Acute Sinusitis Dr. Abdullah Alkhalil MRCS-ENT(UK), DOHNS(London) Higher specialty(JUST), Jordanian Board.

Nasal Obstruction The sensation of unilateral or bilateral nasal obstruction is relatively common. Nasal obstruction may be associated with other symptoms (rhinorrhea, lost or altered sense of smell, facial discomfort) or may be isolated. Nasal obstruction can occur secondary to pathology of the nasal cavity or nasopharynx.

Classification Acute sinusitis is defined as disease lasting less than one month. Subacute sinusitis is defined as disease lasting 1 to 3 months. Chronic sinusitis is defined as disease lasting more than three months, and is usually due to inadequately treated acute or subacute disease.

Ostiomeatal Complex Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain. Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

Ostiomeatal Complex

Acute Sinusitis Acute inflammation of one or all the sinuses may occur (pansinusitis). The maxillary sinus is clinically the most commonly affected, followed by the ethmoid, frontal and sphenoid sinuses in that order.

Predisposing factors 1. Local. • Upper respiratory tract infection (acute infective rhinitis, i.e. common cold or influenza, tonsillitis or adenoiditis). • Pre-existing rhinitis (allergic, vasomotor, rhinitis medicamentosa, etc). • Nasal polyps. • Nasal foreign body.

Predisposing factors • Nasal anatomical variations (septal deviation, abnormal uncinate process, middle turbinate or ethmoid bulla) narrow the infundibulum and predispose to its occlusion when there is intercurrent disease. • Nasal tumour. • Dental extraction or infection (diseases of the upper premolars and molars). • Swimming and diving. • Fractures involving the sinuses.

Predisposing factors 2. General. • Debilitation. • Immunocompromised host. • Mucociliary disorders (e.g. Kartagener’s syndrome, cystic fibrosis). • Atmospheric irritants (dust, fumes, tobacco smoke).

Pathophysiology The majority of cases follow a viral upper respiratory tract infection which involves all of the respiratory epithelium including the paranasal sinuses. Such infections cause hyperaemia and oedema of the mucosa, which blocks the ostia. There will be cellular infiltration and an increase in mucus production.

Pathophysiology The infection will also paralyse the cilia, leading to stasis of secretions predisposing to secondary bacterial infection. The usual causative organisms are Streptococcus pneumoniae, Haemophilus influenzae (pneumococcal and haemophilus infections accounting for 70% of cases in adults), Streptococcus pyogenes, Moraxella catarrhalis, and Staphylococcus aureus. Klebsiella pneumoniae, Escherichia coli and Streptococcus faecalis may spread from a dental source.

Clinical features The symptoms usually occur several days after developing an upper respiratory tract infection. The patient will have pain over the infected sinus, nasal congestion, anterior or posterior rhinorrhea, fullness in the face, malaise and possibly a pyrexia. The fullness in the face and pain may be exacerbated by bending forward or stooping down.

Clinical features Specific features may indicate the sinus that is infected. Pain developing in the cheek or upper teeth indicates maxillary sinus involvement. Frontal sinusitis produces pain in the forehead and tenderness below the eyebrows. Ethmoid sinusitis may cause pain between the eyes accompanied by frontal headache. Sphenoid infection may produce retro-orbital pain, or pain anywhere across the vault.

Clinical features

Clinical features Anterior rhinoscopy may show red oedematous nasal mucosa and turbinates. Endoscopy with a 0° or 30° scope may reveal pus in the middle meatus or sphenoethmoidal recess. It may also be possible to elicit tenderness over the infected sinus. Percussion over the upper teeth may elicit tenderness, suggesting a dental origin of maxillary sinusitis.

Differential diagnosis • Migraine. • Dental pain. • Trigeminal neuralgia. • Temporal arteritis. • Herpes zoster. • Sinonasal tumour.

Investigations Gold standard of diagnosis ? Symptoms & Endoscopic evaluation. Lab: An elevated white cell count and erythrocyte sedimentation rate (ESR) will confirm an acute infection.

Radiology Plain X- ray is out of use ! CT Scan is the best imaging technique for the diagnosis of sinus problem.

