ACUTE SINUSITIS

04/21/2304/21/23 Prof. Sameer BafaqeehProf. Sameer Bafaqeeh 11

ACUTE SINUSITISACUTE SINUSITIS

Professor Sameer Ali BafaqeehProfessor Sameer Ali Bafaqeeh

Otolaryngology DepartmentOtolaryngology Department

KSUKSU


ANATOMYANATOMY

There are four paired paranasal sinuses, the There are four paired paranasal sinuses, the maxillary, ethmoid, frontal and sphenoid maxillary, ethmoid, frontal and sphenoid sinusessinuses

““Anterior” and “posterior” sinusesAnterior” and “posterior” sinuses Lining of the sinuses is pseudostratified, Lining of the sinuses is pseudostratified,

columnar epithelium (respiratory columnar epithelium (respiratory epithelium) which is continuous with the epithelium) which is continuous with the nasal epitheliumnasal epithelium


ANATOMY (continued)ANATOMY (continued)

The muocsa secretes a mucous which traps The muocsa secretes a mucous which traps bacteriabacteria

The mucous is naturally extruded through The mucous is naturally extruded through sinus ostia to be expectorated or swallowedsinus ostia to be expectorated or swallowed

The drainage of the maxillary and frontal The drainage of the maxillary and frontal sinuses follows a circular pattern through sinuses follows a circular pattern through the natural ostiathe natural ostia


The Ethmoid SinusThe Ethmoid Sinus

Appear as evaginations of the lateral nasal Appear as evaginations of the lateral nasal wall around the third month of fetal wall around the third month of fetal gestationgestation

Are present at birth, adult size by age 12Are present at birth, adult size by age 12 Are separated by the ground (basal) lamella Are separated by the ground (basal) lamella

into the anterior and posterior ethmoids, into the anterior and posterior ethmoids, which drain into the middle and superior which drain into the middle and superior meatus, respectivelymeatus, respectively


The Ethmoid Sinus, continuedThe Ethmoid Sinus, continued

Consist of vertical and horizontal platesConsist of vertical and horizontal plates The vertical plate is divided into two The vertical plate is divided into two

portions, the perpendicular plate of the portions, the perpendicular plate of the ethmoids and the crista galliethmoids and the crista galli

The horizontal plate is known laterally as the The horizontal plate is known laterally as the fovea ethmoidalis and medially as the fovea ethmoidalis and medially as the cribriform platecribriform plate

Medially is the lamina papyraceaMedially is the lamina papyracea


The Ethmoid Sinus, continuedThe Ethmoid Sinus, continued

Blood supply is from both the external and Blood supply is from both the external and internal branches of the carotid, through the internal branches of the carotid, through the sphenopalatine and the anterior and sphenopalatine and the anterior and posterior ethmoidal arteriesposterior ethmoidal arteries

Innervation is from V2 and V3Innervation is from V2 and V3


The Maxillary SinusesThe Maxillary Sinuses

The largest sinusThe largest sinus Pyramidal shaped with apex near zygomatic Pyramidal shaped with apex near zygomatic

archarch In child, inferior border near nasal floor. In In child, inferior border near nasal floor. In

adult, 1 cm below nasal flooradult, 1 cm below nasal floor Floor over maxillary dentition, which is Floor over maxillary dentition, which is

often thin and dehiscent over tooth rootsoften thin and dehiscent over tooth roots


Maxillary Sinuses, ContinuedMaxillary Sinuses, Continued

The infraorbital nerve runs along roof, and The infraorbital nerve runs along roof, and is often dehiscent. At risk during antral is often dehiscent. At risk during antral proceduresprocedures

Sinus ostia loacated anteriorly in the middle Sinus ostia loacated anteriorly in the middle meatusmeatus

Accessory ostia are usually more posterior Accessory ostia are usually more posterior and are a sign of chronic diseaseand are a sign of chronic disease


Maxillary Sinus, continuedMaxillary Sinus, continued

Blood supply is from divisions of the Blood supply is from divisions of the maxillary arterymaxillary artery

Innervation is via V2Innervation is via V2 Postganglionic sympathetic fibers are from Postganglionic sympathetic fibers are from

