Chronic sinusitis and management

1. Chronic sinusitis and management Dr.nayana.v.g Senior resident

2. Specific learning objective 1. To learn the definition, etiology, pathophysiology symptoms and signs of chronic rhinosinusitis 2.To learn the diagnostic methods medical and surgical management of chronic rhinosinusitis 3.To know the surgical steps of FESS

3. Definition: Rhinosinusitis Task Force • Inflammation of the nose & PNS characterized by two or more symptoms one of which should be either nasal blockage or nasal discharge • +/- facial pain/pressure • +/-reduction or loss of smell • DNE :Polyps or mucopurulent discharge or edema primarily in middle meatus • +/-CT findings of mucosal changes in OMC or sinuses

4. Chronic sinusitis -Definition • Duration:>12 wks • Persistent inflammatory changes on imaging > 4wks after starting treatment

5. Etiology • Mechanical (OMC) Obstruction • Infections Micro organisms – Secondary invaders • Allergy • Decreased mucocilliary function • Dental disease

6. Micro organisms • Bacteria – Staphylococcus Streptococcus pseudomonas M.catarrhalis Gram negative • Fungi

7. Pathophysiology

8. Major & Minor signs and symptoms in diagnosis of chronic rhinosinusitis Major Factors • Nasal obstruction/blockage • Nasal discharge/purulence • Facial pain/pressure • Hyposmia/ anosmia Minor Factors: • Headache • Fever • Fatigue • Halitosis • Dental pain • Cough • Ear pain/ pressure/fullness

9. Clinical Diagnosis of Rhinosinusitis 2 or more major factors 1 major & 2 minor factors

10. Sinus pain or pressure • Frontal : Frontal Headache • Maxillary : Mid-face, maxillary tooth pain • Ethmoid : Retro-orbital pain • Sphenoid : Nonspecific pain with radiation • Pain increases on bending forward, in late morning, with mastication

11. Management - Diagnosis and Treatment • Routine physical examination of nose and sinus • Diagnostic Nasal endoscopy • Sinus aspiration and culture

12. Physical examination of nose and sinus • Edema and erythema of nasal mucosa • Turbinate Hypertrophy • Purulent discharge from lateral wall • Sinus tenderness.

13. Nasal endoscopy

14. Sinus aspiration and culture • Correlation of routine nasal culture and sinus culture are poor • Endoscopically guided aspiration from medial meatus do correlate with sinus culture

15. RADIOLOGY Indications • Chronic, refractory or recurrent sinusitis • High risk patients (DM, Immunosuppressed) • Complicated sinusitis Studies • X Ray • CT (Gold standard)

16. Findings suggestive of Sinusitis • Opacification • Air fluid levels Efficacy in Acute Sinusitis Sensitivity 76% Specificity 79% Not effective in children under 3

17. Sinus CT

18. Sinus CT Advantages More sensitive than X Ray Better anatomy definition Sphenoid, Ethmoid and OMC Preparation for Surgery

19. CT scan • 3-4 weeks after medical therapy. • 2-5 mm coronal & axial cuts. • Assess sino nasal anatomy & disease pattern • Anatomic variations(Meyers & Valvassori) • Roadmap for surgical intervention

20. Medical manangement of Chronic Sinusitis AIM OF TREATMENT • To reduce symptoms and signs, improve patients quality of life and prevent disease progression and/or recurrence.

