Presented in seminar at capital hospital

1. Dr. Junaid Shahzad
Resident
ENT Department
Capital Hospital
RHINOSINUSITIS

2. Outline
• Introduction
• Classification
• Epidemiology
• Predisposing factors
• Patho-physiology
• Microbiology
• Signs and Symptoms
• Investigation
• Management
01/19/16
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3. 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

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5. 01/19/16 Depertment of E.N.T 5

6. 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

7. 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

8. 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
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9. 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
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A survey on the management of acute rhinosinusitis among Asian physicians.
. Rhinology. 2011 Aug;49(3):264-71. doi: 10.4193/Rhino10.169.

10. Predisposing factors
Local
URI
Allergic rhinitis
Nasal septal defects
Nasal foreign bodies
Dental infections
Overuse of topical decongestants
Nasal polyps or tumors
Aspiration of infected water

11. Cont.
Systemic
Diabetes
Immunocompromise (AIDS)
Malnutrition
Blood dyscrasias
Cystic fibrosis
Chemotherapy
Long term steroid Rx
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12. PATHOGENESIS
Basic cause is osteomeatal complex (the middle
meatal region & the frontal, ethmoid, &
maxillary sinus ostia there) inflammation &
infection
Sinus ostia occluded
Colonizing bacteria replicate
Ciliary dysfunction
Mucosal edema
Lowered PO2 & pH

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14. Microbiology
Aerobic 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)
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15. 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
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17. 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.
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19. 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.
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23. INVESTIGATIONS
• Complete blood picture with ESR
• X-ray PNS
• Nasal Swab C/S
• CT
• MRI
• Biopsy
• ANA/ ANCA
• Rhinometry
• Olfaction assessment
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X-RAYS

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26. CT Scan
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27. CT scan
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31. 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.
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32. Complications
Orbital 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
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33. Management
Conservative Management:
Avoidance
Nasal douching
Antibiotics/Antifungal
Decongestants
Corticosteroids
Anti-Histamines/Anti-Leukotrienes
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34. Surgical Management
• FESS
• Antral lavage
• Caldwell-luc procedure
• Ethmoidectomies
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35. • 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
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FESS

36. • 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.
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37. 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.

38. 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.
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39. Caldwell-Luc’s procedure
 Sublabial approach to maxillary antrum
 Intranasal inspection and disease clearance

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41. 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.
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