Rhinosinusitis 

Hatlan ALHatlan

Paranasal Sinuses

Rhinosinusitis ?• Symptomatic inflammation of the nasal cavity

and paranasal sinuses..• The term "rhinosinusitis" is preferred to

"sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa.

Classifications • Based on patient history and a limited physical

examination , and which the treatment depends on , Rhinosinusitis is classified into :

1. Acute2. Recurrent acute3. Subacute 4. Chronic

General Symptoms of Rhinosinusitis • The symptoms of rhinosinusitis can be

classified generally into : 1. Major symptoms : A. Facial pain/pressure/fullnessB. Nasal obstruction/blockage /congestionC. Nasal or postnasal discharge/purulenceD. Hyposmia/anosmiaE. Fever (in acute rhinosinusitis only)

General Symptoms of Rhinosinusitis 2.Minor symptoms :A. HeadachesB. Fever (other than acute rhinosinusitis)C. HalitosisD. FatigueE. Dental painF. CoughG. Ear pain/pressure/fullness

Classifications AgainAdditions History +

ExaminationDuration Type

Fever + Facial pain not constitute in absence of other nasal symptoms

1- Two or more major 2-One major with two or more minor

Up to 4 weeks Acute

Same 4 or more episodes per year lasts 7 days no intervening signs or symptoms

Recurrent acute

Complete resolution after effective medical therapy.

Same 4 weeks to 12 weeks

Subacute

Same as acute (facial pain)

Same More than 12 weeks

Chronic

Acute Rhinosinusitis • Acute rhinosinusitis (ARS): is defined as

symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks.

• It’s further classified into acute viral or acute bacterial rhinosinusitis.

Epidemiology • It affects 30 million a year in US.• About 1 in 7 people will have it once a year in

the western countries.• Higher in women(20.3%), compared with

(11.5%) in men , more in 45-74 years.• Total costs from medications, outpatient and

emergency room visits, and ancillary tests and procedures, are estimated at $3 billion per year.

Pathophysiology

• Majority are due to viral infections , with bacterial only in 0.5 to 2.0% of the cases.

• (Rhinovirus, Influenza virus, Parainfluenza virus)• The viral infection starts with :1. Inoculation via direct contact (conj+nas.muc)2. Viral replication in nasal secretions 8-10 hrs.3. Spreads to the paranasal sinuses by systemic or

direct routes(nose blowing intranasal presssure).

Pathophysiology

4. Inflammation follows sinonasal hypersecretion and increased vascular permeability transudation of fluid into the nasal cavity and sinuses.

5.Direct toxic effects by the virus impairs the cilia clearance function.

6.Mucosal edema, copious thickened secretions, and ciliary dyskinesia .

Pathophysiology

• Acute bacterial infection is usually a complication of viral .

• Other predisposing factors are :1. allergy2. Mechanical obstruction of the nose,3. Swimming 4. Intranasal cocaine use5. Impaired mucociliary clearance6. Immunodeficiency

Diagnosis • The diagnosis of acute rhinosinusitis (ARS) is

based upon clinical signs and symptoms.(table)

• Diagnostic testing is not indicated in initial evaluation.

• Highly symptoms :1. Purulent rhinorrhea2. Nasal congestion and facial pain/pressure

Diagnosis

Suggestions of bacterial infections ? 1. Persistent symptoms or signs of ARS lasting 10

or more days without evidence of clinical improvement.

2. Onset of severe symptoms or signs of high fever(>39°C )purulent nasal discharge or facial pain 3-4 consecutive days (viral 24-48 hrs)

3. Onset with worsening symptoms or signs (new fever +Headache+ etc..) 5-6 days after improvement.

Bacterial 1) Streptococcus pneumoniae & haemophilus

influenza are the commonest 2) Gram –ve bacilli3) Anaerobic organisms are common in sinusitis

due to dental cause4) Moraxella catarrhalis and H.influenza are

common in pediatric sinusitis

Physical Examination

• Physical examination should encompass the usual evaluation for

1. Respiratory infection, including assessment of vital signs, eyes, ears, pharynx, teeth, sinus tenderness, lymph nodes, and chest.