VII via the sphenopalatine ganglion and the VII via the sphenopalatine ganglion and the greater superficial petrosal nervegreater superficial petrosal nerve


Frontal SinusFrontal Sinus

Begins as evagination of the anterior nasal Begins as evagination of the anterior nasal capsule around the fourth month of capsule around the fourth month of developmentdevelopment

Rarely present at birth; usually not visible Rarely present at birth; usually not visible until age 2until age 2

Great variability in size; congenitally Great variability in size; congenitally absent in 5%absent in 5%


Frontal Sinus, continuedFrontal Sinus, continued

Drains into the frontal recess in the middle Drains into the frontal recess in the middle meatus near the upper portion of the meatus near the upper portion of the infundibuluminfundibulum

Like the maxillary sinuses, have circurlar Like the maxillary sinuses, have circurlar mucociliary clearancemucociliary clearance

Blood supply from the supraorbital and Blood supply from the supraorbital and supratrochlear arteries, innervation from supratrochlear arteries, innervation from nerves of the same namenerves of the same name


Sphenoid SinusesSphenoid Sinuses

Began as outpuchings of the superior nasal Began as outpuchings of the superior nasal vault around the fourth month of gestationvault around the fourth month of gestation

Rarely present at birth, usually seen around Rarely present at birth, usually seen around age 4age 4

Drain into the superior meatus in the Drain into the superior meatus in the sphenoethmoidal recesssphenoethmoidal recess

Ostia of variable sizeOstia of variable size


Sphenoid Sinuses, continuedSphenoid Sinuses, continued

The optic nerve lies superiorlyThe optic nerve lies superiorly The pons lies posteriorlyThe pons lies posteriorly The cavernous sinus is lateral, along with The cavernous sinus is lateral, along with

CNIII, IV and VI and the carotid arteryCNIII, IV and VI and the carotid artery The carotid artery is dehiscent in 50% of The carotid artery is dehiscent in 50% of

specimens specimens


Sphenoid Sinuses, continuedSphenoid Sinuses, continued

Blood supply from both the internal and Blood supply from both the internal and external carotid arteries via the external carotid arteries via the sphenopalatine (floor) and the posterior sphenopalatine (floor) and the posterior ethmoidal arteries (roof)ethmoidal arteries (roof)

Innervation from V2 and V3Innervation from V2 and V3


Pathophysiology of SinusitisPathophysiology of Sinusitis

Lined by respiratory epitheliumLined by respiratory epithelium Mucous blanket is in two layers: a Mucous blanket is in two layers: a

superficial viscous layer and an underlying superficial viscous layer and an underlying serous layer. serous layer.

Cilia beat in the serous layer, moving the Cilia beat in the serous layer, moving the blanket towards the natural ostiablanket towards the natural ostia

Normal function depends on patent ostia, Normal function depends on patent ostia, ciliary function and quality of mucous ciliary function and quality of mucous


Pathophysiology of Sinusitis, continuedPathophysiology of Sinusitis, continued

Most important pathologic process in Most important pathologic process in disease is obstruction of natural ostiadisease is obstruction of natural ostia

Obstruction leads to hypooxygenationObstruction leads to hypooxygenation Hypooxygenation leads to ciliary Hypooxygenation leads to ciliary

dysfunction and poor mucous qualitydysfunction and poor mucous quality Ciliary dysfunction leads to retention of Ciliary dysfunction leads to retention of

secretionssecretions



Local factors can impair ciliary function. Local factors can impair ciliary function. Cold air “stuns” the epithelium, resulting in Cold air “stuns” the epithelium, resulting in retained secretions. Dry air dessicates the retained secretions. Dry air dessicates the blanket. blanket.

