rhino-sinusitis: clinical features, diagnosis & medical treatment dr. vishal sharma
TRANSCRIPT
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Rhino-Sinusitis: Clinical Features,
Diagnosis & Medical Treatment
Dr. Vishal Sharma
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Rhino-sinusitis: inflammation of lining mucosa
of nose & paranasal sinuses
Acute: infection lasting < 4 weeks
Sub acute: infection lasting 4 to 12 weeks
Chronic: infection lasting > 12 weeks
Recurrent: > 3 episodes in 6 months or > 4
episodes per year with
asymptomatic intervals of > 10 days
Definitions
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Types of Sinusitis• Acute / sub acute / chronic / recurrent
• Open / Closed (depending on its drainage)
• Unilateral / bilateral
• Maxillary / frontal / ethmoidal / sphenoidal
• Single sinusitis / multi-sinusitis / pan-sinusitis
• Anterior group / posterior group
• Suppurative / hypertrophic
• Bacterial / fungal / allergic / occupational
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Etiology
• Rhinogenic: commonest (85%)
– following any form of rhinitis
• Dental: for maxillary sinusitis
– root abscess, dental procedures
• Trauma:
– R.T.A., swimming, diving, F.B., barotrauma
– Iatrogenic: nasal packing, septal surgery
• Hematogenous: rare
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• Mucosal odema: viral, bacterial, allergic, irritant,
vasomotor, barotrauma
• Mechanical obstruction: D.N.S. (spur), polyp,
hypertrophic turbinate, concha bullosa,
paradoxical middle turbinate, Haller cell, large
bulla ethmoidalis, agger nasi, uncinate anomaly,
nasal tumour, foreign body, nasal packing
Predisposing factors
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• Mucous abnormality: Young’s syndrome, cystic
fibrosis, mucoviscidosis, dehydration
• Mucociliary dysfunction: Kartagener’s
syndrome, viral, bacterial, allergic, smoking,
pollutants, hypoxia, dry air, extremes of
temperature, synechiae
• Miscellaneous: Poor health, immunodeficiency,
diabetes, nutritional deficiency
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Bacteriology
Acute sinusitis
Streptococcus
pneumoniae
Haemophilus influenzae
Moraxella
Staphylococcus aureus
Neisseria
Chronic sinusitis
Staph. Aureus
Streptococcus
H. influenzae
Bacteroides
Pseudomonas
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Progress
Severity and resolution depends on
– Open / closed
– Organism virulence
– Host resistance
– Treatment received
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Ostio-meatal complex is key area for causation of chronic anterior group sinusitis
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Pathological variants of ostio-meatal
complex
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Concha bullosa
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Concha bullosa
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Paradoxically curved M.T.
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Paradoxically curved M.T.
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Medialized uncinate process
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Large bulla ethmoidalis
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Haller cell
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Agger nasi cell
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Nasal Septal Spur
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Nasal Septal Spur
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Mucosal disease
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Symptoms• Nasal discharge: mucoid / purulent / blood-stained
• Nasal obstruction with hyposmia / anosmia
• Headache / facial pain
• Cheek / eyelid congestion + swelling
• Hawking, sore throat, cough
• Earache: associated Eustachian tube dysfunction
• Constitutional: fever, malaise, body ache
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Location of facial pain
Maxillary: cheek, upper jaw, forehead (supra-orbital)
that es on bending forward
Frontal: forehead that es during morning & es by
late afternoon (Office headache)
Anterior Ethmoid: nasal bridge & peri-orbital, es
with eye movement
Posterior Ethmoid: retro-orbital
Sphenoid: vertex, occipital, retro-orbital
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Signs• Congested & edematous nasal mucosa
• Nasal discharge (anterior & posterior rhinoscopy):
middle meatus: frontal, maxillary, anterior ethmoid
superior meatus: posterior ethmoid, sphenoid
• Paranasal sinus tenderness present
• Postnasal drip, granular pharyngitis
• Cheek swelling: in maxillary sinusitis
• Lid edema: in ethmoid & frontal sinusitis
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Para-nasal sinus tenderness
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Para-nasal sinus tenderness• Maxillary: palpate
over canine fossa
• Anterior ethmoid:
palpate medial to
medial canthus
• Frontal: palpate floor
of sinus or tap over its
anterior wall
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Para-nasal sinus tenderness
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Sinus trans-illumination test
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Sinus trans-illumination test
• Performed in a dark room. High-intensity light
source placed inside patient’s mouth or against
the cheek (for maxillary sinus) & under medial
aspect of supra-orbital ridge (for frontal sinus).
