SINUSITIS

2.  Sinusitis - Inflammation of mucosa of one or more PNS
 Pan Sinusitis – all sinuses involved
 Multi Sinusitis – more than one sinus involved
 MC – Maxillary, 2nd – Ethmoid, Frontal and Sphenoid (rare
alone, mainly as pan sinusitis)
 Acute Sinusitis – if < 4 weeks
 Subacute Sinusitis – 4 weeks to 3 months
 Chronic Sinusitis – persistant for > 3 months due to
incomplete resolution of acute stage, destruction of
respiratory epithelium (cilia) – inadequate drainage of
secretions – mucosal oedema – polypoidal changes
 Open Sinusitis – drainage of secretions, patent ostia
 Closed Sinusitis – no drainage, blocked ostia, more severe

3.  Infection – Nasal infection, adenotonsillitis, dental
infection (maxillary sinus) – upper molar and
premolar
 Persistant infection – chronic sinusitis
 MC cause – viral infection initially (Rhinovirus,
Parainfluenza virus), followed by becterial infection
(H.Influenzae-mc, pneumococci, streptococci)
 Mechanical obstruction – DNS, Hypertrophied
turbinates, nasal polyp, tumours, nasal packing
 Decreased mucociliary clearance – cystic fibrosis,
kartagener’s syndrome, young’s syndrome
 Allergic rhinitis – chronic sinusitis
 Trauma - # or penetrating injuries

4.  Iatrogenic – rhinitis medicamentosa, aspirin
intolerance, drug induced
 Granulomatous diseases – TB, leprosy, syphilis,
rhinoscleroma, rhinosporidiosis
 Hormonal – pregnancy, puberty, menstruation,
honeymoon, emotions, stress
 VMR
 Immunodeficiency and nutritional deficiency
 Enviromental – cold and wet climate, smoke,
dust, swimming and bathing in pond with high
chlorine content, contaminated pond
 Idiopathic

5.  C/F – localised headache
 Pain over cheeks radiating to teeth, aggravating on
bending forward, straining, chewing, coughing – Maxillary
Sinusitis
 Pain between and behind the eyes, over bridge of nose
aggravated by movement of eye ball – Ethmoidal Sinusitis
 Frontal headache starts in the morning, peaks in the
afternoon then subsides (office headache) to again
increase at time of sleep (diurnal) – Frontal Sinusitis
 Pain over the vertex or occiput radiating to the
temporal/mastoid region – Sphenoidal Sinusitis
 Purulent nasal discharge in middle meatus – ant sinuses/
superior meatus – post sinuses/ foul smelling – dental
infection

6.  Nasal blockage
 Loss of smell
 Affects vocal resonance
 Fever, general malaise, bodyache
 Post nasal discharge
 Nocturnal cough – children
 Children – ethmoidal sinusitis more common
as relatively large ethmoids, swelling of
cheeks
 Altered taste

7.  Signs
 Flushing and swelling of cheeks and lower eyelid –
Maxillary sinusitis
 Oedema of lids – puffy and swollen, swelling of inner
canthus – Ethmoidal sinusitis
 Swelling of upper eyelid and orbital swelling – Frontal
Sinusitis
 Tenderness – canine fossa (maxillary), inner canthus
(ethmoidal), floor or anterior wall of frontal bone
(frontal)
 Associated dental infection - maxillary
 Postural test – on bending down discharge in nose –
frontal, on bending head to the opposite side -
maxillary

8.  Diagnosis
 DNE – oedema of middle turbinate, OMC
 X Ray PNS – fluid level, opacity – Waters view,
Caldwel view, Pierre view
 CT Scan OMC/PNS
 Transillumination tests
 D/D – TM Neuralgia (Costen’s syndrome),
Trigeminal neuralgia, Dental neuralgia (caries),
Migraine, Temporal arteritis, Herpetic neuralgia,
Neoplasms, Brain stem lesions
 Complications – Chronic sinusitis, middle ear,
pharyngeal infections, osteomyelitis, orbital
cellulitis, optic nerve damage

