2. Brig Mirza Khizar Hameed
Chronic Sinusitis
Brig Mirza Khizar Hameed

3. Definition
Inflammation of the Paranasal Sinuses lasting > 3 months

4. Etiology Anatomical variations Underlying diseases
Deviated Nasal Septum
Concha Bullosa
Bulla Ethmoidalis
Underlying diseases
Cystic Fibrosis
Ciliary Dyskinesia
Immuno-deficiency
Granulomatous diseases

5. Microbiology Anaerobes Staphylococcus aureus Streptococcus
H. Influenzae
M. catarrhalis

6. Pathophysiology Obstruction of Osteomeatal complex region
Impaired mucociliary clearance ↓
Stagnation & pooling of secretions
Infection  Vicious cycle

7. Symptoms Chronic nasal obstruction Purulent post nasal discharge
Pain over sinuses/ Headache
Halitosis
Chronic cough

8. Physical signs Purulent Nasal discharge Anatomical anomalies
Transillumination ?

9. Investigations X-ray PNS CT Scan PNS Proof puncture/ Sinus lavage
Sinus aspirate/ Pus swab for C/S

10. Treatment
Antibiotics – Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, Metronidazole
Decongestants
Antihistamines
Steroid Nasal Drops/ Sprays
Surgery- To provide drainage & ventilation

11. Operative procedures on Sinuses

12. Maxillary Sinusitis Antral Washout Inferior Meatal Antrostomy
Caldwell-Luc’s Operation
FESS

13. 1. Antral Washout
Puncturing medial wall of sinus for pus aspiration and irrigation of sinus
Indications
- Ch sinusitis refractory to treatment
Contraindications
- Age < 3 yrs
- Hypoplastic maxilla with thick bony walls
- Acute maxillary sinusitis untreated by antibiotics

14. Tilley Lichwitz Trocar & Cannula

15. Higginson Syringe

16. Trocar directed towards I/L tragus

17. Complications Hemorrhage Pain & swelling of cheek
Perforation of orbital floor
Vasovagal shock
Air embolism

18. 2. Inferior Meatal Antrostomy
A window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilley’s Antrum Harpoon & enlarged (1.5-2 cm) with Myle’s perforator

19. Complications Hemorrhage Injury to Naso-lacrimal duct
Perforation of orbital floor

20. 3. Caldwell-Luc’s Surgery
Anterior wall of the Maxillary sinus is entered through a Sub-labial incision
A window is created in the medial wall through Antrostomy
Indications
- Ch sinusitis refractory to treatment
- Repair of Oro-antral fistula
- Reccurrent AC polyp
- Blow out fracture of floor of orbit
- Approach to ethmoids/ PPF

21. Sublabial Incision

22. Hole made in anterior wall followed by Inferior Meatal Antrostomy

23. Complications Hemorrhage Cheek edema Numbness of cheek
Orbital hematoma
Trauma to teeth roots
Oro-antral fistula

24. Ethmoid Sinusitis Intranasal Ethmoidectomy External Ethmoidectomy
- Lynch Howarth procedure
- Patterson transorbital procedure
- Jansen Horgan transantral procedure
FESS

25. Lynch Howarth Ethmoidectomy

26. Patterson Ethmoidectomy

27. Trans-antral ethmoidectomy

28. Complications Hemorrhage
Injury to Lamina papyracea  Periorbital hematoma, proptosis, visual loss
Injury to Medial palpebral ligament
CSF leak
Meningitis
Mucocoele formation

29. Frontal Sinusitis Trephination Osteoplastic flap procedure
- Coronal incision
- Brow incision
FESS

30. Frontal sinus trephination

31. Osteoplastic flap procedure

32. Complications Hematoma Frontal depression CSF leak Meningitis
Mucocoele formation
Osteomyelitis

33. Sphenoid Sinusitis Trans-nasal trans-septal approach
Sublabial trans-septal approach
External ethmoidectomy approach
FESS

34. FESS Indications - Ch sinusitis refractory to treatment - Nasal polyps
- Fungal sinusitis
- Antro choanal polyp
- Fronto-ethmoidal mucocoele
- Repair of CSF leak
- DCR
- Orbital decompression

35. Functional Endoscopic Sinus Surgery
Uncinectomy (Infundibulotomy)
Bullectomy & Anterior ethmoidectomy
Middle meatal antrostomy
Perforation of basal lamella
Posterior ethmoidectomy
Sphenoid sinus exploration
Skull base disease clearance
Frontal recess exploration

36. Complications Major Minor
 Major epistaxis  Orbital hematoma  Diplopia  Blindness or  visual acuity  Internal carotid injury  Intracranial hemorrhage  CSF leak / Meningitis  Pneumocephalus  Anosmia  Nasolacrimal duct trauma
Minor epistaxis
Hyposmia
Adhesions (synechiae)
Headache
Periorbital echhymosis
Periorbital hematoma
Dental / facial pain

37. Fungal Sinusitis

38. Definition
Inflammation of the sinuses due to a fungus

39. Classification Non Invasive Fungal Sinusitis - Allergic
- Fungus Ball (Mycetoma)
Invasive Fungal Sinusitis
- Acute
- Chronic

40. Allergic Fungal Sinusitis
Most common form
Warm humid climate
Among younger, immuno-competent, atopic
Hypersensitivity reaction to inhaled fungus organism
Presents with Nasal polyps & thick greenish mucus

41. Investigations Total IgE - 
CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodelling
Histology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot-Leyden crystals

44. Treatment Surgical clearance of sinuses Topical Steroids
Antihistamines
Immunotherapy
? Antifungal

45. Fungus Ball (Mycetoma)
Older individuals, usually females
Immunocompetent
Asymptomatic/ Cacosmia/ Chronic sinusitis
Fungal mass limited to one sinus
CT Scan- Hyperdense mass with punctate calcifications

47. Fungus Ball- Treatment
Surgical clearance
? Anti fungal

48. Acute Invasive Fungal Sinusitis
Most lethal form
Immunocompromised/ Diabetics
Caused by Mucorales, Aspergillus, Fusarium, Phaeohyphomycosis
Angio invasion, hematogenous spread
Local necrosis, orbital & intracranial spread
Fever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures

50. AIFS- CT Findings Unilateral nasal soft tissue thickening
Bony erosions
Unilateral involvement of PNS
Proptosis
Cavernous sinus thrombosis

51. Acute Invasive Fungal Sinusitis - CT
Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis

53. AIFS- Treatment Aggressive surgical debridement
Systemic anti fungal therapy
Treatment of underlying cause of immunosuppression

54. Chronic Invasive Fungal Sinusitis
Immunocompetent with H/o Ch sinusitis
Progressin over months to years
Maxillofacial soft tissue swelling
Orbital involvement  proptosis, visual loss
Intracranial extension with cranial neuropathies, headaches seizures
CT Scan- Hyperdense mass, bone erosion

56. CIFS- Treatment Aggressive surgical exenteration
Systemic anti fungal therapy

57. Thank you