Chronic Sinusitis

Brig Mirza Khizar Hameed

DefinitionInflammation of the Paranasal Sinuses lasting > 3 months

EtiologyAnatomical variationsDeviated Nasal SeptumConcha BullosaBulla EthmoidalisUnderlying diseasesCystic FibrosisCiliary DyskinesiaImmuno-deficiencyGranulomatous diseases

MicrobiologyAnaerobesStaphylococcus aureusStreptococcusH. InfluenzaeM. catarrhalis

PathophysiologyObstruction of Osteomeatal complex regionImpaired mucociliary clearanceStagnation & pooling of secretionsInfection Vicious cycle

SymptomsChronic nasal obstructionPurulent post nasal dischargePain over sinuses/ HeadacheHalitosisChronic cough

Physical signsPurulent Nasal dischargeAnatomical anomaliesTransillumination ?

InvestigationsX-ray PNSCT Scan PNSProof puncture/ Sinus lavageSinus aspirate/ Pus swab for C/S

Treatment Antibiotics Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, MetronidazoleDecongestantsAntihistamines Steroid Nasal Drops/ SpraysSurgery- To provide drainage & ventilation

Operative procedures on Sinuses

Maxillary SinusitisAntral WashoutInferior Meatal AntrostomyCaldwell-Lucs OperationFESS

1. Antral WashoutPuncturing medial wall of sinus for pus aspiration and irrigation of sinusIndications- Ch sinusitis refractory to treatmentContraindications- Age < 3 yrs- Hypoplastic maxilla with thick bony walls- Acute maxillary sinusitis untreated by antibiotics

Tilley Lichwitz Trocar & Cannula

Higginson Syringe

Trocar directed towards I/L tragus

ComplicationsHemorrhagePain & swelling of cheekPerforation of orbital floorVasovagal shockAir embolism

2. Inferior Meatal AntrostomyA window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilleys Antrum Harpoon & enlarged (1.5-2 cm) with Myles perforator

ComplicationsHemorrhageInjury to Naso-lacrimal ductPerforation of orbital floor

3. Caldwell-Lucs SurgeryAnterior wall of the Maxillary sinus is entered through a Sub-labial incisionA window is created in the medial wall through AntrostomyIndications- Ch sinusitis refractory to treatment- Repair of Oro-antral fistula- Reccurrent AC polyp- Blow out fracture of floor of orbit- Approach to ethmoids/ PPF

Sublabial Incision

Hole made in anterior wall followed by Inferior Meatal Antrostomy

ComplicationsHemorrhageCheek edema Numbness of cheekOrbital hematomaTrauma to teeth rootsOro-antral fistula

Ethmoid SinusitisIntranasal EthmoidectomyExternal Ethmoidectomy- Lynch Howarth procedure- Patterson transorbital procedure- Jansen Horgan transantral procedureFESS

Lynch Howarth Ethmoidectomy

Patterson Ethmoidectomy

Trans-antral ethmoidectomy

ComplicationsHemorrhageInjury to Lamina papyracea Periorbital hematoma, proptosis, visual lossInjury to Medial palpebral ligamentCSF leakMeningitisMucocoele formation

Frontal SinusitisTrephinationOsteoplastic flap procedure- Coronal incision- Brow incisionFESS

Frontal sinus trephination

Osteoplastic flap procedure

ComplicationsHematomaFrontal depressionCSF leakMeningitisMucocoele formationOsteomyelitis

Sphenoid SinusitisTrans-nasal trans-septal approachSublabial trans-septal approachExternal ethmoidectomy approachFESS

FESSIndications- Ch sinusitis refractory to treatment- Nasal polyps- Fungal sinusitis- Antro choanal polyp- Fronto-ethmoidal mucocoele- Repair of CSF leak- DCR- Orbital decompression

Functional Endoscopic Sinus SurgeryUncinectomy (Infundibulotomy)Bullectomy & Anterior ethmoidectomyMiddle meatal antrostomyPerforation of basal lamellaPosterior ethmoidectomySphenoid sinus explorationSkull base disease clearanceFrontal recess exploration

ComplicationsMajor Major epistaxis Orbital hematoma Diplopia Blindness or visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct traumaMinorMinor epistaxisHyposmiaAdhesions (synechiae)HeadachePeriorbital echhymosisPeriorbital hematomaDental / facial pain

Fungal Sinusitis

DefinitionInflammation of the sinuses due to a fungus

ClassificationNon Invasive Fungal Sinusitis- Allergic- Fungus Ball (Mycetoma)Invasive Fungal Sinusitis- Acute- Chronic

Allergic Fungal SinusitisMost common formWarm humid climateAmong younger, immuno-competent, atopic Hypersensitivity reaction to inhaled fungus organismPresents with Nasal polyps & thick greenish mucus

InvestigationsTotal IgE - CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodellingHistology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot-Leyden crystals

TreatmentSurgical clearance of sinusesTopical SteroidsAntihistaminesImmunotherapy? Antifungal

Fungus Ball (Mycetoma)Older individuals, usually femalesImmunocompetentAsymptomatic/ Cacosmia/ Chronic sinusitisFungal mass limited to one sinusCT Scan- Hyperdense mass with punctate calcifications

Fungus Ball- TreatmentSurgical clearance? Anti fungal

Acute Invasive Fungal SinusitisMost lethal formImmunocompromised/ DiabeticsCaused by Mucorales, Aspergillus, Fusarium, PhaeohyphomycosisAngio invasion, hematogenous spreadLocal necrosis, orbital & intracranial spreadFever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures

AIFS- CT FindingsUnilateral nasal soft tissue thickeningBony erosionsUnilateral involvement of PNSProptosisCavernous sinus thrombosis

Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosisAcute Invasive Fungal Sinusitis - CT

AIFS- TreatmentAggressive surgical debridementSystemic anti fungal therapyTreatment of underlying cause of immunosuppression

Chronic Invasive Fungal SinusitisImmunocompetent with H/o Ch sinusitisProgressin over months to yearsMaxillofacial soft tissue swellingOrbital involvement proptosis, visual lossIntracranial extension with cranial neuropathies, headaches seizuresCT Scan- Hyperdense mass, bone erosion

CIFS- TreatmentAggressive surgical exenterationSystemic anti fungal therapy

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