9.  Treatment
 Medical
 Bed rest
 Treat the dental infection
 Antibiotics – Ampicillin, Amoxycillin, Erythromycin,
Doxycycline, Amoxyclav (for H influenzae) ,
metronidazole ( for anaerobes) for 10 – 21 days
 Nasal decongestant drops and systemic
decongestants
 Steam inhalation with inhalant capsules
 Nasal irrigation with saline
 Analgesics and anti inflammatory
 Hot fomentation

10.  Surgical
 Minimal role – only if medical treatment fails
 Drainage of pus
 Antral lavage – maxillary sinusitis
 Trephination of frontal sinus – frontal
sinusitis – 2 cm horizontal incision supero
medial aspect of eyebrow
 Perforation of anterior wall of sphenoid sinus
– sphenoidal sinusitis

11.  Etiology – allergy, dusty enviroment, fungal infection
 C/F
 Less severe headache, dull but persistant/ heavy
head
 Nasal obstruction – persistant and more at night –
polypoidal changes
 Foul smelling purulent nasal discharge/ viscid mucoid
nasal discharge/ mucopurulent
 Loss of taste
 Reduced sense of smell
 Post nasal discharge – hawking sensation
 Nasal bleed
 Halitosis

12.  Signs
 Tenderness present
 Discharge in middle meatus/ superior meatus
 Posterior rhinoscopy – discharge in middle/ superior
meatus
 Excoriation of nasal vestibule skin
 Crusting, hypertrophied turbinates
 Congestion of middle meatus (localised)
 Diagnosis
 DNE, CT Scan, X Ray PNS, antroscopy (maxillary sinus)
 X Ray PNS – opacity, thickened mucosa
 DNE – Discharge, polyp, accessory ostia

13.  Complications
 ET obstruction, pharyngitis, dryness of throat,
cough, hoarseness of voice
 Treatment
 Medical
 Steroid nasal spray
 Alkaline nasal douching
 Antibiotics – rare
 Surgical
 FESS – middle meatal antrostomy (maxillary),
anterior/ posterior ethmoidectomy, frontal recess
clearance, sphenoidectomy

14.  Intra nasal antrostomy – maxillary sinus
 Caldwel luc surgery – maxillary sinus
 Intranasal/ External ethmoidectomy –
ethmoidal sinus
 External fronto ethmoidectomy (Howarth’s
surgery) – frontal sinus
 Osteoplastic flap procedure – frontal sinus
 Spheniodotomy – sphenoid sinus
 NOTE – ISOLATED FRONTAL, SPHENOIDAL
SINUSITIS IS RARE

15.  Aspergillus (mc) – fumigatus/ niger/ flavus
 Alternaria
 Mucor
 Rhizopus
 Common in immunocompromised and those with
trauma (#)
 Predisposing factors – dry and hot climate
 Types
 Invasive - chronic invasive, fulminant fungal
sinusitis
 Non invasive – fungal ball, allergic fungal
sinusitis

16.  Fungal ball/Mycetoma
 Implantation of fungi into healthy sinus
 No bone erosion
 MC – Maxillary Sinus, Sphenoidal (2nd),
Ethmoidal, Frontal
 Thick greenish discharge visualised
 Diagnosis – Histopathology, CT
 Treatment – Surgical removal
 NO ROLE OF ANTI FUNGAL THERAPY

17.  Allergic Fungal Sinusitis
 Allergic reaction to fungi
 Seen in young adults
 h/o asthma
 Sino nasal polyps
 Pan sinusitis
 Nasal secretions – mucin – contains eosinophils,
charcot leyden crystals, fungal hyphae
 No invasion of sinuses, bony erosion by pressure
 Treatment – FESS with pre op and post op
systemic steroids

18.  Chronic invasive sinusitis
 Invades sinus mucosa
 Bone erosion by fungi
 Intracranial and intraorbital invasion
 Treatment
 Surgical removal of invaded mucosa
 Anti fungal therapy – Amphotericin B IV,
Itraconazole oral

19.  Fulminant fungal sinusitis
 Fungi – mucor, aspergillus
 Immunocompromised
 Widespread haemotogenous and intracranial
spread/extension
 Mucor – invades blood vessels, ischaemic
necrosis, black eschar (discolouration)of
turbinates, mucosa, palate
 Aspergillus – tissue invasion, sepsis, no black
eschar
 Treatment – surgical debridement of necrosed
tissue
 Anti fungal therapy – Amphotericin B IV

