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Chronic Sinusitis CHRONIC SINUSITIS BY DR AYUB AHMAD KHAN MBBS,MCPS(ENT),FCPS(ENT),MCPS(HPE), BACO FELLOWSHIP(UK),HOUSE EAR INSTITUTE FELLOWSHIP(USA) Professor/consultant ENT Head of E.N.T. Department Medical educationist CPSP & UHS certified faculty master trainer University college of medicine University of Lahore 1 Ground Rules • Be on time • Put your mobile phones on silent • Participate actively • Have a little fun on the way 2 3 4 5 6 7 8 9 10 Learning outcomes By the end of the session the participants will be able to Describe Chronic Sinusitis and its types Describe clinical presentations of Chronic sinusitis Describe the investigations required to be done for Chronic sinusitis Describe the treatment options for different types of Chronic sinusitis 12 Rhinosinusitis May be Better Term Because Allergic or nonallergic rhinitis nearly always precedes sinusitis Sinusitis without rhinitis is rare Nasal discharge and congestion are prominent symptoms of sinusitis Nasal mucosa and sinus mucosa are similar and are contiguous Differentiating Sinusitis from Rhinitis Rhinitis Sinusitis Nasal congestion Nasal congestion Rhinorrhea clear Purulent rhinorrhea Itching, red eyes Postnasal drip Seasonal symptoms Headache Nasal crease Facial pain Cough, fever Anosmia 15 16 Normal Sinus Sinus health depends on: Mucous secretion of normal viscosity, volume, and composition. Normal muco-ciliary flow to prevent mucous stasis and subsequent infection. Open sinus ostia to allow adequate drainage and aeration. Definition Inflammation of the mucosal lining of the paranasal sinuses. Acute, subacute, and chronic. One of the most common diseases. Definition Acute-up to 3 weeks Subacute-3 weeks to 3 months Chronic-more than 3 months Epidemiology Affects 30-35 million persons/year. 25 million office visits/year. Direct annual cost $2.4 billion and increasing. Added surgical costs: $1 billion. Third most common diagnosis for which antibiotics are prescribed. The Sinusitis-Asthma Connection Failure to control upper airway inflammation leads to suboptimal asthma control. Mechanism is not understood Evidence Implications Correcting the rhinosinusitis results in better asthma control. 21 Ostiomeatal Complex Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain. Posterior ethmoids drain into the upper meatus. Normal Sinus CT Scan through the OMU Eyeball Ethmoid sinus Maxillary sinus Nasal cavity Blow-up View of the Ostiomeatal Unit Area Ethmoid sinus Maxillary infundibulum Uncinate process Middle turbinate Maxillary sinus Obstruction of the OMU with Associated Acute Sinusitis Sinusitis in the ethmoid sinus. Sinusitis in the maxillary sinus. Resolution of Acute Sinusitis after Treatment with Antibiotics Definition of Chronic Sinusitis Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children Eosinophilic inflammation or chronic infection Associated with positive CT scans Poor (if any) response to antibiotics Etiology Allergic and nonallergic rhinitis Uncorrected anatomic conditions Ciliary dyskinesia Cystic fibrosis Tumors Immunodeficiency disorders IgA, IgM Granulomatous diseases Pathogenesis Impaired local mechanisms . Drainage . Mucociliary . Primary . Ciliary-kartegener . Mucous-young’s . Secondary . Viral . Bacterial . OMC . Ventilation Immunodeficiency . Systemic immune deficiency . Chronic infections Classification Duration . Acute . Subacute . Chronic Aetiological . Infections . Allergic . Structural . Others Classification(cont’d) Duration Etiology Diseases Acute Non specific Common cold Acute Non Specific Influenza Acute Specific Diptheria (Bacterial) Acute Specific Syphilis (Bacterial) Duration Pathological Etiology Diseases Chronic CLASSIFICATION(cont’d)Granulomatous Specific Rhinoscleroma (Bacterial) Tuberculosis Spirocheatal Leprosy Chronic Granulomatous Specific Rhinosporiadiasis (Fungal) Asperigillosis Mucor Mycosis Chronic Granulomatous Non specific Wegener’s Mid line lethal Sarcoidosis Chronic Membranous Specific (Bacterial) Chronic Others (irritative rhinitis) Simple Hypertrophic Atrophic Sicca Caseosa Sx of Chronic Sinusitis Nasal discharge Nasal congestion Headache Facial pain or pressure Olfactory disturbance Fever and halitosis Cough (worse when lying down) Quality-of-Life Issues Fatigue Missing school/work Concentration Halitosis Nuisance Decreased production Sleep disturbance Impaired studying Emotional well being Sniffing/snorting Social interactions Blowing nose Diagnosis Primarily based on HPI & PE. Imaging based on demographics and exam findings. Differential diagnosis Granulomatous • Granulomatous (Bacterial) (Non specific) Rhinoscleroma • Wegener’s Tuberculosis • Mid line lethal • Sarcoidosis Spirocheatal • Irritative Leprosy • Simple Granulomatous • Hypertrophic (Fungal) • Atrophic Rhinosporiadiasis • Sicca Asperigillosis • Caseosa Mucor Mycosis Investigations for Chronic Sinusitis CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal Immunoglobulins Radiographic Imaging? CT Scans: Patients presenting with complications of sinusitis . Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema Patients with sinus symptoms accompanied by severe, boring, mid- head pain . Rule out sphenoid sinusitis. X-Ray Image of Sinuses with Maxillary Sinusitis Sinus CT Normal Water’s and Towne’ s Views of the Sinuses Lateral View Showing Normal Sphenoid Sinus Medical Treatment of Chronic Sinusitis Nasal steroid spray Guafenesin Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations Surgical Treatment of Chronic Sinusitis Maxillary sinus Conservative Antral lavage Intranasal antrostomy Radical Caldwell-lac operation Surgical Treatment of Chronic Sinusitis(cont’d) Frontoethmosphenoid sinus Conservative Trephination of frontal sinus Sphenoid sinus washout Intranasal ethmoidectomy Transantral ethmoidectomy Functional endoscopic sinus surgery(FESS) Radical External frontoethmosphenoidectomy Osteoplastic flap Complications of sinusitis Classification Orbital Osteomyelitis of Maxilla and Frontal bone Mucocele Intracranial complications Meningitis, intracranial abscess, cavernous sinus thrombosis Locoregional complications Pharyngitis, laryngitis, otitis media GRANULOMATOUS DISEASES OF NOSE 1.Definition Chronic inflammatory response of the body characterized by granuloma formation in the involved part of the body 2.What is a granuloma? Whenever the infecting agent is overwhelming for the body responses of acute inflammation to handle, body tries to cordon off the offending agent by forming a granuloma. The granuloma consists of macrophages, lymphocytes and plasma cells GRANULOMATOUS Specific Bacterial . Rhinoscleroma . Tuberculosis . Spirochaetal . Leprosy Fungal • Rhinospordiosis • Asperigellosis • Mucormycosis Nonspecific . Wegeners . Midline lethal . Sarcoidosis RHINOSCLEROMA 1.Aetiology Klebsiella rhinoscleromatis or Frisch bacillus 2.Pathology Starts in nose Extends to Nasopharynx Esophagus Larynx Trachea Bronchi RHINOSCLEROMA 3.Incidence . Age- any . Sex-equal 4.Clinical features . Stages a. Atrophic . Resembles –atrophic rhinitis . Characterized by foul smelling purulent discharge, crusting b. Granulomatous . Granulomatous nodules in mucosa . Painless and non-ulcerating . Subdermal infiltration of external lower nose and lip-woody feel c. Cicatricial . Stenosis of nose . Distortion of upper lip . Adhesions of nose,nasopharynx and esophagus . Subglottic Stenosis -stridor RHINOSCLEROMA 5.Diagnosis . Biopsy-shows infiltration of submucosa by plasma cells, lymphocytes,eosinophils,Mikulicz cells and Russell bodies(diagnostic) . Makuliczs cells-large foam cells with central nucleus and vacuolated cytoplasm . Russell bodies-homogenous eosinophilic inclusion bodies found in plasma cells. They occur due to accumulation of immunoglobulin's secreted by plasma cells RHINOSCLEROMA 6.Treatment a. Medical . Streptomycin(1 gm/day) . RIFAMPACIN(2 GM/day)-together for 4-6 weeks . Steriods-to reduce fibrosis b. Surgical . Establish airway . Correct nasal defomity SYPHILIS 1.Types A. Congenital-manifests in two forms . Early . First 03 months . Manifests –snuffles . Purulent nasal discharge . Nasal vestibule and upper lip-fissuring and excoriation . Late . Around puberty . Clinical picture-tertiary syphilis . Gummatous lesions destroy nasal structures . Other stigmata-corneal opacities, deafness and Hutchinson’s teeth SYPHILIS b. Acquired . Primary-chancre of vestibule of nose . Secondary . Rarely recognized . Manifests –rhinitis, crusting and fissuring of vestibule . Diagnosis . Mucous patches in pharynx . Skin rash . Fever . lymphadenitis SYPHILIS . Tertiary syphilis . Commonly nose involved . Manifests as gumma on nasal septum,nasal septum is destroyed leading to perforation . Nasal discharge is offensive with crusts SYPHILIS 2.Diagnosis . Serological tests . VDRL . TPHA . Biopsy 3.Treatment . Benzathaine pencillin-2.4 million units I/M every week for 03 weeks . Crusts-irrigation with alkaline solution . Bony and cartilaginous sequestra removed SYPHILIS 4.Complications . Vestibular stenosis . Perforation of septum and hard palate . Secondary atrophic rhinitis . Saddle nose deformity TUBERCULOSIS 1.Types . Primary-rare . Secondary-lung infection 2.Sites . Anterior part of septum . Anterior
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