Dr. Junaid ShahzadResident

ENT DepartmentCapital Hospital

RHINOSINUSITIS

Outline• Introduction• Classification• Epidemiology• Predisposing factors• Patho-physiology• Microbiology• Signs and Symptoms• Investigation• Management

05/03/232

INTRODUCTION

The sinuses are a connected system of hollow cavities in the skull. The sinus cavities include:

• The maxillary sinuses• The frontal sinuses• The ethmoid sinuses• The sphenoid sinuses

05/03/23 4

05/03/23 Depertment of E.N.T 5

RHINOSINUSITIS

• Inflammation of the lining mucus membrane of a sinus and nose as a result of infection, allergy, structural or mechanical abnormalities

– Multi- Sinusitis:- If more than one sinus is infected,

– Pan- Sinusitis:- If all the sinuses are involved in the inflammatory process

CLASSIFICATION Acute Rhino-sinusitis:- Acute onset of symptoms Duration of symptoms <4weeks Symptoms resolve completely

Recurrent Acute Rhino-sinusitis:- >1 to <4 episodes of acute rhino-sinusitis per year complete recovery b/w attacks symptom free period of > 8 weeks

Cont.Chronic Rhino-sinusitis:- Duration of symptoms >12 weeks and Persistent

inflammatory changes on imaging for more then 4 weeks after starting appropriate medical therapy

Acute Exacerbation of chronic Rhino-sinusitis:- Worsening of existing symptoms or appearance

of new symptoms with complete resolution of acute (but not chronic) symptoms between episodes

05/03/23 8

Epidemiology• ARS is affecting an estimated 6 - 10% of patients seen in a

daily out-patient practice*• Bacterial sinusitis develops in 90% of patients with a viral

upper respiratory tract infection. • more often seen with 25–30% of allergic patients, 43% of asthmatic patients, 37% of patients with transplants, and 54–68% of patients with AIDS

9

A survey on the management of acute rhinosinusitis among Asian physicians.. Rhinology. 2011 Aug;49(3):264-71. doi: 10.4193/Rhino10.169.

Predisposing factors

LocalURIAllergic rhinitisNasal septal defectsNasal foreign bodiesDental infectionsOveruse of topical decongestantsNasal polyps or tumorsAspiration of infected water

Cont.

SystemicDiabetesImmunocompromise (AIDS)MalnutritionBlood dyscrasiasCystic fibrosisChemotherapyLong term steroid Rx

05/03/23 11

PATHOGENESISBasic cause is osteomeatal complex (the middle

meatal region & the frontal, ethmoid, & maxillary sinus ostia there) inflammation & infectionSinus ostia occludedColonizing bacteria replicateCiliary dysfunctionMucosal edemaLowered PO2 & pH

05/03/23 Depertment of E.N.T 13

MicrobiologyAerobic bacteria

Strep. pneumoniae Alpha & beta hemolytic Strep Staph. aureus Moraxella catarrhalis Hemophilus influenzae Escherichia coli

Anerobes (10 % acute, 66 % chronic)Peptostreptococcus,Bacteroides, Fusobacterium

Fungi (2 to 5)

Viruses (5 to 10)

05/03/23 14

Fungal Rhino-sinusitis

• Allergic fungal Rhino-sinusitis• Sinus Fungal Ball (Mycetoma)• Acute invasive fungal Rhino-sinusitis• Chronic Invasive fungal Rhino-sinusitis • Granulomatous Invasive fungal Rhino-Sinusitis

05/03/23 15

05/03/23 16

Examination

Anterior rhinoscopic examination with or without a topical decongestant,

is important to assess the status of the nasal mucosa and the presence and color of nasal discharge.

Predisposing anatomical variations can also be noted during anterior rhinoscopy.

05/03/23 17

NASOENDOSCOPY may reveal the origin of the purulent discharge from the middle meatus and may provide information about the nature of ostiomeatal obstruction. The use of endoscopy may also aid in the etiologic diagnosis of acute sinusitis by allowing the careful attainment of purulent secretions from the sinus ostia for culture. Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) may be seen using a nasal speculum and a directed light.

05/03/23 19

05/03/23 20

05/03/23 21

05/03/23 22

INVESTIGATIONS

• Complete blood picture with ESR• X-ray PNS• Nasal Swab C/S• CT• MRI• Biopsy• ANA/ ANCA• Rhinometry• Olfaction assessment

23

05/03/23 24

X-RAYS

05/03/23 25

CT Scan

05/03/23 26

CT scan

05/03/23 27

05/03/23 28

05/03/23 29

05/03/23 30

MRI

• MRI allows better differentiation of soft tissue structures within the sinuses. It is used occasionally in cases of suspected tumors or fungal sinusitis.Otherwise, MRI has no advantages over CT scanning in the evaluation of sinusitis.

05/03/23 31

ComplicationsOrbital Complications

Inflammatory oedema Orbital cellulitis Subperiosteal abscess Orbital abscess Cavernous sinus thrombosis

Intracranial Complications Meningitis Epidural abscess Subdural abscess Brain abscess

Misc.Complications Osteomyelitis (pott’s puffy tumour) Mucocele or pyocele

05/03/23 32

Management

Conservative Management:AvoidanceNasal douchingAntibiotics/AntifungalDecongestantsCorticosteroidsAnti-Histamines/Anti-Leukotrienes

05/03/23 33

Surgical Management

• FESS• Antral lavage• Caldwell-luc procedure• Ethmoidectomies

05/03/23 34

• Functional endoscopic sinus surgery (FESS) is a minimally invasive technique in which sinus air cells and sinus ostia are opened under direct visualization. The goal of this procedure is to restore sinus ventilation and normal function

05/03/23 35

FESS

• Functional endoscopic sinus surgery should be reserved for use in patients in whom medical treatment has failed. The procedure can be performed under general or local anesthesia on an outpatient basis, and patients usually experience minimal discomfort. The complication rate for this procedure is lower than that for conventional sinus surgery.

05/03/23 36

BAWO It may open the sinus

ostium at least temporarily and clear any mucopurulent material (alsoprovide sample for C/S or H/P)

Concomittant medical treatment is necessary or otherwise the saline left in the sinus will merely reinfect.

Transnasal approach via. Medial wall of maxilla.

Sublabial approach via. anterior wall of maxilla.

Intranasal Antrostomy

A large dependent opening in the medial wall of the antrum is made in the inferior meatus.

This allows good aeration of the maxillary sinus. It allows ciliary motion to be restored but adequate removal of all irreversibly changed antral lining is not possible.

38

Caldwell-Luc’s procedure

Sublabial approach to maxillary antrum

Intranasal inspection and disease clearance

40

CONCLUSION• Studies needs to be done to see incidence of Rhino-

sinusitis in our community Two researches are in progress in our department

• Comparison of Ciprofloxacin and Amoxicillin/clavulanic acid in the treatment of chronic Rhinosinusitis

• Pathogens responsible for Rhinosinusitis in our setup.

• Surgical treatment should be reserved for patients not responding to conservative management

• FESS only improves drainage of osteomeatal complex and is the treatment of choice for cases not responsive to conservative treatment.

41