- often vague and similar to those of acute sinusitis but of lesser severity - Purulent nasal discharge - Foul-smelling discharge - Local pain and headache - nasal stuffiness and anosmia.

- X-ray - X-rays after injection of contrast material - Computed tomography (CT) scan - Aspiration and irrigation:

- search for underlying aetiological factors which obstruct sinus drainage and ventilation - A work-up for nasal allergy - Culture and sensitivity of sinus discharge ➡️ proper selection of an antibiotic. - conservative rx ➡️antibiotics, decongestants, antihistaminics and sinus irrigations - surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus.

Chronic Sinusitis Flashcards by Aravind dakshan

CHRONIC SINUSITIS

Sinus infection lasting for months or years is called chronic sinusitis

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cause of chronic sinusitis

failure of acute infection to resolve.

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PATHOPHYSIOLOGY of CHRONIC SINUSITIS

Acute infection ➡️destroys normal ciliated epithelium ➡️impairing drainage from the sinus➡️ Pooling and stagnation of secretions in the sinus ➡️ infection ➡️mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle

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PATHOLOGY CHRONIC SINUSITIS

In chronic infections, process of destruction and attempts at healing proceed simultaneously. Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis) or under- goes atrophy (atrophic sinusitis). Surface epithelium may show desquamation, regeneration or metaplasia. Submu- cosa is infiltrated with lymphocytes and plasma cells and may show microabscesses, granulations, fibrosis or polyp formation.

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BACTERIOLOGY

Mixed aerobic and anaerobic organisms

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CLINICAL FEATURES

often vague and similar to those of acute sinusitis but of lesser severity
Purulent nasal discharge
Foul-smelling discharge
Local pain and headache
nasal stuffiness and anosmia.

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commonest complaint

Purulent nasal discharge

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Foul-smelling discharge sug- gests

anaerobic infection

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Local pain and headache are often not marked except in

acute exacerbations

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DIAGNOSIS

X-ray
X-rays after injection of contrast material
Computed tomography (CT) scan
Aspiration and irrigation:

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X-ray of the involved sinus may show

mucosal thickening or opacity.

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X-rays after injection of contrast material may show

soft tissue changes in the sinus mucosa.

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Computed tomography (CT) scan is particularly useful in

ethmoid and sphenoid sinus infections and has replaced studies with contrast materials

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Aspiration and irrigation

Finding of pus in the sinus is confirmatory.

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TREATMENT

search for underlying aetiological factors which obstruct sinus drainage and ventilation
A work-up for nasal allergy
Culture and sensitivity of sinus discharge ➡️ proper selection of an antibiotic.
conservative rx ➡️antibiotics, decongestants, antihistaminics and sinus irrigations
surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus.

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SURGERY FOR CHRONIC MAXILLARY SINUSITIS

Antral puncture and irrigation
Intranasal antrostomy
Caldwell–Luc operation

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Antral puncture and irrigation

Sinus cavity is irrigated with a cannula passed through the inferior meatus. Removal of pus and exudates helps the sinus mucosa to revert to normal.

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Intranasal antrostomy

is indicated if sinus irrigations fail to resolve infection. A window is created in the infe- rior meatus to provide aeration to the sinus and its free drainage.

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Caldwell–Luc operation

In this operation, antrum is entered through its anterior wall by a sublabial incision. All irreversible diseases are removed and a window is cre- ated between the antrum and inferior meatus.

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SURGERY FOR CHRONIC FRONTAL SINUSITIS

Intranasal drainage operations
Trephination of frontal sinus
External frontoethmoidectomy (Howarth’s or Lynch operation
Osteoplastic flap operation

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Intranasal drainage operations

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Correction of deviated septum, removal of a polyp or anterior portion of middle turbinate, or intranasal ethmoidectomy provide drainage through the frontonasal duct. Treatment of associated max- illary sinusitis also helps to resolve chronic frontal sinusitis

External frontoethmoidectomy (Howarth’s or Lynch
operation)

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The frontal sinus is entered through its floor by a curvilinear incision round the inner margin of the orbit. Diseased mucosa is removed, ethmoid cells exen- terated and a new frontonasal duct created.

