ACUTE SINUSITIS - Welcome to UTMB Health, The … · · 2013-08-28ANATOMY There are four ... Acute sinusitis is defined as disease lasting ... Known as Pott’s puffy tumor

ACUTE SINUSITISACUTE SINUSITIS

Michael E. Prater, MDMichael E. Prater, MDFrancis B. Quinn, MDFrancis B. Quinn, MD

March 19, 1997March 19, 1997

ANATOMYANATOMY

➤➤ There are four pairedThere are four paired paranasal paranasal sinuses, the sinuses, themaxillary,maxillary, ethmoid ethmoid, frontal and sphenoid, frontal and sphenoidsinusessinuses

➤➤ “Anterior” and “posterior” sinuses“Anterior” and “posterior” sinuses➤➤ Lining of the sinuses isLining of the sinuses is pseudostratified pseudostratified,,

columnar epithelium (respiratorycolumnar epithelium (respiratoryepithelium) which is continuous with theepithelium) which is continuous with thenasal epitheliumnasal epithelium

ANATOMY (continued)ANATOMY (continued)

➤➤ TheThe muocsa muocsa secretes a mucous which traps secretes a mucous which trapsbacteriabacteria

➤➤ The mucous is naturally extruded throughThe mucous is naturally extruded throughsinussinus ostia ostia to be expectorated or swallowed to be expectorated or swallowed

➤➤ The drainage of the maxillary and frontalThe drainage of the maxillary and frontalsinuses follows a circular pattern throughsinuses follows a circular pattern throughthe naturalthe natural ostia ostia

The Ethmoid SinusThe Ethmoid Sinus

➤➤ Appear asAppear as evaginations evaginations of the lateral nasal of the lateral nasalwall around the third month of fetalwall around the third month of fetalgestationgestation

➤➤ Are present at birth, adult size by age 12Are present at birth, adult size by age 12➤➤ Are separated by the ground (basal) lamellaAre separated by the ground (basal) lamella

into the anterior and posteriorinto the anterior and posterior ethmoids ethmoids,,which drain into the middle and superiorwhich drain into the middle and superiormeatusmeatus, respectively, respectively

The Ethmoid Sinus, continuedThe Ethmoid Sinus, continued

➤➤ Consist of vertical and horizontal platesConsist of vertical and horizontal plates➤➤ The vertical plate is divided into twoThe vertical plate is divided into two

portions, the perpendicular plate of theportions, the perpendicular plate of theethmoidsethmoids and the and the crista galli crista galli

➤➤ The horizontal plate is known laterally asThe horizontal plate is known laterally asthe foveathe fovea ethmoidalis ethmoidalis and medially as the and medially as thecribriformcribriform plate plate

➤➤ Medially is the laminaMedially is the lamina papyracea papyracea

The Ethmoid Sinus, continuedThe Ethmoid Sinus, continued

➤➤ Blood supply is from both the external andBlood supply is from both the external andinternal branches of the carotid, through theinternal branches of the carotid, through thesphenopalatinesphenopalatine and the anterior and and the anterior andposteriorposterior ethmoidal ethmoidal arteries arteries

➤➤ InnervationInnervation is from V2 and V3 is from V2 and V3

The Maxillary SinusesThe Maxillary Sinuses

➤➤ The largest sinusThe largest sinus➤➤ Pyramidal shaped with apex nearPyramidal shaped with apex near zygomatic zygomatic

archarch➤➤ In child, inferior border near nasal floor. InIn child, inferior border near nasal floor. In

adult, 1 cm below nasal flooradult, 1 cm below nasal floor➤➤ Floor over maxillary dentition, which isFloor over maxillary dentition, which is

often thin and dehiscent over tooth rootsoften thin and dehiscent over tooth roots

Maxillary Sinuses, ContinuedMaxillary Sinuses, Continued

➤➤ TheThe infraorbital infraorbital nerve runs along roof, and nerve runs along roof, andis often dehiscent. At risk duringis often dehiscent. At risk during antral antralproceduresprocedures

➤➤ SinusSinus ostia loacated anteriorly ostia loacated anteriorly in the middle in the middlemeatusmeatus

➤➤ AccessoryAccessory ostia ostia are usually more posterior are usually more posteriorand are a sign of chronic diseaseand are a sign of chronic disease

Maxillary Sinus, continuedMaxillary Sinus, continued

➤➤ Blood supply is from divisions of theBlood supply is from divisions of themaxillary arterymaxillary artery

➤➤ InnervationInnervation is via V2 is via V2➤➤ PostganglionicPostganglionic sympathetic fibers are from sympathetic fibers are from

