Acute Sinusitis Flashcards
Defn of acute sinusitis
Acute inflammation of sinus mucosa
Order of involvement of sinusitis
maxillary >ethmoid>frontal > sphenoid
pansinusitis unilateral or bilateral
the sinuses of one or both sides are involved simultaneously
multisinusitis
more than one sinus is infected
Types of Sinusitis
open
closed
depending on whether the inflammatory products of sinus cavity can drain freely into the nasal cavity through the natural ostia or not
EXCITING CAUSES OF SINUSITIS
Nasal infections
Swimming and diving
Trauma
Dental infections
How does nasal infection lead to sinusitis
Sinus mucosa is a continuation of nasal mucosa and infections from nose can travel directly by continuity or by way of submucosal lymphatics. Most common cause of acute sinusitis is viral rhinitis followed by bacterial invasion.
How does Swimming and diving cause sinusitis
Infected water can enter the sinuses through their ostia. High content of chlorine gas in swim- ming pools can also set up chemical inflammation
How does trauma cause sinusitis
Compound fractures or penetrating injuries of sinuses—frontal, maxillary and ethmoid—may permit direct infection of sinus mucosa. Similarly, barotrauma may be followed by infection.
Dental infects affects which sinus
maxillary sinus
How does dental infection causes sinusitis
Infection from the molar or premolar teeth or their extraction may be followed by acute sinusitis.
PREDISPOSING CAUSES
- Obstruction to sinus ventilation and drainage
- Stasis of secretions in the nasal cavity
- Previous attacks of sinusitis
Causes of Obstruction to sinus ventilation and drainage.
(a) Nasal packing
(b) Deviated septum
(c) Hypertrophic turbinates
(d) Oedema of sinus ostia due to allergy or vasomotor rhinitis
(e) Nasal polypi
(f) Structural abnormality of ethmoidal air cells (g) Benign or malignant neoplasm
How does Obstruction to sinus ventilation and drainage cause sinusitis
Normally, sinuses are well-ventilated. They also secrete small amount of mucus, which by ciliary movement, is directed towards the sinus ostia from where it drains into the nasal cavity. Any factor(s) which interfere with this function can cause sinusitis due to stasis of secretions in the sinus.
How does climate affect sinus
Sinusitis is common in cold and wet cli- mate
Environment factor causing sinusitis
Atmospheric pollution, smoke, dust and overcrowd- ing also predispose to sinus infection.
General cause
Recent attack of exanthematous fever (measles, chickenpox, whooping cough), nutritional deficiencies and systemic disorders (diabetes, immune deficiency syndromes).
BACTERIOLOGY of sinusitis
acute sinusitis start as viral infections followed soon by bacterial invasion
Bacteria involved are
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus and Klebsiella pneumoniae.
Anaerobic organisms and mixed infections are seen in sinusitis of ———- origin
dental origin.
PATHOLOGY OF SINUSITIS
Acute inflammation of sinus mucosa causes hyperaemia, exu- dation of fluid, outpouring of polymorphonuclear cells and increased activity of serous and mucous glands. Depending on the virulence of organisms, defences of the host and capabil- ity of the sinus ostium to drain the exudates, the disease may be mild (nonsuppurative) or severe (suppurative). Initially, the exudate is serous; later it may become mucopurulent or purulent. Severe infections cause destruction of mucosal lining. Failure of ostium to drain results in empyema of the sinus and destruction of its bony walls leading to complica- tions. Dental infections are very fulminating and soon result in suppurative sinusitis.
AETIOLOGY of ACUTE MAXILLARY SINUSITIS
-viral rhinitis ➡️ bacterial invasion
-Diving and swimming in contaminated water
-Dental infections
-Trauma➡️ compound fractures, pen-
etrating injuries or gunshot wounds
How Dental infections AETIOLOGY of ACUTE MAXILLARY SINUSITIS
Roots of premolar and molar teeth are related to the floor of sinus and may be separated only by a thin layer of mucosal covering. Periapical dental abscess may burst into the sinus; or the root of a tooth, during extrac- tion, may be pushed into the sinus. In case of oroantral fistula, following tooth extraction, bacteria from oral
cavity enter the maxillary sinus.
