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Chronic Sinusitis

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

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Chronic Sinusitis

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  1. Chronic Sinusitis Brig MirzaKhizarHameed

  2. Definition • Inflammation of the Paranasal Sinuses lasting > 3 months

  3. Etiology • Anatomical variations • Deviated Nasal Septum • ConchaBullosa • Bulla Ethmoidalis • Underlying diseases • Cystic Fibrosis • CiliaryDyskinesia • Immuno-deficiency • Granulomatous diseases

  4. Microbiology • Anaerobes • Staphylococcus aureus • Streptococcus • H. Influenzae • M. catarrhalis

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

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

  7. Physical signs • Purulent Nasal discharge • Anatomical anomalies • Transillumination ?

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

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

  10. Operative procedures on Sinuses

  11. Maxillary Sinusitis • Antral Washout • Inferior MeatalAntrostomy • Caldwell-Luc’s Operation • FESS

  12. 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

  13. Tilley LichwitzTrocar & Cannula

  14. Higginson Syringe

  15. Trocar directed towards I/L tragus

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

  17. 2. Inferior MeatalAntrostomy • 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

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

  19. 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

  20. Sublabial Incision

  21. Hole made in anterior wall followed by Inferior MeatalAntrostomy

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

  23. Ethmoid Sinusitis • Intranasal Ethmoidectomy • External Ethmoidectomy - Lynch Howarth procedure - Patterson transorbital procedure - Jansen Horgantransantral procedure • FESS

  24. Lynch HowarthEthmoidectomy

  25. Patterson Ethmoidectomy

  26. Trans-antralethmoidectomy

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

  28. Frontal Sinusitis • Trephination • Osteoplastic flap procedure - Coronal incision - Brow incision • FESS

  29. Frontal sinus trephination

  30. Osteoplastic flap procedure

  31. Complications • Hematoma • Frontal depression • CSF leak • Meningitis • Mucocoele formation • Osteomyelitis

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

  33. FESS • Indications - Ch sinusitis refractory to treatment - Nasal polyps - Fungal sinusitis - Antrochoanal polyp - Fronto-ethmoidalmucocoele - Repair of CSF leak - DCR - Orbital decompression

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

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

  36. Fungal Sinusitis

  37. Definition • Inflammation of the sinuses due to a fungus

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

  39. 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

  40. Investigations • Total IgE -  • 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

  41. Treatment • Surgical clearance of sinuses • Topical Steroids • Antihistamines • Immunotherapy • ? Antifungal

  42. 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

  43. Fungus Ball- Treatment • Surgical clearance • ? Anti fungal

  44. 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

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

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