Chronic Sinusitis Flashcards
CHRONIC SINUSITIS
Sinus infection lasting for months or years is called chronic sinusitis
cause of chronic sinusitis
failure of acute infection to resolve.
PATHOPHYSIOLOGY of CHRONIC SINUSITIS
Acute infection ➡️destroys normal ciliated epithelium ➡️impairing drainage from the sinus➡️ Pooling and stagnation of secretions in the sinus ➡️ infection ➡️mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle
PATHOLOGY CHRONIC SINUSITIS
In chronic infections, process of destruction and attempts at healing proceed simultaneously. Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis) or under- goes atrophy (atrophic sinusitis). Surface epithelium may show desquamation, regeneration or metaplasia. Submu- cosa is infiltrated with lymphocytes and plasma cells and may show microabscesses, granulations, fibrosis or polyp formation.
BACTERIOLOGY
Mixed aerobic and anaerobic organisms
CLINICAL FEATURES
- often vague and similar to those of acute sinusitis but of lesser severity
- Purulent nasal discharge
- Foul-smelling discharge
- Local pain and headache
- nasal stuffiness and anosmia.
commonest complaint
Purulent nasal discharge
Foul-smelling discharge sug- gests
anaerobic infection
Local pain and headache are often not marked except in
acute exacerbations
DIAGNOSIS
- X-ray
- X-rays after injection of contrast material
- Computed tomography (CT) scan
- Aspiration and irrigation:
X-ray of the involved sinus may show
mucosal thickening or opacity.
X-rays after injection of contrast material may show
soft tissue changes in the sinus mucosa.
Computed tomography (CT) scan is particularly useful in
ethmoid and sphenoid sinus infections and has replaced studies with contrast materials
Aspiration and irrigation
Finding of pus in the sinus is confirmatory.
TREATMENT
- search for underlying aetiological factors which obstruct sinus drainage and ventilation
- A work-up for nasal allergy
- Culture and sensitivity of sinus discharge ➡️ proper selection of an antibiotic.
- conservative rx ➡️antibiotics, decongestants, antihistaminics and sinus irrigations
- surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus.
SURGERY FOR CHRONIC MAXILLARY SINUSITIS
Antral puncture and irrigation
Intranasal antrostomy
Caldwell–Luc operation
Antral puncture and irrigation
Sinus cavity is irrigated with a cannula passed through the inferior meatus. Removal of pus and exudates helps the sinus mucosa to revert to normal.
Intranasal antrostomy
is indicated if sinus irrigations fail to resolve infection. A window is created in the infe- rior meatus to provide aeration to the sinus and its free drainage.
Caldwell–Luc operation
In this operation, antrum is entered through its anterior wall by a sublabial incision. All irreversible diseases are removed and a window is cre- ated between the antrum and inferior meatus.
SURGERY FOR CHRONIC FRONTAL SINUSITIS
- Intranasal drainage operations
- Trephination of frontal sinus
- External frontoethmoidectomy (Howarth’s or Lynch operation
- Osteoplastic flap operation
Intranasal drainage operations
Correction of deviated septum, removal of a polyp or anterior portion of middle turbinate, or intranasal ethmoidectomy provide drainage through the frontonasal duct. Treatment of associated max- illary sinusitis also helps to resolve chronic frontal sinusitis
External frontoethmoidectomy (Howarth’s or Lynch operation)
The frontal sinus is entered through its floor by a curvilinear incision round the inner margin of the orbit. Diseased mucosa is removed, ethmoid cells exen- terated and a new frontonasal duct created.
Osteoplastic flap operation
It may be unilateral or bilat- eral. A coronal or a brow incision is used. The anterior wall of frontal sinus is reflected as an osteoplastic flap, based inferiorly. The diseased tissues are removed and the sinus drained through a new frontonasal duct. If it is desired to obliterate the sinus, all diseased as well as healthy mucosa are stripped off and the sinus obliterated with fat
SURGERY FOR CHRONIC ETHMOID SINUSITIS
Intranasal ethmoidectomy
External ethmoidectomy
Intranasal ethmoidectomy
This operation is done for chronic ethmoiditis with polyp formation. The ethmoid air cells and the diseased tissue are removed between the middle turbinate and the medial wall of orbit by the intranasal route. The frontal and sphenoid sinuses can also be drained by this operation.
