Chronic Sinusitis
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Transcript of Chronic Sinusitis
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Chronic Sinusitis
Brig Mirza Khizar Hameed
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DefinitionInflammation of the Paranasal Sinuses lasting > 3 months
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EtiologyAnatomical variationsDeviated Nasal SeptumConcha BullosaBulla EthmoidalisUnderlying diseasesCystic FibrosisCiliary DyskinesiaImmuno-deficiencyGranulomatous diseases
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MicrobiologyAnaerobesStaphylococcus aureusStreptococcusH. InfluenzaeM. catarrhalis
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PathophysiologyObstruction of Osteomeatal complex regionImpaired mucociliary clearanceStagnation & pooling of secretionsInfection Vicious cycle
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SymptomsChronic nasal obstructionPurulent post nasal dischargePain over sinuses/ HeadacheHalitosisChronic cough
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Physical signsPurulent Nasal dischargeAnatomical anomaliesTransillumination ?
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InvestigationsX-ray PNSCT Scan PNSProof puncture/ Sinus lavageSinus aspirate/ Pus swab for C/S
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Treatment Antibiotics Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, MetronidazoleDecongestantsAntihistamines Steroid Nasal Drops/ SpraysSurgery- To provide drainage & ventilation
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Operative procedures on Sinuses
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Maxillary SinusitisAntral WashoutInferior Meatal AntrostomyCaldwell-Lucs OperationFESS
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1. Antral WashoutPuncturing medial wall of sinus for pus aspiration and irrigation of sinusIndications- Ch sinusitis refractory to treatmentContraindications- Age < 3 yrs- Hypoplastic maxilla with thick bony walls- Acute maxillary sinusitis untreated by antibiotics
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Tilley Lichwitz Trocar & Cannula
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Higginson Syringe
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Trocar directed towards I/L tragus
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ComplicationsHemorrhagePain & swelling of cheekPerforation of orbital floorVasovagal shockAir embolism
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2. Inferior Meatal AntrostomyA window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilleys Antrum Harpoon & enlarged (1.5-2 cm) with Myles perforator
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ComplicationsHemorrhageInjury to Naso-lacrimal ductPerforation of orbital floor
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3. Caldwell-Lucs SurgeryAnterior wall of the Maxillary sinus is entered through a Sub-labial incisionA window is created in the medial wall through AntrostomyIndications- Ch sinusitis refractory to treatment- Repair of Oro-antral fistula- Reccurrent AC polyp- Blow out fracture of floor of orbit- Approach to ethmoids/ PPF
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Sublabial Incision
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Hole made in anterior wall followed by Inferior Meatal Antrostomy
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ComplicationsHemorrhageCheek edema Numbness of cheekOrbital hematomaTrauma to teeth rootsOro-antral fistula
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Ethmoid SinusitisIntranasal EthmoidectomyExternal Ethmoidectomy- Lynch Howarth procedure- Patterson transorbital procedure- Jansen Horgan transantral procedureFESS
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Lynch Howarth Ethmoidectomy
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Patterson Ethmoidectomy
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Trans-antral ethmoidectomy
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ComplicationsHemorrhageInjury to Lamina papyracea Periorbital hematoma, proptosis, visual lossInjury to Medial palpebral ligamentCSF leakMeningitisMucocoele formation
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Frontal SinusitisTrephinationOsteoplastic flap procedure- Coronal incision- Brow incisionFESS
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Frontal sinus trephination
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Osteoplastic flap procedure
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ComplicationsHematomaFrontal depressionCSF leakMeningitisMucocoele formationOsteomyelitis
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Sphenoid SinusitisTrans-nasal trans-septal approachSublabial trans-septal approachExternal ethmoidectomy approachFESS
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FESSIndications- Ch sinusitis refractory to treatment- Nasal polyps- Fungal sinusitis- Antro choanal polyp- Fronto-ethmoidal mucocoele- Repair of CSF leak- DCR- Orbital decompression
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Functional Endoscopic Sinus SurgeryUncinectomy (Infundibulotomy)Bullectomy & Anterior ethmoidectomyMiddle meatal antrostomyPerforation of basal lamellaPosterior ethmoidectomySphenoid sinus explorationSkull base disease clearanceFrontal recess exploration
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ComplicationsMajor Major epistaxis Orbital hematoma Diplopia Blindness or visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct traumaMinorMinor epistaxisHyposmiaAdhesions (synechiae)HeadachePeriorbital echhymosisPeriorbital hematomaDental / facial pain
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Fungal Sinusitis
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DefinitionInflammation of the sinuses due to a fungus
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ClassificationNon Invasive Fungal Sinusitis- Allergic- Fungus Ball (Mycetoma)Invasive Fungal Sinusitis- Acute- Chronic
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Allergic Fungal SinusitisMost common formWarm humid climateAmong younger, immuno-competent, atopic Hypersensitivity reaction to inhaled fungus organismPresents with Nasal polyps & thick greenish mucus
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InvestigationsTotal IgE - CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodellingHistology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot-Leyden crystals
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TreatmentSurgical clearance of sinusesTopical SteroidsAntihistaminesImmunotherapy? Antifungal
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Fungus Ball (Mycetoma)Older individuals, usually femalesImmunocompetentAsymptomatic/ Cacosmia/ Chronic sinusitisFungal mass limited to one sinusCT Scan- Hyperdense mass with punctate calcifications
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Fungus Ball- TreatmentSurgical clearance? Anti fungal
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Acute Invasive Fungal SinusitisMost lethal formImmunocompromised/ DiabeticsCaused by Mucorales, Aspergillus, Fusarium, PhaeohyphomycosisAngio invasion, hematogenous spreadLocal necrosis, orbital & intracranial spreadFever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures
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AIFS- CT FindingsUnilateral nasal soft tissue thickeningBony erosionsUnilateral involvement of PNSProptosisCavernous sinus thrombosis
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Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosisAcute Invasive Fungal Sinusitis - CT
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AIFS- TreatmentAggressive surgical debridementSystemic anti fungal therapyTreatment of underlying cause of immunosuppression
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Chronic Invasive Fungal SinusitisImmunocompetent with H/o Ch sinusitisProgressin over months to yearsMaxillofacial soft tissue swellingOrbital involvement proptosis, visual lossIntracranial extension with cranial neuropathies, headaches seizuresCT Scan- Hyperdense mass, bone erosion
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CIFS- TreatmentAggressive surgical exenterationSystemic anti fungal therapy
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Thank you
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