2. Pain localized to the sinuses when the patient is asked to bend forward(more reliable)

3. Pain provoked by direct percussion in the diagnosis of rhinosinusitis (less reliable)

Physical Examination

• Nasal speculum AS anterior rhinoscopy. findings may include:

1. Diffuse mucosal edema 2. Narrowing of the middle meatus3. Inferior turbinate hypertrophy4. Copious rhinorrhea or purulent discharge.

Diagnostic Tests • Microbiologic culture :• Viral culture of nasal secretions is impractical

and unnecessary, given the self-limited nature of AVRS

• Bacterial culture of material from blind swabs of the nasal cavity or from purulent nasal secretions is not recommended, as results are not reliable.

Diagnostic Tests • Endoscopy :• Indicated in intracranial extension or other

serious complications , better tolerated than the classic antral puncture.

• Corner stone with biopsy in early diagnosis of Acute fulminant invasive fungal rhinosinusitis (IFRS).

• Endoscopic image of purulent drainage from the middle meatus in a patient with acute bacterial rhinosinusitis.

Diagnostic Tests • Radiologic studies:• Indicated in complicated cases mainly .• These signs of complications , which needs

urgent referral and imaging :1. High fevers (>39°C or 102°F) 2. Severe headache 3. Abnormal vision (diplopia, blindness)4. Change in mental status5. Periorbital edema

Diagnostic Tests

• CT is the modality of choice : • A CT scan with contrast is indicated for

suppurative complication such as orbital cellulitis or intracranial infection.

• Noncontrast CT scan is for evaluation of recurrent or treatment-resistant sinusitis. (Ability to discern bony and soft tissue detail)

Diagnostic Tests

• Common findings CT :1. Air-fluid levels2. Mucosal edema3. Air bubbles within the sinuses.• However , it cannot distinguish viral from

bacterial, only in diagnosis in the disease.

CT

CT

Diagnostic Tests • Other modalities :• MRI used with CT when extra sinus

complications is suspected, mainly by ABRS.• Ultrasound is of limited value.

Managements • Managements goals : 1. Eradicate the infection2. Decrease the severity and duration of

symptoms3. Prevent complications.

Managements • Symptomatic Treatment:

1. Humidification/vaporizer2. Warm compressor 3. Adequate hydration4. Smoking cessation5. Balanced nutrition 6. Analgesia

Managements

• Antimicrobial Therapy• Choice of antibiotic depends on whether the

sinusitis is acute, chronic, or recurrent. • Use of antibiotics in ARS is mainly for ABRS.• Penicillins+ cephalosporins+ macrolides seem

to be equally efficacious.

Managements

• Surgical choice:• Recurrent or persistent sinusitis and presence

of complications with failure of treatment may require surgical therapy.

• Functional endoscopic sinus surgery (FESS) has revolutionized the treatment of sinusitis in recent years. The therapeutic benefits of FESS have helped a large number of patients with chronic sinus disease.

FESS

FEES Complications

1) orbital:a) Injury to orbital fat & musclesb) Orbital haematoma lead to optic nerve

compression & blindnessc) Optic nerve injury and blindness2) intracranial:d) CSF leake) Brain tissue nasal herniation(from the lecture)

Sinusitis Complications

1. Local Complications 2. Orbital Complications (Most Common)3. Intracranial Complications4. Systemic Complications

Complications • Local complications1. Mucoceles are chronic epithelial cysts that

develop in sinuses in the presence of either an obstructed sinus ostium or minor salivary gland duct.

2. Osteomyelitis (more with frontal , called Pott puffy tumor presenting subperiosteal abscess)

Complications • Orbital complications:• The most common , direct spread through thin bone of

ethmoid or frontal or by thrombophlebitis of the ethmoid veins.

• 5 groups (Chandlr’s classifications):1. Inflammatory edema (preseptal cellulitis).2. Orbital cellulitis with diffuse orbital edema3. Subperiosteal abscess beneath the periosteum 4. Orbital abscess with chemosis, ophthalmoplegia, and

decreased visual acuity5. Cavernous sinus thrombosis with rapidly progressive

bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity.

• Ttt :sinus drainage and intravenous antibiotics,

Complications• Intracranial complications1. Subdural abscess is the most common, 2. Cerebral abscesses 3. InfarctionTreated by surgical drainage both cranium+sinus• Systemic complications:1. Sepsis 2. Multisystem organ failure

Complications

Complications

Complications

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