Inflammations of the Inflammations of the paranasal sinusesparanasal sinuses

Inflammations of the paranasal Inflammations of the paranasal sinusessinuses

Inflammations may be restricted to a Inflammations may be restricted to a single sinus or may be present in several single sinus or may be present in several (multisinusitis) or in all of one or both (multisinusitis) or in all of one or both sides (pan sinusitis , unilateral or sides (pan sinusitis , unilateral or bilateral).bilateral).

Acute and chronic non-specific infections Acute and chronic non-specific infections occur with the production of either occur with the production of either suppurative or non-suppurative forms.suppurative or non-suppurative forms.

A sinusitis is said to be (closed) if the A sinusitis is said to be (closed) if the contained inflammatory exudate can not contained inflammatory exudate can not escape, either through the viscosity of the escape, either through the viscosity of the exudate or through closure of the ostium exudate or through closure of the ostium by oedema. It is said to be (open) if ciliary by oedema. It is said to be (open) if ciliary action and overflow permit escape of the action and overflow permit escape of the exudate. Specific infections are rare.exudate. Specific infections are rare.

Acute non-specific Acute non-specific sinusitissinusitis

Aetiology:Aetiology:

1.1. Acute infective rhinitis, generally due to a cold Acute infective rhinitis, generally due to a cold or influenza.or influenza.

2. Swimming and diving may similarly cause 2. Swimming and diving may similarly cause direct spread through the ostium.direct spread through the ostium.

3. Dental extraction or infection may cause 3. Dental extraction or infection may cause infection to enter the maxillary antrum from a infection to enter the maxillary antrum from a dental root.dental root.

4. Fractures involving the sinuses may followed 4. Fractures involving the sinuses may followed by sinusitis.by sinusitis.

Predisposing factors include: Predisposing factors include:

a. Local : Nasal obstruction from any cause.Nasal obstruction from any cause. Obstruction of the sinus ostium Obstruction of the sinus ostium

especially by nasal polypi, vasomotor especially by nasal polypi, vasomotor an allergic swellings , rarely by a an allergic swellings , rarely by a tumor .tumor .

Neighboring infection , example Neighboring infection , example ( tonsillitis and adenoids).( tonsillitis and adenoids).

Previous infection in the same sinus.Previous infection in the same sinus.

b. General:b. General: Debilitation.Debilitation. Mucociliary disorders.Mucociliary disorders. Immunodeficiency.Immunodeficiency. Irritating atmospheric conditions.Irritating atmospheric conditions.

Bacteriology:Bacteriology:

The causative organisms are :The causative organisms are :

Pneumococcus, streptococcus, staphylococcus, Pneumococcus, streptococcus, staphylococcus, H.Influenzae, klebsiella pneumonae.H.Influenzae, klebsiella pneumonae.

E.Coli and anaerobic streptococci are E.Coli and anaerobic streptococci are associated with sinusitis of dental origin.associated with sinusitis of dental origin.

Acute maxillary sinusitisAcute maxillary sinusitisMaxillary sinusitis is the commonest of all sinus Maxillary sinusitis is the commonest of all sinus

infection to present as a single clinical entity. The infection to present as a single clinical entity. The origin of the infection may be either nasal(90%) or origin of the infection may be either nasal(90%) or dental(10%).dental(10%).

Acute maxillary sinusitis of nasal origin:Acute maxillary sinusitis of nasal origin: Pain in cheek, its frequently referred to the Pain in cheek, its frequently referred to the

region of the frontal sinus, temporal region , or region of the frontal sinus, temporal region , or upper teeth.upper teeth.

Tenderness over the cheek .Its not present over Tenderness over the cheek .Its not present over the orbital roof unless a frontal sinusitis coexists.the orbital roof unless a frontal sinusitis coexists.

Oedema of cheek is rare except in children.Oedema of cheek is rare except in children. Discharge in the middle meatus or postnasal Discharge in the middle meatus or postnasal

space in (open) sinusitis. Spontaneous evacuation space in (open) sinusitis. Spontaneous evacuation of the sinus content in to the nose may occur of the sinus content in to the nose may occur suddenly, especially on bending down.suddenly, especially on bending down.

Constitutional symptoms include pyrexia,malaise Constitutional symptoms include pyrexia,malaise &mental depression.&mental depression.

Special local treatment:Special local treatment:

The sinus is irrigated, by puncture through the inferior The sinus is irrigated, by puncture through the inferior meatus ,with isotonic saline, if there is no response meatus ,with isotonic saline, if there is no response to medical treatment. This is repeated as to medical treatment. This is repeated as necessary.necessary.

Intranasal antrostomy, needed urgently in closed Intranasal antrostomy, needed urgently in closed infections failing to respond to antibiotics.infections failing to respond to antibiotics.