20.  Infection spreads into or beyond the bony walls
of PNS
 EXTRA CRANIAL
 Mucocele
 Pyocele
 Osteomyelitis
 Orbital – Orbital cellulitis and abscess
 Descending infections – ASOM,CSOM,
Pharyngitis, Tonsillitis, Laryngitis, Bronchitis
 Focal infections – Polyarthritis, Tenosynovitis,
skin diseases
 Distant infections – Septicaemia, TSS

21.  INTRACRANIAL
 Meningitis
 Encephalitis
 Brain abscess, Subdural abscess, Extradural
abscess
 Cavernous Sinus Thrombophlebitis
 Ant PNS complications – mucocele, pyocele,
osteomyelitis, orbital, intracranial
 Post PNS complications – CST, Supraorbital
fissure syndrome, Orbital apex syndrome,
optic neuritis

22.  Chronic epithelial lined, oval cystic swelling of PNS
containing mucus occurs as a complication of chronic
sinusitis
 Etiology
 Due to permanent/chronic obstruction of sinus
ostium
 Due to obstruction of ducts of mucus/minor salivary
glands of sinus mucosa
 Leading to expansion of sinus and erosion of bony
wall or collection of secretions in the sinus leading to
retention cyst without wall erosion
 Any age group, mc 40-60 years
 Frontal (mc), Ethmoid (2nd mc), Maxillary, Sphenoid

23.  Spread
 Direct – through walls of sinus –
 Osteomyelitis, Mucocele
 Venous – through subepithelial venous plexus
 Lymphatics – through perivascular lymphatic
spread
 Olfactory nerve – through perineural sheath
 INVESTIGATIONS
 X Ray PNS
 CT Scan OMC
 DNE

24.  Frontal Mucocele
 Due to chronic diseases of frontal
sinus/recess, post surgery or traumatic
fibrosis of ostia – blockage of ostia
 Invades superomedial wall of orbit – displaces
the eye ball downwards, laterally and
foarwards
 Invades anterior wall – swelling in forehead
 Invades posterior wall – displacement of dura
 Can occur as fronto ethmoid mucocele

25.  C/F
 Supraorbital swelling above and lateral to medial
canthus
 Diplopia
 Proptosis with downward, forward and lateral
displacement of eye ball
 Mild and dull frontal headache
 Swelling is cystic, non tender, egg shell cracking
elicited
 Cystic swelling in forehead, result in fistulae
formation
 Retention cyst – may be asymptomatic

26.  Diagnosis
 X Ray PNS – Cloudiness of affected sinus, loss of
scalloping/outline of sinuses
 CT Scan OMC and PNS
 DNE – Swelling in region of attachment of middle
turbinate
 Treatment
 FESS with frontal recess clearance
 External fronto ethmoidectomy (Lynch Howarth
operation)
 Osteoplastic flap operation
 Asymptomatic retention cyst – no treatment
required

27.  Ethmoidal mucocele
 Expansion of cyst towards lamina papyracea – expansion
of medial wall of orbit – displacement of eyeball laterally
 Bulge in middle meatus of nose
 Rarely seen in children (anterior ethmoid)
 Treatment – Intranasal surgery/ external ethmoidectomy
 Maxillary mucocele – mainly affects floor of maxillary sinus
 Sphenoethmoidal mucocele – extends to retrobulbar area
with pressure on optic nerve leading to exophthalmos,
visual disturbance
 Diagnosis – CT Scan
 Treatment – Endoscopic sphenoidotomy/ External
sphenoethmoidectomy

28.  Can lead to –
 Superior orbital fissure syndrome
 Involvement of III, IV, V-1and VI CN
 Deep seated orbital pain
 Frontal headache/ pain over occiput/vertex
 Due to infection of sphenoid sinus
 Orbital apex syndrome
 Involvement of II, III, IV, V-1, V-2 and VI CN

29.  Complication of acute sinusitis
 Infection of mucocele
 Pain and fever
 Ethmoidal pyocele – seen in children
 Treatment – evacuation of pus and excision
of diseased mucosa
 IV broad spectrum antibiotics

