management of sinusitis

8/3/2019 Management of Sinusitis

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4/28/2012 Abou-Elhamd 1


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Management of Sinusitis

Dr. Kamal Abou-Elhamd MD

Professor in ENTAl-Ahsa College of Medicine

King Faisal University


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Medical Treatment of

Sinusitis

Treatment is aimed at:1. Blocking the inflammatory reactions

that cause the symptoms includes:first generation antihistaminesdecongestants, and nonsteroidal

anti-inflammatory drugs (NSAIDs)2. While antibiotics should be given to

eliminate the infection in acute

bacterial sinusitis.


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Antibiotics in CRS

Should be based on culture resultsEndoscopic directed culture of

purulent secretions from the nasalvestibule or middle meatus correlatewell with maxillary tap results

S. aureus, Anaerobes & Gramnegative

Pseudomona Aeruginosa


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Antibiotics in CRS

First-lineamoxicillin-clavulanate

cephalosporin second-or third-generation

Second-line

For adultsThe respiratory quinolones

ciprofloxin, levofloxacin,

gatifloxacin, and moxifloxacin


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Antibiotics in CRS

Additional and backup

Clarithromycin and azithromycinachieve excellent mucosal levelsClindamycin should be reserved for

culture-documented resistant S.pneumoniae


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Antibiotics in CRS

Broad-spectrum antibiotic for up to 3weeks.

Improvement in symptoms within 3 to 5 days.Resolution of symptoms within 7 to 10 daysafter first improvement.Another week- to diminish mucosal edema and

improve mucociliary functionRapid recurrence after previous treatment

Add 3- to 6-week course of once-dailyprophylactic antibiotic therapy


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Surgical treatment

With failure of the previousmedical treatment, there areindications for surgicaltreatment


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Indications for

Surgical treatment

1. History of at least 3 months of intermittent orpersistent facial pain

2. Intermittent or persistent fever3. Tenderness or headache over the areas of the

maxillary, ethmoid or frontal sinuses4. Purulent discharge from nasal passages or

nasopharynx5. Radiographic evidence of opacification on CT

scans


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HARKNESS P[ \ BROWN P[ \ FOWLER S[ \ TOPHAM J[ + MEMBERS OF ENT STEERING COMMITTEE OF THE COMPARATIVE AUDIT SERVICE(1997). A national audit of sinus surgery. Results of the Royal College of Surgeons of England comparative audit of ENT surgery Clin Otolaryn; 22,:147-151

Indications for

Surgical treatment


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The number of people with chronic

sinusitis is 30 million in the United

States, andThe number of sinus surgeriesperformed in general (about 300,000

annually)Revisions estimates vary from 20%

to 60%.

Surgical Treatment


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To avoid recurrence

if the first surgeon did an incomplete job in terms ofremoving tissue, then the second surgical procedure is acompletion of the first surgery

For surgeons doing primary procedures, approaching thesinus with the intent to treat all the affected areas isimportant, Some surgeons may be comfortable withoperating on just the ethmoid and maxillary sinuses, and

arent comfortable with the frontal or sphenoid sinusesIf a patient needs more extensive surgery, refer him orher to a more experienced surgeon.Doing only part of it can be worse than doing nothing


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Seeing a patient in the office one or two weeksafter surgery, once or twice, to inspect how well

the sinuses are healing is good practiceOverall, the best way to avoid RESS is to usemeticulous surgical technique and avoid tissuetrauma in critical and unforgiving areas like the

frontal and sphenoid sinusesRevision surgery is a good reason to use animage-guided system

To avoid recurrence


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Surgical Approaches

Aim: to provide ventilation of the sinuses as wellpromotes drainage of secretionsEndoscopic widening of natural ostia (ESS):

Maxillary : middle meatal antrosotmyFrontal : frontal sinusotomySphenoidal : sphenoidotomyEthmoids : ethmoidectomy

Old surgical procedures:seldom used nowadays:Antral lavageIntranasal antrostomyRadical antrum operation


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Surgical Approaches

External surgical procedures:

External EthmoidectomyExternal FrontoEthmoidectomyFrontal sinus Trephination

Osteoplastic Flap/Frontal sinus Obliteration


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FESSFunctional Endoscopic sinussurgery:

to remove any obstruction in theostia or osteomeatal complex:

90% improvementWe can use it to removepituitary tumors


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FESS Complications

1) Orbital:a) Injury to orbital fat & muscles

b) Orbital haematoma lead to opticnerve compression & blindnessc) Optic nerve injury and blindness

2)Intracranial:a) CSF leakb) Brain tissue nasal herniation


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Balloon Sinuplasty

Sinuplasty: a new technique of sinus ostiaballoon dilatation, is specifically aimed at restoringostium patency without removing tissue, and is

performed with the patient under local anesthesia,thus decreasing the morbidity associated withFESSThe dilatation of the sinus ostia by advancingballoon catheters under fluoroscopic guidance tothe narrowed segment and inflating them with highpressure


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Balloon Sinuplasty

The system follows the principles of over-the-wire,catheter-based balloon dilatation, commonly usedin vascular and urologic surgery, as well as ininterventional cardiology


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Balloon Sinuplasty equipment . Sinus guiding catheters (A). From top to bottom: 0, 30, 70, 90, and 110.

Sinus balloon catheter, passed over a guidewire into the sinus guiding catheter (B). Inflation device, consisting of a high-pressure piston syringe and a manometer (C). Figure shows device attached to balloon catheter. Sinus lavage catheter (D).


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Sinus balloons. From top to bottom: 7, 5, and 3 mm.