VII via theVII via the sphenopalatine sphenopalatine ganglion and the ganglion and thegreater superficialgreater superficial petrosal petrosal nerve nerve

Frontal SinusFrontal Sinus

➤➤ Begins asBegins as evagination evagination of the anterior nasal of the anterior nasalcapsule around the fourth month ofcapsule around the fourth month ofdevelopmentdevelopment

➤➤ Rarely present at birth; usually not visibleRarely present at birth; usually not visibleuntil age 2until age 2

➤➤ Great variability in size; congenitallyGreat variability in size; congenitallyabsent in 5%absent in 5%

Frontal Sinus, continuedFrontal Sinus, continued

➤➤ Drains into the frontal recess in the middleDrains into the frontal recess in the middlemeatusmeatus near the upper portion of the near the upper portion of theinfundibuluminfundibulum

➤➤ Like the maxillary sinuses, haveLike the maxillary sinuses, have circurlar circurlarmucociliarymucociliary clearance clearance

➤➤ Blood supply from theBlood supply from the supraorbital supraorbital and andsupratrochlearsupratrochlear arteries, arteries, innervation innervation from fromnerves of the same namenerves of the same name

Sphenoid SinusesSphenoid Sinuses

➤➤ Began asBegan as outpuchings outpuchings of the superior nasal of the superior nasalvault around the fourth month of gestationvault around the fourth month of gestation

➤➤ Rarely present at birth, usually seen aroundRarely present at birth, usually seen aroundage 4age 4

➤➤ Drain into the superiorDrain into the superior meatus meatus in the in thesphenoethmoidalsphenoethmoidal recess recess

➤➤ OstiaOstia of variable size of variable size

Sphenoid Sinuses, continuedSphenoid Sinuses, continued

➤➤ The optic nerve liesThe optic nerve lies superiorly superiorly➤➤ The pons liesThe pons lies posteriorly posteriorly➤➤ The cavernous sinus is lateral, along withThe cavernous sinus is lateral, along with

CNIII, IV and VI and the carotid arteryCNIII, IV and VI and the carotid artery➤➤ The carotid artery is dehiscent in 50% ofThe carotid artery is dehiscent in 50% of

specimensspecimens

Sphenoid Sinuses, continuedSphenoid Sinuses, continued

➤➤ Blood supply from both the internal andBlood supply from both the internal andexternal carotid arteries via theexternal carotid arteries via thesphenopalatinesphenopalatine (floor) and the posterior (floor) and the posteriorethmoidalethmoidal arteries (roof) arteries (roof)

➤➤ InnervationInnervation from V2 and V3 from V2 and V3

Pathophysiology of SinusitisPathophysiology of Sinusitis

➤➤ Lined by respiratory epitheliumLined by respiratory epithelium➤➤ Mucous blanket is in two layers: aMucous blanket is in two layers: a

superficial viscous layer and an underlyingsuperficial viscous layer and an underlyingserous layer.serous layer.

➤➤ Cilia beat in the serous layer, moving theCilia beat in the serous layer, moving theblanket towards the naturalblanket towards the natural ostia ostia

➤➤ Normal function depends on patentNormal function depends on patent ostia ostia,,ciliaryciliary function and quality of mucous function and quality of mucous

Pathophysiology of Sinusitis,continuedPathophysiology of Sinusitis,continued

➤➤ Most important pathologic process inMost important pathologic process indisease is obstruction of naturaldisease is obstruction of natural ostia ostia

➤➤ Obstruction leads toObstruction leads to hypooxygenation hypooxygenation➤➤ HypooxygenationHypooxygenation leads to leads to ciliary ciliary

dysfunction and poor mucous qualitydysfunction and poor mucous quality➤➤ CiliaryCiliary dysfunction leads to retention of dysfunction leads to retention of

secretionssecretions


➤➤ Local factors can impairLocal factors can impair ciliary ciliary function. function.Cold air “stuns” the epithelium, resulting inCold air “stuns” the epithelium, resulting inretained secretions. Dry airretained secretions. Dry air dessicates dessicates the theblanket.blanket.

