Sinusitis

Dr. T. Balasubramanian

Sinusitis

Can be defined as inflammation of the mucosa lining the paranasal sinuses Can be classified into acute and chronic Allergic & infective types Pan sinusitis is the term used to indicate inflammation of all the paranasal sinuses

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Acute sinusitis

Acute inflammation of mucosa lining paranasal sinuses of less than 4 weeks duration Infection is said to be closed if the inflammatory exudate cannot escape from the sinus because of blocked ostium or viscous secretion Infection is said to be open if the exudate escapes from the sinuses due to normal functioning mucociliary clearence mechanism

Pathophysiology

Acute sinusitis is caused when the normal defence mechanisms like lysozymes and mucociliary clearance mechanism is breached due to viral infection. After the defences are breached, secondary bacterial infection follows.

Aetiology

Infections Swiming / bathing Trauma to paranasal sinuses As a component of general diseases

Infections

Nasal infections Pharyngeal infections Dental infections

Swiming / bathing

Infected pool / ponds Chemical rhinitis Bacterial sinusitis – due to water contamination

Trauma to sinuses

Compound fractures involving sinuses Foreign bodies involving sinuses Barotrauma - aerosinusitis

General diseases

Influenza Measles Whooping cough Pneumonia

Contributing factors

Unhygenic environment Low resistence to infections Over crowding Anatomical obstructions Conditions like Kartagener's syndrome Osteomeatal complex block

Importance of OMC

It represents an important anatomic site where the drainage channels of maxillary,frontal and ethmoidal sinuses drain Bounded by middle turbinate medially, basal lamella posteriorly and superiorly and lamina papyracea laterally It drains anteriorly and inferiorly Blockage in this zone causes bacterial sinusitis

Microbiology

Viruses include – Rhinovirus, Parainfluenzae I and II, Coxsackie, and Respiratory syncitial virus Bacteria include – Pneumococci, streptococci, staphylococci, H influenzae, E coli, Micrococcus Specific infections – Fungi, syphilis, tuberculosis and leprosy

Pathological stages

Catarrhal stage Exudative stage Suppurative stage Stage of complications Stage of resolution

Criteria to suggest bacterial sinusitis

Diagnosis of bacterial sinusitis requires two major / one major or two or more minor criteria History should be strongly suggestive of bacterial sinusitis Gold standard investigations would be pus culture and sensitivity

Major criteria

Facial pain / tenderness Facial fullness & congestion Nasal congestion & obstruction Purulent nasal discharge / post nasal drip Hyposmia / anosmia Fever

Minor criteria

Headache Halitosis Fatigue Cough Dental pain Ear fullness / ear pain

Clinical types

Acute catarrhal type – Earliest stage. There is oedema, mucous secretion, presence of leukocytes. There is no destruction of mucous membrane lining the sinuses. Acute suppurative type – Inflammation is very severe. Large number of leukocytes seen. Pus could be seen accumulating due to suppuration. The mucous membrane may be necrotic and polypoidal

Symptoms

General symptoms – Malaise, headache, mild fever, facial pain, sorethroat and periorbital oedema. Local symptoms – Nasal block, loss of vocal resonance, reduction in sense of smell, nasal discharge, post nasal drip, cough, pain over sinus area

Features of pain

Antral pain – Occurs along the infraorbital margins, and is referred to upper teeth Ethmoidal pain – Over bridge of nose, and inner canthus of eye. May be referred to parietal eminence Frontal sinus pain – Localized to forehead. Shows classic periodicity Sphenoidal pain – Occipital in nature. May radiate to the neck

Signs

Swelling over cheek Swelling over lower eyelids / upper eyelids Swelling over inner canthus of eye Tenderness over affected sinus Anterior rhinoscopy – Congested nasal mucosa, sometimes discharge from middle meatus

Investigations

Radiology Culture sensitivity Routine hematology

Treatment

Purely medical Antibiotics Nasal decongestants Anti histamines Anti inflammatory drugs Surgery very rare – complications common. Indicated only in cases of impending complications

Complications

Osteomyelitis of the surrounding bone Orbital cellulitis Orbital abscess formation Intracranial complications – cavernous sinus thrombosis, meningitis, and intracranial abscess Ch sinusitis Middle ear infections Laryngitis, oroantral fistula, mucoceles