1. Rhinosinusitis
Jihan AL Maddah

2. Definition Inflammation of the mucous membrane of nose and sinuses.
One of the most common conditions presenting to clinicians worldwide, and can potentially have enormous and a devastating socioeconomic impact.

3. Classification Rhinosinusitis can be categorized based on:
Duration of infection, and then further.
Subdivided by the cause.

4. Duration of symptoms Acute sinusitis : symptoms <4 weeks.
Sub-acute sinusitis: 4-12 weeks.
Chronic sinusitis: >12 weeks.
Recurrent sinusitis: > 4 episodes/year.

5. Etiology Infective: Viral (majority). Bacterial (minority).
Rhinovirus, Para-influenza, RSV, Adenovirus
Bacterial (minority).
Non-specific
Specific (syphilis, TB)
Fungal (minority).
Non-infective:
Allergic (Common) (ARIA)
Mild, Moderate, Severe
Persistent, Intermittent

6. Etiology Non- allergic Non-infective
Non-allergic eosinophilic rhinitis
Occupational
Hormonal
Drug induced
Gustatory
Vasomotor

7. Symptoms Three cardinal symptoms:
Purulent nasal discharge (purulent-cloudy)
Nasal obstruction (congestion, blockage, or stuffiness)
Facial pain-pressure-fullness (involves the anterior face and peri-orbital region or manifests with headache that can be localized or diffuse).

8. Allergic Rhinitis and its Impact on Asthma (ARIA)
30% of patients with AR have asthma
The majority of patients with asthma have AR
AR is a major risk factor for poor asthma control
All patients with AR should be assessed for asthma

9. Allergic Rhinitis and its Impact on Asthma (ARIA)
Comorbidities:
Up to 80% of patients with bilateral chronic sinusitis have AR
Otitis media
Conjunctivitis
Lower respiratory tract infections
Dental problems – malocclusion, discoloration
Sleep disorders

10. ALLERGIC RHINITIS (ARIA)
Moderate-severe one or more items
Abnormal sleep.
Impairment of daily activities, sport, leisure.
Problems caused at school or work.
Troublesome symptoms.
Intermittent symptoms
< 4 days per week Or < 4 weeks
Mild
Normal sleep.
Normal daily activities.
Normal work and school.
No troublesome symptoms.
Persistent symptoms
> 4 days per week and > 4 weeks

11. Allergic Rhinitis - Causes
Seasonal
(Intermittent)
Pollen from
Grasses
Weeds
Trees
Perennial
(Persistent)
House dust mites
Mold and fungus spores
Cockroaches
Animal dander
Food
Chemicals

13. Allergic Rhinitis Predisposing Factors +ve family history
Personal history of atopic disease e.g eczema, urticaria and asthma

15. Allergic Rhinitis - Symptoms
Sensitive to specific allergens ( dust mites, pollens)
Pruritus of the nose, eyes, palate, ears
Sneezing > 2 at a time
Watery rhinorrhoea
Coexistant asthma or eczema
Seasonal symptoms
Family history of allergies

16. Diagnosis
History – Present illness, past medical history, family history, environmental history and impact on quality of life.
Physical Examination – Nose, Eyes, Ears, Lungs and Skin
Nasal exam with endoscope – edematous Inferior turbinate, polyps

18. Investigations Blood test : IgE ( total & specific), eosinophilia
Nasal biopsy for differential dx
Skin test ( In vivo)
RAST (radio-allergosorbent test) ( In vitro)

19. Treatment Avoidance of allergen Normal Saline douching
Local and/or antihistamine
Local and/or steroids
Sublingual / Subcutaneous Immunotherapy (Desensitization)

20. Treatment-Surgical Surgical - for nasal obstruction only Septoplasty
Turbinate reduction
Functional endoscopic sinus surgery (FESS)

21. Vasomotor Rhinitis
Autonomic disturbance – excessive parasympathetic activity
No specific cause found
Symptoms : rhinorrhoea, sneezing, nasal obstruction
Treatment: Local nasal steroids, anticholinergic medication

22. Rhinitis Rhinitis Medicamentosa
Avoid prolong use of vasoconstrictor nose drop
Treatment: stop vasoconstrictors, local/systemic steroids

23. Sinusitis
Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition.
Rhinosinusitis affects an estimated 35 million people per year in the United States and accounts for close to 16 million office visits per year

24. The vast majority of rhinosinusitis episodes are caused by viral infection.
Most viral upper respiratory tract infections are caused by rhinovirus, but coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus are also causative agents. Rhinovirus, influenza, and parainfluenza viruses are the primary pathogens in 3-15% of patients with acute sinusitis.
In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis.