➤➤ Anatomical factors,Anatomical factors, ie ie, polyps, tumors,, polyps, tumors,foreign bodies andforeign bodies and rhinitis rhinitis, block the, block the ostia ostia

➤➤ Kartagener’sKartagener’s Syndrome ( Syndrome (immotileimmotile cilia ciliasyndrome)syndrome)


➤➤ Acute sinusitis is defined as disease lastingAcute sinusitis is defined as disease lastingless than one monthless than one month

➤➤ SubacuteSubacute sinusitis is defined as disease sinusitis is defined as diseaselasting 1 to 3 monthslasting 1 to 3 months

➤➤ Chronic sinusitis is defined as diseaseChronic sinusitis is defined as diseaselasting more than three months, and islasting more than three months, and isusually due to inadequately treated acute orusually due to inadequately treated acute orsubacutesubacute disease disease


➤➤ Acute sinusitis andAcute sinusitis and subacute subacute sinusitis are sinusitis aretreated medicallytreated medically

➤➤ Chronic sinusitis is considered irreversibleChronic sinusitis is considered irreversibleby medical therapy alone, and it is currentlyby medical therapy alone, and it is currentlybelieved oxygenation of the sinuses throughbelieved oxygenation of the sinuses throughopening of theopening of the ostia ostia is the primary treatment is the primary treatment

History and Physical ExamHistory and Physical Exam

➤➤ Acute sinusitis presents as pain overAcute sinusitis presents as pain overinfected areas, with or without headacheinfected areas, with or without headache

➤➤ Pain to palpation is common with anteriorPain to palpation is common with anteriorsinusitis, but is usually absent with thesinusitis, but is usually absent with theposterior sinusesposterior sinuses

➤➤ Posterior sinuses present asPosterior sinuses present as bitemporal bitemporal or orvertex headachesvertex headaches

➤➤ Fever, malaise, nasal discharge presentFever, malaise, nasal discharge present

History and Physical, continuedHistory and Physical, continued

➤➤ Chronic sinusitis usually seen with aChronic sinusitis usually seen with amucopurlentmucopurlent discharge, but fever is usually discharge, but fever is usuallynot presentnot present

➤➤ Acute sinusitis is often imposed on chronicAcute sinusitis is often imposed on chronicdiseasedisease

➤➤ Note any facial edema, tenderness,Note any facial edema, tenderness, mucosal mucosaledema,edema, septal septal perforations and deviations perforations and deviations

History and PhysicalHistory and Physical

➤➤ Diagnosis is primarily clinical, butDiagnosis is primarily clinical, butradiographs can be usedradiographs can be used

➤➤ TransilluminationTransillumination of the sinuses can of the sinuses cansometimes be used, but due to differences insometimes be used, but due to differences insinus size andsinus size and patency patency , these tests are not , these tests are notreliablereliable

➤➤ Antral lavageAntral lavage can be performed in select can be performed in selectcases where the diagnosis is in doubtcases where the diagnosis is in doubt

Acute Bacterial SinusitisAcute Bacterial Sinusitis

➤➤ Acute sinusitis can be thought of as anAcute sinusitis can be thought of as anabscess orabscess or empyema empyema

➤➤ Cornerstone is drainage and antibioticsCornerstone is drainage and antibiotics➤➤ Drainage is usually medical with topicalDrainage is usually medical with topical

decongestants and sometimesdecongestants and sometimesantihistaminesantihistamines

➤➤ In rare cases where medical treatment fails,In rare cases where medical treatment fails,surgical drainage may be requiredsurgical drainage may be required

Acute Bacterial Sinusitis,continuedAcute Bacterial Sinusitis,continued

➤➤ S.S. pneumo pneumo, H. flu and M., H. flu and M. carrarhalis carrarhalis➤➤ AmoxicillinAmoxicillin is the first line antibiotic. is the first line antibiotic.

Failure to respond toFailure to respond to amoxicillin amoxicillinnecessitatesnecessitates broading broading coverage with coverage withclavulonicclavulonic acid and possible Gram’s stain acid and possible Gram’s stainand cultureand culture

➤➤ Surgical drainage is required for failures onSurgical drainage is required for failures onaugmentinaugmentin and topical decongestants and topical decongestants

Acute Bacterial Sinusitis,continuedAcute Bacterial Sinusitis,continued

➤➤ Maxillary sinuses are surgically drained byMaxillary sinuses are surgically drained byantral lavageantral lavage, inferior, inferior meatal meatal windows or windows ormiddlemiddle meatal meatal windows windows

➤➤ Frontal sinuses are drained by trephination,Frontal sinuses are drained by trephination,and a drain is left in place and irrigatedand a drain is left in place and irrigatedtwice a day until drainage through thetwice a day until drainage through thefrontal duct is observedfrontal duct is observed

➤➤ AnAn ethmoidectomy ethmoidectomy drains the drains the ethmoids ethmoids

Acute Fungal SinusitisAcute Fungal Sinusitis

➤➤ UncommonUncommon➤➤ Seen usually inSeen usually in immunocompromised immunocompromised➤➤ AspergillosisAspergillosis,, mucormycosis mucormycosis,, candidiasis candidiasis,,

histoplasmosishistoplasmosis and and coccidiomycosis coccidiomycosis seen seen➤➤ AspergillosisAspergillosis most common most common➤➤ Requires high index ofRequires high index of suspscion suspscion➤➤ Diagnosed by biopsy and cultureDiagnosed by biopsy and culture