Radiology CT scans of the paranasal sinuses should be reserved for: Patients in whom surgery is being considered as a management strategy Patients who do not respond to medical regimes which include adequate antibiotic use Assisting in diagnosis of anatomical changes interfering with airflow or drainage Patients presenting with complications of sinusitis

Management The aims of treatment are to resolve and limit the course of the acute infection, to prevent complications and to correct any precipitating factor.

Management Medical treatment Rest and adequate analgesia. Broad spectrum antibiotics. Topical Decongestant.

Management The patient should have a full 7-day course of the antibiotic. The decongestant may reduce nasal oedema, and hopefully open the natural ostia of the sinuses to allow free drainage. The current practice of many rhinologists is to shrink the mucosal lining, and aid infundibular drainage, by placing a pledget of cocainized cotton wool into the middle meatus for 20 minutes.

Management Surgical treatment Functional endoscopic sinus surgery is now considered to be the treatment of choice. If acute sinusitis fails to respond to medical treatment, then the patient may need surgery. This will not only treat any infection in the sinuses but will also promote drainage from these sinuses. Any pus obtained should be cultured.

When to Refer Sinusitis not responding to medical treatment. Recurrent acute sinusitis. Chronic sinusitis Sinusitis presented with complications, like orbital cellulitis.

Complications of Acute Sinusitis In most cases sinusitis is uncomplicated and spread of infection beyond the walls of the sinus is uncommon. Complications may follow an acute infection, but are most frequent during an acute exacerbation of chronic sinusitis. They can be divided into: • Orbital complications (orbital cellulitis and orbital abscess). • Osteomyelitis (maxilla or frontal bone). • Intracranial complications (meningitis, intracranial abscess, cavernous sinus thrombosis). • Mucocele. • Locoregional complications (pharyngitis, laryngitis, otitis media).

Orbital Complication

Orbital Complication Occurs more commonly in child Ill with spiking pyrexia Chemosis and diplopia. Proptosis and painful eye movement. Color blindness.

Orbital Complication

Orbital Complication Treatment: Emergency condition? Immediate admission. Start with IV antibiotics + Decongestant If there is abscess formation  Drinage.

Osteomyelitis This only occurs in diploic bone and thus only in the maxilla of children and the frontal sinus of adolescents and adults. The common organism is Staphylococcus aureus. Osteomyelitis of the maxilla is rare and usually only seen in third world countries. It presents as a painful swelling of the cheek and lower eyelid. Treatment comprises intravenous antibiotics and debridement when necessary.

Osteomyelitis Osteomyelitis of the frontal bone is more extensive and dangerous. There is a build-up of dull local pain with oedema of the forehead and the upper eyelids. A subperiosteal abscess of the forehead may form (Pott’s puffy tumour). This is a life-threatening condition with a high risk of intracranial complications. High resolution CT scan and MRI will illustrate the extent of the problem. Prompt treatment with high doses of intravenous antibiotics, surgical drainage of the frontal sinus, and appropriate debridement is required.

Intracranial complications Meningitis Extradural abscess Subdural abscess Frontal lobe abscess Cavernous sinus thrombosis associated with sphenoid sinus infection

Mucocele and Pyocele If the dependant ostium of the frontal sinus is blocked, sterile mucus accumulates within it and its contents become increasingly viscous. The cyst expands gradually and thins the anterior and inferior wall. If there is superadded infections , the cyst is termed as pyocele. Mucocele can also rarely affect the ethmoid, maxillary, and sphenoid sinuses.

Mucocele and Pyocele Pain and swelling over the frontal sinus, occasionally with egg-shell cracking felt on palpation. Diplopia, proptosis and displacement of the globe laterally and inferiorly. Treatment by drainage of the sinus and evacuation of its contents.

Mucocele and Pyocele

Locoregional complications Regional complications occur as a result of infection and inflammation spreading through the rest of the upper aerodigestive tract mucosa. Mucopus from sinusitis is carried back through the nasal airway into the pharynx and may cause a pharyngitis. Invasion of the subepithelial lymphoid tissue will produce a granular pharyngitis with visible nodules as the lymphatic tissue hypertrophies.

Locoregional complications Further downward spread may lead to irritation of the vocal cords causing a laryngitis. Sinusitis is also implicated as a cause and complication of tonsillitis and otitis media.