Rhino-Sinusitis: Clinical Features, Diagnosis & Medical Treatment

1. Rhino-Sinusitis:Clinical Features, Diagnosis & Medical Treatment Dr. Vishal Sharma

2. Definitions Rhino-sinusitis:inflammation of lining mucosa of nose & paranasal sinuses Acute: infection lasting < 4 weeks Sub acute:infection lasting 4 to 12 weeks Chronic: infection lasting > 12 weeks Recurrent:> 3 episodes in 6 months or > 4 episodes per year with asymptomatic intervals of > 10 days

3. Types of Sinusitis • Acute / sub acute / chronic / recurrent • Open / Closed (depending on its drainage) • Unilateral / bilateral • Maxillary / frontal / ethmoidal / sphenoidal • Single sinusitis / multi-sinusitis / pan-sinusitis • Anterior group / posterior group • Suppurative / hypertrophic • Bacterial / fungal / allergic / occupational

4. Etiology • Rhinogenic:commonest (85%) • following any form of rhinitis • Dental: for maxillary sinusitis • root abscess, dental procedures • Trauma: • R.T.A., swimming, diving, F.B., barotrauma • Iatrogenic: nasal packing, septal surgery • Hematogenous: rare

5. Predisposing factors • Mucosal odema: viral, bacterial, allergic, irritant, vasomotor, barotrauma • Mechanical obstruction:D.N.S. (spur), polyp, hypertrophic turbinate, concha bullosa, paradoxical middle turbinate, Haller cell, large bulla ethmoidalis, agger nasi, uncinate anomaly, nasal tumour, foreign body, nasal packing

6. Mucous abnormality: Young’s syndrome, cystic fibrosis, mucoviscidosis, dehydration • Mucociliary dysfunction:Kartagener’s syndrome, viral, bacterial, allergic, smoking, pollutants, hypoxia, dry air, extremes of temperature, synechiae • Miscellaneous: Poor health, immunodeficiency, diabetes, nutritional deficiency

10. Acute sinusitis  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella  Staphylococcus aureus  Neisseria Chronic sinusitis  Staph. Aureus  Streptococcus  H. influenzae  Bacteroides  Pseudomonas Bacteriology

11. Progress Severity and resolution depends on • Open / closed • Organism virulence • Host resistance • Treatment received

12. Ostio-meatal complex is key area for causation of chronic anterior group sinusitis

13. Pathological variants of ostio-meatal complex

14. Concha bullosa

15. Concha bullosa

16. Paradoxically curved M.T.

17. Paradoxically curved M.T.

18. Medialized uncinate process

19. Large bulla ethmoidalis

20. Haller cell

21. Agger nasi cell

22. Nasal Septal Spur

23. Nasal Septal Spur

24. Mucosal disease

25. Symptoms • Nasal discharge:mucoid / purulent / blood-stained • Nasal obstruction with hyposmia / anosmia • Headache / facial pain • Cheek / eyelid congestion + swelling • Hawking, sore throat, cough • Earache: associated Eustachian tube dysfunction • Constitutional:fever, malaise, body ache

26. Location of facial pain Maxillary:cheek, upper jaw, forehead (supra-orbital) that es on bending forward Frontal:forehead that es during morning & es by late afternoon (Office headache) Anterior Ethmoid:nasal bridge & peri-orbital, es with eye movement Posterior Ethmoid:retro-orbital Sphenoid:vertex, occipital, retro-orbital

27. Signs • Congested & edematous nasal mucosa • Nasal discharge (anterior & posterior rhinoscopy):middle meatus: frontal, maxillary, anterior ethmoid superior meatus: posterior ethmoid, sphenoid • Paranasal sinus tenderness present • Postnasal drip, granular pharyngitis • Cheek swelling:in maxillary sinusitis • Lid edema:in ethmoid & frontal sinusitis

28. Para-nasal sinus tenderness

29. Para-nasal sinus tenderness • Maxillary:palpate over canine fossa • Anterior ethmoid:palpate medial to medial canthus • Frontal:palpate floor of sinus or tap over its anterior wall

30. Para-nasal sinus tenderness

31. Sinus trans-illumination test

32. Sinus trans-illumination test • Performed in a dark room. High-intensity light source placed inside patient’s mouth or against the cheek (for maxillary sinus) & under medial aspect of supra-orbital ridge (for frontal sinus). • Trans-illumination normal = no sinusitis • Trans-illumination absent = sinus filled with pus • Trans-illumination dull = equivocal result

33. Postural test Performed in acute sinusitis (active nasal discharge) Pus cleaned in supine position & pt sits upright Pus appears = frontal or ethmoid sinusitis Pus appears on stooping forwards = sphenoid sinusitis No discharge  pt lies in lateral position with affected side up. Pus appears = maxillary sinusitis

34. Rhinosinusitis Task Force Criteria Major Minor 1. Facial pain / pressure1. Headache 2. Nasal obstruction2. Fever (non-acute sinusitis) 3. Nasal discharge or3. Halitosis discolored postnasal drip4. Fatigue 4. Hyposmia / anosmia5. Dental pain 5. Purulence on examn6. Cough 6. Fever (acute sinusitis)7. Ear pain / pressure / fullness Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

35. Investigations

36. Diagnostic nasal endoscopy (D.N.E.) • Maxillary Sinoscopy • X-ray of P.N.S. • U.S.G. of maxillary sinus (Rhinoscan) • C.T. scan of P.N.S. • M.R.I. of P.N.S.: rarely done • Allergic tests • Proof puncture (antral wash):for maxillary sinus • Endoscopic microswab for culture & sensitivity • Fungal culture: of cheesy nasal discharge

37. Diagnostic Nasal Endoscopy

38. Indications for D.N.E. 1. Patients not responding to medical therapy 2. Anatomic factor preventing adequate examination by anterior rhinoscopy 3. Collection of pus from hiatus semilunaris for culture & sensitivity 4. Objective monitoring of patients 5. Peri-operative nasal inspection & cleaning

39. Pus in middle meatus in D.N.E.

40. Maxillary sinoscopy

41. Maxillary sinoscopy • Anterior sinus wall perforated directly (in canine fossa between roots of 3rd & 4th teeth) with maxillary sinus trocar & cannula • Trocar removed & sinoscope introduced through cannula

42. X-ray paranasal sinus Water’s view (Occipito-mental) maxillary Caldwell’s view (Occipito-frontal) frontal Rhese’s view (lateral oblique) ethmoid Base skull view (Submento-vertical) sphenoid Lateral view Pierre’s view (occipito-mental with mouth open) Air-fluid level: acute sinusitis Mucosal thickening chronic sinusitis

43. Acute maxillary sinusitis

44. Chronic maxillary sinusitis

45. Frontal sinusitis

46. Pierre’s view

47. Lateral view

48. Para-nasal sinus sonography • Bony anterior wall is seen as hyper-echoic line. Maxillary cavity filled with air appears as hyper-echoic hence posterior sinus margin not seen. • Fluid in sinus, cyst & mucosal thickening are hypoechoic so posterior sinus margin is visible. • B mode sonogram differentiates between fluid in sinus, cyst & mucosal thickening.

49. Normal sinus sonography (A-mode)

50. A-mode sonography of sinusitis