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 sinusitisAny form of rhinitis Mucosal

odema in OMC Pathological obstruction

Any anatomical variation Anatomical obstruction

Stagnation and secondary chronic sinusitis

Impaired drainage of sinuses in the MM/ OMC

Pathological obstruction

Anatomical obstruction

Mucosal odema/ polyp formation

Mechanical: DNS, anatomical

variations in the MM/ OMC, etc.

Infective / reactive rhinitis

Stagnation and secondary infection

Chronic sinusitis

Pathological mucous/ mucociliary dysfunction

Pathogenesis :Mucosal odemaMechanical obstruction (anatomical)Mucous- thickPrimary mucociliary dysfunction

Anterior ethmoids is the key area for causation of chronic anterior group sinusitis because Ostiomeatal complex is situated within itActs as reservoir of infection

Types & Mucosal changesOpen/ closed typeMucosal changes:

HyperemiaHypertrophy Increased mucosal glands Polypoidal changesMucopurulent secretionsMicroabscessesFibrosis, hyalinizationAtrophy, 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

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 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 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: SurgicalWhen refractory to medical treatmentSurgery for predisposing causes like

DNS, polyp, etc.Surgical procedure depends on the

sinus involvedAll sinuses may be surgically accessed endoscopically

Chronic maxillary sinusitis

Surgical options

Antral punctureIntranasal antrostomyCaldwel-Luc operationFESS (Functional endoscopic sinus surgery)

• Opening through canine fossa• Counter opening into inferior

meatus • Radical mucosal debridement

CALDWELL LUC SURGERY

Chronic ethmoiditis

Intranasal ethmoidectomy Blind & dangerous

Trans-antral ethmoidectomy 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