1. SINUSITIS

2. Anatomy
Paranasal Sinuses

3. Sinuses
The sinuses are hollow air-filled sacs lined by mucous membrane. The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2nd year of life and the sphenoid sinus develops during the 3rd year.

4. Sinuses – types Four pairs of paranasal sinuses
Frontal-above eyes in forehead bone
Maxillary-in cheekbones, under eyes
Ethmoid-between eyes and nose
Sphenoid-in center of skull, behind nose and eyes

5. Sinuses have small orifices (ostia) which open into recesses (meatus) of the nasal cavities.
Meatus are covered by turbinates (conchae).
Turbinates consist of bony shelves
There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).

6. Sinusitis
Inflammation of the mucosal lining of paranasal sinuses

7. An acute inflammatory process involving one or more of the paranasal sinuses.
Occurs when the ostia from the sinuses are narrowed or blocked by inflammation or hypertrophy of the mucosa
Maxillary and ethmoid sinuses are most frequently involved.

8. Causes
Bacterial sinusitis – streptococcus pneumoniae, hemophilus influenzae, beta hemolytic streptococci, klebsiella, pneumoniae
Viral sinusitis – rhinovirus, influenza virus, adenovirus
Fungal sinusitis – aspergillus and candida

9. Risk factors
Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection.
Respiratory tract infection
Cold weather
Day care attendance
Smoking in the home

10. Pathopysiology
Usually follows rhinitis, which may be viral or allergic.
May also result from abrupt pressure changes ( diving) or dental extractions or infections.
Inflammation and edema of mucous membranes lining -the sinuses leads to obstruction of the sinuses

11. With inflammation, the mucosal lining of the sinuses produce mucoid drainage. Bacteria invade and pus accumulates inside the sinus cavities.
If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.
Signs and symptoms

12. Classification
Acute Sinusitis – respiratory symptoms last up to four weeks
Subacute sinusitis – respiratory symptoms last between 4 to 12 weeks
Chronic sinusitis – respiratory symptoms last more than 12 weeks .

13. Complications of Sinusitis
Cellulitis or abscess
Meningitis
Brain abscess
Wheezing in children with asthma

14. Signs and symptoms -Sinusitis
Pressure, pain, or tenderness over sinuses
Low-grade temperature, Malaise
Persistent nasal discharge, often purulent
Postnasal drip- upper airway cough syndrome
Cough, worsens at night
Mouthing breathing, snoring
Sore throat, bad breath
Headache
Nasal congestion, nasal obstruction
Acute sinusitis – hyperemic and edematous mucosa, discolored purulent nasal drainage and enlarged turbinates

15. Diagnostic Tests History collection Physical examination X ray
Sinus CT, MRI
Nasal endoscopy – to examine the sinuses, obtain drainage for culture and restore normal drainage
Rhinoscopy – fiberoptic examination of the nose

16. Management
Antibiotics-treat for days, depending upon severity, with one of the following:
Amoxicillin:20-40mg/kg/d in 3 divided doses(>20kg, 250mg tid)
Augmentin:25-45mg/kg/d in 2 divided doses(>20kg, 400mg bid)

17. Biaxin (clarithromycin):15mg/kg/d in 2 divided doses
Cefzil:15mg/kg/d in 2 divided doses
Lorabid (loracarbef): 30mg/kg/d in 2 divided doses

18. Codeine (antitussive) – for severe pain and cough
Rhinocort nasal spray – 2 sprays in each nostril every 12 hours for children over 6 years of age.
Acetaminophen or ibuprofen to relieve pain
Decongestants – relieve nasal congestion
Antihistamines

19. Non-pharmacological treatment
Humidifier to relieve the drying of mucous membranes associated with mouth breathing, steam inhalation
Increase oral fluid intake 6 to 8 glass of water
Saline irrigation of the nostrils
Moist heat over affected sinus
Prolonged warm shower to promote drainage
Do not smoke or avoid exposure to smoke

20. Saline solution can be prepared at home
1/4 tsp of salt dissolved in 8 oz of tap water . A pinch of baking soda may be added
3 times daily

21. Surgical management Functional endoscopic sinus surgery (FESS)
Uses Fiberoptic endoscope
Diseased tissue which is located by CT scan will be dissected
If surgery is doing with local anesthesia, patient is only kept for 2-3 hours postoperatively and then discharged
This will promote sinus drainage and ventilation and remove diseased tissue and also opens ostia
This can be also used for the removal of polys, foreign bodies

23. CALDWELL – LUC sinus operation
Also known as radical antrum operation - It is a radical operation to the maxillary sinus performed through the oral vestibule
Incision under the upper lip
Surgeon removes part of anterior bony wall of the maxillary sinus, producing a permanent window
The diseased tissues are dissected and drained.
Antrum or cavity may be packed to prevent bleeding
Packing removed after 24 to 48 hours after surgery
As the maxillary sinus heals, the exposed bone is covered by mucosa

25. Ethmoidecotmy Removal of enthmoid air cells
Diseased mucosa, nasal polyps or mucocele are removed
Mucocele – mucous cyst that leads to repeated infection
Ethmoidectomy is performed in 3 ways – transnasal, transantral and external

26. Sphenoid sinus surgery
Endoscopic technique
External or transantral approach
Removes ethmoid sinus and opens the anterior wall of the sphenoid sinus
Diseased tissue is removed along with mucus membrane lining the sinus.

28. Frontal sinusectomy OSTEOPLASTIC FLAP OPERATION
Complete removal of diseased mucosa of the frontal sinus and for obliteration of the sinus so that it is no longer functional or continuous with the inner nose.
Obliteration is done with subcutaneous fat obtained from the left lower abdominal quadrant

32. Nursing management Pre operative teaching
NPO for 6-8 hours before surgery
Explain that the patient will:
receive a sedative , feel pressure not pain during surgery
Have a nasal pack for 24 to 48 hours after surgery
Have a mustache dressing after surgery
Have black eyes and swelling around nose and eyes for 1 to 2 weeks
Feel pressure, not pain during surgery

33. Post operative teaching
Precautions for the first week
After general anesthesia, position the patinet in side line.
Do not blow nose atleast 3 to 5 days after surgery
After caldwell luc operation do not blow nose for 2 weeks
Tell the patinent to expectorate secretion instead of swallow
Try not to sneeze, Do not bent over
Avoid constipation, Maintain Oral hygiene

34. Encourage mid fowlers position when fully awake to promote drainage and decrease edema
Apply ice compresses over nose
Encourage liberal fluid intake

35. Managing pain – acetaminophen
Taking care of drainage – bright red bleeding is expected for a week
Change the pad several time each day depending on the amount of drainage
After initial bloody drainage stops, a thicker, yellowish green drainage may continue for several weeks

36. Breathing difficulties
Keep the head elevated
Sleep with an extra pillow- more comfort, decrease edema and allow better drainage
Cool mist humidifier usage

37. Rest and activity
Avoid strenuous activities
After a week swimming, jogging are permitted
If bleeding occurs, stop activity
Avoid heavy lifting
Self monitoring
Report signs of infections
Expect ecchymosis for 1 – 2 weeks
Expect tarry stools from swallowed blood for a few days
Avoid aspirin which can cause bleeding