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Chronic Sinusitis. Brig Mirza Khizar Hameed. Definition. Inflammation of the Paranasal Sinuses lasting > 3 months. Etiology. Anatomical variations Deviated Nasal Septum Concha Bullosa Bulla Ethmoidalis Underlying diseases Cystic Fibrosis Ciliary Dyskinesia Immuno -deficiency - PowerPoint PPT Presentation
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Chronic Sinusitis
Brig Mirza Khizar Hameed
DefinitionInflammation of the Paranasal Sinuses lasting > 3 months
EtiologyAnatomical variationsDeviated Nasal SeptumConcha BullosaBulla EthmoidalisUnderlying diseasesCystic FibrosisCiliary DyskinesiaImmuno-deficiencyGranulomatous diseases
MicrobiologyAnaerobesStaphylococcus aureusStreptococcusH. InfluenzaeM. catarrhalis
PathophysiologyObstruction of Osteomeatal complex regionImpaired mucociliary clearanceStagnation & pooling of secretionsInfection Vicious cycle
SymptomsChronic nasal obstructionPurulent post nasal dischargePain over sinuses/ HeadacheHalitosisChronic cough
Physical signsPurulent Nasal dischargeAnatomical anomaliesTransillumination ?
InvestigationsX-ray PNSCT Scan PNSProof puncture/ Sinus lavageSinus aspirate/ Pus swab for C/S
Treatment Antibiotics Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, MetronidazoleDecongestantsAntihistamines Steroid Nasal Drops/ SpraysSurgery- To provide drainage & ventilation
Operative procedures on Sinuses
Maxillary SinusitisAntral WashoutInferior Meatal AntrostomyCaldwell-Lucs OperationFESS
1. Antral WashoutPuncturing medial wall of sinus for pus aspiration and irrigation of sinusIndications- Ch sinusitis refractory to treatmentContraindications- Age < 3 yrs- Hypoplastic maxilla with thick bony walls- Acute maxillary sinusitis untreated by antibiotics
Tilley Lichwitz Trocar & Cannula
Higginson Syringe
Trocar directed towards I/L tragus
ComplicationsHemorrhagePain & swelling of cheekPerforation of orbital floorVasovagal shockAir embolism
2. Inferior Meatal AntrostomyA window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilleys Antrum Harpoon & enlarged (1.5-2 cm) with Myles perforator
ComplicationsHemorrhageInjury to Naso-lacrimal ductPerforation of orbital floor
3. Caldwell-Lucs SurgeryAnterior wall of the Maxillary sinus is entered through a Sub-labial incisionA window is created in the medial wall through AntrostomyIndications- Ch sinusitis refractory to treatment- Repair of Oro-antral fistula- Reccurrent AC polyp- Blow out fracture of floor of orbit- Approach to ethmoids/ PPF
Sublabial Incision
Hole made in anterior wall followed by Inferior Meatal Antrostomy
ComplicationsHemorrhageCheek edema Numbness of cheekOrbital hematomaTrauma to teeth rootsOro-antral fistula
Ethmoid SinusitisIntranasal EthmoidectomyExternal Ethmoidectomy- Lynch Howarth procedure- Patterson transorbital procedure- Jansen Horgan transantral procedureFESS
Lynch Howarth Ethmoidectomy
Patterson Ethmoidectomy
Trans-antral ethmoidectomy
ComplicationsHemorrhageInjury to Lamina papyracea Periorbital hematoma, proptosis, visual lossInjury to Medial palpebral ligamentCSF leakMeningitisMucocoele formation
Frontal SinusitisTrephinationOsteoplastic flap procedure- Coronal incision- Brow incisionFESS
Frontal sinus trephination
Osteoplastic flap procedure
ComplicationsHematomaFrontal depressionCSF leakMeningitisMucocoele formationOsteomyelitis
Sphenoid SinusitisTrans-nasal trans-septal approachSublabial trans-septal approachExternal ethmoidectomy approachFESS
FESSIndications- Ch sinusitis refractory to treatment- Nasal polyps- Fungal sinusitis- Antro choanal polyp- Fronto-ethmoidal mucocoele- Repair of CSF leak- DCR- Orbital decompression
Functional Endoscopic Sinus SurgeryUncinectomy (Infundibulotomy)Bullectomy & Anterior ethmoidectomyMiddle meatal antrostomyPerforation of basal lamellaPosterior ethmoidectomySphenoid sinus explorationSkull base disease clearanceFrontal recess exploration
ComplicationsMajor Major epistaxis Orbital hematoma Diplopia Blindness or visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct traumaMinorMinor epistaxisHyposmiaAdhesions (synechiae)HeadachePeriorbital echhymosisPeriorbital hematomaDental / facial pain
Fungal Sinusitis
DefinitionInflammation of the sinuses due to a fungus
ClassificationNon Invasive Fungal Sinusitis- Allergic- Fungus Ball (Mycetoma)Invasive Fungal Sinusitis- Acute- Chronic
Allergic Fungal SinusitisMost common formWarm humid climateAmong younger, immuno-competent, atopic Hypersensitivity reaction to inhaled fungus organismPresents with Nasal polyps & thick greenish mucus
InvestigationsTotal IgE - CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodellingHistology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot-Leyden crystals
TreatmentSurgical clearance of sinusesTopical SteroidsAntihistaminesImmunotherapy? Antifungal
Fungus Ball (Mycetoma)Older individuals, usually femalesImmunocompetentAsymptomatic/ Cacosmia/ Chronic sinusitisFungal mass limited to one sinusCT Scan- Hyperdense mass with punctate calcifications
Fungus Ball- TreatmentSurgical clearance? Anti fungal
Acute Invasive Fungal SinusitisMost lethal formImmunocompromised/ DiabeticsCaused by Mucorales, Aspergillus, Fusarium, PhaeohyphomycosisAngio invasion, hematogenous spreadLocal necrosis, orbital & intracranial spreadFever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures
AIFS- CT FindingsUnilateral nasal soft tissue thickeningBony erosionsUnilateral involvement of PNSProptosisCavernous sinus thrombosis
Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosisAcute Invasive Fungal Sinusitis - CT
AIFS- TreatmentAggressive surgical debridementSystemic anti fungal therapyTreatment of underlying cause of immunosuppression
Chronic Invasive Fungal SinusitisImmunocompetent with H/o Ch sinusitisProgressin over months to yearsMaxillofacial soft tissue swellingOrbital involvement proptosis, visual lossIntracranial extension with cranial neuropathies, headaches seizuresCT Scan- Hyperdense mass, bone erosion
CIFS- TreatmentAggressive surgical exenterationSystemic anti fungal therapy
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