Sinusitis

Dr.Kaminee Kumar Tripura

MBBS, DLO (BSMMU)
Assistant Professor,
President Abdul Hamid Medical College & Hospital, Kishoreganj.
ANATOM
Y
• Supreme
turbinate
• Basal
Lamella

• Uncinate
process

• Bulla
Ethmoidalis

• Hiatus
Semilunaris

• Infundibulum
Osteomeatal complex
• Drainage pathway for ant. group of sinuses

• Medially - middle turbinate

• Laterally - lamina papyracea

• Superiorly & Posteriorly- the basal lamella

1. Multiple
bony structures - Middle turbinate, uncinate
process, Bulla ethmoidalis

2. Air spaces - Frontal recess, ethmoidal infundibulum,

middle meatus

3. Ostia of anterior ethmoidal, maxillary and frontal

Osteomeatal
Complex
1. Sphenoethmoidal recess:
sphenoid sinus
2. Superior meatus: posterior
ethmoid sinuses

3. Middle meatus:

• Frontal sinus
• Maxillary sinus
• Anterior ethmoid sinuses
4. Inferior meatus : nasolacrimal
duct
Para Nasal Sinuses
 Anterior Posterior
Group Group
• Posterior
• Maxillary Sinus Ethmoidal Sinus
• Sphenoid Sinus
• Frontal Sinus

• Anterior

ethmoidal
• The Ethmoid and
Maxillary sinuses -
birth.

• The frontal sinus

- 2nd year

• Sphenoid sinus -
3rd year
Functions Of Paranasal Sinuses

• Air Conditioning

• Resonance to voice

• Thermal insulators

• Lighten skull bones

 Maxillary Sinus ( Antrum Of Highmore)
• Largest

• Pyramidal

Base - lateral wall of nose

Apex – zygomatic process

• Capacity – 15ml

• Normal ostium – posterior

part of infundibulum
• Roof – floor
of orbit
• Anterior wall – facial surface of
maxilla

• Posterior wall – Infratemporal &

Pterygopalatine fossa

• Medial wall – middle & inferior

meatuses

• Floor – alveolar & palatine process

of maxilla
• 1cm below level of floor of nose
 Frontal Sinus
• 2nd largest

• Rarely symmetrical……..Thin
bony septum

• Anterior wall – skin forehead

• Inferior wall – orbit

• Posterior wall – meninges,

frontal lobe

• Frontonasal duct

• Drains to – Frontal recess,

infundibulum
Frontonasal duct
 Ethmoidal Sinuses

• Anterior group – middle

meatus
• Posterior group – superior
meatus

• Roof – anterior cranial

fossa( lateral to
cribriform plate)
• Lateral wall – orbit ( Lamina
Papyracea )
 Sphenoid Sinus

• Rarely symmetrical……..Thin
bony septum
• Below sella tursica

• Ostium – upper

anterior wall -------

sphenoethmoidal
recess
Relations….

• Anterior part roof – olfactory tract, optic

chiasma, frontal lobe
Physiology Of
Paranasal Sinuses
Ventilation & Mucous Drainage

• Inspiration – negative pressure – emptied

• Expiration – positive pressure – filled

• Mucous from anterior
groups – lateral pharyngeal gutter

• Posterior groups – posterior pharyngeal wall

 It is the acute inflammation of sinus mucosa.
 Most commonly involved sinus is maxillary sinus(ethmoid
»frontal
»sphenoid sinuses)
Multisinusitis
 SINUSITIS
Pansinusitis

Open type
 SINUSITIS
Closed type
BACTERIOLOGY:
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis,
Streptococcus pyogenes, Satphylococcus aureus, Klebsiella
pneumoniae .Anaerobic infections are seen in sinusitis of dental origin.

A) EXCITING CAUSES :

 Nasal infections: Viral rhinitis followed by bacterial invasion.

 Swimming and diving: infected water enters sinuses through
ostia.
 Trauma: Compound fractures or penetrating injuries.

B) PREDISPOSING CAUSES :
LOCAL:
 Obstruction to sinus ventilation and drainage ( DNS,hypertrophic
turbinates, polyp,edema of ostia, neoplasms, edema of ostia).
 Stasis of secretions in nasal cavity( Cystic fibrosis ,enlarged
adenoids, choanal atresia)
 Previous attacks of sinusitis.

GENERAL
 Environment: Cold and wet climate.
 Poor general health: Exanthematous fever
(measles,chickenpox),nutritional deficiencies, systemic disorders.
 AETIOLOGY:
 Dental infections(periapical dental abscess, oroantral
fistula).
 Viral rhinitis followed by bacterial invasion.
 Diving and swimming.
 Trauma (fractures and penetrating injuries).

Clinical features :
 Constitutional symptoms.
 Headache.
 Pain.
 Tenderness.
 Redness and edema of cheek.
 Nasal discharge.
 Postnasal discharge.
 DIAGNOSIS:
 Xray: WATER’S VIEW.

 CT is
preferred..