30.  Commonly seen in ethmoid sinus infections as
closely related to orbit by lamina papyracea
 2nd – frontal sinus infections
 Can lead to orbital cellulitis, subperiosteal
abscess, intra orbital abscess
 Inflammatory oedema of eyelids – upper lid
(frontal), lower lid (maxillary), both (ethmoidal)
 Proptosis
 Lid oedema
 Chemosis of conjuctiva
 Exophthalmos
 Ophthalmoplegia

31.  High grade fever – 102 to 104 F
 Limited eye movements
 Headache
 Partial or total visual loss
 Displacement of eyeball
 Complications – can lead to meningitis, CST
 Diagnosis – CT/USG Orbit
 Treatment
 Exploration and drainage of affected sinus
 IV antibiotics
 Pencillin/Vancomycin – for gram positive
 IIIrd gen Cephalosporins/ Metronidazole/
Clindamycin – for gram negative

32.  Osteitis – infection of compact bone
 Osteomyelitis – infection of cancellous/diploic bone,
infection of bone marrow
 Involves – Frontal Sinus (mc), Maxillary sinus (2nd mc)
 Etiology
 Suppurative sinusitis (acute infection)
 Trauma
 Surgery
 Thrombophlebitis of infected bone
 Staph aureus, streptococci, pneumococci, anaerobes
 F>M
 Frontal – adults, Maxillary – infants and children

33.  Frontal Osteomyelitis
 Fever – low grade
 Headache
 Purulent discharge from infected bone
 Edema of upper eyelid
 Erosion of anterior wall – Pott’s Puffy tumour –
swelling in the frontal region- soft and doughy with
pus beneath the swelling, moth eaten appearance on
X Ray
 Erosion of posterior wall – extradural abscess,
intracranial spread
 Diagnosis – CT
 Treatment – exploration and drainage of frontal sinus

34.  Maxillary Osteomyelitis
 MC in children and infants as anterior wall of maxilla
is spongy
 Etiology
 Acute maxillary sinusitis
 Dental infection – children
 Buccal infection – infants
 C/F
 Erythema and swelling of cheeks
 Edema of lower eyelid
 Purulent nasal discharge
 Fever
 Can lead to subperiosteal abscess
 C/F

35.  Can lead to fistula formation – infra orbital
region, alveolus, palate, zygoma
 Sequestration of bone
 Treatment
 IV high dose antibiotics
 Drainage of abscess
 Removal of damaged bone

36.  Meningitis
 Extradural abscess
 Subdural abscess
 Cerebral abscess
 CST
 Etiology
 Sinusitis – Destruction of roof of frontal,
ethmoidal, sphenoidal sinus – anterior cranial
fossa
 Otitis Media
 Treatment – IV antibiotics and anti convulsive
therapy

37.  Etiology
 Infection of PNS – posterior ethmoid and sphenoid
 Orbital complications of sinusitis
 Furunculosis of nose, infection of vestibule
 Due to valveless nature of veins of cavernous sinus –
easy spread of infection
 C/F
 Abrupt onset with B/L involvement
 High grade fever 105 F with chills and rigor
 Acute ill
 Swollen eyelids and proptosis of eyeball
 Ophthalmoplegia with retinal congestion

38.  Diminished vision
 Dilated and fixed pupil
 Papilloedema and chemosis of conjuctiva
 Affects III, IV, V-1 and VI CN
 Diagnosis
 CT Scan
 Blood culture
 Fundus examination – papilloedema
 CSF – normal
 Treatment
 IV antibiotics/ anticoagulant therapy
 Drainage of infected sinus
 Orbital decompression

39.  Communication between oral cavity and maxillary
sinus
 Etiology
 Dental extraction – upper premolar and molar
 Malignancy
 Granulomatous disorders
 Complication of acute maxillary sinusitis
 Trauma
 Surgery – Caldwel Luc Surgery
 C/F – passage of food and fluids from oral cavity
to nose
 Blow of air from nose to oral cavity

40.  Treatment
 Antibiotics
 Large fistula – surgery with flaps – palatal and
buccal flaps
 TOXIC SHOCK SYNDROME
 Staph aureus (mc), Streptococci
 Fever
 Rash, desquamation of skin
 Hypotension
 Multi organ failure