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

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

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

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

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

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

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

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

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

Pathological variants of ostio-meatal complex

Concha bullosa

Concha bullosa

Paradoxically curved M.T.

Paradoxically curved M.T.

Medialized uncinate process

Large bulla ethmoidalis

Haller cell

Agger nasi cell

Nasal Septal Spur

Nasal Septal Spur

Mucosal disease

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

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

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

Para-nasal sinus tenderness

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

Para-nasal sinus tenderness

Sinus trans-illumination test

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

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

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

Investigations

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

Diagnostic Nasal Endoscopy

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

Pus in middle meatus in D.N.E.

Maxillary sinoscopy

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

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

Acute maxillary sinusitis

Chronic maxillary sinusitis

Frontal sinusitis

Pierre’s view

Lateral view

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.

Normal sinus sonography (A-mode)

A-mode sonography of sinusitis

C.T. scan: maxillary sinusitis

C.T. scan: ethmoid sinusitis

C.T. scan: frontal sinusitis

C.T. scan: sphenoid sinusitis

C.T. scan paranasal sinus Coronal & axial cuts, plain (without contrast) Coronal planes, cuts of 4 mm or less Indications: In recurrent acute / chronic sinusitis not responding to medical therapy Before endoscopic surgery Impending complications of sinusitis

M.R.I. of P.N.S.

Medical Treatment Systemic Antibiotics Nasal decongestants: topical & systemic Anti-histamines Analgesic-anti-inflammatory drugs Medicated steam inhalation & nasal douching Mucolytics: Ambroxol Anti-allergy treatment Hot fomentation

Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days Ciprofloxacin: 500mg B.D. X 7 days Doxycycline: 100 mg B.D. X 7 days Cefadroxil: 500 mg B.D. X 7 days Cefaclor: 500 mg T.I.D. X 7 days Cefuroxime: 250 mg B.D. X 7 days Cefixime: 200 mg B.D. X 7 days Cefpodoxime: 200 mg B.D. X 7 days Azithromycin: 500 mg O.D. X 3-5 days Clarithromycin: 250 mg B.D. X 7 days

Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical: Azelastine spray (0.1%): 1-2 puff BD

Nasal Decongestants Systemic decongestants  Phenylephrine  Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

Anti-cold preparations Name Chlorpheniramine Decongestant Paracetamol COLDIN 4 mg PsE 60 mg 500 mg SINAREST DECOLD PhE 7.5 mg SUPRIN 2 mg PhE 5 mg PsE = Pseudoephedrine; PhE = Phenylephrine

Topical Decongestants Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) Oxymetazoline 0.025 %: 2 drops BD (NASIVION-P) Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) Saline 2 %: 3 drops TID Saline 0.67 %: 2 drops BD (NASIVION-S)

Fungal Sinusitis A. Invasive (hyphae present in submucosa) Acute invasive or fulminant (< 4 weeks) Chronic invasive or indolent (> 4 weeks) B. Non-invasive Allergic Fungal ball or mycetoma Saprophytic Aspergillosis & Mucormycosis are common

Acute invasive fungal sinusitis Usually mucormycosis Predisposing factors: Immune-compromise: AIDS, Lymphoma, Cyto-toxic drugs, chronic use of steroid, aplastic anemia Insulin dependent diabetes mellitus Long term use of broad-spectrum antibiotics C/F: Unilateral nasal discharge with black crusts due to ischaemic necrosis. Cerebral & vascular invasion present. Absence of significant inflammation.

Black crusting

Chronic invasive fungal sinusitis Treatment: Remove precipitating factors Surgical debridement of necrotic debris Anti-fungal drugs: Amphotericin B infusion for 1-2 months Itraconazole 100 mg BD for 6-12 months Chronic invasive fungal sinusitis Significant inflammation with fibrosis & granuloma formation Locally destructive with minimal bone erosion Tx: Debridement + Anti-fungal agents

Surgical debridement

Allergic fungal sinusitis Associated with ethmoid polyps & asthma Unilateral thick yellow nasal discharge with mucin, eosinophils & Charcot Leyden crystals C.T. scan: radio-opaque mass with central area of hyper density (due to hyphae) Tx: Surgical debridement + anti-histamines + steroids (oral & topical)

Allergic fungal sinusitis

Allergic fungal sinusitis

C.T. scan coronal cuts

C.T. scan axial cuts

Fungal ball (Mycetoma) Refractory sinusitis with foul smelling cheesy material in maxillary sinus Tx: Surgical removal. No anti-fungal drugs. Saprophytic fungal sinusitis Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts

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