By

Dr. Hazem El-Mehairy

Prof. Otorhinolaryngology and Head & Neck SurgeryAin-Shams University

Cairo-EGYPT

Definition

• The condition manifested by inflammatory response involving the mucous membrane (possibly involving the neuroepithelium) of the nose and para-nasal sinuses , fluids within these cavities and / or underlying bone.

Why called Rhinosinusitis ?

• The mucous membrane of the nose and paranasal sinuses are anatomically and embryologically contiguous.

• Clinical symptoms are inseparable .

• They respond similarly to medical and surgical therapy.

• CT study showed that the mucosal lining of the nose and the sinuses are simultaneously involved in common cold.

Rhinosinusitis• Rhinosinusitis is defined as inflammation of the nose and the

paranasal sinuses resulting in:

AND eitherENDOSCOPIC SIGNS of• Polyps or• Mucopurulent discharge from middle

meatus or• Edema/mucosal obstruction primarily

in middle meatus

ORCT CHANGES• Mucosal changes within ostiomeatal

complex and/or sinuses

EAACI. Rhinol Suppl. 2005;18:1.Fokkens et al. Allergy. 2005;60:583.

≥2 MAJOR SYMPTOMS• Blockage/congestion• Loss of smell• Discharge anterior/postnasal drip• Facial pain/pressure

Rhinosinusitis

Severity

• Mild = VAS 0-4

• Moderate/severe = VAS 5-10

Duration• Acute/intermittent

– <12 weeks– Complete resolution

of symptoms

• Persistent/chronic– >12 weeks– No complete

resolution of symptoms

No Worst possible

10 cm

VAS = visual analogue scale.EAACI. Rhinol Suppl. 2005;18:1.Fokkens et al. Allergy. 2005;60:583.

ROUTES OF INFECTION

1- Nasal route: through the natural ostium of the involved sinus

2- Dental route (only in maxillary sinusitis)

3- Trauma

4- Hematogenous ( in immuno-compromized patient)

Rhinosinusitis Intensity of Symptoms and Signs

• Acute rhinosinusitis• Chronic rhinosinusitis• Recurrent acute rhinosinusitis • Acute exacerbations of chronic

rhinosinusitis

• Adults

• Children

Inte

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Acute rhinosinusitis

Chronic rhinosinusitis

Recurrent acute rhinosinusitis

Acute exacerbationof chronic rhinosinusitis

12Weeks

Classification(Lanza and Kennedy,1997)

Acute Rhinosinusitis: rapid onset, following viral UR infection, lasts 4 weeks, 2 major factors or 1 major & 2 minor factors. Histologically, exudative process associated with necrosis, hemorrhage and / or ulceration in which neutrophils predominate. Complete resolution after effective medical treatment.

Subacute Rhinosinusitis: unresolved acute rhinosinusitis. Symptoms are identical but less severe, persists more than 4 weeks (4-11 weeks).

Recurrent Acute Rhinosinusitis: Acute RS occurs in patients 4 or more times per year. Each lasts 7-10 days. Patient’s symptoms completely resolve with antibiotic therapy.

Chronic Rhinosinusitis: persists more than 12 weeks, symptoms identical to acute.Histologically, there is proliferative process associated with fibrosis of the lamina propria in which lymphocytes, plasma cells and eosinophils predominate along with changes in bone.

Acute exacerbation of chronic rhinosinusitis: sudden worsening of chronic RS, with return to baseline aftertreatment

Etiology

The development of Rhinosinusitis depends on variety of enviromental and host factors.

Host factors:-Genetic/ Congenital conditions, cystic fibrosis, immobile cilia syndrome allergy/ immune conditions, anatomic abnormalities, systemic diseases, endocrine, metabolic, neuromechanisms and neoplasms.

Environmental factors:-Infectious / viral agents, trauma, noxious chemicals, iatrogenic (medications & surgery).

Acute Rhinosinusitis

Spectrum of acute rhinosinusitis based on clinical criteria

Mildrhinosinusitis

Moderate to severe acute rhinosinusitis• Allergic• Viral• Bacterial colonization/infection

Fulminantbacterial rhinosinusitis

Increasing symptom severity

Clinical Diagnosis

Major factor:Facial pain / pressure, facial congestion / fullness, nasal obstruction / blockage, hyposmia / anosmia , purulence in nasal cavity and fever.

