Chronic SinusitisChronic Sinusitis

Brig Mirza Khizar HameedBrig Mirza Khizar Hameed

DefinitionDefinition

Inflammation of the Paranasal Sinuses Inflammation of the Paranasal Sinuses lasting > 3 monthslasting > 3 months

EtiologyEtiology

Anatomical variationsAnatomical variations Deviated Nasal SeptumDeviated Nasal Septum Concha BullosaConcha Bullosa Bulla EthmoidalisBulla Ethmoidalis

Underlying diseasesUnderlying diseases Cystic FibrosisCystic Fibrosis Ciliary DyskinesiaCiliary Dyskinesia Immuno-deficiencyImmuno-deficiency Granulomatous diseasesGranulomatous diseases

MicrobiologyMicrobiology

AnaerobesAnaerobes Staphylococcus aureusStaphylococcus aureus StreptococcusStreptococcus H. InfluenzaeH. Influenzae M. catarrhalisM. catarrhalis

PathophysiologyPathophysiology

Obstruction of Osteomeatal complex regionObstruction of Osteomeatal complex region Impaired mucociliary clearanceImpaired mucociliary clearance

↓↓ Stagnation & pooling of secretionsStagnation & pooling of secretions Infection Infection Vicious cycle Vicious cycle

SymptomsSymptoms

Chronic nasal obstructionChronic nasal obstruction Purulent post nasal dischargePurulent post nasal discharge Pain over sinuses/ HeadachePain over sinuses/ Headache HalitosisHalitosis Chronic coughChronic cough

Physical signsPhysical signs

Purulent Nasal dischargePurulent Nasal discharge Anatomical anomaliesAnatomical anomalies Transillumination ? Transillumination ?

InvestigationsInvestigations

X-ray PNSX-ray PNS CT Scan PNSCT Scan PNS Proof puncture/ Sinus lavageProof puncture/ Sinus lavage Sinus aspirate/ Pus swab for C/SSinus aspirate/ Pus swab for C/S

TreatmentTreatment

Antibiotics – Antibiotics – Ciprofloxacin, Augmentin, Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, Clarithromycin, Cefuroxime, Clindamycin, MetronidazoleMetronidazole

DecongestantsDecongestants Antihistamines Antihistamines Steroid Nasal Drops/ SpraysSteroid Nasal Drops/ Sprays Surgery- Surgery- To provide drainage & ventilationTo provide drainage & ventilation

Operative procedures on Operative procedures on SinusesSinuses

Maxillary SinusitisMaxillary Sinusitis

Antral WashoutAntral Washout Inferior Meatal AntrostomyInferior Meatal Antrostomy Caldwell-Luc’s OperationCaldwell-Luc’s Operation FESSFESS

1. Antral Washout1. Antral Washout

Puncturing medial wall of sinus for pus Puncturing medial wall of sinus for pus aspiration and irrigation of sinusaspiration and irrigation of sinus

IndicationsIndications- Ch sinusitis refractory to treatment- Ch sinusitis refractory to treatment

ContraindicationsContraindications- Age < 3 yrs- Age < 3 yrs

- Hypoplastic maxilla with thick bony walls- Hypoplastic maxilla with thick bony walls

- Acute maxillary sinusitis untreated by - Acute maxillary sinusitis untreated by antibioticsantibiotics

Tilley Lichwitz Trocar & CannulaTilley Lichwitz Trocar & Cannula

Higginson SyringeHigginson Syringe

Trocar directed towards I/L tragusTrocar directed towards I/L tragus

ComplicationsComplications

HemorrhageHemorrhage Pain & swelling of cheekPain & swelling of cheek Perforation of orbital floorPerforation of orbital floor Vasovagal shockVasovagal shock Air embolismAir embolism

2. Inferior Meatal Antrostomy2. Inferior Meatal Antrostomy

A window is created in A window is created in medial wall of Maxillary medial wall of Maxillary antrum by perforating it antrum by perforating it in the Inferior meatus in the Inferior meatus with Tilley’s Antrum with Tilley’s Antrum Harpoon & enlarged Harpoon & enlarged (1.5-2 cm) with Myle’s (1.5-2 cm) with Myle’s perforatorperforator

ComplicationsComplications

HemorrhageHemorrhage Injury to Naso-lacrimal ductInjury to Naso-lacrimal duct Perforation of orbital floorPerforation of orbital floor

3. Caldwell-Luc’s Surgery3. Caldwell-Luc’s Surgery Anterior wall of the Maxillary sinus is entered through a Anterior wall of the Maxillary sinus is entered through a