Anatomical factors, ie, polyps, tumors, Anatomical factors, ie, polyps, tumors, foreign bodies and rhinitis, block the ostiaforeign bodies and rhinitis, block the ostia

Kartagener’s Syndrome (immotile cilia Kartagener’s Syndrome (immotile cilia syndrome) syndrome)



Acute sinusitis is defined as disease lasting Acute sinusitis is defined as disease lasting less than one monthless than one month

Subacute sinusitis is defined as disease Subacute sinusitis is defined as disease lasting 1 to 3 monthslasting 1 to 3 months

Chronic sinusitis is defined as disease Chronic sinusitis is defined as disease lasting more than three months, and is lasting more than three months, and is usually due to inadequately treated acute or usually due to inadequately treated acute or subacute diseasesubacute disease



Acute sinusitis and subacute sinusitis are Acute sinusitis and subacute sinusitis are treated medicallytreated medically

Chronic sinusitis is considered irreversible Chronic sinusitis is considered irreversible by medical therapy alone, and it is currently by medical therapy alone, and it is currently believed oxygenation of the sinuses through believed oxygenation of the sinuses through opening of the ostia is the primary treatmentopening of the ostia is the primary treatment


History and Physical ExamHistory and Physical Exam

Acute sinusitis presents as pain over infected Acute sinusitis presents as pain over infected areas, with or without headacheareas, with or without headache

Pain to palpation is common with anterior Pain to palpation is common with anterior sinusitis, but is usually absent with the sinusitis, but is usually absent with the posterior sinusesposterior sinuses

Posterior sinuses present as bitemporal or Posterior sinuses present as bitemporal or vertex headachesvertex headaches

Fever, malaise, nasal discharge presentFever, malaise, nasal discharge present


History and Physical, continuedHistory and Physical, continued

Chronic sinusitis usually seen with a Chronic sinusitis usually seen with a mucopurlent discharge, but fever is usually mucopurlent discharge, but fever is usually not presentnot present

Acute sinusitis is often imposed on chronic Acute sinusitis is often imposed on chronic diseasedisease

Note any facial edema, tenderness, mucosal Note any facial edema, tenderness, mucosal edema, septal perforations and deviationsedema, septal perforations and deviations


History and PhysicalHistory and Physical

Diagnosis is primarily clinical, but Diagnosis is primarily clinical, but radiographs can be usedradiographs can be used

Transillumination of the sinuses can Transillumination of the sinuses can sometimes be used, but due to differences sometimes be used, but due to differences in sinus size and patency , these tests are in sinus size and patency , these tests are not reliablenot reliable

Antral lavage can be performed in select Antral lavage can be performed in select cases where the diagnosis is in doubtcases where the diagnosis is in doubt


Acute Bacterial SinusitisAcute Bacterial Sinusitis

Acute sinusitis can be thought of as an Acute sinusitis can be thought of as an abscess or empyemaabscess or empyema

Cornerstone is drainage and antibioticsCornerstone is drainage and antibiotics Drainage is usually medical with topical Drainage is usually medical with topical

decongestants and sometimes antihistaminesdecongestants and sometimes antihistamines In rare cases where medical treatment fails, In rare cases where medical treatment fails,

surgical drainage may be requiredsurgical drainage may be required


Acute Bacterial Sinusitis, continuedAcute Bacterial Sinusitis, continued

S. pneumo, H. flu and M. carrarhalisS. pneumo, H. flu and M. carrarhalis Amoxicillin is the first line antibiotic. Amoxicillin is the first line antibiotic.

Failure to respond to amoxicillin Failure to respond to amoxicillin necessitates broading coverage with necessitates broading coverage with clavulonic acid and possible Gram’s stain clavulonic acid and possible Gram’s stain and cultureand culture

Surgical drainage is required for failures on Surgical drainage is required for failures on augmentin and topical decongestantsaugmentin and topical decongestants


Acute Bacterial Sinusitis, continuedAcute Bacterial Sinusitis, continued

Maxillary sinuses are surgically drained by Maxillary sinuses are surgically drained by antral lavage, inferior meatal windows or antral lavage, inferior meatal windows or middle meatal windowsmiddle meatal windows

Frontal sinuses are drained by trephination, Frontal sinuses are drained by trephination, and a drain is left in place and irrigated and a drain is left in place and irrigated twice a day until drainage through the twice a day until drainage through the frontal duct is observedfrontal duct is observed

An ethmoidectomy drains the ethmoidsAn ethmoidectomy drains the ethmoids


Acute Fungal SinusitisAcute Fungal Sinusitis

UncommonUncommon Seen usually in immunocompromisedSeen usually in immunocompromised Aspergillosis, mucormycosis, candidiasis, Aspergillosis, mucormycosis, candidiasis,

histoplasmosis and coccidiomycosis seenhistoplasmosis and coccidiomycosis seen Aspergillosis most commonAspergillosis most common Requires high index of suspscionRequires high index of suspscion Diagnosed by biopsy and cultureDiagnosed by biopsy and culture