Acute maxillary sinusitis of dental origin:Acute maxillary sinusitis of dental origin:

There are three types: There are three types:

1.1. Following dental extraction.Following dental extraction.

2.Following apical abscess. of the premolar or molar 2.Following apical abscess. of the premolar or molar teeth.teeth.

3.In acute dental sac infection.3.In acute dental sac infection.

Treatment is by systemic antibiotics &drainage of any Treatment is by systemic antibiotics &drainage of any collection of pus, dead tooth buds are removed collection of pus, dead tooth buds are removed later.later.

Diffrential diagnosis of acute Diffrential diagnosis of acute sinusitissinusitis

1.1. Pain of dental origin.Pain of dental origin.2.2. Migraine.Migraine.3.3. Trigeminal neuralgia.Trigeminal neuralgia.4.4. Neoplasms of sinuses.Neoplasms of sinuses.5.5. Erysipelas.Erysipelas.6.6. Temporal arteritis.Temporal arteritis.7.7. Herpes zoster.Herpes zoster.

Principles of treatment of acute Principles of treatment of acute sinusitissinusitis

1.1. Treatment of the infections. Systemic penicillin is Treatment of the infections. Systemic penicillin is nearly always effective.nearly always effective.

Ampicillin & flucloxacillin will cover most organisms. Ampicillin & flucloxacillin will cover most organisms.

In infection of dental origin Metronidazole should be In infection of dental origin Metronidazole should be added.added.

2. Treatment of the pain:2. Treatment of the pain: Analgesics.Analgesics. Local heat as by hot water bottle, or steam, short Local heat as by hot water bottle, or steam, short

wave diathermy is often comforting & it must not wave diathermy is often comforting & it must not be used in acute stage. be used in acute stage.

3- Establishment of drainage may be affected by :3- Establishment of drainage may be affected by :

Decongestant solutions such as 0.5 or 1% ephedrine Decongestant solutions such as 0.5 or 1% ephedrine in NS used either as drops or spray.in NS used either as drops or spray.

Acute frontal sinusitis Acute frontal sinusitis

Usually associated with an infection of Usually associated with an infection of the homolateral anterior ethmoidal the homolateral anterior ethmoidal cells , and often of the maxillary cells , and often of the maxillary sinus .sinus .

Acute frontal sinusitis Acute frontal sinusitis

Clinical features :Clinical features :1- frontal head ache may be severe .1- frontal head ache may be severe .Its usually periodic , in that it starts soon after Its usually periodic , in that it starts soon after

waking and subsides in the afternoonwaking and subsides in the afternoon2- extreme tenderness to pressure on the 2- extreme tenderness to pressure on the

orbital roof , at a point internal to the supra orbital roof , at a point internal to the supra orbital notch . Percussion of the anterior orbital notch . Percussion of the anterior sinus wall is painful. sinus wall is painful.

3-oedema of the upper lid is not uncommon .3-oedema of the upper lid is not uncommon .4-discharge is seen in the high anterior 4-discharge is seen in the high anterior

portion of the middle meatus when the portion of the middle meatus when the infection is open .infection is open .

Acute ethmoiditis Acute ethmoiditis

Though very commonly involved with either sinuses Though very commonly involved with either sinuses an infection of the ethmoidal labyrinth seldome an infection of the ethmoidal labyrinth seldome produces a separate clinical entity in the adult .produces a separate clinical entity in the adult .

Clinical features :Clinical features :1-pain between the eyes . Accompanied by frontal 1-pain between the eyes . Accompanied by frontal

head ache .head ache .2- discharge in the middle and superior meatus 2- discharge in the middle and superior meatus

from the ostia of the anterior and the posterior from the ostia of the anterior and the posterior group of cells .group of cells .

Treatment :usually non is necessary . The treatment Treatment :usually non is necessary . The treatment of any acute infection in the larger sinuses of any acute infection in the larger sinuses commonly procures resolution in the ethmoids commonly procures resolution in the ethmoids

Chronic sinusitisChronic sinusitis Definition :long standing infection of the Definition :long standing infection of the

sinus.sinus. change of the mucosa over change of the mucosa over

this time may be irreversablethis time may be irreversable

Continuation of infection is inhanced if Continuation of infection is inhanced if there is obstruction of the ostiathere is obstruction of the ostia

Chronic sinusitisChronic sinusitis Classification ;Classification ;

Chronic non specificChronic non specific Simple infective chronic sinusitisSimple infective chronic sinusitis

Mixed infective & vasomotor chronic Mixed infective & vasomotor chronic sinusitissinusitis

Simple chronic suppurative sinusitisSimple chronic suppurative sinusitis

Chronic specific Chronic specific TB &TB & Syphilitic infection Syphilitic infection

