OBJECTIVES: 1- Describe chronic sinusitis. 2-Classify & discuss the complication of sinusitis.

Chronic sinusitis Definition: long standing infection of the sinus mucosa for more than 3 months. Aetiology: chronic sinusitis follows single or repeated attacks of acute sinusitis

Pathology: Oedema: oedema range from slight thickening of sinus mucosa to gross polyposis. Chronic inflammatory cells infiltration (lymphocyte). Fibrosis: due to infiltration of fibroblast → fibrosis of sub-mucosa → impairment of venous and lymphatic drainage → oedema. Multiple small abscesses in the sinus mucosa. Glandular hypertrophy → ↑ secretion. Cyst formation due to compression of the glands by fibrosis. Metaplasia and ulceration of the lining epithelium-granulation tissue formation

Bacteriology: The organisms in chronic sinusitis usually mixed: Gram −ve bacteria (Pseudomonas pyocyamea, E. coli, B. proteus... etc) Gram +ve bacteria (Streptococci, Pneumococci, Haemophilus influenzae Staphylococcus aureus) Anaerobic bacteria (Bacteroid species e.g. Bacteroid fragilis).

Clinical features: Constitutional symptoms: usually mild like: fever, malaise, anorexia... Nasal obstruction. Nasal and Postnasal discharge (may be purulent or mucoid). Headache: it occurs due to obstruction of the sinus drainage. It is not severe as in acute sinusitis, usually it is described by the patient as heavy feeling in the head or dull ache over the affected sinus. (headache of sinusitis is aggravated by bending forward). Anosmia. Cacosmia (sensation of foul smell due to intrinsic cause). Secondary effects like Eustachian tube dysfunction. Nasal endoscope

Investigations: (same as acute sinusitis) Plain X-ray of Paranasal sinuses (mucosal thickening, polypoid mucosa), plain X-ray is of poor diagnostics value in chronic sinusitis, but very useful in acute sinusitis). CT scan: axial and coronal view → mucosal thickening, polypoid mucosa, see osteometal complex in coronal view. Swab of nasal discharge for culture and sensitivity. Blood tests (complete blood picture, ESR, IgG, IgA (when suspect immunodeficiency)

Treatment: Principles of treatment Treatment of underlying cause. Restoration of the functional integrity of the sinus mucosa Restoration of the sinus ventilation Restoration of mucociliary clearance system

A- Medical treatment: Systemic antibiotics: according to the result of culture and sensitivity. In choosing the antibiotics we should take into consideration the causative organisms of chronic sinusitis (gram +ve, gram −ve anaerobics). So empirical treatment with co-amoxiclav and metronidazole may be good choice. Duration of treatment is for 2−6 weeks. Decongestants: which could be systemic decongestant e.g. pseudo-ephidrine or topical decongestant e.g. phenylephrine. (decongestant drugs are alpha agonists cause shrinkage of nasal mucosa due to vaso-constriction). Corticosteroids: can be used topically as drops or spray such as dexamethasone.

B- Surgical treatment: used when there is failure of medical treatment. 1- Functional Endoscopic Sinus Surgery (FESS): It's now the preferred alternative to open sinus surgical procedures in FESS we can: Remove the uncinate process (uncinectomy) by knife. Enlarge the natural ostium of maxillary sinus; middle meatus (antrostomy). Stepwise removal of anterior ethmoidal cells extending to posterior ethmoidal cells and sphenoid sinus. Clearance of any disease in the frontal duct.

2- Open Sinus Surgery Procedures : A- Chronic maxillary sinusitis: Repeated antral washout (every week) to clean the sinus from irritant infected secretion (of little usefulness in chronic sinusitis). Inferior meatal antrostomy: it is useful by 2 ways: 1- Sinus aeration. 2- Gravitational drainage. It is done by removal of part of the bone of inferior meatus (part of the lower medial maxillary sinus wall). It is done through the nose and we remove a circle of 2 × 2 cm of inferior meatus wall.

Cald well-luc operation: used when the above 2 methods have failed. In this operation by sublabial incision: we remove part of bone from the anterior sinus wall in the canine fossa and then remove the diseased mucosa of the sinus and then we do inferior meatal antrostomy.

B- Chronic ethmoid sinusitis: Intranasal ethmoidectomy External ethmoidectomy (Patterson's operation) Transantral ethmoidectomy (Horgan's operation) External fronto-ethmoidectomy (Howarth's operation).

C- Chronic frontal sinusitis: External fronto-ethmoidectomy (Howarth's operation). Osteoplastic flap procedure (macBeth operation). D- Chronic sphenoiditis via: Intranasal ethmoidectomy. Transantral to the posterior ethmoid sinus then to the sphenoid sinus.

