Brig Mirza Khizar Hameed Chronic Sinusitis Brig Mirza Khizar Hameed

Definition Inflammation of the Paranasal Sinuses lasting > 3 months

Etiology Anatomical variations Underlying diseases Deviated Nasal Septum Concha Bullosa Bulla Ethmoidalis Underlying diseases Cystic Fibrosis Ciliary Dyskinesia Immuno-deficiency Granulomatous diseases

Microbiology Anaerobes Staphylococcus aureus Streptococcus H. Influenzae M. catarrhalis

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

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

Physical signs Purulent Nasal discharge Anatomical anomalies Transillumination ?

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

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

Operative procedures on Sinuses

Maxillary Sinusitis Antral Washout Inferior Meatal Antrostomy Caldwell-Luc’s Operation FESS

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

Tilley Lichwitz Trocar & Cannula

Higginson Syringe

Trocar directed towards I/L tragus

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

2. Inferior Meatal Antrostomy 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

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

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

Sublabial Incision

Hole made in anterior wall followed by Inferior Meatal Antrostomy

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

Ethmoid Sinusitis Intranasal Ethmoidectomy External Ethmoidectomy - Lynch Howarth procedure - Patterson transorbital procedure - Jansen Horgan transantral procedure FESS

Lynch Howarth Ethmoidectomy

Patterson Ethmoidectomy

Trans-antral ethmoidectomy

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

Frontal Sinusitis Trephination Osteoplastic flap procedure - Coronal incision - Brow incision FESS

Frontal sinus trephination

Osteoplastic flap procedure

Complications Hematoma Frontal depression CSF leak Meningitis Mucocoele formation Osteomyelitis

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

FESS Indications - Ch sinusitis refractory to treatment - Nasal polyps - Fungal sinusitis - Antro choanal polyp - Fronto-ethmoidal mucocoele - Repair of CSF leak - DCR - Orbital decompression

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

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

Fungal Sinusitis

Definition Inflammation of the sinuses due to a fungus

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

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

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

Treatment Surgical clearance of sinuses Topical Steroids Antihistamines Immunotherapy ? Antifungal

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

Fungus Ball- Treatment Surgical clearance ? Anti fungal

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

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

Acute Invasive Fungal Sinusitis - CT Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis

AIFS- Treatment Aggressive surgical debridement Systemic anti fungal therapy Treatment of underlying cause of immunosuppression

Chronic Invasive Fungal Sinusitis Immunocompetent with H/o Ch sinusitis Progressin over months to years Maxillofacial soft tissue swelling Orbital involvement  proptosis, visual loss Intracranial extension with cranial neuropathies, headaches seizures CT Scan- Hyperdense mass, bone erosion

CIFS- Treatment Aggressive surgical exenteration Systemic anti fungal therapy

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