1. Rhino-Sinusitis: Clinical Features, Diagnosis & Medical Treatment
Dr. Vishal Sharma

2. Definitions
Rhino-sinusitis: inflammation of lining mucosa of nose & paranasal sinuses
Acute: infection lasting < 4 weeks
Sub acute: infection lasting 4 to 12 weeks
Chronic: infection lasting > 12 weeks
Recurrent: > 3 episodes in 6 months or > episodes per year with asymptomatic intervals of > 10 days

3. Types of Sinusitis Acute / sub acute / chronic / recurrent
Open / Closed (depending on its drainage)
Unilateral / bilateral
Maxillary / frontal / ethmoidal / sphenoidal
Single sinusitis / multi-sinusitis / pan-sinusitis
Anterior group / posterior group
Suppurative / hypertrophic
Bacterial / fungal / allergic / occupational

4. Etiology Rhinogenic: commonest (85%) following any form of rhinitis
Dental: for maxillary sinusitis
root abscess, dental procedures
Trauma:
R.T.A., swimming, diving, F.B., barotrauma
Iatrogenic: nasal packing, septal surgery
Hematogenous: rare

5. Predisposing factors
Mucosal odema: viral, bacterial, allergic, irritant, vasomotor, barotrauma
Mechanical obstruction: D.N.S. (spur), polyp, hypertrophic turbinate, concha bullosa, paradoxical middle turbinate, Haller cell, large bulla ethmoidalis, agger nasi, uncinate anomaly, nasal tumour, foreign body, nasal packing

6. Mucous abnormality: Young’s syndrome, cystic fibrosis, mucoviscidosis, dehydration
Mucociliary dysfunction: Kartagener’s syndrome, viral, bacterial, allergic, smoking, pollutants, hypoxia, dry air, extremes of temperature, synechiae
Miscellaneous: Poor health, immunodeficiency, diabetes, nutritional deficiency

10. Bacteriology Chronic sinusitis Acute sinusitis  Staph. Aureus
 Streptococcus
 H. influenzae
 Bacteroides
 Pseudomonas
Acute sinusitis
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella
 Staphylococcus aureus
 Neisseria

11. Progress Severity and resolution depends on Open / closed
Organism virulence
Host resistance
Treatment received

12. Ostio-meatal complex is key area for causation
of chronic anterior group sinusitis

13. Pathological variants of ostio-meatal complex

14. Concha bullosa

15. Concha bullosa

16. Paradoxically curved M.T.

17. Paradoxically curved M.T.

18. Medialized uncinate process

19. Large bulla ethmoidalis

20. Haller cell

21. Agger nasi cell

22. Nasal Septal Spur

23. Nasal Septal Spur

24. Mucosal disease

25. Symptoms Nasal discharge: mucoid / purulent / blood-stained
Nasal obstruction with hyposmia / anosmia
Headache / facial pain
Cheek / eyelid congestion + swelling
Hawking, sore throat, cough
Earache: associated Eustachian tube dysfunction
Constitutional: fever, malaise, body ache

26. Location of facial pain
Maxillary: cheek, upper jaw, forehead (supra-orbital) that es on bending forward
Frontal: forehead that es during morning & es by late afternoon (Office headache)
Anterior Ethmoid: nasal bridge & peri-orbital, es with eye movement
Posterior Ethmoid: retro-orbital
Sphenoid: vertex, occipital, retro-orbital

27. Signs Congested & edematous nasal mucosa
Nasal discharge (anterior & posterior rhinoscopy): middle meatus: frontal, maxillary, anterior ethmoid superior meatus: posterior ethmoid, sphenoid
Paranasal sinus tenderness present
Postnasal drip, granular pharyngitis
Cheek swelling: in maxillary sinusitis
Lid edema: in ethmoid & frontal sinusitis

28. Para-nasal sinus tenderness

29. Para-nasal sinus tenderness
Maxillary: palpate over canine fossa
Anterior ethmoid: palpate medial to medial canthus
Frontal: palpate floor of sinus or tap over its anterior wall

30. Para-nasal sinus tenderness

31. Sinus trans-illumination test

32. Sinus trans-illumination test
Performed in a dark room. High-intensity light source placed inside patient’s mouth or against the cheek (for maxillary sinus) & under medial aspect of supra-orbital ridge (for frontal sinus).
Trans-illumination normal = no sinusitis
Trans-illumination absent = sinus filled with pus
Trans-illumination dull = equivocal result

33. Postural test Performed in acute sinusitis (active nasal discharge)
Pus cleaned in supine position & pt sits upright
Pus appears = frontal or ethmoid sinusitis
Pus appears on stooping forwards = sphenoid sinusitis
No discharge  pt lies in lateral position with affected side up. Pus appears = maxillary sinusitis

34. Rhinosinusitis Task Force Criteria
Major Minor
1. Facial pain / pressure Headache
2. Nasal obstruction Fever (non-acute sinusitis)
3. Nasal discharge or Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia Dental pain
5. Purulence on examn Cough
6. Fever (acute sinusitis) Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

35. Investigations

36. Diagnostic nasal endoscopy (D.N.E.)
Maxillary Sinoscopy
X-ray of P.N.S.
U.S.G. of maxillary sinus (Rhinoscan)
C.T. scan of P.N.S.
M.R.I. of P.N.S.: rarely done
Allergic tests
Proof puncture (antral wash): for maxillary sinus
Endoscopic microswab for culture & sensitivity
Fungal culture: of cheesy nasal discharge

37. Diagnostic Nasal Endoscopy

38. Indications for D.N.E. 1. Patients not responding to medical therapy
2. Anatomic factor preventing adequate examination by anterior rhinoscopy
3. Collection of pus from hiatus semilunaris for culture & sensitivity
4. Objective monitoring of patients
5. Peri-operative nasal inspection & cleaning