Acute Fungal Sinusitis, continuedAcute Fungal Sinusitis, continued

➤➤ AspergillosisAspergillosis a common pathogen of soil, a common pathogen of soil,fruits, vegetables, grains, birds andfruits, vegetables, grains, birds andmammalsmammals

➤➤ Suspect if dark, greasy material seenSuspect if dark, greasy material seen➤➤ Cultures of nose usually not diagnosticCultures of nose usually not diagnostic➤➤ AntrostomyAntrostomy with biopsy and fungal stain with biopsy and fungal stain

requiredrequired


➤➤ NoninvasiveNoninvasive Aspergillosis Aspergillosis seen as fungal seen as fungalball, usually in maxillary sinusball, usually in maxillary sinus

➤➤ InvasiveInvasive aspergillosis aspergillosis can invade bone. can invade bone.➤➤ Fulminant aspergillosisFulminant aspergillosis occurs in occurs in

immunocompromisedimmunocompromised and invades adjacent and invades adjacentstructuresstructures

➤➤ Therapy for noninvasive forms is surgicalTherapy for noninvasive forms is surgicalexcision followed usually by POexcision followed usually by PO antifungals antifungals


➤➤ Therapy for invasive forms requires wideTherapy for invasive forms requires widelocallocal debridement debridement and intravenous and intravenous ampo ampo B B

➤➤ MucormycosisMucormycosis is encountered in dust and is encountered in dust andsoil and enters through the respiratory tractsoil and enters through the respiratory tract

➤➤ The fungus invades vascular channels andThe fungus invades vascular channels andcausescauses hemorrhagic ischemia hemorrhagic ischemia and necrosis and necrosis

➤➤ Frequently fatal. 90% mortality inFrequently fatal. 90% mortality inimmunocompromisedimmunocompromised


➤➤ KetoacidosisKetoacidosis predisposes to predisposes to mucormycosis mucormycosis,,as the fungus thrives in acidic environmentsas the fungus thrives in acidic environments

➤➤ Initially seen as engorgement ofInitially seen as engorgement of turbinates turbinates,,followed byfollowed by ischemia ischemia and necrosis of the and necrosis of theturbinatesturbinates and adjacent nose and adjacent nose

➤➤ Treated with radical surgicalTreated with radical surgical debridement debridement,,amphotericinamphotericin B and correction of B and correction ofunderlyingunderlying immunosuppression immunosuppression

Complications: MucocelesComplications: Mucoceles

➤➤ MucocelesMucoceles are chronic, cystic lesions of the are chronic, cystic lesions of thesinuses lined bysinuses lined by pseudostratified pseudostratified epithelium epithelium

➤➤ Expand slowly, often requiring many yearsExpand slowly, often requiring many years➤➤ Etiology is debated. Either due toEtiology is debated. Either due to

obstruction ofobstruction of ostia ostia or to simple obstruction or to simple obstructionof minor salivary glandof minor salivary gland

➤➤ 30% are idiopathic30% are idiopathic


➤➤ Frequently noted on routine CT scan ofFrequently noted on routine CT scan ofmaxillary sinuses. No treatment is requiredmaxillary sinuses. No treatment is requiredunless near naturalunless near natural ostia ostia

➤➤ Frontal sinusFrontal sinus mucoceles mucoceles are important to are important torecognize as they causerecognize as they cause proptosis proptosis and even and evenblindnessblindness

➤➤ Therapy involves obliteration of sinusTherapy involves obliteration of sinus


➤➤ SphenoidalSphenoidal and and ethmoidal mucoceles ethmoidal mucoceles are areless commonless common

➤➤ Seen with vertex headaches and deep nasalSeen with vertex headaches and deep nasalpainpain

➤➤ Treatment is controversial; wide drainageTreatment is controversial; wide drainageinto the nasal vault is commoninto the nasal vault is common

Complications: OrbitalComplications: Orbital

➤➤ Orbit separated fromOrbit separated from ethmoids ethmoids by thin by thinlaminalamina papyracea papyracea

➤➤ First indication of orbitalFirst indication of orbital involvemnt involvemnt is isinfalmmatoryinfalmmatory edema of eyelids edema of eyelids

➤➤ Inflammatory edema of eyelids progressesInflammatory edema of eyelids progressestoto cellulitis cellulitis,, proptosis proptosis,, chemosis chemosis and andophthalmoplegiaophthalmoplegia


