Sinusitis :

Sinusitis is the inflammation of sinus mucosa, which may be caused due to infections, allergy or autoimmune disorders. Sinusitis may be open and closed. The inflammatory products of sinusitis can be drained in case of open type, whereas in case of closed type, the inflammatory secretions are not drained, which is the reason behind more severe symptoms and more likely complications in closed type of sinusitis. Sinusitis may be acute or chronic.

Acute Sinusitis:

Acute inflammation of sinus mucosa is termed acute sinusitis. Nasal infections, Trauma, Dental infections, chemical inflammations are major exciting causes for development of acute sinusitis. Obstruction to sinus ventilation and its drainage is one of the major predisposing factor, along with stasis of nasal cavity secretions and previous attacks of sinusitis. Acute sinusitis is usually caused by viral infection, followed by bacterial infections. common bacteria involved are Streptococcus pneumoniae, Haemophilus influenza, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus, Klebsiella pneumoniae, etc.

 

Acute Maxillary Sinusitis:

Dental infections form an important source for acute maxillary sinusitis. It may also be caused by viral rhinits, which spreads into the sinus mucosa, followed by bacterial invasion, other causes include trauma to sinus, contaminated water, etc.

Clinical features: Headache, Toxaemia, Pain in the upper jaw, gums, Tenderness, Redness and oedema of cheek, Nasal Discharge are the common symptoms.

Diagnosis: Transilluminatin test shows opaque affected sinus. X-ray shows opacity or fluid level in the involved sinus in Water’s view. CT scan is preferred modality to investigate the sinuses.

Treatment:

• Medical Treatment is by antimicrobial drugs like Ampicillin, Amoxicillin, Erythromycin, Doxycyline, Cotrimoxazole are used. Nasal decongestand drops of 1% ephedrine, 0.1% xylometazoline or oxymetazoline are used to encourage drainage. Steam inhalation with menthol provides symptomatic relief. Inhalation to be given after 20 minutes of nasal decongestion for better penetration. Analgesics like paracetamol can be given to relieve pain or headache. Hot fomentaion of affected sinus aids in resolution of inflammation.
• Surgical Treatment is by Antral lavage, this is only done when medical treatment has failed and only under the cover of antibiotics.

Complications:

Acute form may change into subacute or chronic forms.

Frontonasal duct, may be obstructed, leading to Frontal sinusitis.

Osteitis or Osteomyelitis of the maxila, Orbital abcess may develop.

Acute Frontal Sinusitis:

Acute frontal sinusitis usually follows viral infections of upper respiratory tract, followed by bacterial invasion. Other causes include trauma, infected water, oedema of middle meatus(a complication seen in maxillary and ethmoid sinus infection).

Clinical Features: Frontal headache, tenderness, oedema of upper eyelid, nasal discharge are prominent clinical features.

Diagnosis: X-rays show either opacity or fluid level at the affected sinus.

Treatment:

• Medical : Antibiotics, decongestion of sinus ostium for drainage and analgesics, similar to the management of acute maxillary sinus. Antihistaminics given along with oral nasal decongestant like pseudoephedrine or phenylephrine hydrochloride is found to be useful.
• Surgical: Trephination of frontal sinus and Antral lavage.

Complications:

Orbital Cellulitis, Osteomyelitis of frontal bone and fistula formation, Meningitis, extradural abscess or frontal lobe abcess, if infection breaks through posterior wall of the sinus, Chronic frontal sinusitis.

 

Acute Ethmoid Sinusitis:

Also termed acute ethmoiditis is usually associated with infection of other sinuses. Ethmoid sinusitis is usually seen in infants and young children.

Clinical Features: Pain, Oedema of lids, Nasal discharge, Swelling of middle turbinate.

Treatment:

• Medical : Medical treatment of ethmoiditis is similar to to acute maxillary sinusitis.
• Surgical : Visual deterioration and exopthalmos indicate abscess of posterior orbit and may require drainage of ethmoid sinus through External Ethmoidectomy incision.

Complications:
Orbital Cellulitis, abcess, Visual deterioration, blindness due to optic nerve involvement, Cavernous sinus thrombosis
, Extradural abcess, meningitis or brain abcess.

Acute Sphenoid Sinusitis:

Acute Sphenoid sinusitis occurs as a part of pansinusitis usuallya nd is usually associated with infections of posterior ethmoid sinuses.

Clinical Features: Headache, Postnasal discharge is seen in posterior rhinoscopy.

Diagnosis:

Opacity or fluid level may be seen at the sphenoid sinus in X-rays. Lateral view of sphenoid as seen from prone or supine position is helpful to demonstrate fluid level.

 

 

Chronic Sinusitis:

Sinus infection lasting for months to years is called Chronic Sinusitis. Chronic sinusitis is usually seen as advanced infective stages of acute infections, which fail to resolve.

Pathophysiology:

Since Chronic sinusitis is usually seen in cases where acute infection fails to resolve, the pooling and stagnation of secretions in the sinus invites infections. Persistance of infections cause mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle.

 

Pathology:

Chronic infections lead to destruction and healing processes proceed simultaneously. Hence the sinus mucosa gets thick and polypoidal leading to hypertrophic sinusitis. It may also undergo atropy to form atrophic sinusitis. The surface epithelium may show desquamation, regeneration,  or metaplasia.

Clinical Features:

Vague clinical features, similar to acute sinusitis are usually seen, but of lesser severity. The commonest complaint being purulent nasal discharge. Some patients may complain nasal stuffiness and lack of smell sensation.

Diagnosis:

X-ray shows mucosal thickening and opacity, Using contrast material shows soft tissue changes in sinus mucosa.

CT-scan is very useful in ethmoid and sinus infections.

Aspiration and Irrigation helps for confirmation of the disease.

Treatment:

• Medical: Antibiotics, decongestants, antihistaminics and sinus irrigations.
• Surgical: Surgical invasion is commonly required for the proper treatment of chronic sinusitis. The surgical processes employed depends on the site and extent of the infection. Endoscopic sinus surgery is much better than radical operations as they provide good drainage and ventilation along with avoiding external incisions.

 

 

Chronic Maxillary Sinusitis

1. Antral puncture and irrigation.

2. Intranasal antrostomy.

3. Caldwell-Luc Operation.

 

Chronic Frontal Sinusitis

1. Intranasal Drainage Operations.

2. Trephination of Frontal Sinus.

3. External Frontoethmoidectomy.

4. Osteoplastic Flap Operation

 

Chronic Ethmoid Sinusitis

 1. Intranasal Ethmoidectomy.

2. External Ethmoidectomy

 

Chronic Sphenoiditis

1. Sphenoidectomy