1. Chronic sinusitis
Prof. Ehab Taha Yaseen

2. Objectives
To keep in mind for the rest of your life that facial pain is not the main symptoms in chronic sinusitis
Hence, patient present with facial pain as the their chief complaint are usually not have chronic sinusitis
2. Usually present with other nasal features or ear and throat symptoms
3. The main type of surgery (FESS)

3. Definition
Better terms
Types
Specific (TB, Fungal, etc…)
Non specific 2 types
Simple (infective) (repeated acute rs)
Mixed type (infective and VMR) usually there is predisposing factor as obstruction of sinus ostia

4. Pathology:
Edema
Polyposis
chronic inflammatory cellular infiltration
fibrosis of submucosa
multiple small abscesses
metaplasia and glandular hypertrophy.

5. Symptoms: Postnasal or nasal discharge
Symptoms: Postnasal or nasal discharge. Nasal obstruction Recurrent pharyngitis (sore throat). Headache. Anosmia or cacosmia Cough Eustachian obstruction are common secondary effects Constitutional symptoms are usually mild or absent.

6. often unremarkable and non-specific,
Signs:
often unremarkable and non-specific,
you may see (endoscopy is important tool )
polyps
septal deviation
signs of allergic rhinitis (extrinsic rhinitis)
vasomotor rhinitis (intrinsic rhinitis)
postnasal drip
granular pharyngitis
you may notice bad smell
features of Eustachian obstruction.

7. Investigations:
Endoscopy (again)
CT scan is the gold standard investigation
To prove the diagnosis
Looking for predisposing factors (anatomical variation or pathological findings)
To address the anatomy (if surgery is decided)
To exclude the presence of complications (especially orbital and intracranial complications)

8. Treatment:
Medical: for 4-6 weeks, this will include:
Antibiotics are given orally and should cover both aerobic, anaerobic, gram positive and gram negative bacteria e.g. amoxicillin + metronidazol or amoxicillin + calvulonic acid.
Steroids as nasal spray
Antihistamines especially when there is allergy.
Analgesic usually not needed.
Surgical : treatment is indicated when there is failure of medical treatment, and these may include:
Intranasal antrostomy. (obsolete)
Caldwell – Luc operation. (only one indication)
Internal and external ethmoidectomy. (obsolete)
Internal ethmoidectomy. (obsolete)
external fronto – ethmoidectomy. (obsolete)
frontal sinus obliteration. (obsolete)
Sphenoid surgery is usually part of surgery on the other sinuses.
Functional endoscopic sinus surgery (FESS).

9. The gold standard operation nowadays is the FESS: Aims of FESS are to
Remove diseased mucosa, polyps, bones and widen sinus ostia
Restore sinus ventilation
Restore normal mucocilliary clearance
What are the indications of FESS
Chronic rhinosinusitis after failure of medical therapy
Recurrent acute rhinosinusitis (more than 3 attacks per year in the presence of predisposing anatomical variation)  
Chronic Specific Sinusitis ( Fungous infection)
Usually due to aspergilli, common in immune compromised patients as diabetic or uraemic patients. Treated by evacuation surgery and systemic antifungal agents as amphotericin B.

10. Case
35 y old man seeking advice to remove his tonsils because of recurrent infection that affect his QOL. How you will approach the diagnosis in this patient? History Examination Investigation Treatment