Paranasal Sinus Flashcards
Pathophysiology
-Normal function depends on patent ostia, ciliary function, & quality of mucous
-Obstruction of natural ostia -> hypo-oxygenation -> ciliary dysfunction and poor mucous quality -> retention of secretions
-Local factors can impair ciliary function
-Cold air “stuns” the epithelium -> retained secretions
-Dry air desiccates the blanket
-Anatomical factors- polyps, tumors, foreign bodies and rhinitis, block the ostia
-Kartagener’s Syndrome (immotile cilia syndrome)
Kartagener’s Syndrome (immotile cilia syndrome)
-Situs inversus- rare disease when organs on the right side are on left (vice versa)
-chronic sinusitis
-bronchiectasis- destroyed architecture of bronchi - widened and tram like + mucus
-defect in the formation of cilia -> particles will get past and infect
-Autosomal recessive pattern
-result from defective cilia motility
-Immotile cilia and immotile spermatozoa
upper respiratory infection (URI)
-Common Cold, acute infective rhinitis,acute rhinopharyngitis/nasopharyngitis,acute coryza, andacute nasal catarrh
-Nasal congestion, clear rhinorrhea, and hyposmia
-malaise, headache, and cough
-Erythematous- engorged nasal mucosa without intranasal purulence (differs from allergic rhinitis)
-self-limited (goes away without treatment)
- < 4 weeks and typically < 10 days
-Numerous serologic types of rhinoviruses, adenoviruses, and other viruses -> this is why you catch it frequently
-can develop into viral sinus infection
3 types of rhinosinusitis
-1. acute rhinosinusitis (ARS)- acute viral rhinosinusitis & acute bacterial rhinosinusitis (ABRS)
-2. subacute rhinosinusitis- 4-12 weeks
-3. chronic rhinosinusitis (CRS)
-classified by length of time
classification of sinus infection
-symptomatic inflammation of paranasal sinuses and nasal cavity
-divided into Acute rhinosinusitis (ARS) & Chronic rhinosinusitis (CRS).
-ARS- < 4 weeks
-CRS- > 12 weeks, with or without acute exacerbations
-ARS -> acute bacterial rhinosinusitis (ABRS) or viral rhinosinusitis (VRS)
-Treatment depends on classification
-Recurrent-ARS - 4+ annual episodes of rhinosinusitis, without symptoms between.
-Uncomplicated rhinosinusitis- no extension of inflammation outside the paranasal sinuses and nasal cavity at time of dx -> no neurologic, ophthalmologic, or soft tissue involvement -> dont necessarily need antibiotics
VRS and ARBS diagnosis
-primarily clinical- use duration and pattern
-radiographs- used rarely- must be a complication
-transillumination- not reliable
acute viral rhinosinusitis (VRS)
-numerous serologic types of rhinoviruses, adenoviruses, and other
-recurrent
-3-4 weeks
-subacute- 4-12 weeks (not a separate entity)
-benign and self limited
-high loss of productivity, cost, overuse of antibiotics
-predisposing factors- URTI, allergic rhinitis, nasal polyps, immunodeficiency, environmental factors (smog, smoking)
-when acute viral rhinosinusitis is longer than 10 days or double worsening you suspect acute bacterial rhinosinusitis
VRS symptoms and signs
-nasal congestion
-initial watery discharge
-AVR- must have purulent discharge
-hyposmia
-associated symptoms- cough, postnasal drip, toothache, headache, facial pressure pain, sneezing, irritated throat, general malaise
-tenderness over sinus cavities
-increased posterior pharyngeal secretions
-purulent (Infected, colored, oozing) secretions (middle meatal region)
-reddened, edematous mucosa
-dark circles beneath eyes
-absence of transillumination
VRS differential diagnosis
-acute bacterial rhinosinusitis (ARBS)
-COVID-19
-URTI
-nasal polyposis
-orbital cellulitis
-headache differentials
-wegener’s granulomatosis
-immotile cilia syndrome
-neoplasms- rare
management of acute viral rhinosinusitis
-generally self-limited process
-Supportive; symptom relief
-NSAIDs; Acetaminophen
-Mechanical irrigation
-Intranasal corticosteroids; decongestants -> max 3 days
-? Antihistamines - efficacy
-? Mucolytics – thin secretions
-? high dose Zinc lozenges
COVID-19 and URI
-Predominantly lower respiratory
-Viral prodromal S&S
-Fever, nasal inflammation, rhinorrhea, cough, myalgias, fatigue
-*Hyposmia and anosmia - ? Pathognomonic
-If suspicious –> test immediately
-Can be transient or permanent
Complications of AVR
-Acute bacterial rhinosinusitis
-Chronic rhinosinusitis
-Eustachian tube dysfunction
-Middle ear effusion
-Precursor to more serious conditions:
-S pneumoniae, other streptococci, H influenzae, S aureus, and Moraxella catarrhalis
-Acute otitis media, asthma, and cystic fibrosis exacerbation, and bronchitis
complication of treatment AVR
-Rhinitis medicamentosa
-cannot use more than 3 days
-decongestants-> oxymetazoline or phenylephrine - rapidly effective BUT!!!