External ethmoidectomy
In this operation, ethmoid sinuses are approached through medial orbital incision. Access can also be obtained to sphenoid and frontal sinuses and the operation is called fronto-spheno-ethmoidectomy.
SURGERY FOR CHRONIC SPHENOIDITIS SINUSITIS
Sphenoidotomy. Access to the sphenoid sinus can be obtained by removal of its anterior wall. This is accomplished by external ethmoidectomy or trans-septal approach, usu- ally the former, because of the coexistence of ethmoid dis- ease with chronic sphenoiditis.
FUNGUS CAUSING SINUSITIS
Aspergillus, Alternaria, Mucor or Rhizopus
They may involve single or multiple sinuses.
Fungal ball is due to
implantation of fungus into an otherwise healthy sinus which on CT shows a hyperdense area with no evidence of bone erosion or expansion
most commonly involved sinus in Fungal ball
Maxillary sinus >sphenoid>ethmoid >frontal
Treatment for Fungal ball
surgical removal of the fungal ball and adequate drainage of the sinus. No antifungal therapy is required
Allergic fungal sinusitis
allergic reaction to the causative fungus
Presentation of Allergic fungal sinusitis
presents with sinunasal polyposis and mucin
mucin of Allergic fungal sinusitis contains
- eosinophils
- Charcot- Leyden crystals
- fungal hyphae
CT scan of Allergic fungal sinusitis shows
mucosal thickening with hyperdense areas
How many sinus are involved in Allergic fungal sinusitis
There is no invasion of the sinus mucosa with fungus. Usually more than one sinus are involved on one or both sides.
Treatment of Allergic fungal sinusitis
endoscopic surgical clearance of the sinuses with provision of drainage and ventilation. This is combined with pre and postoperative systemic steroids.
Chronic invasive sinusitis
Here the fungus invades into the sinus mucosa. There is bone erosion by fungus
In Chronic invasive sinusitis Patient presents with
chronic rhinosinusitis
CT scan of Chronic invasive sinusitis shows
thick- ened mucosa with opacification of sinus and bone erosion. Patient may have intracranial or intraorbital invasion.
Histopathology of Chronic invasive sinusitis shows
fungal invasion of submucosa and granulomatous reaction with multinucleated giant cells.
Treatment for Chronic invasive sinusitis
surgical removal of the involved mucosa, bone and soft tissues followed by antifungal ther- apy
antifungal ther- apy for Chronic invasive sinusitis
i.v. amphotericin B. Up to a total of 2–3 g of the drug is given. followed by itraconazole therapy for 12 months or more monitored by serial CT or MRI scans.
Fulminant fungal sinusitis
It is an acute presentation and is mostly seen in immunocompromised or dia- betic individuals.
Common fungal species for Fulminant fungal sinusitis
Mucor
Aspergillus
Mucor causes which disease
rhinocerebral disease
How does mucor causes black eschar of inferior turbi- nate, palate or the sinus
invasion of the blood vessels, mucor fungus causes ischaemic necro- sis presenting as a black eschar, involving inferior turbi- nate, palate or the sinus
Where does mucor spreads to
face, eye, skull base and the brain
Treatment for mucor
Treatment is surgical debridement of necrotic tissue and i.v. amphotericin B.
Aspergillus infection can also cause
acute fulminant sinusitis with tissue invasion.
acute fulminant sinusitis due to Aspergillus presentation
acute sinusitis and develop sepsis and other sinus com- plications. Unlike Mucor infection, there is no black eschar.
For for acute fulminant sinusitis due to Aspergillus presentation
antifungal therapy and surgery.