25. Rarely, sinusitis is caused by fungi.
Fungal sinusitis (eg, allergic fungal sinusitis) may appear similar to lower airway disorder and allergic bronchopulmonary aspergillosis.
Fungal agents associated with this condition include:
Aspergillus and Alternaria species (60%).
Bipolaris and Curvularia (20%).

26. Sinusitis Acute sinusitis Viral Bacterial Dental origin – 10% Fungal
Chronic sinusitis
Anatomical
Allergy
Polyps
Immune deficiency

27. 75% bacterial isolates, most commonly in adults:
35% coagulase-negative staphylococci (CNS)
23% Corynebacterium species
8% Staph aureus Low numbers of these species were present.
In children, the most common organisms:
40% H influenzae
34% M catarrhalis
50% S pneumoniae

28. Pathophysiology
The pathophysiology of rhinosinusitis is related to 3 factors:
1. Obstruction of sinus drainage pathways (sinus ostia) (trauma, rhinitis)
2. Ciliary impairment (Primary ciliary dyskinesia)
3. Altered mucus quantity and quality ( Cystic fibrosis).

29. Acute sinusitis - Symptoms
Proceeding URTI or Dental infection
Pain - depends on the involving sinus
throbbing
aggravated by coughing
Nasal obstruction
Purulent rhinorrhoea

30. Acute Sinusitis - Signs
Fever
Local tenderness
Mucous in nose or nasopharynx
Dental origin
X-ray with opacity or fluid level

33. Acute Sinusitis Streptococcus pneumoniae Haemophilus Influenza
Staphylococcus
Anaerobes

34. Acute sinusitis is a clinical diagnosis
Acute sinusitis is a clinical diagnosis. However, the evaluation might include the following laboratory tests :
Nasal cytology (allergy)
Nasal-sinus biopsy (mass, polyp, tumor)
Tests for immunodeficiency (recurrent sinusitis associated with other infections)
Sweat chloride test and electron microscopy in cystic fibrosis, or ciliary dysfunction

35. Treatment of acute sinusitis consists of providing adequate drainage of the involved sinus and appropriate systemic treatment of the likely bacterial pathogens.
Drainage can be achieved surgically with sinus puncture and irrigation techniques. Options for medical drainage are as follows:
Oral alpha-adrenergic vasoconstrictors days
Topical vasoconstrictors for a maximum of 3-5 days
Antibiotic treatment is usually given for 14 days.
Usual first-line therapy is Amoxicillin, Clarithromycin
Azithromycin

36. Acute Sinusitis - Treatment
Antibiotics x 2 weeks
Amoxycillin
Augmentin
Cefuroxime + metronidazole
Vasoconstrictor nose drops – aid drainage
Antral washout – for resistance case
both diagnostic and therapeutic
Functional endoscopic sinus surgery

37. Chronic Sinusitis - Symptoms
Usually less - no pain
Nasal obstruction
Nasal/Post nasal purulnt discharge
Cacosmia

38. Chronic Sinusitis - Signs
Mucopus in the meati
Nasal mucosa congested
X-ray show fluid level or opacity

40. Chronic Sinusitis - Treatment
Medical
Antibiotic
Nasal Decongestant
Topical steroid

41. Chronic Sinusitis - Treatment
Surgical
Open-depends on the site
Caldwell-Luc Operation
Osteoplastic flap
Endoscopic-FESS

42. FESS Functional Endoscopic Sinus Surgery Messerklinger 1960s
resume the normal function of sinus
drainage
ventilation
Messerklinger 1960s
sinus mucus drain in a genetically determined path to the natural ostium

43. Post FESS

44. Complications of Sinusitis
Local
Mucocele
Osteomyelitis-Pott’s tumor
Orbital
Orbital cellulitis
Orbital abscess
Cavernous sinus thrombosis
Intracranial
Epidural abscess
Subdural abscess
Intracerebral abscess