Fungus infectionFungus infection

Chronic sinusitisChronic sinusitis Predisposing factor for chronic sinusitisPredisposing factor for chronic sinusitis

Nasal :Nasal :blockageblockage

adenoid hypertrophyadenoid hypertrophy

deviated nasal septumdeviated nasal septum

nasal polyposisnasal polyposis

enlarged inferior turbinateenlarged inferior turbinate

recurrent acute infectionrecurrent acute infection

irritation:irritation: gasesgases

Teeth :Teeth : root infectionroot infection

dental abscessesdental abscesses

ManagementManagement DiagnosisDiagnosis:: Radiography:Radiography: if it is clear, it excludes hypertrophic but not if it is clear, it excludes hypertrophic but not

atrophicatrophic

thickening of mucosa: unifornthickening of mucosa: uniforn

polypoidal (opacified sinus)polypoidal (opacified sinus)

fluid level: signifies infectionfluid level: signifies infection

AntroscopyAntroscopy * direct vision * direct vision

* biopsy* biopsy * operative treatment* operative treatment

Treatment Treatment : : Maxillary sinus is the most commonly affected .if all Maxillary sinus is the most commonly affected .if all

sinuses are infected , treatment of maxillary sinus often sinuses are infected , treatment of maxillary sinus often allow spontanous resolution of other sinusesallow spontanous resolution of other sinuses

Provition of drainageProvition of drainage byby decongestant decongestant antrum puncture & lavageantrum puncture & lavage conservative surgery ( antrostomy )conservative surgery ( antrostomy ) radical surgery ( removal of lining mucsa) radical surgery ( removal of lining mucsa) Systemic antibioticsSystemic antibiotics Correction of predisposing factorsCorrection of predisposing factors

Indication for surgeryIndication for surgery

to control infectionto control infection

to remove polypito remove polypi

to remove other manifestation of vasomotor or allergic to remove other manifestation of vasomotor or allergic

component which includes:component which includes:

* rcurrent non_secreting cysts* rcurrent non_secreting cysts

* collection of thick , gluey, mucoidal material * collection of thick , gluey, mucoidal material which may completely fill the sinuswhich may completely fill the sinus

Operative procedures :Operative procedures :

intranasal polypectomyintranasal polypectomy

external fronto_spheno_ethmoidectomyexternal fronto_spheno_ethmoidectomy

Chronic maxillary sinusitisChronic maxillary sinusitis * * irrigation by repeated puncture.irrigation by repeated puncture.

* intranasal antrostomy :* intranasal antrostomy :failure of resolution after irrigationfailure of resolution after irrigation short durationshort duration

* * sublabial antrostomy ( Caldwell_luc operation)sublabial antrostomy ( Caldwell_luc operation) if above methods have failed if above methods have failed long standing caseslong standing cases

Sinusitis in childrenSinusitis in children Aetiology:Aetiology: systemic factorssystemic factors allergyallergy Ab dificiencyAb dificiency mucoviscidosismucoviscidosis heredityheredity environmental factorsenvironmental factors dietary deficiencydietary deficiency social deprivationsocial deprivation lack of exerciselack of exercise lack of ventilationlack of ventilation locallocal causescauses::intranatalintranatal

neonatalneonatal older childrenolder children clinical causesclinical causes : : repeated coldrepeated cold influenzainfluenza dental sac infectiondental sac infection adenoidsadenoids inborn errors of cilial structureinborn errors of cilial structure

Sinusitis in childrenSinusitis in children pathologypathology : :maxillary & ethmoidal sinus are usual sitesmaxillary & ethmoidal sinus are usual sites

after 10 years the condition is similar to that in adultafter 10 years the condition is similar to that in adult

non suppurative cases are more commonnon suppurative cases are more common

Clinical featuresClinical features

acute sinusitis: features more pronounced than in adultacute sinusitis: features more pronounced than in adult

oedema of eyelids & cheeks oedema of eyelids & cheeks

chronic sinusitis: chronic nasal obstruction associated with chronic sinusitis: chronic nasal obstruction associated with nasal dischargenasal discharge

mouth breathingmouth breathing

snoringsnoring

coughingcoughing

early morning vomitingearly morning vomiting

apathetic & dullapathetic & dull

Sinusitis in childrenSinusitis in children Diagnosis Diagnosis ; ; radiographyradiography

proof puncture ( under GA)proof puncture ( under GA)

Difrential diagnosis :foreing body Difrential diagnosis :foreing body

TreatmentTreatment : : acute:non operativeacute:non operative

chronic :antiallergicchronic :antiallergic

decongestant nasal dropsdecongestant nasal drops intermitent intermitent irrigation(polythine tube)irrigation(polythine tube)

infected tonsils& adenoidinfected tonsils& adenoid

dental causes treatnent dental causes treatnent