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Balloon Sinuplasty

Sinus balloon dilatation requires:1. Sinus guiding catheters2. Flexible sinus guidewires

3. Sinus balloon catheters4. Sinus lavage catheters, and5. A sinus balloon inflation device with a

manometer.

The inflation device consists of a highpressuresyringe barrel with a piston handle, and a gaugeused to monitor the pressure inside the balloonat the tip of the catheter.


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Balloon Sinuplasty

The solution used for injection into the balloon consists ofiodine contrast media, diluted in sterile saline or water ata concentration of approximately 150-180 mg/mL.

Contrast is used so that the sinus balloon can be visualizedfluoroscopically as it is inflated.

Six to 8 mL are necessary to reach the required pressuresThe standard sinus balloon size is 5 mm, although there

are 7 mm and 3 mm balloonsThe maximum pressure recommended by themanufacturer is 16 atm, although usually pressures of 8-12atm are used with satisfactory results


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The guiding catheter ispositioned close to thesinus ostia to guide theinsertion of the

guidewire into thesinus.Maxillary sinus ostium(A). Frontal recess (B).Sphenoid sinus ostium(C).Sphenoid sinus, lateral

view (D).EB, ethmoid bulla;FS, frontal sinus;LNW, lateral nasal wall;MO, maxillary sinusostium;MT, middle turbinate;S, septum;SO, sphenoid sinusostium;ST, superior turbinate;UP, uncinate process

Fluoroscopic imaging


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p g gguidance for sinuscannulation and balloonpositioning. Guidingcatheters in position, wireadvanced intosinus, balloon catheter

advanced over the wire, anddeflated balloon in position.AP view of the left maxillarysinus (A). Notice thecurvatureof the deflated balloon whenpositioned across the naturalostium. AP view of the leftfrontal sinus (B). Lateralview of the frontal sinus(C). Lateral view of thesphenoid sinus (D). Theanterior wall of the sphenoidsinus helps position theballoon across the sinus

ostium. Tipof guiding catheter (whitearrow). Guidewire in sinus(bold black arrow). Tip andtail markings of balloon(black arrows). Sella turcica(grayarrow). Sinus guidingcatheter (striped arrow).

Anterior wall of the sphenoidsinus (dashed arrow).


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Frontal sinus ostium balloon dilatation sequence.Guiding catheter in position, wire advanced into frontal sinus, and ballooncatheter at the tip of guiding catheter (A).Balloon catheter out of guiding catheter and inflated balloon positioned across ostium(B).Dilated ostium, drained sinus, and balloon catheter and wire removed (C).


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Inflated balloons in position.Maxillary sinus (A).Frontal sinus (B).Sphenoid sinus (C).

Tip and tail markings inballoon (black arrows).Inflated balloon (whitearrow).Tip of guiding catheter (boldblack arrow).


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An inadequate positioning of theballoon across the ostium (A)causes slipping of the balloon into

the sinus (B) on inflation.Anterior wall of the sphenoid bone(white arrow).Direction of balloon movement(black arrows).Inflated balloon (striped arrow)


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Sinus lavage catheter insertion,frontal sinus.Over the-wire lavage catheter

positioning (A).Lavage catheter in position,Guide wire removed (B).Tip of lavage catheter (bold blackarrow).Guidewire in frontal sinus (white

arrow).Tip of guidingcatheter (striped arrow).


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Balloon Sinuplasty

Balloon inflation is performed once, and pressure is thenreleased by aspirating the contrast back into the pressuredevice.Due to the fact that the frontal outflow tract is not a trueostium, two overlapping dilatations should be performedto ensure that the entire outflow tract is dilated.A confirmatory fluoroscopic image of the deflated balloon isobtained before pulling the balloon catheter out through the

guiding catheter.The dilated ostium is also visualized with an endoscope, toconfirm adequate dilatation of the ostium and assess thesinus Interior


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Balloon Sinuplasty

The sinus balloon catheter can be exchanged fora sinus lavage catheter at this point, for the purpose ofperforming culture sampling, sinus drainage, and/or

irrigationThe sinus lavage catheter is advanced over thewire, after its appropriate positioning inside the sinus underfluoroscopic guidance.

Drainage and lavage are then performed with salinesolution or antibiotic irrigation.A variety of instruments can also be inserted underfluoroscopic guidance to perform biopsies, if indicated


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The right maxillary ostium 12 months postoperatively:Anterior to Posterior (AP) diameter 10 mm. Cuttinginstruments were not used to create this ostium. The 7-mm balloonused to dilate the ostium split the membranous posterior fontanel,resulting in an antrostomy larger than the balloon diameter


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Old Surgical Approaches

Repeated puncture &lavage: sinus

wash out withsaline usingLichtwitz trocar &canula and

Higginsonssyringe in inferiormeatus


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Intranasal antrostomy:make wide opening in inferior

meatus by perforator & burr incases of cystic fibrosis

(replaced by widening ofnatural ostium in middlemeatus endoscopically)


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Caldwell Lucs operation: only to

Remove big polyps, F.B. orcysts or

Control of epistaxis &

Vidian neurectomy


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External Ethmoidectomy

In cases of subperiosteal abscessThe incision is midway between midline of

nose and medial canthus


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External FrontoEthmoidectomy

In cases of orbital complications of sinusitisThe incision is extended over the orbital rim into the eyebrow


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Frontal sinus Trephination

In cases of revision and frontal stenosisThe incision in the superomedial aspect of the orbital rim

1-2 cm under the eyebrow

O t l ti Fl


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Osteoplastic FlapFrontal sinus Obliteration

In cases of fracture or tumorsBicoronal flap, the incision 1 inch behind hairline

O t l ti Fl


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Osteoplastic FlapFrontal sinus Obliteration


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Thank You for


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Thank You forAttention

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Email:[email protected]

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