• Trans-illumination normal = no sinusitis
• Trans-illumination absent = sinus filled with pus
• Trans-illumination dull = equivocal result
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Postural test
Performed in acute sinusitis (active nasal discharge)
Pus cleaned in supine position & pt sits upright
Pus appears = frontal or ethmoid sinusitis
Pus appears on stooping forwards = sphenoid sinusitis
No discharge pt lies in lateral position with affected
side up. Pus appears = maxillary sinusitis
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Rhinosinusitis Task Force CriteriaMajor Minor
1. Facial pain / pressure 1. Headache
2. Nasal obstruction 2. Fever (non-acute sinusitis)
3. Nasal discharge or 3. Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia 5. Dental pain
5. Purulence on examn 6. Cough
6. Fever (acute sinusitis) 7. Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor
factors = sinusitis
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Investigations
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1. Diagnostic nasal endoscopy (D.N.E.)
2. Maxillary Sinoscopy
3. X-ray of P.N.S.
4. U.S.G. of maxillary sinus (Rhinoscan)
5. C.T. scan of P.N.S.
6. M.R.I. of P.N.S.: rarely done
7. Allergic tests
8. Proof puncture (antral wash): for maxillary sinus
9. Endoscopic microswab for culture & sensitivity
10. Fungal culture: of cheesy nasal discharge
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Diagnostic Nasal Endoscopy
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1. Patients not responding to medical therapy
2. Anatomic factor preventing adequate
examination by anterior rhinoscopy
3. Collection of pus from hiatus semilunaris for
culture & sensitivity
4. Objective monitoring of patients
5. Peri-operative nasal inspection & cleaning
Indications for D.N.E.
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Pus in middle meatus in D.N.E.
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Maxillary sinoscopy
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Maxillary sinoscopy
• Anterior sinus wall
perforated directly (in
canine fossa between
roots of 3rd & 4th teeth)
with maxillary sinus
trocar & cannula
• Trocar removed &
sinoscope introduced
through cannula
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X-ray paranasal sinus
Water’s view (Occipito-mental) maxillary
Caldwell’s view (Occipito-frontal) frontal
Rhese’s view (lateral oblique) ethmoid
Base skull view (Submento-vertical) sphenoid
Lateral view
Pierre’s view (occipito-mental with mouth open)
Air-fluid level: acute sinusitis
Mucosal thickening chronic sinusitis
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Acute maxillary sinusitis
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Chronic maxillary sinusitis
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Frontal sinusitis
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Pierre’s view
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Lateral view
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Para-nasal sinus sonography
• Bony anterior wall is seen as hyper-echoic line.
Maxillary cavity filled with air appears as hyper-
echoic hence posterior sinus margin not seen.
• Fluid in sinus, cyst & mucosal thickening are
hypoechoic so posterior sinus margin is visible.
• B mode sonogram differentiates between fluid in
sinus, cyst & mucosal thickening.
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Normal sinus sonography (A-mode)
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A-mode sonography of sinusitis
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C.T. scan: maxillary sinusitis
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C.T. scan: ethmoid sinusitis
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C.T. scan: frontal sinusitis
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C.T. scan: sphenoid sinusitis
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Coronal & axial cuts, plain (without contrast)
Coronal planes, cuts of 4 mm or less
Indications:
– In recurrent acute / chronic sinusitis not
responding to medical therapy
– Before endoscopic surgery
– Impending complications of sinusitis
C.T. scan paranasal sinus
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M.R.I. of P.N.S.
