SINUSITIS

DR SRAVYA M V
SEC YEAR MS
DEPT. OF SALAKYATANTRA
GAVC TPRA
Paranasal sinuses
• Air-containing cavities in certain bones of skull

• 4 on each side
• Clinically divided into 2 groups

1. Anterior group

• Maxillary, frontal & anterior ethmoidal

• Open in the middle meatus

2. Posterior group

• Posterior ethmoidal sinuses - open in the superior meatus

• Sphenoid sinus - opens in sphenoethmoidal recess

FRONTAL SINUS

• Between the inner & outer tables of frontal bone, above & deep to the
supraorbital margin
• Anterior wall of the sinus is related to the skin over the forehead

• Inferior wall - to the orbit & its contents

• Posterior wall to the meninges & frontal lobe of the brain

• Its average dimensions - height 32 mm, breadth 24 mm & depth 16 mm

Drainage of the frontal sinus

• Through its ostium into the frontal recess

• Frontal recess is situated in the anterior part of middle meatus & is bounded
by the
• middle turbinate (medially)
• lamina papyracea (laterally)
• agger nasi cells (anteriorly)
• bulla ethmoidalis (posteriorly)
• Frontal recess drains into the infundibulum / medial to it, depending on the
superior attachment of the uncinate process
MUCOUS MEMBRANE OF PARANASAL SINUSES

• Lined by mucous membrane which is continuous with that of the nasal cavity
through the ostia of sinuses

• Ciliated columnar epithelium with goblet cells which secrete mucus

• Cilia are more marked near the ostia of sinuses & help in drainage of mucus
into the nasal cavity
Mucociliary clearance

• Mucus travels up along the interfrontal septum, along the roof of the lateral
wall, along the floor and then exits through the natural ostium

• Circulation - anticlockwise in the right & clockwise in the left frontal sinus
EXAMINATION FRONTAL SINUS

• Inspection

• Palpation

• Transillumination

(a) External examination

Forehead
Root of nose
Orbital margins
Orbit & its contents
Look for

• Redness

• Swelling

• Fistula

• Proptosis

• Displacement of the eye balls

• Tenderness of the frontal sinus can be elicited by pressure / percussion with a
finger on its anterior wall above the medial part of eyebrow, / by pressing
upwards on its floor above the medial canthus
(b) Examination of nose

• Anterior & posterior rhinoscopy for evidence of discharge in the middle

meatus & for any neoplasm
Transillumination

• Done by placing a small light source in the superomedial angle of the orbit &
observing the transmission of light from the anterior wall of the sinus

• It is compared on both sides

Acute sinusitis

• Acute inflammation of sinus mucosa

• Maxillary > ethmoid > frontal > sphenoid

• More than one sinus is infected - multisinusitis

• All the sinuses of one / both sides involved simultaneously pansinusitis

unilateral / bilateral

• “open” / “closed ” type depending on whether the inflammatory products of

sinus cavity can drain freely into the nasal cavity through the natural ostia or
not
AETIOLOGY OF SINUSITIS IN GENERAL

A. EXCITING CAUSES

• Nasal infections

• Swimming & diving

• Trauma

• Dental infections
B. PREDISPOSING CAUSES

• LOCAL

1. Obstruction to sinus ventilation & drainage

Any factor(s) which interfere drainage can cause sinusitis due to stasis of secretions in the sinus
(a) Nasal packing

(b) Deviated septum

(c) Hypertrophic turbinates

(d) Oedema of sinus ostia due to allergy / vasomotor rhinitis

(e) Nasal polypi

(f) Structural abnormality of ethmoidal air cells

(g) Benign / malignant neoplasm

2. Stasis of secretions in the nasal cavity

Normal secretions of nose may not drain into the nasopharynx because of
their
viscosity

obstruction (enlarged adenoids)

and get infected

3. Previous attacks of sinusitis

• GENERAL

1. Environment

• Common in cold & wet climate

• Atmospheric pollution, smoke, dust & overcrowding also predispose

2. Poor general health

• Recent attack of exanthematous fever (measles, chickenpox)

• Nutritional deficiencies & systemic disorders (diabetes, immune deficiency

syndromes)
BACTERIOLOGY

• Start as viral infections followed soon by bacterial invasion

• Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus

& Klebsiella pneumoniae
PATHOLOGY OF SINUSITIS

• Hyperaemia

• Exudation of fluid

• Outpouring of polymorphonuclear cells

• Increased activity of serous & mucous glands

• Depending on the virulence of organisms, defences of the host & capability of the
sinus ostium to drain the exudates
mild (nonsuppurative)
severe (suppurative)
• Initially - exudate is serous