Sub-labial incisionSub-labial incision A window is created in the medial wall through AntrostomyA window is created in the medial wall through Antrostomy IndicationsIndications

- Ch sinusitis refractory to treatment- Ch sinusitis refractory to treatment

- Repair of Oro-antral fistula- Repair of Oro-antral fistula

- Reccurrent AC polyp- Reccurrent AC polyp

- Blow out fracture of floor of orbit- Blow out fracture of floor of orbit

- Approach to ethmoids/ PPF- Approach to ethmoids/ PPF

Sublabial IncisionSublabial Incision

Hole made in anterior wall followed Hole made in anterior wall followed by Inferior Meatal Antrostomyby Inferior Meatal Antrostomy

ComplicationsComplications

HemorrhageHemorrhage Cheek edema Cheek edema Numbness of cheekNumbness of cheek Orbital hematomaOrbital hematoma Trauma to teeth rootsTrauma to teeth roots Oro-antral fistulaOro-antral fistula

Ethmoid SinusitisEthmoid Sinusitis

Intranasal EthmoidectomyIntranasal Ethmoidectomy External EthmoidectomyExternal Ethmoidectomy

- Lynch Howarth procedure- Lynch Howarth procedure

- Patterson transorbital procedure- Patterson transorbital procedure

- Jansen Horgan transantral procedure- Jansen Horgan transantral procedure FESSFESS

Lynch Howarth EthmoidectomyLynch Howarth Ethmoidectomy

Patterson EthmoidectomyPatterson Ethmoidectomy

Trans-antral ethmoidectomyTrans-antral ethmoidectomy

ComplicationsComplications

HemorrhageHemorrhage Injury to Lamina papyracea Injury to Lamina papyracea Periorbital Periorbital

hematoma, proptosis, visual losshematoma, proptosis, visual loss Injury to Medial palpebral ligamentInjury to Medial palpebral ligament CSF leakCSF leak MeningitisMeningitis Mucocoele formationMucocoele formation

Frontal SinusitisFrontal Sinusitis

TrephinationTrephination Osteoplastic flap procedureOsteoplastic flap procedure

- Coronal incision- Coronal incision

- Brow incision- Brow incision FESSFESS

Frontal sinus trephinationFrontal sinus trephination

Osteoplastic flap procedureOsteoplastic flap procedure

ComplicationsComplications

HematomaHematoma Frontal depressionFrontal depression CSF leakCSF leak MeningitisMeningitis Mucocoele formationMucocoele formation OsteomyelitisOsteomyelitis

Sphenoid SinusitisSphenoid Sinusitis

Trans-nasal trans-septal approachTrans-nasal trans-septal approach Sublabial trans-septal approachSublabial trans-septal approach External ethmoidectomy approachExternal ethmoidectomy approach FESSFESS

FESSFESS

IndicationsIndications- Ch sinusitis refractory to treatment- Ch sinusitis refractory to treatment

- Nasal polyps- Nasal polyps

- Fungal sinusitis- Fungal sinusitis

- Antro choanal polyp- Antro choanal polyp

- Fronto-ethmoidal mucocoele- Fronto-ethmoidal mucocoele

- Repair of CSF leak- Repair of CSF leak

- DCR- DCR

- Orbital decompression- Orbital decompression

Functional Endoscopic Sinus SurgeryFunctional Endoscopic Sinus Surgery

Uncinectomy (Infundibulotomy)Uncinectomy (Infundibulotomy) Bullectomy & Anterior ethmoidectomyBullectomy & Anterior ethmoidectomy Middle meatal antrostomyMiddle meatal antrostomy Perforation of basal lamellaPerforation of basal lamella Posterior ethmoidectomyPosterior ethmoidectomy Sphenoid sinus explorationSphenoid sinus exploration Skull base disease clearanceSkull base disease clearance Frontal recess explorationFrontal recess exploration

ComplicationsComplications

MajorMajor Major epistaxisMajor epistaxis

Orbital hematomaOrbital hematoma

DiplopiaDiplopia

Blindness or Blindness or visual acuity visual acuity

Internal carotid injuryInternal carotid injury

Intracranial hemorrhageIntracranial hemorrhage

CSF leak / MeningitisCSF leak / Meningitis

PneumocephalusPneumocephalus

AnosmiaAnosmia

Nasolacrimal duct traumaNasolacrimal duct trauma

MinorMinor Minor epistaxisMinor epistaxis

HyposmiaHyposmia

Adhesions (synechiae)Adhesions (synechiae)