➤➤ Five classifications of orbital complicationsFive classifications of orbital complications1) Inflammatory edema: lid edema1) Inflammatory edema: lid edemaotherwise normal.otherwise normal.2) Orbital2) Orbital cellulitis cellulitis: diffuse edema: diffuse edema3)3) Subperiosteal Subperiosteal abscess: usually seen near abscess: usually seen nearlaminalamina papyracea papyracea4)Orbital abscess: collection within orbit4)Orbital abscess: collection within orbit5) Cavernous sinus thrombosis: bilateral5) Cavernous sinus thrombosis: bilateral


➤➤ Orbital complications sometimes seen inOrbital complications sometimes seen infrontal sinusitis as the floor of the sinus isfrontal sinusitis as the floor of the sinus isthinthin

➤➤ Known asKnown as Pott’s Pott’s puffy tumor puffy tumor➤➤ Treatment of orbital inflammation andTreatment of orbital inflammation and

cellulitiscellulitis is with IV is with IV antibitoics antibitoics with or with orwithout sinus drainagewithout sinus drainage


➤➤ Abscesses are treated with surgical drainageAbscesses are treated with surgical drainageand IV antibioticsand IV antibiotics

➤➤ Indications for surgical drainage includeIndications for surgical drainage includeprogresiveprogresive orbital orbital cellulitis cellulitis, symptoms, symptomswhich do not resolve, abscess, loss of visualwhich do not resolve, abscess, loss of visualacuityacuity

Complications: Cavernous SinusThrombosisComplications: Cavernous SinusThrombosis

➤➤ High mortality rateHigh mortality rate➤➤ Usually results from retrogradeUsually results from retrograde

transmission throughtransmission through valveless valveless veins veinsleading to the cavernous sinusleading to the cavernous sinus

➤➤ Heralded by bilateral orbital involvement,Heralded by bilateral orbital involvement,progessive chemosisprogessive chemosis, T 105F, T 105F

➤➤ Treat with drainage, IV antibioticsTreat with drainage, IV antibiotics➤➤ Heparin is controversialHeparin is controversial

Complications: IntracranialComplications: Intracranial

➤➤ SubduralSubdural abscess, abscess, intracranial intracranial abscess, abscess,meningitis seenmeningitis seen

➤➤ Meningitis common in childrenMeningitis common in children➤➤ 1/3 to 2/3 of all1/3 to 2/3 of all subdural subdural abscesses believed abscesses believed

due to sinusitisdue to sinusitis➤➤ NuchalNuchal rigidity first symptom rigidity first symptom➤➤ NeurosurgeyNeurosurgey consult to manage ICP, consult to manage ICP,

surgical drainagesurgical drainage

RadiologyRadiology

➤➤ Plain films are generally obsoletePlain films are generally obsolete➤➤ Exceptions include confirmation of air fluidExceptions include confirmation of air fluid

levels in acute sinusitis, and evaluating sizelevels in acute sinusitis, and evaluating sizeand integrity of theand integrity of the paranasal paranasal sinuses sinuses

➤➤ CT scan the study of choice in chronicCT scan the study of choice in chronicsinusitis, but usually not useful in acutesinusitis, but usually not useful in acutesinusitis, as diagnosis primarily clinicalsinusitis, as diagnosis primarily clinical

Radiology: Plain FilmsRadiology: Plain Films

➤➤ Three general views: Waters’,Three general views: Waters’, Caldwell’s Caldwell’sand lateraland lateral

➤➤ Waters’ view with nose and chin on film.Waters’ view with nose and chin on film.Useful for maxillary sinusesUseful for maxillary sinuses

➤➤ Caldwell view with nose and forehead onCaldwell view with nose and forehead onfilm. Useful for frontal andfilm. Useful for frontal and ethmoid ethmoid sinuses sinuses

➤➤ Lateral film useful for sphenoid sinusesLateral film useful for sphenoid sinuses

Radiology: Plain Films,continuedRadiology: Plain Films,continued

➤➤ Viral sinusitis usually seen as minimalViral sinusitis usually seen as minimalmucosalmucosal thickening thickening

➤➤ Bacterial sinusitis more often unilateral andBacterial sinusitis more often unilateral andseen with an air fluid levelseen with an air fluid level

➤➤ AllergicAllergic rhinitis rhinitis more often bilateral and more often bilateral andwith morewith more mucosal mucosal thickening thickening

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ACUTE SINUSITIS - Welcome to UTMB Health, The … · · 2013-08-28ANATOMY There are four ... Acute sinusitis is defined as disease lasting ... Known as Pott’s puffy tumor