• Later - mucopurulent / purulent

• Severe infections - destruction of mucosal lining

• Failure of ostium to drain - empyema of the sinus & destruction of its bony
walls leading to complications

• Dental infections are very fulminating & soon result in suppurative sinusitis
ACUTE FRONTAL SINUSITIS

AETIOLOGY

1. Viral infections of upper respiratory tract followed later by bacterial invasion

2. Entry of water into the sinus during diving / swimming

3. External trauma to the sinus, fractures / penetrating injuries

4. Oedema of middle meatus, secondary to associated ipsilateral maxillary /

ethmoid sinus infection
CLINICAL FEATURES

1. Frontal headache

• Usually severe & localized over the affected sinus

• Shows characteristic periodicity, i.e. comes up on waking, gradually increases

and reaches its peak by about mid day & then starts subsiding

• Office headache
2. Tenderness

• Pressure upwards on the floor of frontal sinus, just above the medial canthus,
causes exquisite pain

• By tapping over the anterior wall of frontal sinus in the medial part of
supraorbital region

3. Oedema of upper eyelid

4. 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

X-rays

• Opacity of the affected sinus or fluid level can be seen

• Both Waters’ and lateral views should be taken

CT scan is the preferred modality

TREATMENT

MEDICAL

• Antimicrobials, decongestion of the sinus ostium for drainage, analgesics

• A combination of antihistaminic with an oral nasal decongestant

• Placing a pledget of cotton soaked in a vasoconstrictor in the middle meatus,

once / twice daily, helps to relieve ostial oedema & promotes sinus drainage &
ventilation

• If patient shows response to medical treatment & pain is relieved, treatment is

continued for full 10 days to 2 weeks
SURGICAL

Trephination of frontal sinus

• If there is persistence / exacerbation of pain / pyrexia in spite of medical

treatment for 48 h/ if the lid swelling is increasing & threatening 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

• Floor of frontal sinus is exposed & a hole drilled with a burr

• Pus is taken for culture & sensitivity, a plastic tube inserted & fixed

• Sinus can now be irrigated with normal saline two / three times daily until
frontonasal duct becomes patent

• This can be determined by adding a few drops of methylene blue to the

irrigating fluid & its exit seen through the nose.

• Drainage tube is removed when frontonasal duct becomes patent

COMPLICATIONS

1. Orbital cellulitis

2. Osteomyelitis of frontal bone & fistula formation

3. Meningitis, extradural abscess / frontal lobe abscess, if infection breaks

through the posterior wall of the sinus

4. Chronic frontal sinusitis, if the acute infection is neglected / improperly

treated
CHRONIC SINUSITIS IN GENERAL

• Sinus infection lasting for months / years

• Most important cause - failure of acute infection to resolve

PATHOPHYSIOLOGY

• Acute infection destroys normal ciliated epithelium impairing drainage from

the sinus

• Pooling & stagnation of secretions in the sinus invites infection

• Persistence of infection causes mucosal changes, such as loss of cilia, oedema

& polyp formation, thus continuing the vicious cycle
PATHOLOGY

• In chronic infections, process of destruction & attempts at healing proceed

simultaneously

• Sinus mucosa becomes thick & polypoidal (hypertrophic sinusitis) / undergoes

atrophy (atrophic sinusitis)
CLINICAL FEATURES

• Often vague & similar to those of acute sinusitis but of lesser severity

• Purulent nasal discharge – common

• Foul-smelling discharge - anaerobic infection

• Local pain & headache are often not marked except in acute exacerbations

• Some patients complain of nasal stuffiness & anosmia

TREATMENT

• Search for underlying aetiological factors which obstruct sinus drainage &
ventilation

• A work-up for nasal allergy

• Culture & sensitivity of sinus discharge helps in the proper selection of an

antibiotic

• Initial treatment - conservative, including antibiotics, decongestants,

antihistaminics & sinus irrigations
• More often, some form of surgery is required either to provide free drainage &
ventilation

• Recently, endoscopic sinus surgery is replacing radical operations on the

sinuses & provides good drainage & ventilation

• It also avoids external incisions

CHRONIC FRONTAL SINUSITIS

1. Intranasal drainage operations

• Correction of deviated septum, removal of a polyp provide drainage through

the frontonasal duct

• Treatment of associated maxillary sinusitis

2. Trephination of frontal sinus

3. External frontoethmoidectomy (Howarth’s / Lynch operation)

4. Osteoplastic flap operation

THANK YOU…