HeadacheHeadache

Periorbital echhymosisPeriorbital echhymosis

Periorbital hematomaPeriorbital hematoma

Dental / facial painDental / facial pain

Fungal SinusitisFungal Sinusitis

DefinitionDefinition

Inflammation of the sinuses due to a Inflammation of the sinuses due to a fungusfungus

ClassificationClassification

Non Invasive Fungal SinusitisNon Invasive Fungal Sinusitis

- Allergic- Allergic

- Fungus Ball (Mycetoma)- Fungus Ball (Mycetoma) Invasive Fungal SinusitisInvasive Fungal Sinusitis

- Acute- Acute

- Chronic- Chronic

Allergic Fungal SinusitisAllergic Fungal Sinusitis

Most common formMost common form Warm humid climateWarm humid climate Among younger, immuno-competent, atopic Among younger, immuno-competent, atopic Hypersensitivity reaction to inhaled fungus Hypersensitivity reaction to inhaled fungus

organismorganism Presents with Nasal polyps & thick greenish Presents with Nasal polyps & thick greenish

mucus mucus

InvestigationsInvestigations

Total IgE - Total IgE - CT Scan PNS- CT Scan PNS- Sinus filled with high signal Sinus filled with high signal

intensity soft tissue with calcium deposits, intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodellingthinning/ pressure bony erosion & remodelling

Histology of greasy mucous- Histology of greasy mucous- branching, non branching, non invasive fungal hyphae, eosinophils & Charcot-invasive fungal hyphae, eosinophils & Charcot-Leyden crystalsLeyden crystals

TreatmentTreatment

Surgical clearance of sinusesSurgical clearance of sinuses Topical SteroidsTopical Steroids AntihistaminesAntihistamines ImmunotherapyImmunotherapy ? Antifungal? Antifungal

Fungus Ball (Mycetoma)Fungus Ball (Mycetoma)

Older individuals, usually femalesOlder individuals, usually females ImmunocompetentImmunocompetent Asymptomatic/ Cacosmia/ Chronic sinusitisAsymptomatic/ Cacosmia/ Chronic sinusitis Fungal mass limited to one sinusFungal mass limited to one sinus CT Scan- Hyperdense mass with punctate CT Scan- Hyperdense mass with punctate

calcificationscalcifications

Fungus Ball- TreatmentFungus Ball- Treatment

Surgical clearanceSurgical clearance ? Anti fungal? Anti fungal

Acute Invasive Fungal SinusitisAcute Invasive Fungal Sinusitis

Most lethal formMost lethal form Immunocompromised/ DiabeticsImmunocompromised/ Diabetics Caused by Mucorales, Aspergillus, Caused by Mucorales, Aspergillus,

Fusarium, PhaeohyphomycosisFusarium, Phaeohyphomycosis Angio invasion, hematogenous spreadAngio invasion, hematogenous spread Local necrosis, orbital & intracranial spreadLocal necrosis, orbital & intracranial spread Fever, pain, nasal congestion, epistaxis, Fever, pain, nasal congestion, epistaxis,

proptosis, headaches, seizuresproptosis, headaches, seizures

AIFS- CT FindingsAIFS- CT Findings

Unilateral nasal soft tissue thickeningUnilateral nasal soft tissue thickening Bony erosionsBony erosions Unilateral involvement of PNSUnilateral involvement of PNS ProptosisProptosis Cavernous sinus thrombosisCavernous sinus thrombosis

Unilateral ethmoid involvement with bone destruction, Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosisintraorbital spread and proptosis

Acute Invasive Fungal Sinusitis - CTAcute Invasive Fungal Sinusitis - CT

AIFS- TreatmentAIFS- Treatment

Aggressive surgical debridementAggressive surgical debridement Systemic anti fungal therapySystemic anti fungal therapy Treatment of underlying cause of Treatment of underlying cause of

immunosuppressionimmunosuppression

Chronic Invasive Fungal SinusitisChronic Invasive Fungal Sinusitis

Immunocompetent with H/o Ch sinusitisImmunocompetent with H/o Ch sinusitis Progressin over months to yearsProgressin over months to years Maxillofacial soft tissue swellingMaxillofacial soft tissue swelling Orbital involvement Orbital involvement proptosis, visual loss proptosis, visual loss Intracranial extension with cranial neuropathies, Intracranial extension with cranial neuropathies,

headaches seizuresheadaches seizures CT Scan- Hyperdense mass, bone erosionCT Scan- Hyperdense mass, bone erosion

CIFS- TreatmentCIFS- Treatment

Aggressive surgical exenterationAggressive surgical exenteration Systemic anti fungal therapySystemic anti fungal therapy

Thank Thank youyou