Rhino-Sinusitis: Clinical Features,

Diagnosis & Medical Treatment

Dr. Vishal Sharma

Rhino-sinusitis: inflammation of lining mucosa

of nose & paranasal sinuses

Acute: infection lasting < 4 weeks

Sub acute: infection lasting 4 to 12 weeks

Chronic: infection lasting > 12 weeks

Recurrent: > 3 episodes in 6 months or > 4

episodes per year with

asymptomatic intervals of > 10 days

Definitions

Types of Sinusitis• Acute / sub acute / chronic / recurrent

• Open / Closed (depending on its drainage)

• Unilateral / bilateral

• Maxillary / frontal / ethmoidal / sphenoidal

• Single sinusitis / multi-sinusitis / pan-sinusitis

• Anterior group / posterior group

• Suppurative / hypertrophic

• Bacterial / fungal / allergic / occupational

Etiology

• Rhinogenic: commonest (85%)

– following any form of rhinitis

• Dental: for maxillary sinusitis

– root abscess, dental procedures

• Trauma:

– R.T.A., swimming, diving, F.B., barotrauma

– Iatrogenic: nasal packing, septal surgery

• Hematogenous: rare

• Mucosal odema: viral, bacterial, allergic, irritant,

vasomotor, barotrauma

• Mechanical obstruction: D.N.S. (spur), polyp,

hypertrophic turbinate, concha bullosa,

paradoxical middle turbinate, Haller cell, large

bulla ethmoidalis, agger nasi, uncinate anomaly,

nasal tumour, foreign body, nasal packing

Predisposing factors

• Mucous abnormality: Young’s syndrome, cystic

fibrosis, mucoviscidosis, dehydration

• Mucociliary dysfunction: Kartagener’s

syndrome, viral, bacterial, allergic, smoking,

pollutants, hypoxia, dry air, extremes of

temperature, synechiae

• Miscellaneous: Poor health, immunodeficiency,

diabetes, nutritional deficiency

Bacteriology

Acute sinusitis

Streptococcus

pneumoniae

Haemophilus influenzae

Moraxella

Staphylococcus aureus

Neisseria

Chronic sinusitis

Staph. Aureus

Streptococcus

H. influenzae

Bacteroides

Pseudomonas

Progress

Severity and resolution depends on

– Open / closed

– Organism virulence

– Host resistance

– Treatment received

Ostio-meatal complex is key area for causation of chronic anterior group sinusitis

Pathological variants of ostio-meatal

complex

Concha bullosa

Concha bullosa

Paradoxically curved M.T.

Paradoxically curved M.T.

Medialized uncinate process

Large bulla ethmoidalis

Haller cell

Agger nasi cell

Nasal Septal Spur

Nasal Septal Spur

Mucosal disease

Symptoms• Nasal discharge: mucoid / purulent / blood-stained

• Nasal obstruction with hyposmia / anosmia

• Headache / facial pain

• Cheek / eyelid congestion + swelling

• Hawking, sore throat, cough

• Earache: associated Eustachian tube dysfunction

• Constitutional: fever, malaise, body ache

Location of facial pain

Maxillary: cheek, upper jaw, forehead (supra-orbital)

that es on bending forward

Frontal: forehead that es during morning & es by

late afternoon (Office headache)

Anterior Ethmoid: nasal bridge & peri-orbital, es

with eye movement

Posterior Ethmoid: retro-orbital

Sphenoid: vertex, occipital, retro-orbital

Signs• Congested & edematous nasal mucosa

• Nasal discharge (anterior & posterior rhinoscopy):

middle meatus: frontal, maxillary, anterior ethmoid

superior meatus: posterior ethmoid, sphenoid

• Paranasal sinus tenderness present

• Postnasal drip, granular pharyngitis

• Cheek swelling: in maxillary sinusitis

• Lid edema: in ethmoid & frontal sinusitis

Para-nasal sinus tenderness

Para-nasal sinus tenderness• Maxillary: palpate

over canine fossa

• Anterior ethmoid:

palpate medial to

medial canthus

• Frontal: palpate floor

of sinus or tap over its

anterior wall

Para-nasal sinus tenderness

Sinus trans-illumination test

Sinus trans-illumination test

• Performed in a dark room. High-intensity light

source placed inside patient’s mouth or against

the cheek (for maxillary sinus) & under medial

aspect of supra-orbital ridge (for frontal sinus).