 ANTERIOR NASAL
ENDOSCOPY

PUS SEEN IN MIDDLE

CT CORONAL SECTION
TRANSILLUMINATION TEST:

TRANSILLUMINOSCOPE TRANSILLUMINATION OF MAXILLARY

SINUS
 TREATMENT
:
MEDICAL drugs( ampicillin/amoxicillin/erythromycin)
 Antimicrobial
 Nasal decongestant drops ( 0.1% oxy or xylometazoline).
 Steam inhalation.
 Analgesics.
 Hot fomentation.

SURGICAL
 Antral lavage

NASAL
SPRAYS
AETIOLOGY
: Viral rhinitis followed by bacterial invasion.
 Diving and swimming.
 Trauma (fractures and penetrating injuries).
 Oedema of middle meatus 2⁰ to ipsilateral maxillary sinus infection.

CLINICAL FEATURES:
 Frontal headache.(OFFICE HEADACHE)
 Tenderness.
 Oedema of upper eyelid.
 Nasal discharge.
 DIAGNOSIS:
 Xray: WATER”S VIEW/LATERAL VIEW.
 CT is preferred.

TREATMENT:
MEDICAL
 Antimicrobial drugs.
 Nasal decongestant
drops.
 Steam inhalation.
 Analgesics.
 Hot fomentation.
SURGICAL
Trephination of frontal sinus.
 AETIOLOGY:
 Associated with infection of other
sinuses.

CLINICAL FEATURES:
 Pain.
 Oedema of lids.
 Nasal discharge(middle or superior
meatus).
 Swelling of the middle turbinate.
 DIAGNOSIS:
 Computed tomography.

TREATMENT:
 Medical treatment same as for acute maxillary sinusitis.
 In case of posterior orbit abscess ,drainage of ethmoid sinuses into
nose through external ethmoidectomy incision may be required.
 AETIOLOGY:
 As a part of pansinusitis.
 Associated with infection of posterior ethmoid sinuses.

CLINICAL FEATURES:
 Headache.
 Postnasal discharge.

DIAGNOSIS:
 Xray/CT.

 TREATMENT:
 Medical treatment same as for acute maxillary
 It is the sinus infection lasting for months or
 years.
Important cause is failure of acute infection to
resolve.
 PATHOPYSIOLOGY:
Pollution,chemicals,infections.

LOSS OF CILIA
Polypi,DNS,
adenoids, IMPAIRED MUCOSAL
tumors, ALLERGY
DRAINAGE CHANGES
allergy

INFECTION

Inadequate therapy of acute

 PATHOLOGY:
 Destruction and healing of sinus mucosa.
 Hypertrophic sinusitis.
 Atrophic sinusitis.
 Submucosa infiltrated with lymphocytes and plasma
cells.

CLINICAL FEATURES:
 Similar to acute sinusitis but of lesser severity.
 Purulent nasal discharge is the commonest
complaint.
 Foul smelling discharge( anerobic infections).
 Local pain and tenderness are not marked.
 Nasal stuffiness and anosmia(in some patients).
 DIAGNOSIS:

 Xray (mucosal thickening)

 Xray with contrast.
 CT
 Aspiration( pus is
confirmatory).

TREATMENT
 Cause for obstruction of sinus drainage and ventilation to be found
out.
 Work up on nasal allergy may be required..
 Culture and sensitivity ( selection of antibiotic).
 Conservative management(antibiotics, decongestants, antihistaminics)
 SURGICAL TREATMENT:
 CHRONIC MAXILLARY SINUSITIS
 Antral puncture and
irrigation.
 Intranasal antrostomy.
 Caldwell-luc operation.

ANTRAL PUNCTURE
 CHRONIC FRONTAL SINUSITIS

 Intranasal drainage operations.

 Trephination of frontal sinus.
 External fronto-ethmoidectomy.

( Howarth or Lynch’s operation)

 Osteoplastic flap operation.

HOWARTH’S OR LYNCH
OPERATION
 CHRONIC ETHMOID SINUSITIS
 Intranasal ethmoidectomy.
 External ethmoidectomy.

CHRONIC SPHENOID SINUSITIS

 Sphenoidotomy.

FESS HAS NOW REPLACED CONVENTIONAL

SURGERIES.
TYPES
A- Local Mucocele/Pyocele
Mucous retention cyst
Osteomyelitis- frontal
bone and maxila

B- Orbital Preseptal inflammatory oedema of lids

Subperiosteal abscess
Orbital cellulitis
Orbital abscess
Superior orbital
fissure syndrome
Orbital apex
syndrome
C- Intacranial Meningitis Extradural
abscess Subdural
abscess Brain
abscess
Cavernous sinus
thrombosis
D- Descending 1) Otitis media
infections 2) Pharyngitis and tonsillitis: hypertrophy of lateral lymphoid
3) Persistent laryngitis and tracheobronchitis
E- Focal infections Sinusitis may act as focus of infection is conditions like:
Polyarthritis, tenosynovitis, fibrositis and certain skin diseases.