-> Chronic use of vasoconstrictor nasal sprays or intranasal cocaine abuse -> Beefy red nasal membranes
-Management:
-Stop offending drug
-Severe nasal congestion
-Topical intranasal corticosteroids
-Oral prednisone (5 days)
presentation of AVR in children vs adult
-children -> increased irritability and vomiting as result of gagging on mucus and prolonged cough
-Both adults & children- less frequent symptoms include fever, nausea, malaise, fatigue, halitosis, and sore throat (fever is more common in children than in adults)
acute bacterial rhinosinusitis (ABRS)
-DIAGNOSE WHEN:
-symptoms or signs of acute rhinosinusitis (AVR) are present 10 days or more beyond the onset of URS
OR
-symptoms or signs of acute rhinosinusitis (AVR) worsen within 10 days after initial improvement (double worsening)
-additional symptoms/signs: fever, cough, fatigue, malaise, reduced sense of smell (Hyposomnia), lack of smell (anosmia), maxillary dental pain, ear fullness or pressure
acute bacterial etiology
-streptococcus pneumoniae
-haemophilus influenzae
-moraxella catarrhalis
chronic sinusitis etiology
-pseudeomonas aeruginosa
-group A streptococcus
-staphylococcus aureus
-anaerobes: bacteriodes spp. and fusobacterium spp.
-more serious pathogens
management of ABRS
-symptom relief
-drainage with topical decongestants and sometimes antihistamines
-watchful waiting
-observation without use of antibiotics is an option for adults with uncomplicated ABRS with mild illness (mild pain, temperature < 101 and assurance of follow up)
ABRS treatment
-1st episode- no recent antibiotic use
-symptoms relief- saline irrigation, pseudoephedrine (sudafed), guafenesin (Tussin, muscinex), oxymetazoline (afrin), fluticasone
-cornerstone - drainage and antibiotics -> especially pts with recurrent or chronic attacks
-choice of antibiotic depends on suspected pathogen and antimicrobial susceptibility of the pathogen, cost of drug, side effects
-first line, second line
-may need to be extend to 12 weeks of use
first line antibiotics
- amoxicillin+Clavulanate (Augmentin)
-500 mg/125 mg orally 3x daily OR
-875 mg/125 mg orally 2x daily for 5–7 days*
-Higher risks:
-High dose Amoxicillin/Clavulanate- 2000 mg/125 mg extended-release orally 2x daily for 7–10 days
-PCN allergy – clindamycin
second line antibiotics
-Clindamycin Or Trimethoprim and sulfamethaxazole
-Or Levofloxacin Or Azithromycin
-Dupilumab- monoclonal antibody
-no improvement after 5-7 days -> appropriate, broad-spectrum, potent antibiotic
-no response within 3-4 weeks -> metronidazole or clindamycin may be added -> gives anaerobic coverage
-Hospital patients
surgical drainage: other treatment
-maxillary - Antral lavage, inferior or middle meatal windows- cannula inserted into maxillary sinus for drainage and irrigation
-Frontal sinuses - trephination, and a drain is left in place and irrigated
-Ethmoidectomy- removes infected tissue and bone in the ethmoid sinuses that blocks natural drainage
chronic sinusitis
-Acute sinusitis- often imposed on chronic disease
-Note any facial edema, tenderness, mucosal edema, septal perforations and deviations
- > 12 weeks with abnormal findings on Nasal Endoscopy, CT or MRI
-Mucopurulent discharge
-Fever -usually not present
investigations
-Paranasal sinus biopsy / Nasal Endoscopy
-Sweat Chloride test
-Ciliary function studies
-tests for immunodeficiency
paranasal sinus biopsy/nasal endoscopy
-detects underlying allergic rhinitis, nonallergic rhinitis with eosinophilia syndrome, nasal polyposis
-diagnoses chronic sinusitis
-R/O if a lesion is neoplastic
-confirms presence of suspected fungal disease
-assesses the possibility of granulomatous disease
imaging investigation
-Plain films are generally obsolete; limited value
-Exceptions : confirmation of air fluid levels in acute sinusitis; evaluating size and integrity of sinuses
-CT- for recurrent/chronic sinusitis or if diagnosis is uncertain
-MRI- For fungal sinusitis and tumors
referral
-otolaryngologist
-Failure of acute bacterial rhinosinusitis to resolve after antibiotics
-suspected extension of disease outside the sinuses -> urgent -> orbital cellulitis, cranial nerve involvement, or central nervous system involvement
-for Imaging and testing:
-Endoscopic cultures may direct further treatment choices.