Minor factors:Headache, halitosis, fatigue, dental pain, cough, otalgia / fullness and fever.

Criteria for Clinical Diagnosis

Patient history and physical examination is sufficed for routine diagnosis of most forms.

Endoscopy and C T scans are essential in diagnosis of difficult, recalcitrant or complicated cases.

EXAMINATION

1- External.

2- Nasal examination by anterior rhinoscopy.

3- Posterior rhinoscopy.

4- Nasal endoscopy.

5- Dental examination.

Adapted from Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.

0 5 10 15Days

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sEP3OS - Acute/Intermittent Rhinosinusitis

12Weeks

Acute/Intermittent Rhinosinusitis

Increase in symptoms after 5 days

persistent symptoms after 10 days

Common Cold/Viral Rhinosinusitis

Common Cold/Acute Rhinosinusitis

0 5 10 15

Days

Sy

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Viral rhinosinusitis/common cold

Acute rhinosinusitis/increase after 5 days

Acute rhinosinusitis/persist after 10 days

No need for antibiotictherapy Consider treatment with antibiotics

and/or steroids

Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.

Microbiology

Viral colds lead to 0.5 – 2.5% of adult RS, 10% in children RS and 15% of Sinus aspirate contain viruses mainly rhinovirus, influenza and parainfluenza viruses.

Acute rhinosinusitis: Strept. Pneumoniae 31%, Haemophilus influenza 21% , Anearobes 6%, Staph. aureus 4%, Strept.pyogenes 2% and Moreaxalla catarrhalis 2%.

Chronic Rhinosinusitis: Coagulase- negative Staph. 51% , Staph. aureus 20% , Anearobes 3% and Strept.pneumoniae 4%. Allergic fungal sinusitis 2-7% of chronic rhinosinusitis, but seems to be increasing in frequency.

Staging of Rhinosinusitis- C.T. scan parameters.- Pattern of involvement of the sinuses.- Numerical score of each sinus group.- Actual measurement of the mucosal thickness.- C.T.findings with other factors (immune system, surgery,infection).

Lund – Mackay system (1993):

Structure Right LeftMaxillaryAnterior EthmoidPosterior EthmoidSphenoidFrontalOsteomeatal sinus Total points for each sideScoring for sinuses: 0 =No abnormality 1=Partial opacification 2= Total opacificationFor osteomeatal complex: 0=not occluded 2= occluded

Radiology

Ultrasound.

Plain sinus radiography.

Coronal CT (3- 4 mm sections).

Magnetic resonance imaging (MRI).

PharmacotherapyPharmacotherapy

The crus of the treatment is the compromised mucociliary clearance, for if the sinuses can regain normal clearance, this defense mechanism will tend to prevent recurrence of infection in the normal manner. If the normal mucociliary clearance can not be achieved and the mucosa may be denuded to be irreversibly damaged and complete removal of the lining mucosa will be the only alternative.

Saline nasal sprays & nasal irrigation.

Mucoevacuants.

Decongestants (systemic & topical)

Topical nasal steroids .

Systemic corticosteroids.

Antiobiotics. The optimal duration for antimicrobial therapy is 10 – 14 days in acute cases. For chronic rhinosinusitis, the duration of therapy should be at least 4 weeks. The use of antibiotics in CRS is a topic of controversy. Its efficacy , duration of therapy and agents to be use have been extensively debated.

Antihistamines

Antireflux regime:

• There is a new trend of research in the involvement of GERD in upper airway pathologies. Reflux is said to be associated to chronic rhinosinusitis.

• It is though that the reflux of acid content reach the nasopharynx and nasal cavities leading to chronic mucosal irritation and rhinosinusitis.

• Adult patients with history of heartburn can benefit from antireflux regimen including precautions and medications

Immunotherapy

An important adjunct in the management of those with atopy who develops chronic rhinosinusitis or recurrent acute rhinosinusitis.

Reduction of mucosal edema and secretions by suppression of the atopic response, would diminish the persistence or recurrence of sinus disease.