39. Pus in middle meatus in D.N.E.

40. Maxillary sinoscopy

41. Maxillary sinoscopy
Anterior sinus wall perforated directly (in canine fossa between roots of 3rd & 4th teeth) with maxillary sinus trocar & cannula
Trocar removed & sinoscope introduced through cannula

42. X-ray paranasal sinus Water’s view (Occipito-mental)  maxillary
Caldwell’s view (Occipito-frontal)  frontal
Rhese’s view (lateral oblique)  ethmoid
Base skull view (Submento-vertical)  sphenoid
Lateral view
Pierre’s view (occipito-mental with mouth open)
Air-fluid level: acute sinusitis
Mucosal thickening chronic sinusitis

43. Acute maxillary sinusitis

44. Chronic maxillary sinusitis

45. Frontal sinusitis

46. Pierre’s view

47. Lateral view

48. Para-nasal sinus sonography
Bony anterior wall is seen as hyper-echoic line. Maxillary cavity filled with air appears as hyper-echoic hence posterior sinus margin not seen.
Fluid in sinus, cyst & mucosal thickening are hypoechoic so posterior sinus margin is visible.
B mode sonogram differentiates between fluid in sinus, cyst & mucosal thickening.

49. Normal sinus sonography (A-mode)

50. A-mode sonography of sinusitis

51. C.T. scan: maxillary sinusitis

52. C.T. scan: ethmoid sinusitis

53. C.T. scan: frontal sinusitis

54. C.T. scan: sphenoid sinusitis

55. C.T. scan paranasal sinus
Coronal & axial cuts, plain (without contrast)
Coronal planes, cuts of 4 mm or less
Indications:
In recurrent acute / chronic sinusitis not responding to medical therapy
Before endoscopic surgery
Impending complications of sinusitis

56. M.R.I. of P.N.S.

57. Medical Treatment Systemic Antibiotics
Nasal decongestants: topical & systemic
Anti-histamines
Analgesic-anti-inflammatory drugs
Medicated steam inhalation & nasal douching
Mucolytics: Ambroxol
Anti-allergy treatment
Hot fomentation

58. Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days
Ciprofloxacin: 500mg B.D. X 7 days
Doxycycline: 100 mg B.D. X 7 days
Cefadroxil: 500 mg B.D. X 7 days
Cefaclor: 500 mg T.I.D. X 7 days
Cefuroxime: 250 mg B.D. X 7 days
Cefixime: 200 mg B.D. X 7 days
Cefpodoxime: 200 mg B.D. X 7 days
Azithromycin: 500 mg O.D. X 3-5 days
Clarithromycin: 250 mg B.D. X 7 days

59. Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD
Loratidine: 10 mg OD
Levocetrizine: 5 mg OD
Desloratidine: 5 mg OD
Topical: Azelastine spray (0.1%): 1-2 puff BD

60. Nasal Decongestants Systemic decongestants  Phenylephrine
 Pseudoephedrine
Topical decongestants
 Xylometazoline
 Oxymetazoline
 Saline

61. Anti-cold preparations
Name
Chlorpheniramine
Decongestant
Paracetamol
COLDIN
4 mg
PsE 60 mg
500 mg
SINAREST
DECOLD
PhE 7.5 mg
SUPRIN
2 mg
PhE 5 mg
PsE = Pseudoephedrine; PhE = Phenylephrine

62. Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION)
Oxymetazoline %: 2 drops BD (NASIVION-P)
Xylometazoline 0.1 %: 3 drops TID (OTRIVIN)
Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P)
Saline 2 %: 3 drops TID
Saline 0.67 %: 2 drops BD (NASIVION-S)

63. Fungal Sinusitis A. Invasive (hyphae present in submucosa)
Acute invasive or fulminant (< 4 weeks)
Chronic invasive or indolent (> 4 weeks)
B. Non-invasive
Allergic
Fungal ball or mycetoma
Saprophytic
Aspergillosis & Mucormycosis are common

64. Acute invasive fungal sinusitis
Usually mucormycosis
Predisposing factors:
Immune-compromise: AIDS, Lymphoma, Cyto-toxic drugs, chronic use of steroid, aplastic anemia
Insulin dependent diabetes mellitus
Long term use of broad-spectrum antibiotics
C/F: Unilateral nasal discharge with black crusts due to ischaemic necrosis. Cerebral & vascular invasion present. Absence of significant inflammation.

65. Black crusting

66. Chronic invasive fungal sinusitis
Treatment:
Remove precipitating factors
Surgical debridement of necrotic debris
Anti-fungal drugs:
Amphotericin B infusion for 1-2 months
Itraconazole 100 mg BD for 6-12 months
Chronic invasive fungal sinusitis
Significant inflammation with fibrosis & granuloma formation
Locally destructive with minimal bone erosion
Tx: Debridement + Anti-fungal agents

67. Surgical debridement

68. Allergic fungal sinusitis
Associated with ethmoid polyps & asthma
Unilateral thick yellow nasal discharge with mucin, eosinophils & Charcot Leyden crystals
C.T. scan: radio-opaque mass with central area of hyper density (due to hyphae)
Tx: Surgical debridement + anti-histamines steroids (oral & topical)

69. Allergic fungal sinusitis

70. Allergic fungal sinusitis

71. C.T. scan coronal cuts

72. C.T. scan axial cuts

73. Fungal ball (Mycetoma)
Refractory sinusitis with foul smelling cheesy material in maxillary sinus
Tx: Surgical removal. No anti-fungal drugs.
Saprophytic fungal sinusitis
Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts

74. Thank You