• Trans-illumination normal = no sinusitis

• Trans-illumination absent = sinus filled with pus

• Trans-illumination dull = equivocal result

Postural test

Performed in acute sinusitis (active nasal discharge)

Pus cleaned in supine position & pt sits upright

Pus appears = frontal or ethmoid sinusitis

Pus appears on stooping forwards = sphenoid sinusitis

No discharge pt lies in lateral position with affected

side up. Pus appears = maxillary sinusitis

Rhinosinusitis Task Force CriteriaMajor Minor

1. Facial pain / pressure 1. Headache

2. Nasal obstruction 2. Fever (non-acute sinusitis)

3. Nasal discharge or 3. Halitosis

discolored postnasal drip 4. Fatigue

4. Hyposmia / anosmia 5. Dental pain

5. Purulence on examn 6. Cough

6. Fever (acute sinusitis) 7. Ear pain / pressure / fullness

Presence of 2 major factors or 1 major + 2 minor

factors = sinusitis

Investigations

1. Diagnostic nasal endoscopy (D.N.E.)

2. Maxillary Sinoscopy

3. X-ray of P.N.S.

4. U.S.G. of maxillary sinus (Rhinoscan)

5. C.T. scan of P.N.S.

6. M.R.I. of P.N.S.: rarely done

7. Allergic tests

8. Proof puncture (antral wash): for maxillary sinus

9. Endoscopic microswab for culture & sensitivity

10. Fungal culture: of cheesy nasal discharge

Diagnostic Nasal Endoscopy

1. Patients not responding to medical therapy

2. Anatomic factor preventing adequate

examination by anterior rhinoscopy

3. Collection of pus from hiatus semilunaris for

culture & sensitivity

4. Objective monitoring of patients

5. Peri-operative nasal inspection & cleaning

Indications for D.N.E.

Pus in middle meatus in D.N.E.

Maxillary sinoscopy

Maxillary sinoscopy

• Anterior sinus wall

perforated directly (in

canine fossa between

roots of 3rd & 4th teeth)

with maxillary sinus

trocar & cannula

• Trocar removed &

sinoscope introduced

through cannula

X-ray paranasal sinus

Water’s view (Occipito-mental) maxillary

Caldwell’s view (Occipito-frontal) frontal

Rhese’s view (lateral oblique) ethmoid

Base skull view (Submento-vertical) sphenoid

Lateral view

Pierre’s view (occipito-mental with mouth open)

Air-fluid level: acute sinusitis

Mucosal thickening chronic sinusitis

Acute maxillary sinusitis

Chronic maxillary sinusitis

Frontal sinusitis

Pierre’s view

Lateral view

Para-nasal sinus sonography

• Bony anterior wall is seen as hyper-echoic line.

Maxillary cavity filled with air appears as hyper-

echoic hence posterior sinus margin not seen.

• Fluid in sinus, cyst & mucosal thickening are

hypoechoic so posterior sinus margin is visible.

• B mode sonogram differentiates between fluid in

sinus, cyst & mucosal thickening.

Normal sinus sonography (A-mode)

A-mode sonography of sinusitis

C.T. scan: maxillary sinusitis

C.T. scan: ethmoid sinusitis

C.T. scan: frontal sinusitis

C.T. scan: sphenoid sinusitis

Coronal & axial cuts, plain (without contrast)

Coronal planes, cuts of 4 mm or less

Indications:

– In recurrent acute / chronic sinusitis not

responding to medical therapy

– Before endoscopic surgery

– Impending complications of sinusitis

C.T. scan paranasal sinus

M.R.I. of P.N.S.