Clinical features of ACUTE MAXILLARY SINUSITIS
- Constitutional symptoms - fever, general malaise and body ache - result of toxaemia.
- Headache - confined to forehead and may thus be confused with frontal sinusitis.
- Pain - over the upper jaw, but may be referred to the gums or teeth. aggravated by stooping, coughing or chewing. Occasionally, pain is referred to the ipsilateral supraorbital region and thus may simulate frontal sinus infection.
- Tenderness. Pressure or tapping over the anterior wall of antrum produces pain.
- Redness and oedema of cheek. Commonly seen in chil- dren. The lower eyelid may become puffy.
- Nasal discharge. Anterior rhinoscopy/nasal endoscopy shows pus or mucopus in the middle meatus. Mucosa of the middle meatus and turbinate - red and swollen.
Postural test. If no pus seen in the middle meatus, it is decongested with a pledget of cotton soaked with a vaso- constrictor and the patient is made to sit with the affected sinus turned up. Examination after 10–15 min may show discharge in the middle meatus. - Postnasal discharge. Pus may be seen on the upper soft palate on posterior rhinoscopy or nasal endoscopy.
DIAGNOSIS ACUTE MAXILLARY SINUSITIS
Transillumination test. Affected sinus will be found opaque X-rays. Waters’ view will show either an opacity or a fluid level in the involved sinus Computed tomography (CT) scan is
the preferred
Antimicrobial drugs for ACUTE MAXILLARY SINUSITIS
- Ampicillin and amoxicillin
- Erythromycin or doxycycline or cotrimoxazole - sensitive to penicillin
- β-lactamase-producing strains -amoxicillin/ clavulanic acid or cefuroxime axetil.
Antibiotics which has single daily dose advantage used in ACUTE MAXILLARY SINUSITIS
Sparfloxacin
Nasal decongestant drops used in ACUTE MAXILLARY SINUSITIS
One per cent ephedrine or 0.1% xylo- or oxymetazoline
Steam inhalation used in ACUTE MAXILLARY SINUSITIS
Steam alone or medicated with men- thol or Tr. Benzoin Co. provides symptomatic relief and encourages sinus drainage. Inhalation should be given 15–20 min after nasal decongestion for better penetration
Analgesics indication for ACUTE MAXILLARY SINUSITIS
relief of pain and headache
Hot fomentation in acute maxillary sinusitis
Local heat to the affected sinus is often soothing and helps in the resolution of inflammation
SURGICAL methods for acute maxillary sinusitis
Antral lavage
It is done only when medical treatment has failed and that too only under cover of antibiotics.
COMPLICATIONS of acute maxillary sinusitis
- Acute maxillary sinusitis may change to subacute or chronic sinusitis.
- Frontal sinusitis. Due to obstruction of frontal sinus drainage pathway because of oedema.
- Osteitis or osteomyelitis of the maxilla.
- Orbital cellulitis or abscess. Infection spreads to the
orbit because of oedema either directly from the roof of maxillary sinus or indirectly, after involvement of ethmoid sinuses.
AETIOLOGY of ACUTE FRONTAL SINUSITIS
- Usually follows viral infections of upper respiratory tract followed later by bacterial invasion.
- Entry of water into the sinus during diving or swimming.
- External trauma to the sinus, e.g. fractures or penetrating injuries.
- Oedema of middle meatus, secondary to associated ipsilateral maxillary or ethmoid sinus infection.
CLINICAL FEATURES of ACUTE FRONTAL SINUSITIS
- Frontal headache - severe and localized over the affected sinus. It shows characteristic periodicity, i.e. comes up on waking, gradually increases and reaches its peak by about mid day and then starts subsiding. It is also called “office headache” because of its presence only during the office hours.