Osteoplastic flap operation

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It may be unilateral or bilat- eral. A coronal or a brow incision is used. The anterior wall of frontal sinus is reflected as an osteoplastic flap, based inferiorly. The diseased tissues are removed and the sinus drained through a new frontonasal duct. If it is desired to obliterate the sinus, all diseased as well as healthy mucosa are stripped off and the sinus obliterated with fat

SURGERY FOR CHRONIC ETHMOID SINUSITIS

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Intranasal ethmoidectomy

External ethmoidectomy

Intranasal ethmoidectomy

This operation is done for chronic ethmoiditis with polyp formation. The ethmoid air cells and the diseased tissue are removed between the middle turbinate and the medial wall of orbit by the intranasal route. The frontal and sphenoid sinuses can also be drained by this operation.

External ethmoidectomy

In this operation, ethmoid sinuses are approached through medial orbital incision. Access can also be obtained to sphenoid and frontal sinuses and the operation is called fronto-spheno-ethmoidectomy.

SURGERY FOR CHRONIC SPHENOIDITIS SINUSITIS

Sphenoidotomy. Access to the sphenoid sinus can be obtained by removal of its anterior wall. This is accomplished by external ethmoidectomy or trans-septal approach, usu- ally the former, because of the coexistence of ethmoid dis- ease with chronic sphenoiditis.

FUNGUS CAUSING SINUSITIS

Aspergillus, Alternaria, Mucor or Rhizopus They may involve single or multiple sinuses.

Fungal ball is due to

implantation of fungus into an otherwise healthy sinus which on CT shows a hyperdense area with no evidence of bone erosion or expansion

most commonly involved sinus in Fungal ball

Maxillary sinus >sphenoid>ethmoid >frontal

Treatment for Fungal ball

surgical removal of the fungal ball and adequate drainage of the sinus. No antifungal therapy is required

Allergic fungal sinusitis

allergic reaction to the causative fungus

Presentation of Allergic fungal sinusitis

presents with sinunasal polyposis and mucin

mucin of Allergic fungal sinusitis contains

- eosinophils - Charcot- Leyden crystals - fungal hyphae

CT scan of Allergic fungal sinusitis shows

mucosal thickening with hyperdense areas

How many sinus are involved in Allergic fungal sinusitis

There is no invasion of the sinus mucosa with fungus. Usually more than one sinus are involved on one or both sides.

Treatment of Allergic fungal sinusitis

endoscopic surgical clearance of the sinuses with provision of drainage and ventilation. This is combined with pre and postoperative systemic steroids.

Chronic invasive sinusitis

Here the fungus invades into the sinus mucosa. There is bone erosion by fungus

In Chronic invasive sinusitis Patient presents with

chronic rhinosinusitis

CT scan of Chronic invasive sinusitis shows

thick- ened mucosa with opacification of sinus and bone erosion. Patient may have intracranial or intraorbital invasion.

Histopathology of Chronic invasive sinusitis shows

fungal invasion of submucosa and granulomatous reaction with multinucleated giant cells.

Treatment for Chronic invasive sinusitis

surgical removal of the involved mucosa, bone and soft tissues followed by antifungal ther- apy

antifungal ther- apy for Chronic invasive sinusitis

i.v. amphotericin B. Up to a total of 2–3 g of the drug is given. followed by itraconazole therapy for 12 months or more monitored by serial CT or MRI scans.

Fulminant fungal sinusitis

It is an acute presentation and is mostly seen in immunocompromised or dia- betic individuals.

Common fungal species for Fulminant fungal sinusitis

Mucor Aspergillus

Mucor causes which disease

rhinocerebral disease

How does mucor causes black eschar of inferior turbi- nate, palate or the sinus

invasion of the blood vessels, mucor fungus causes ischaemic necro- sis presenting as a black eschar, involving inferior turbi- nate, palate or the sinus

Where does mucor spreads to

face, eye, skull base and the brain

Treatment for mucor

Treatment is surgical debridement of necrotic tissue and i.v. amphotericin B.

Aspergillus infection can also cause

acute fulminant sinusitis with tissue invasion.

acute fulminant sinusitis due to Aspergillus presentation

acute sinusitis and develop sepsis and other sinus com- plications. Unlike Mucor infection, there is no black eschar.

For for acute fulminant sinusitis due to Aspergillus presentation

antifungal therapy and surgery.

Chronic Sinusitis Flashcards

(52 cards)