Medical Treatment• Systemic Antibiotics

• Nasal decongestants: topical & systemic

• Anti-histamines

• Analgesic-anti-inflammatory drugs

• Medicated steam inhalation & nasal douching

• Mucolytics: Ambroxol

• Anti-allergy treatment

• Hot fomentation

Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days

Ciprofloxacin: 500mg B.D. X 7 days

Doxycycline: 100 mg B.D. X 7 days

Cefadroxil: 500 mg B.D. X 7 days

Cefaclor: 500 mg T.I.D. X 7 days

Cefuroxime: 250 mg B.D. X 7 days

Cefixime: 200 mg B.D. X 7 days

Cefpodoxime: 200 mg B.D. X 7 days

Azithromycin: 500 mg O.D. X 3-5 days

Clarithromycin: 250 mg B.D. X 7 days

Antihistamines

Systemic:

Cetirizine: 10 mg OD

Fexofenadine: 120 mg OD

Loratidine: 10 mg OD

Levocetrizine: 5 mg OD

Desloratidine: 5 mg OD

Topical: Azelastine spray (0.1%): 1-2 puff BD

Nasal Decongestants

Systemic decongestants

Phenylephrine

Pseudoephedrine

Topical decongestants

Xylometazoline

Oxymetazoline

Saline

Anti-cold preparationsName Chlorpheniramine Decongestant Paracetamol

COLDIN 4 mg PsE 60 mg 500 mg

SINAREST 4 mg PsE 60 mg 500 mg

DECOLD 4 mg PhE 7.5 mg 500 mg

SUPRIN 2 mg PhE 5 mg 500 mg

PsE = Pseudoephedrine; PhE = Phenylephrine

Topical Decongestants

• Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)

• Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P)

• Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)

• Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)

• Saline 2 %: 3 drops TID

• Saline 0.67 %: 2 drops BD (NASIVION-S)

Fungal Sinusitis

A. Invasive (hyphae present in submucosa)

– Acute invasive or fulminant (< 4 weeks)

– Chronic invasive or indolent (> 4 weeks)

B. Non-invasive

– Allergic

– Fungal ball or mycetoma

– Saprophytic

Aspergillosis & Mucormycosis are common

Acute invasive fungal sinusitis• Usually mucormycosis

• Predisposing factors:

• Immune-compromise: AIDS, Lymphoma, Cyto-toxic

drugs, chronic use of steroid, aplastic anemia

• Insulin dependent diabetes mellitus

• Long term use of broad-spectrum antibiotics

• C/F: Unilateral nasal discharge with black crusts due

to ischaemic necrosis. Cerebral & vascular invasion

present. Absence of significant inflammation.

Black crusting

Treatment:• Remove precipitating factors• Surgical debridement of necrotic debris• Anti-fungal drugs:• Amphotericin B infusion for 1-2 months• Itraconazole 100 mg BD for 6-12 months

Chronic invasive fungal sinusitis• Significant inflammation with fibrosis & granuloma

formation• Locally destructive with minimal bone erosion• Tx: Debridement + Anti-fungal agents

Surgical debridement

Allergic fungal sinusitis• Associated with ethmoid polyps & asthma

• Unilateral thick yellow nasal discharge with

mucin, eosinophils & Charcot Leyden crystals

• C.T. scan: radio-opaque mass with central area

of hyper density (due to hyphae)

• Tx: Surgical debridement + anti-histamines +

steroids (oral & topical)

Allergic fungal sinusitis

Allergic fungal sinusitis

C.T. scan coronal cuts

C.T. scan axial cuts

Fungal ball (Mycetoma)

• Refractory sinusitis with foul smelling cheesy

material in maxillary sinus

• Tx: Surgical removal. No anti-fungal drugs.

Saprophytic fungal sinusitis

Seen after sino-nasal surgery due to proliferation

of fungal spores on mucous crusts

Tx: Surgical removal. No anti-fungal drugs.

Thank You