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Medical Treatment• Systemic Antibiotics
• Nasal decongestants: topical & systemic
• Anti-histamines
• Analgesic-anti-inflammatory drugs
• Medicated steam inhalation & nasal douching
• Mucolytics: Ambroxol
• Anti-allergy treatment
• Hot fomentation
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Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days
Ciprofloxacin: 500mg B.D. X 7 days
Doxycycline: 100 mg B.D. X 7 days
Cefadroxil: 500 mg B.D. X 7 days
Cefaclor: 500 mg T.I.D. X 7 days
Cefuroxime: 250 mg B.D. X 7 days
Cefixime: 200 mg B.D. X 7 days
Cefpodoxime: 200 mg B.D. X 7 days
Azithromycin: 500 mg O.D. X 3-5 days
Clarithromycin: 250 mg B.D. X 7 days
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Antihistamines
Systemic:
Cetirizine: 10 mg OD
Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD
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Nasal Decongestants
Systemic decongestants
Phenylephrine
Pseudoephedrine
Topical decongestants
Xylometazoline
Oxymetazoline
Saline
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Anti-cold preparationsName Chlorpheniramine Decongestant Paracetamol
COLDIN 4 mg PsE 60 mg 500 mg
SINAREST 4 mg PsE 60 mg 500 mg
DECOLD 4 mg PhE 7.5 mg 500 mg
SUPRIN 2 mg PhE 5 mg 500 mg
PsE = Pseudoephedrine; PhE = Phenylephrine
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Topical Decongestants
• Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
• Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)
• Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
• Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
• Saline 2 %: 3 drops TID
• Saline 0.67 %: 2 drops BD (NASIVION-S)
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Fungal Sinusitis
A. Invasive (hyphae present in submucosa)
– Acute invasive or fulminant (< 4 weeks)
– Chronic invasive or indolent (> 4 weeks)
B. Non-invasive
– Allergic
– Fungal ball or mycetoma
– Saprophytic
Aspergillosis & Mucormycosis are common
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Acute invasive fungal sinusitis• Usually mucormycosis
• Predisposing factors:
• Immune-compromise: AIDS, Lymphoma, Cyto-toxic
drugs, chronic use of steroid, aplastic anemia
• Insulin dependent diabetes mellitus
• Long term use of broad-spectrum antibiotics
• C/F: Unilateral nasal discharge with black crusts due
to ischaemic necrosis. Cerebral & vascular invasion
present. Absence of significant inflammation.
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Black crusting
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Treatment:• Remove precipitating factors• Surgical debridement of necrotic debris• Anti-fungal drugs:• Amphotericin B infusion for 1-2 months• Itraconazole 100 mg BD for 6-12 months
Chronic invasive fungal sinusitis• Significant inflammation with fibrosis & granuloma
formation• Locally destructive with minimal bone erosion• Tx: Debridement + Anti-fungal agents
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Surgical debridement
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Allergic fungal sinusitis• Associated with ethmoid polyps & asthma
• Unilateral thick yellow nasal discharge with
mucin, eosinophils & Charcot Leyden crystals
• C.T. scan: radio-opaque mass with central area
of hyper density (due to hyphae)
• Tx: Surgical debridement + anti-histamines +
steroids (oral & topical)
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Allergic fungal sinusitis
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Allergic fungal sinusitis
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C.T. scan coronal cuts
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C.T. scan axial cuts
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Fungal ball (Mycetoma)
• Refractory sinusitis with foul smelling cheesy
material in maxillary sinus
• Tx: Surgical removal. No anti-fungal drugs.
Saprophytic fungal sinusitis
Seen after sino-nasal surgery due to proliferation
of fungal spores on mucous crusts
Tx: Surgical removal. No anti-fungal drugs.
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Thank You