Chronic Sinusitis Brig Mirza Khizar Hameed Definition Inflammation

Chronic Sinusitis Brig Mirza Khizar Hameed

Definition Inflammation of the Paranasal Sinuses lasting > 3 months

Etiology Anatomical variations Deviated Nasal Septum Concha Bullosa Bulla Ethmoidalis Underlying diseases Cystic Fibrosis Ciliary Dyskinesia Immuno-deficiency Granulomatous diseases

Microbiology Anaerobes Staphylococcus aureus Streptococcus H. Influenzae M. catarrhalis

Pathophysiology Obstruction of Osteomeatal complex region Impaired mucociliary clearance ↓ Stagnation & pooling of secretions Infection Vicious cycle

Symptoms Chronic nasal obstruction Purulent post nasal discharge Pain over sinuses/ Headache Halitosis Chronic cough

Physical signs Purulent Nasal discharge Anatomical anomalies Transillumination ?

Investigations X-ray PNS CT Scan PNS Proof puncture/ Sinus lavage Sinus aspirate/ Pus swab for C/S

Treatment Antibiotics – Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, Metronidazole Decongestants Antihistamines Steroid Nasal Drops/ Sprays Surgery- To provide drainage & ventilation

Operative procedures on Sinuses

Maxillary Sinusitis Antral Washout Inferior Meatal Antrostomy Caldwell-Luc’s Operation FESS

1. Antral Washout Puncturing medial wall of sinus for pus aspiration and irrigation of sinus Indications - Ch sinusitis refractory to treatment Contraindications - Age < 3 yrs - Hypoplastic maxilla with thick bony walls - Acute maxillary sinusitis untreated by antibiotics

Tilley Lichwitz Trocar & Cannula

Higginson Syringe

Trocar directed towards I/L tragus

Complications Hemorrhage Pain & swelling of cheek Perforation of orbital floor Vasovagal shock Air embolism

2. Inferior Meatal Antrostomy A window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilley’s Antrum Harpoon & enlarged (1. 5 -2 cm) with Myle’s perforator

Complications Hemorrhage Injury to Naso-lacrimal duct Perforation of orbital floor

3. Caldwell-Luc’s Surgery Anterior wall of the Maxillary sinus is entered through a Sub-labial incision A window is created in the medial wall through Antrostomy Indications - Ch sinusitis refractory to treatment - Repair of Oro-antral fistula - Reccurrent AC polyp - Blow out fracture of floor of orbit - Approach to ethmoids/ PPF

Sublabial Incision

Hole made in anterior wall followed by Inferior Meatal Antrostomy

Complications Hemorrhage Cheek edema Numbness of cheek Orbital hematoma Trauma to teeth roots Oro-antral fistula

Ethmoid Sinusitis Intranasal Ethmoidectomy External Ethmoidectomy - Lynch Howarth procedure - Patterson transorbital procedure - Jansen Horgan transantral procedure FESS

Lynch Howarth Ethmoidectomy

Patterson Ethmoidectomy

Trans-antral ethmoidectomy

Complications Hemorrhage Injury to Lamina papyracea Periorbital hematoma, proptosis, visual loss Injury to Medial palpebral ligament CSF leak Meningitis Mucocoele formation

Frontal Sinusitis Trephination Osteoplastic flap procedure - Coronal incision - Brow incision FESS

Frontal sinus trephination

Osteoplastic flap procedure

Complications Hematoma Frontal depression CSF leak Meningitis Mucocoele formation Osteomyelitis

Sphenoid Sinusitis Trans-nasal trans-septal approach Sublabial trans-septal approach External ethmoidectomy approach FESS

FESS Indications - Ch sinusitis refractory to treatment - Nasal polyps - Fungal sinusitis - Antro choanal polyp - Fronto-ethmoidal mucocoele - Repair of CSF leak - DCR - Orbital decompression

Functional Endoscopic Sinus Surgery Uncinectomy (Infundibulotomy) Bullectomy & Anterior ethmoidectomy Middle meatal antrostomy Perforation of basal lamella Posterior ethmoidectomy Sphenoid sinus exploration Skull base disease clearance Frontal recess exploration

Complications Major epistaxis Orbital hematoma Diplopia Blindness or visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct trauma Minor © Minor epistaxis © Hyposmia © Adhesions (synechiae) © Headache © Periorbital echhymosis © Periorbital hematoma © Dental / facial pain

Fungal Sinusitis

Definition Inflammation of the sinuses due to a fungus

Classification Non Invasive Fungal Sinusitis - Allergic - Fungus Ball (Mycetoma) Invasive Fungal Sinusitis - Acute - Chronic

Allergic Fungal Sinusitis Most common form Warm humid climate Among younger, immuno-competent, atopic Hypersensitivity reaction to inhaled fungus organism Presents with Nasal polyps & thick greenish mucus

Investigations Total Ig. E - CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodelling Histology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot. Leyden crystals

Treatment Surgical clearance of sinuses Topical Steroids Antihistamines Immunotherapy ? Antifungal

Fungus Ball (Mycetoma) Older individuals, usually females Immunocompetent Asymptomatic/ Cacosmia/ Chronic sinusitis Fungal mass limited to one sinus CT Scan- Hyperdense mass with punctate calcifications

Fungus Ball- Treatment Surgical clearance ? Anti fungal

Acute Invasive Fungal Sinusitis Most lethal form Immunocompromised/ Diabetics Caused by Mucorales, Aspergillus, Fusarium, Phaeohyphomycosis Angio invasion, hematogenous spread Local necrosis, orbital & intracranial spread Fever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures

AIFS- CT Findings Unilateral nasal soft tissue thickening Bony erosions Unilateral involvement of PNS Proptosis Cavernous sinus thrombosis

Acute Invasive Fungal Sinusitis - CT Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis

AIFS- Treatment Aggressive surgical debridement Systemic anti fungal therapy Treatment of underlying cause of immunosuppression

Chronic Invasive Fungal Sinusitis Immunocompetent with H/o Ch sinusitis Progressin over months to years Maxillofacial soft tissue swelling Orbital involvement proptosis, visual loss Intracranial extension with cranial neuropathies, headaches seizures CT Scan- Hyperdense mass, bone erosion

CIFS- Treatment Aggressive surgical exenteration Systemic anti fungal therapy

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