Acute Fungal Sinusitis, continuedAcute Fungal Sinusitis, continued

Aspergillosis a common pathogen of soil, Aspergillosis a common pathogen of soil, fruits, vegetables, grains, birds and fruits, vegetables, grains, birds and mammalsmammals

Suspect if dark, greasy material seenSuspect if dark, greasy material seen Cultures of nose usually not diagnosticCultures of nose usually not diagnostic Antrostomy with biopsy and fungal stain Antrostomy with biopsy and fungal stain

requiredrequired



Noninvasive Aspergillosis seen as fungal Noninvasive Aspergillosis seen as fungal ball, usually in maxillary sinusball, usually in maxillary sinus

Invasive aspergillosis can invade bone.Invasive aspergillosis can invade bone. Fulminant aspergillosis occurs in Fulminant aspergillosis occurs in

immunocompromised and invades adjacent immunocompromised and invades adjacent structuresstructures

Therapy for noninvasive forms is surgical Therapy for noninvasive forms is surgical excision followed usually by PO antifungalsexcision followed usually by PO antifungals



Therapy for invasive forms requires wide Therapy for invasive forms requires wide local debridement and intravenous ampo Blocal debridement and intravenous ampo B

Mucormycosis is encountered in dust and Mucormycosis is encountered in dust and soil and enters through the respiratory tractsoil and enters through the respiratory tract

The fungus invades vascular channels and The fungus invades vascular channels and causes hemorrhagic ischemia and necrosiscauses hemorrhagic ischemia and necrosis

Frequently fatal. 90% mortality in Frequently fatal. 90% mortality in immunocompromisedimmunocompromised



Ketoacidosis predisposes to mucormycosis, Ketoacidosis predisposes to mucormycosis, as the fungus thrives in acidic environmentsas the fungus thrives in acidic environments

Initially seen as engorgement of turbinates, Initially seen as engorgement of turbinates, followed by ischemia and necrosis of the followed by ischemia and necrosis of the turbinates and adjacent noseturbinates and adjacent nose

Treated with radical surgical debridement, Treated with radical surgical debridement, amphotericin B and correction of amphotericin B and correction of underlying immunosuppressionunderlying immunosuppression


Complications: MucocelesComplications: Mucoceles

Mucoceles are chronic, cystic lesions of the Mucoceles are chronic, cystic lesions of the sinuses lined by pseudostratified epitheliumsinuses lined by pseudostratified epithelium

Expand slowly, often requiring many yearsExpand slowly, often requiring many years Etiology is debated. Either due to Etiology is debated. Either due to

obstruction of ostia or to simple obstruction obstruction of ostia or to simple obstruction of minor salivary glandof minor salivary gland

30% are idiopathic30% are idiopathic



Frequently noted on routine CT scan of Frequently noted on routine CT scan of maxillary sinuses. No treatment is required maxillary sinuses. No treatment is required unless near natural ostiaunless near natural ostia

Frontal sinus mucoceles are important to Frontal sinus mucoceles are important to recognize as they cause proptosis and even recognize as they cause proptosis and even blindnessblindness

Therapy involves obliteration of sinusTherapy involves obliteration of sinus



Sphenoidal and ethmoidal mucoceles are Sphenoidal and ethmoidal mucoceles are less commonless common

Seen with vertex headaches and deep nasal Seen with vertex headaches and deep nasal painpain

Treatment is controversial; wide drainage Treatment is controversial; wide drainage into the nasal vault is commoninto the nasal vault is common


Complications: OrbitalComplications: Orbital

Orbit separated from ethmoids by thin Orbit separated from ethmoids by thin lamina papyracealamina papyracea

First indication of orbital involvemnt is First indication of orbital involvemnt is infalmmatory edema of eyelidsinfalmmatory edema of eyelids

Inflammatory edema of eyelids progresses Inflammatory edema of eyelids progresses to cellulitis, proptosis, chemosis and to cellulitis, proptosis, chemosis and ophthalmoplegiaophthalmoplegia



