sinus) & under medial
aspect of supra-orbital ridge (for frontal sinus).
• Trans-illumination normal = no sinusitis
• Trans-illumination absent = sinus filled with pus
• Trans-illumination dull = equivocal result
Postural test
Performed in acute sinusitis (active nasal discharge)
Pus cleaned in supine position & pt sits upright
Pus appears = frontal or ethmoid sinusitis
Pus appears on stooping forwards = sphenoid sinusitis
No discharge  pt lies in lateral position with affected
side up. Pus appears = maxillary sinusitis
Rhinosinusitis Task Force Criteria
Major
Minor
1. Facial pain / pressure
1. Headache
2. Nasal obstruction
2. Fever (non-acute sinusitis)
3. Nasal discharge or
3. Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia
5. Dental pain
5. Purulence on examn
6. Cough
6. Fever (acute sinusitis)
7. Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor
factors = sinusitis
Investigations
1. Diagnostic nasal endoscopy (D.N.E.)
2. Maxillary Sinoscopy
3. X-ray of P.N.S.
4. U.S.G. of maxillary sinus (Rhinoscan)
5. C.T. scan of P.N.S.
6. M.R.I. of P.N.S.: rarely done
7. Allergic tests
8. Proof puncture (antral wash): for maxillary sinus
9. Endoscopic microswab for culture & sensitivity
10. Fungal culture: of cheesy nasal discharge
Diagnostic Nasal Endoscopy
Indications for D.N.E.
1. Patients not responding to medical therapy
2. Anatomic factor preventing adequate
examination by anterior rhinoscopy
3. Collection of pus from hiatus semilunaris for
culture & sensitivity
4. Objective monitoring of patients
5. Peri-operative nasal inspection & cleaning
Pus in middle meatus in D.N.E.
Maxillary sinoscopy
Maxillary sinoscopy
• Anterior sinus wall
perforated directly (in
canine fossa between
roots of 3rd & 4th teeth)
with maxillary sinus
trocar & cannula
• Trocar removed &
sinoscope introduced
through cannula
X-ray paranasal sinus
Water’s view (Occipito-mental)  maxillary
Caldwell’s view (Occipito-frontal)  frontal
Rhese’s view (lateral oblique)  ethmoid
Base skull view (Submento-vertical)  sphenoid
Lateral view
Pierre’s view (occipito-mental with mouth open)
Air-fluid level: acute sinusitis
Mucosal thickening chronic sinusitis
Acute maxillary sinusitis
Chronic maxillary sinusitis
Frontal sinusitis
Pierre’s view
Lateral view
Para-nasal sinus sonography
• Bony anterior wall is seen as hyper-echoic line.
Maxillary cavity filled with air appears as hyperechoic hence posterior sinus margin not seen.
• Fluid in sinus, cyst & mucosal thickening are
hypoechoic so posterior sinus margin is visible.
• B mode sonogram differentiates between fluid
in sinus, cyst & mucosal thickening.
Normal sinus sonography (A-mode)
A-mode sonography of sinusitis
C.T. scan: maxillary sinusitis
C.T. scan: ethmoid sinusitis
C.T. scan: frontal sinusitis
C.T. scan: sphenoid sinusitis
C.T. scan paranasal sinus
Coronal & axial cuts, plain (without contrast)
Coronal planes, cuts of 4 mm or less
Indications:
– In recurrent acute / chronic sinusitis not
responding to medical therapy
– Before endoscopic surgery
– Impending complications of sinusitis
M.R.I. of P.N.S.
Medical Treatment
• Systemic Antibiotics
• Nasal decongestants: topical & systemic
• Anti-histamines
• Analgesic-anti-inflammatory drugs
• Medicated steam inhalation & nasal douching
• Mucolytics: Ambroxol
• Anti-allergy treatment
• Hot fomentation
Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days
Ciprofloxacin: 500mg B.D. X 7 days
Doxycycline: 100 mg B.D. X 7 days
Cefadroxil: 500 mg B.D. X 7 days
Cefaclor: 500 mg T.I.D. X 7 days
Cefuroxime: 250 mg B.D. X 7 days
Cefixime: 200 mg B.D. X 7 days
Cefpodoxime: 200 mg B.D. X 7 days
Azithromycin: 500 mg O.D. X 3-5 days
Clarithromycin: 250 mg B.D. X 7 days
Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD
Nasal Decongestants
Systemic decongestants
 Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline
Anti-cold preparations
Name
Chlorpheniramine Decongestant Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
4 mg
PsE 60 mg
500 mg
DECOLD
4 mg
PhE 7.5 mg
500 mg
SUPRIN
2 mg
PhE 5 mg
500 mg
PsE = Pseudoephedrine;
PhE = Phenylephrine
Topical Decongestants
• Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
• Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)
• Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
• Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
• Saline 2 %: 3 drops TID
• Saline 0.67 %: 2 drops BD (NASIVION-S)
Fungal Sinusitis
A. Invasive (hyphae present in submucosa)
–
Acute invasive or fulminant (< 4 weeks)
–
Chronic invasive or indolent (> 4 weeks)
B. Non-invasive
–
Allergic
–
Fungal ball or mycetoma
–
Saprophytic
Aspergillosis & Mucormycosis are common
Acute invasive fungal sinusitis
• Usually mucormycosis
• Predisposing factors:
• Immune-compromise: AIDS, Lymphoma, Cyto-toxic
drugs, chronic use of steroid, aplastic anemia
• Insulin dependent diabetes mellitus
• Long term use of broad-spectrum antibiotics
• C/F: Unilateral nasal discharge with black crusts due
to ischaemic necrosis. Cerebral & vascular invasion
present. Absence of significant inflammation.
Black crusting
Treatment:
• Remove precipitating factors
• Surgical debridement of necrotic debris
• Anti-fungal drugs:
• Amphotericin B infusion for 1-2 months
• Itraconazole 100 mg BD for 6-12 months
Chronic invasive fungal sinusitis
• Significant inflammation with fibrosis & granuloma
formation
• Locally destructive with minimal bone erosion
• Tx: Debridement + Anti-fungal agents
Surgical debridement
Allergic fungal sinusitis
• Associated with ethmoid polyps & asthma
• Unilateral thick yellow nasal discharge with
mucin, eosinophils & Charcot Leyden crystals
• C.T. scan: radio-opaque mass with central area
of hyper density (due to hyphae)
• Tx: Surgical debridement + anti-histamines +
steroids (oral & topical)
Allergic fungal sinusitis
Allergic fungal sinusitis
C.T. scan coronal cuts
C.T. scan axial cuts
Fungal ball (Mycetoma)
• Refractory sinusitis with foul smelling cheesy
material in maxillary sinus
• Tx: Surgical removal. No anti-fungal drugs.
Saprophytic fungal sinusitis
Seen after sino-nasal surgery due to proliferation
of fungal spores on mucous crusts
Tx: Surgical removal. No anti-fungal drugs.
Thank You