- Tenderness. Pressure upwards on the floor of frontal sinus, just above the medial canthus, causes exquisite pain. It can also be elicited by tapping over the anterior wall of frontal sinus in the medial part of supraorbital region.
- Oedema of upper eyelid with suffused conjunctiva and photophobia.
- Nasal discharge. A vertical streak of mucopus is seen high up in the anterior part of the middle meatus. This may be absent if the ostium is closed with no drainage. Nasal mucosa is inflamed in the middle meatus.
MEDICAL TREATMENT for ACUTE FRONTAL SINUSITIS
same as for acute maxillary sinusitis
SURGICAL TREATMENT of FRONTAL SINUSITIS
Trephination of frontal sinus. If there is persistence or exacerbation of pain or pyrexia in spite of medical treat- ment for 48 h, or if the lid swelling is increasing and threat- ening orbital cellulitis, frontal sinus is drained externally. A 2 cm long horizontal incision is made in the superomedial aspect of the orbit below the eyebrow (Figure 36.1). Floor of frontal sinus is exposed and a hole drilled with a burr. Pus is taken for culture and sensitivity, and a plastic tube inserted and fixed. Sinus can now be irrigated with nor- mal saline two or three times daily until frontonasal duct becomes patent. This can be determined by adding a few drops of methylene blue to the irrigating fluid and its exit seen through the nose. Drainage tube is removed when frontonasal duct becomes patent.
COMPLICATIONS of FRONTAL SINUSITIS
- Orbital cellulitis.
- Osteomyelitis of frontal bone and fistula formation.
- Meningitis, extradural abscess or frontal lobe abscess, if
infection breaks through the posterior wall of the sinus. - Chronic frontal sinusitis, if the acute infection is
neglected or improperly treated.
ACUTE ETHMOID SINUSITIS
AETIOLOGY
associated with infection of other sinuses. Ethmoid sinuses are more often involved in infants and young children.
CLINICAL FEATURES of
ACUTE ETHMOID SINUSITIS
- Pain - localized over the bridge of the nose, medial and deep to the eye. It is aggravated by movements of the eye ball.
- Oedema of lids - Both eyelids become puffy and swollen. There is increased lacrimation. Orbital cellulitis is an early complication in such cases.
- Nasal discharge. On anterior rhinoscopy, pus may be seen in middle or superior meatus depending on the involvement of anterior or posterior group of ethmoid sinuses.
- Swelling of the middle turbinate.
TREATMENT for ACUTE ETHMOID SINUSITIS
same as for acute maxillary sinusitis
Indication for drainage of the ethmoid sinuses
Visual deterioration and exophthalmos indicate abscess in the posterior orbit
COMPLICATIONS of ACUTE ETHMOID SINUSITIS
- Orbital cellulitis and abscess.
- Visual deterioration and blindness due to involvement of
optic nerve. - Cavernous sinus thrombosis.
- Extradural abscess, meningitis or brain abscess.
ACUTE SPHENOID SINUSITIS
AETIOLOGY
often a part of pansinusitis or is associated with infection of poste- rior ethmoid sinuses.
CLINICAL FEATURES of ACUTE SPHENOID SINUSITIS
- Headache. Usually localized to the occiput or vertex. Pain may also be referred to the mastoid region.
- Postnasal discharge. It can only be seen on posterior rhi- noscopy. A streak of pus may be seen on the roof and posterior wall of nasopharynx or above the posterior end of middle turbinate.
X-rays of ACUTE SPHENOID SINUSITIS shows
Opacity or fluid level may be seen in the sphenoid sinus. Lateral view of the sphenoid sinus is taken in supine or prone position and is helpful to demonstrate the fluid level
TREATMENT for ACUTE SPHENOID SINUSITIS
Treatment is the same as for acute infection of other sinuses.