Five classifications of orbital complications Five classifications of orbital complications 1) Inflammatory edema: lid edema 1) Inflammatory edema: lid edema otherwise normal. otherwise normal. 2) Orbital cellulitis: diffuse edema 2) Orbital cellulitis: diffuse edema 3) Subperiosteal abscess: usually seen near 3) Subperiosteal abscess: usually seen near lamina papyracea lamina papyracea 4)Orbital abscess: collection within orbit 4)Orbital abscess: collection within orbit 5) Cavernous sinus thrombosis: bilateral 5) Cavernous sinus thrombosis: bilateral



Orbital complications sometimes seen in Orbital complications sometimes seen in frontal sinusitis as the floor of the sinus is frontal sinusitis as the floor of the sinus is thinthin

Known as Pott’s puffy tumorKnown as Pott’s puffy tumor Treatment of orbital inflammation and Treatment of orbital inflammation and

cellulitis is with IV antibitoics with or cellulitis is with IV antibitoics with or without sinus drainagewithout sinus drainage



Abscesses are treated with surgical drainage Abscesses are treated with surgical drainage and IV antibioticsand IV antibiotics

Indications for surgical drainage include Indications for surgical drainage include progresive orbital cellulitis, symptoms progresive orbital cellulitis, symptoms which do not resolve, abscess, loss of visual which do not resolve, abscess, loss of visual acuityacuity


Complications: Cavernous Sinus ThrombosisComplications: Cavernous Sinus Thrombosis

High mortality rateHigh mortality rate Usually results from retrograde transmission Usually results from retrograde transmission

through valveless veins leading to the through valveless veins leading to the cavernous sinuscavernous sinus

Heralded by bilateral orbital involvement, Heralded by bilateral orbital involvement, progessive chemosis, T 105Fprogessive chemosis, T 105F

Treat with drainage, IV antibioticsTreat with drainage, IV antibiotics Heparin is controversialHeparin is controversial


Complications: IntracranialComplications: Intracranial

Subdural abscess, intracranial abscess, Subdural abscess, intracranial abscess, meningitis seenmeningitis seen

Meningitis common in childrenMeningitis common in children 1/3 to 2/3 of all subdural abscesses believed 1/3 to 2/3 of all subdural abscesses believed

due to sinusitisdue to sinusitis Nuchal rigidity first symptomNuchal rigidity first symptom Neurosurgey consult to manage ICP, surgical Neurosurgey consult to manage ICP, surgical

drainagedrainage


RadiologyRadiology

Plain films are generally obsoletePlain films are generally obsolete Exceptions include confirmation of air fluid Exceptions include confirmation of air fluid

levels in acute sinusitis, and evaluating size levels in acute sinusitis, and evaluating size and integrity of the paranasal sinusesand integrity of the paranasal sinuses

CT scan the study of choice in chronic CT scan the study of choice in chronic sinusitis, but usually not useful in acute sinusitis, but usually not useful in acute sinusitis, as diagnosis primarily clinicalsinusitis, as diagnosis primarily clinical


Radiology: Plain FilmsRadiology: Plain Films

Three general views: Waters’, Caldwell’s Three general views: Waters’, Caldwell’s and lateraland lateral

Waters’ view with nose and chin on film. Waters’ view with nose and chin on film. Useful for maxillary sinusesUseful for maxillary sinuses

Caldwell view with nose and forehead on Caldwell view with nose and forehead on film. Useful for frontal and ethmoid sinusesfilm. Useful for frontal and ethmoid sinuses

Lateral film useful for sphenoid sinusesLateral film useful for sphenoid sinuses


Radiology: Plain Films, continuedRadiology: Plain Films, continued

Viral sinusitis usually seen as minimal Viral sinusitis usually seen as minimal mucosal thickeningmucosal thickening

Bacterial sinusitis more often unilateral and Bacterial sinusitis more often unilateral and seen with an air fluid levelseen with an air fluid level

Allergic rhinitis more often bilateral and Allergic rhinitis more often bilateral and with more mucosal thickeningwith more mucosal thickening

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ACUTE SINUSITIS

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