Fungal sinusitis: Mycetoma: usually due to Aspergillus fumigatus. Mycetoma is a fungus ball inside the maxillary sinus, clinically presented as chronic sinusitis. Rx: is by endoscopic removal of the fungus ball and ventilation of the sinus. Allergic fungal sinusitis: Typically occurs in atopic immunocompetent young adult. Usually associated with polyp and asthma. Usually caused by Aspergillus. O/E there's greenish brown sludge. Rx: is by polypectomy, ventilation of the sinus, systemic steroid and antifungal therapy - itraconazole.

Chronic indolent sinusitis: it's slowly progressive disease characterized by granulomatous infection, most commonly caused by Aspergillus fungatus. It should be suspected in healthy patient presented by chronic sinusitis resistant to conventional therapy. Rx: is by surgical debridement and removal of all the debris from the sinus and amphotericine B.

Acute invasive (fulminant) sinusitis: Occurs in immunocompromised individuals e.g. Diabetic ketoacidosis, chemotherapy patients, AIDS, leukaemia, lymphoma. It may be caused by Aspergillus, mucor or Rhizopus. It is rapidly progressive and fatal disease (mortality rate 50%−80%), Rx is by: 1- I.V. amphotericin. 2- Radical debridement which can extend to total maxillectomy. The earlier the treatment is started, the better the prognosis.

Complications of sinusitis 1- Acute A-Local 1- Orbital Preseptal cellulitis Orbital cellulitis without abcess Orbital cellulitis with extraperiosteal abcess Orbital cellulitis with intraperiosteal abcess Cavernous sinus thrombosis 2- Intracranial (abcess; meningitis; encephalitis) 3- Bony (Pott's puffy tumor) 4-Dental

B- Systemic (Toxic shock syndrome) 2- chronic(Mucocoele) 3- Associated diseases Otitis media Adeno-tosillitis Bronchiectasis

Complications of Sinusitis: 1- Acute A- Local: 1- Orbital (more common in young under 20 years and mostly due to ethmoiditis) Preseptal cellulites → there is painless eyelids oedema only Orbital cellulites without abscess → there is pain, tenderness and proptosis. Orbital cellulites with extraperiosteal abscess. Orbital cellulites with intraperiosteal abscess. In extraperiosteal abscess & intraperiosteal abscess; there is pain, tenderness, proptosis, limitation of extraocular movements and may be blindness. Cavernous sinus thrombosis (fever, convulsions, opthalmoplagia bilateral blindness, involvement of cranial nerve II−VI, pain and parasthesia in the distribution of ophthalmic and maxillary divisions of V cranial nerve, the condition is bilateral).

Management of orbital complications: Careful examination of the vision including visual acuity and color blindness (it is the early sign of compression of optic nerve) In addition to investigation for sinusitis (nasal endoscope, plain X-ray). CT scan is of great advantage provided that the clinical condition is stable (no affection of vision).

Treatment is by: Hospitalization. Systemic antibiotics (I.V) e.g. cefuroxime and metronidazole, or co-amoxiclav and metronidazole (same causative organisms as in chronic sinusitis) Intranasal decongestant. Analgesia. Antral washout. Surgical decompression by external fronto-ethmoidectomy is needed if there is any affection of vision or if there is no response to medical treatment within 24 hours.

2- Intracranial complications: Abscess (cerebral, subdural & extradural). Meningitis. Encephalitis.

3- Bony: Pott's puffy tumor: it is osteomyelitis of frontal bone due to frontal sinusitis characterized by fluctuant swelling over forehead. Causative organisms include Staphylococcus aureus, streptococci and anaerobic bacteria. Diagnosis: by CT scan & MRI. Treatment: is by systemic antibiotics (intravenously) and surgical drainage of frontal sinus & debridement.   4- Dental.

B- Systemic: Toxic shock syndrome: caused by Staphylococcus aureus; characterized by fever, rash, vomiting, diarrhea and hypotension treated by appropriate antibiotic and I.V. fluid.

2- Chronic: Mucocoele: it is an epithelial-lined mucus-containing sac completely filling the sinus and capable of expansion. It occurs most commonly in the frontal and ethmoidal sinuses (fronto-ethmoidal mucocoele), usually unilateral. It occurs due to obstruction and inflammation of the sinus. Fronto-ethmoidal mucocoele cause orbital compression so it clinically presents with proptosis, infero-lateral ocular displacement diplopia, and limitation of the eye movement in upward gaze. O/E: it may be felt in the upper medial quadrant of the orbit with a characteristic egg-shell cracking sensation due to thin overlying bone.

3-Associated diseases: Diagnosis is by x-ray and CT scan show expansion of the sinus & bone erosion. Treatment is by surgery; options include external fronto-ethmoid-ectomy (Howarth's operation), osteoplastic flab procedure or even endoscopic approach. 3-Associated diseases: Otitis media. Adeno-tonsillitis. Bronchiectasis.