Maxillary sinusitis

Dr. Rizwan Elahi Chohan

Medical Officer

ENT Department

04/11/23 Depertment of E.N.T 2

Para-nasal SinusesThey are paired, air filled chambers in the skull. Several theories propose that they serve to lighten the skull, protect the brain during head trauma and add resonance to the voice.

Varieties-Four pairs of para-nasal sinuses:

The Maxillary, The Frontal, The Ethmoid, The Sphenoid,


Sinusitis-Inflammation of the lining mucus membrane of a sinus as a result of infection, allergy, structural or mechanical abnormalities,

Multi- Sinusitis- If more than one sinus is infected,Pan- Sinusitis- If all the sinuses are involved in the inflammatory process,

Universal Law“Where there is stasis, there is infection.”

Normally, secreted mucus is kept cleared off by the action of gravity, of course aided by ciliary action but when the ostium is obstructed, the mucus collects in the sinus and gets infected, giving rise to sinusitis,


Classification

Acute Sinusitis- Infection of sinuses that lasts less than two weeks and responds to antibiotic therapy,

Chronic Sinusitis- Infection of sinuses that lasts longer than two weeks, require longer courses of medical therapy, and may require surgery.

Recurrent Sinusitis- Either acute or chronic; it starts to resolve but recurs because the treatment is either inadequate or is stopped prematurely,


…Classification

Catarrhal

Acute

Suppurative (Gram + cocci, i.e.

Sinusitis Strept./ Staph. /Pneumo. & H. influenzae)

Catarrhal

ChronicSuppurative (Mix Gram + cocci & Gram – bacilli)


Pathogens

Acute Sinusitis- Aerobic bacteria like streptococcus pneumoniae, haemophilus influenzae, moraxella catarrhalis; Anaerobic bacteria (10%)-; Viral (10-20%)- rhinovirus, influenza virus;

Chronic Sinusitis- Anaerobic bacteria like peptococcus, streptococcus, either alone or in combination with aerobic bacterium like staphlococcus aureus;

Nosocomial Sinusitis- commonly due to pseudomonas aeruginosa, klebsiella pneumoniae, enterobactor species & proteus mirabilis,

Fungal Sinusitis- Aspergillosis, mucormycosis,


Patho- physiology

Located in the cheeks, the maxillary sinuses are the largest. The natural ostium of each maxillary sinus is situated high above the floor of the sinus, and the evacuating effect of gravity is unfortunately missing. No wonder, therefore that this sinus is the most commonly infected. Infection of other sinuses is frequently secondary to the infection of maxillary sinus. Thus, treatment directed towards the maxillary sinus often cures the secondarily infected sinuses. For these reasons, the maxillary sinus is often called the ‘master’ sinus.

Contd…


The mucus membranes of the nose and sinuses normally produce 1 to 2 liters of mucus a day. If the nasal passages become irritated by allergies, air pollution, smoke or infection, more clear watery mucus is produced to wash away irritants or foreign substances. This profuse secretion is the most common cause of postnasal drip. Bacterial infections produce a thick, sticky mucus containing pus, which is usually yellow or green. This mucus blanket is propelled backwards by the metachronous movement of cilia. Therefore lack of ciliary movement will also result in stasis and infection.


Aetiology All cases of rhinitis by continuity of mucosa through

sinus ostia, Acue infectious fevers, concerned with the respiratory

tract/ or through blood stream, Trauma (accidental)- e.g. RTAs, gun shot injuries, and

trauma (operative)- e.g. SMR, polypectomy, Severe deflected septum pressing on the lateral wall, Nasal polypi, adenoids, tonsillitis tend to cause stasis, Infections in the pharynx, the larynx, the tracheo-

bronchial tree and the lungs, Contd…


Root abscess in Teeth (bicuspid & tricuspid)/ dental extraction leading to oro-antral fistula- 10% of all cases are dental in origin,

Bathing and diving in infected water, Poor state of health with lowered body

resistance, an imbalanced diet with excess of starches & little proteins/ vitamins; dark, damp, overcrowded living conditions, favour cross- infection,

Wet and cold weather, Sedentary occupations & working conditions with

dusty, polluted atmosphere,


Pathology Acute catarrhal stage- Hyperema and

swelling of sinus mucosa with exudation of some thin mucoid discharge; under microscope, blood vessels are seen dilated with slight leucocytic infiltration, cilia present on lining mucosa,

Acute suppurative stage- Mucosal swelling increases, cilia may be shed off with gross leucocytic infilteration- polymorphs and eiosinophilia, retension of discharge in the sinus cavity due to blocked ostia,

Contd…


Chronic suppurative stage- Gross hypertrophy of sinus mucosa leading to polypoidal excrescences, easily seen on x-ray examination; mucosa may be shed off in places or may have undergone stratified squamous metaplasia; in late cases, erosion of the wall of the sinus in some places and thickening in others; At some places, there may be polypus or cyst formation in the mucus membrane and in other places, sinus mucosa may have undergone atrophy.