Chronic Rhinosinusitis

Symptoms of Chronic Rhinosinusitis

• Major symptoms– Facial pain/pressure

– Facial congestion/fullness

– Nasal obstruction/ blockage

– Nasal discharge/ purulence/postnasal drip

– Hyperosmia/anosmia

– Fever

• Minor symptoms– Headache

– Fever

– Halitosis

– Fatigue

– Dental pain

– Cough

– Ear pain/pressure/fullness

Differential Diagnosis of Chronic Rhinosinusitis

• Infectious rhinitis (eg; viral upper respiratory tract infections)• Allergic rhinitis: seasonal, perennial, occupational• Nonallergic rhinitis: ‘vasomotor rhinitis’, nonallergic rhinitis eosinophilia

syndrome, aspirin sensitivity, Rhinitis medicamentosa• Rhinitis secondary to pregnancy, hypothyroidism• Anatomical abnormalities: severe septal deviation, foreign body• Nasal polyps• Inverted papilloma, benign and malignant tumours• Cerebrospinal fluid leak, meningoencephaloceles• Mucoceles• Morbus wegener• Cocaine abuse• Atrophic rhinitis• Specific or tropic infections• Fungal sinus disease • Ophthalmologic or neurologic diseases

Symptoms Suggestive of Chronic Rhinosinusitis

Initial evaluation

Special indications(differential diagnosis

and underlying disease)• Medical history: major, minor symptoms• General examination• Anterior rhinoscopy, nasal endoscopy• Evaluation of underlying disease and

comorbidities• CT scan (after treatment,

not in acute episode)

• Allergy tests • Microbiology (eventually sinus puncture)• Challenge test for aspirin sensitivity• Nasal cytology (eosinophils, neutrophils)• MRI • Ciliary function studies• Biopsy• Blood examinations (Morbus wegener,

immunodeficiencies)• Sweat chloride test • Electron microscopy• Genetic analyses• Consultations of other specialties

(ophthalmologist, neurologist, etc)

Chronic Rhinosinusitis: Bacteriology

• Streptococcus pneumoniae

• Haemophilus influenzae

• Moraxella catarrhalis

• Staphylococcus aureus

• Coagulase-negative Staphylococcus

• Pseudomonas aeruginosa

• Anaerobes

• Mixed infections

Pathogenic?All fungus?

Diagnosis

Medical treatment

Topical Systemic

CT scan

Surgery

Management of Chronic Rhinosinusitis

Medical Treatment

• Steroids– Topical– Systemic

• Antibiotics: short/long courses

• Douching

• Mucolytics, immunomodulators, immunostimulants, bacterial lysates

• Antifungals

Possible Strategies for Treating CRS

CRSCRS

Infectious

Allergy

TreatEtiology–Allergen Allergen

AvoidanceAvoidance–Antibiotics–Surgery

TreatEtiology–Allergen Allergen

AvoidanceAvoidance–Antibiotics–Surgery

IL-5, IL-4IL-8, IF-GM-CSF

IL-5, IL-4IL-8, IF-GM-CSF

AttenuateInflammation–Steroids–Immunotherapy–Antileukotrienes–Macrolides?

AttenuateInflammation–Steroids–Immunotherapy–Antileukotrienes–Macrolides?

Anatomic

Indications for Surgery

Absolute indications: Massive nasal polyposis, acute complicated rhinosinusitis, mucocele, mucopyocele, invasive or allergic fungal rhinosimusitis, suspected tumor causing nasal/sinus obstruction and cerebrospinal fluid rhinorrhea.

Relative indications: Chronic rhinosinusitis refractory to an appropriate length of therapy and recurrent acute RS in which a source of anatomic, micropolyp, or similar obstruction to sinus drainage can be identified.

Most consider failure of 4 – 6 weeks of aggressive pharmacotherapy (documented by nasal endoscopy or coronal CT) to be an indication of surgery in adults, whereas 2 – 3 months of similar therapy is usually delivered before consideration of surgery in children.

SURGICAL TREATMENT

Aims at :- Correcting predisposing factor e.g. D.S- Clearance of sinus disease itself.

A- Functional Endoscopic sinus surgery FESS

For maxillary sinus, endoscopic middle meatal antrostomy.For frontal sinus, endoscopic clearance of frontonasal recess or frontal sinosotmy.For ethmoids, endoscopic ethmoidecytomy.For sphenoid, endoscopic sphenoidectomy.Combinations of all.

B- Conventional surgery

1-For maxillary sinusitis: * Repeated puncture and lavage under local anesthesia . * Intranasal antrosotomy. * Radical antrosotomy ( Caldwell Luc’s) operation.

2- For frontal sinusitis: external frontoethmoidectomy or osteoplastic flap operation with obliteration

3- For ethmoiditis : external ethmoidectomy or external fronto-ethmoidectomy or spheno-ethmoidectomy operations.