21. Medical management of chronic rhinosinusitis 1. Avoidance of allergens2.Avoidance of irritants 3. Antibiotics 4.Antihistamines 5. Decongestants 6. Corticosteroids 7.Sinus irrigation

22. Treatment to improve OMC drianage • Decongestant • Nasal Douching • Topical corticosteroids • Review at 6 week,if no improvement -> CT scan

23. Surgery for maxillary sinusitis • Antral puncture • Intranasal antrostomy • Caldwell luc surgery • FESS

24. Antral puncture

25. Intranasal Antrostomy

26. Caldwell luc surgery

27. Surgeries for Chronic Frontal Sinusitis • Frontal sinus trephination • External frontoethmoidectomy • Osteoplastic flap operation • FESS

28. Frontal Sinus Trephination

29. External Fronto Ethmoidectomy

30. Surgeries for Ethmoid Sinusitis • Intranasal ethmoidectomy • External ethmoidectomy

31. FUNCTIONAL ENDOSCOIC SINUS SURGERY • The concept is to surgically remove inflamed tissue and involved bone from critical points in the mucociliary clearance pathways

32. AIMS of FESS • Restore paranasal sinus function. • Re-establish the physiologic pattern of mucociliary clearance & ventilation. • Remove diseased mucosa & bone. • Preserve normal tissue . • Judiciously widen the natural ostia.

33. Anaesthesia Local Anaesthesia • Awake patients can report manipulation of the orbital periosteum or dura. • Young patients undergoing primary sinus surgery that lasts less than 2 hours General anaesthesia • Anxious patient • Operation in a child • Anticipation of a long procedure.

34. Preparation & positioning • Supine position • Local anaesthetic- 2% lignocaine + adrenaline (1:100,000) • Nasal septum, inferior turbinate, and middle turbinate are injected. • Cotton pledgets soaked in conc adrenaline kept in nasal cavity. • Throat pack . • Eyes lubricated & taped in GA

35. Nasal endoscopy • Look for landmarks • Condition of the mucosa, • The presence of any polyps or pus • Structural abnormalities identified • Additional injections of local anesthetic can be given

36. uncinectomy A ball-tipped probe is slid into the infundibulum Identified with the 0-degree endoscope Middle turbinate can be gently rotated using a Freerelevator.

37. A backbiter punch is used to incise the uncinate process. Between the inferior one third and superior two thirds of the uncinate process Incision is continued anteriorly until the harder lacrimal bone is encountered

38. Inferior aspect is rotated medially with a probe and is removed with a Microdebrider

39. Maxillary Antrostomy • A Lusk probe used to identify the ostium • Ostium widened posteriorly & inferiorly. • Probe should not be forced into the ostium. • Accessory ostium and natural ostium joined

40. Anterior Ethmoidectomy • Ethmoid bulla is the largest cell. • Anterior and medial walls then taken down. • Lateral wall of the ethmoid bulla is the lamina papyracea. • Mucosa should be preserved laterally • Agger nasi and supra bullar cells opened

41. Basal lamella puncture and posterior etmoidectomy

42. Sphenoid Sinusotomy • Ostium is located approximately halfway between the superior and inferior borders of the anterior wall. • Natural ostium can be located by gentle sliding of a probe along the anterior wall. • The probe should never be forced.

43. Sphenoid Sinusotomy • Ostium , once identified, should be widened. • Forceps inserted, opened & pulled out to out fracture the anterior wall. • Disease removed from the sinus.

44. Frontal Sinusotomy • If not diseased, it should be left alone. • Minimize mucosal injury and prevent middle turbinate lateralization. • Remnants of the uncinate process should be carefully removed. • Mucosal stripping in the region of frontal recess causes recurrence of disease.

45. Small bone fragments removed. • Hemostasis attained • The areas of the sphenopalatine, posterior septal, anterior ethmoidal, and posterior ethmoidal arteries are carefully examined. • Pack can be kept in the middle meatus to prevent lateralisation.

46. Summary • Rhinosinusitis persisting more than 12 weeks • Nasal obstruction, discharge, Facial pain and hyposmia are the major symptoms • CT Nose and PNS is the gold standard investigation • Initially treated with medical management if it fails endoscopic sinus surgery is the treatment of choice

47. Reference.. 1.Disease of Ear, Nose, Throat &Head and Neck surgery – PL Dhingra, Shruthi Dhingra Acknowledgement Images from google images and text book(Disease of Ear, Nose, Throat &Head and Neck surgery – PL Dhingra, Shruthi Dhingra)