Symptoms

Local- A sense of fullness or tension around

the affected sinus, aggravated on stooping & coughing,

Pain in cheek below the eye and upper teeth on affected side, may refer to supra-orbital region,

Puffiness over the face, forehead or the eyelids,

Nasal discharge- muco-purulent or purulent, moderate in amount,

General- Rise of temperature, rise of pulse

rate, and other symptoms of generalized toxemia,


Examination First of all, see pt. as such: looks

very toxic with raised temperature & pulse, flushed face, appear in agony,

On local exam.- Ant. Rhinoscopy shows

congestion and swelling of nasal mucosa, septum seen in contact with swollen turbinals, with thin or thick discharge,

Post. Rhinoscopy shows generalized congestion and discharge sticking to the boundaries of post. nares & walls of naso-pharynx,

Contd…


Palpation elicits tenderness over the affected sinus. with comparison to the opposite side, provided it is healthy. Tapping over the sinus is also helpful, Hyperasthesia tested with wool or pin prick gives additional information,

Trans-illumination test- a small bulb

placed in pt.’s mouth in a dark room lits the skull and sinuses. If both sides illuminate equally, either both sides are healthy or they are equally diseased. If one side illuminates less than the other, that side may be at fault from collection of pus, blood or growth in the antrum. Test is not carried out below the age of nine, and is only 50% trustworthy,

Palpation of Max. sinus

Contd…


X-rays are trustworthy in 90% cases when taken in suitable positions, False haziness of a sinus means thickened mucosa, growth or blood in the sinus, thick normal bones or swollen overlying tissues unless fluid level can be seen in the suspected sinus; therefore, x-rays should be considered in association with history & clinical examination.

Lt. Max. SinusitisPansinusitis


Fluid level in the Lt. max. sinus in a case of Acute Max. Sinusistis.

Bil. Hazy Max. Sinuses in a case of Chronic Max. Sinusitis.


Laboratory workup CBC with a differential white blood count

provides useful information regarding infection, ESR monitors the course of infection, Culturing of sinus discharge, ideally when the

patient is not being treated with antibiotics, is the most important test.


Recent sinus investigations Sinogram- Ultrasonic examination of a sinus to

differentiate fluid or mucosal thickening from a solid growth,

Sinocopy- Physical examination of a sinus by a fibroptic sinoscope, now performed in the physician’s office; clarifies the diagnosis in patients who are not responding adequately to medical treatment,

CT Scan- Imaging studies are indicated for refractory or recurrent sinusitis; sinusitis with complications and preparations for surgery to build a `road map` that the surgeon follows during surgery,

MRI Scan- used to access soft tissue changes and to evaluate the extent of sinus tumor.


Clinical correlation of radiological findings is essential


Orbital Complications Inflammatory oedema Orbital cellulitis Subperiosteal abscess Orbital abscess

Cavernous sinus thrombosis Intracranial Complications

Meningitis Epidural abscess Subdural abscess Brain abscess

Misc.Complications Osteomyelitis of the Skull Osteomyelitis of superior Maxilla Mucocele or pyocele

Complications


…ComplicationsBecause of these serious consequences, physician must learn to diagnose the disease and be ready to treat it aggressively. Any sign of intra-orbital or intracranial spread demands contrast enhanced CT scan of the head in both axial and coronal planes.Complications of sinusitis usually follow the acute stage of the disease or occur during an acute exacerbation of a chronic infection


Signs of Complications Generalized persistent headache Vomiting Convulsions Chills or high fever Edema or increasing swelling of the

forehead or eyelids Blurring of vision, diplopia, or persistent

retroocular pain Signs of increased intracrial pressure Personality changes or dulling of the

sensorium.


Treatment

Inflammatory sinus disease is first treated conservatively with medication.

GOAL OF MEDICAL TREATMENT

“Re-establish patency of the sinus ostea & restore normal mucociliary clearance”

CAUSE OF THE INFLAMMATION OR OBSTRUCTIONMUST BE TARGETTED FOR MEDICAL THERAPY TO

BE SUCCESSFUL Allergy Nasal polypi etc.


General “Complete rest in bed, easily digestible nourishing diet,&

analgesia for the relief of pain is usually rewarding.” Antibiotics:

Acute and chronic sinus infections should be treated with antibiotic to eradicate causative bacteria.Ideally antibiotic is chosen after a nasal swab for C/S or sinus aspirate for C/S.Generally treatment is started with broad spectrum antibiotics, i.e. ampicillin or amoxicillin, given 14 days for acute sinusitis or 3-4 weeks for chronic Sinusitis, they are effective against the most likely pathogens; if ineffective, a second generation cephalosporin may be used for 3-6 weeks.

Anti-histamines are effective in relieving the allergic symptoms, use of topical or oral corticosteroids may help reduce inflammation and secretions.

contd…


Allergic Desensitization- In patients with seasonal allergies, desensitization (allergy shots) may help relieving chronic symptoms,

Sinus drainage & irrigation- With clogged sinus ostia and failed drainage system, nasal decongestant sprays to open up sinus channels are more helpful than antihistamines and corticosteroids & help restore normal drainage. Oral decongestants reduce nasal and sinus mucosal congestion and can be used over a long period of time. Saline nasal douches are also helpful in restoring nasal mucociliary function and in return improve sinus drainage. When medical treatment fails, mechanical irrigation and aspiration is undertaken.

Antifungal Chemotherapy- Is sometimes required especially in cases of rhinocerebral mucormycosis or aspergillosis with or without surgical removal of disease depending on the extent of disease.

Maxillary sinusitis

Health & Medicine

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