4- For sphenoditis: external spheno-ethmoidectomy operation

FUNGAL RHINOSINUSITIS

Noninvasive Fungal RS

1- Fungal Ball-Fungal ball occurs in adults, in immunocomptent patients without invasion of the mucus membrane on histopathology.-Unilateral postnasal discharge is the most frequent symptom.-C.T scan is helpful in diagnosis ( heterogeneous opacification ).-Aspergillus is the most common agent involved-Surgery is the most effective treatment.

2- Allergic fungal RSImmunocomptent patient with an allergy to fungus.The most common fungi reported are dematiaceous species.The clinical and biological criteria for diagnosis are under debate including nasal polyps, thick mucin , hypersensitivity type I for fungus, oesinophilic mucin .C.T scan show sinus opacities with bone erosion.Treatment is controversial. Removal of all mucin is recommended. Recurrences are common, so combination with medical therapy (prednisone) is suggested.

Invasive Fungal RS

1- Chronic or indolent invasive FTS Two forms: granulomatous and non-granulomatous. Occurs in healthy individuals. Pain is the main symptom, but chronic headache, proptosis and cranial nerve defects were reported. Aspergillus is the most frequent agent isolated and histopathology reveals fungus invasion of the tissue ( bone , mucus membrane , vessels). MRI confirm extension to soft tissues. Most patients are treated with combination of surgery and anitfungal chemotherapy.

2- Acute fulminant FRSOccurs in immuno-compromised patients (AIDs, hematologic disease, chemo- therapy, diabetius) . Fatal outcome Mycotic infiltrations of the mucus membranes of the nasal cavity and / or paranasal sinuses. Fever of unknown cause and rhinorrhoea are the most common first symptoms. Later proptosis , ophthalmoplegia and focal neurological signs occur. Nasal endoscopy is the crux of early diagnosis ( discoloration , black necrosis, granulations or crusts). Fungi show marked predilection for vascular invasion with direct nvasion of the large and small arteries . Mucur and aspergillus most frequently isolated.C.T scan is commonest imaging modality, but MRI for intracranial extension. Treatment combination of anti fungal chemotherapy , aggressive surgergical debridement and reversal of immuno-compromised condition.

Pediatric Rhinosinusitis

Children have a higher rate of exposure to viral infections and their immune systems are not as mature. Children anatomy is significantly different. Frontal and sphenoid sinuses are not usually developed. Also, adenoid hypertrophy and allergic rhinitis are common in children.

The main symptoms in children are rhinorrhoea, nasal obstruction,mouth breathing, hyponasal speech and snoring.

The use of saline nasal sprays or trial of allergen avoidance and age- appropriate topical nasal anti-inflammatory sprays should be tried.

Rhinosinusitis in children is not a surgical disease and watchful waiting is advised. It is likely that growth and maturation of the immunological response play a major role in the resolution of the disease.

The few exceptions to this principle are nasal polyps and periorbital cellulites, where an assessment of vision, parenteral antibiotics and there is concern about the possibility of subperiosteal abscess, CT and drainage of any pus is indicated.

COMPLICATIONS OF SINUSITS

ORBITAL

• Pre-& post septal cellulitis• Orbital abscess• Subperiosteal abscess• Cavernous sinus

thrombosis• Hematoma• Enophthalmous• Mucocele• blindness

NON ORBITAL

• CRANIAL• BONY• GENERAL

ROUTS OF EXTENSION

• Suture lines• Congenital bony

dehiscences• Natural pathways

as AEC PEC• Necrosis of bone by

acute infection or

Bone erosion by chronic infection

• Retrograde thrombophlebitis

SOF ON FRIOF

Complications of sinusitis

• Periorbital cellulitis

• Intraorbital abscess

• Osteomyelitis

• Meningitis

• Intracranial abscess

• Cavernous sinus thrombosis

MUCOCELE

1. Stage I - preseptal cellulitis

2. Stage II - orbital cellulitis

3. Stage III - subperiosteal abscess (which may arise from orbital cellulitis or paranasal sinusitis)

4. Stage IV - orbital abscess (a complication of orbital cellulitis)

5. Stage V - cavernous sinus thrombosis and infection (the cavernous sinus drains venous blood from

Staging Of Orbital infections

Orbital Cellulitis

SUBPERIOSTEAL ABSCESS

ORBITAL ABSCESS