-Nasal endoscopy and CT scan- when symptoms > 4–12 weeks
-unusual opportunistic infections
-Suspected structural abnormalities with recurrent sinusitis
-Suspected underlying allergic or immunologic response
-things that complicate assessment -> asthma, nasal polyps, immunodeficiency
Otitis media, asthma, or fungal sinusitis
when to admit
-Facial swelling and erythema indicative of facial cellulitis.
-Proptosis- orbital cellulitis especially posterior - eyes are being pushed out
-Vision change or gaze abnormality indicative of orbital cellulitis.
-Abscess or cavernous sinus involvement.
-Mental status changes suggestive of intracranial extension.
-Immunocompromised status.
-Failure to respond to appropriate first-line treatment for acute bacterial rhinosinusitis
-symptoms > 4 weeks
complications: orbital involvement
-Orbit separated from ethmoids by thin lamina papyracea
-First indication - inflammatory edema of eyelids -> progresses to cellulitis, proptosis, chemosis (collection of fluid in the eye) and ophthalmoplegia (paralysis of eye)
-Osteomyelitis - infection spread to the bone- Seen in frontal sinusitis bc floor of the sinus is thin-> Pott’s puffy tumor
-Treatment: IV antibiotics with or without sinus drainage
-Abscesses -> surgical drainage and IV antibiotics
-Indications: progressive orbital cellulitis, symptoms which do not resolve, abscess, loss of visual acuity
pre septal orbital cellulitis
-Lid edema and redness
-spreading into the eye
-Tenderness
-Absence of proptosis
-Absence of extraocular muscle restriction
-Absence of fever
post septal cellulitis
-becomes emergency when its post
-Results from infection traversing the orbital septum
-Requires emergency immediate hospitalization
-Urgent ophthalmologic examination
-Treatment with IV antibiotic therapy
-May require surgery
nasal polyps
-often associated with allergic rhinitis
-samter’s triad- asthma, nasal polyps, acute hypersensitivity reactions to aspirin NSAIDs)
fungal sinusitis
-uncommon
-aspergillosis most common- high index of suspicion -> farmers
-dx by biopsy and culture
-soil, fruits, vegetables, grains, birds, mammals
-suspect if dark, greasy material seen
HIV and AIDS
-incididence of sinusitis ranges from 30-68%
-sinusitis is common in aids
-direct association between CD4+ T cell deficiency and sinusitis may exist
cystic fibrosis (CF) and sinusitis
-chronic sinusitis- significant cause of morbidity
-common pathogens- pseudomonas aeruginosa, E coli, S aureus
-nasal polyps
mucormycoses
-dust and soil
-enters through respiratory tract
-invades vascular channels
-causes hemorrhagic ischemia and necrosis
-fungal
-frequently fatal
-90% mortality in immuno-compromised
-diabetes complication- ketoacidosis predisposes to mucormycoses -> thrives in acidic environment
-engorgement of turbinate’s -> followed by ischemia and necrosis of the turbinate’s and adjacent nose
-loss of vision
-treated with:
-radical surgical debridement (drainage)
-amphotericin B
-correction of underlying immunosuppression
cavernous sinus thrombosis complications
-High mortality rate
-cavernous sinus infection
-Usually from retrograde transmission through valveless veins leading to the cavernous sinus
-Heralded by bilateral orbital involvement
-progressive chemosis- Temp: 105F
-Treat with drainage, IV antibiotics
-Heparin is controversial
intracranial sinus infection complications
-subdural abscess, intracranial abscess, meningitis
-meningitis is common in children
-1/3 to 2/3 of all subdural abscesses believed due to sinusitis
-nuchal rigidity is first symptom
-neurosurgery consult to manage ICP -> surgical drainage
antibiotics
-dont want to use antibiotics if they had just taken some
-especially the same antibiotic
QUIZ QUESTION: Normal vitals, college student, symptoms for 13 days, rhinitis, facial pain, bilateral congestion, moderate maxillary tenderness
-bacterial sinusitis
-facial pain and maxillary tenderness
-> 13 days
