1. Chronic Sinusitis

2. Definition
Chronic inflammation of the mucosal lining of one or more paranasal sinuses, usually caused by anatomical / pathological obstruction to its drainage, and is characterized by chronic postnasal mucopurulent discharge with or without recurrent headache / facial pain. (more than 1month).

3. Types Open / Close Unilateral / bilateral
Single sinus / multi-sinusitis / pan-sinusitis
Anterior group / posterior group
Suppurative / Hypertrophic

5. Osteomeatal complex : before and after fess

6. Mucociliary function

7. Etiopathogenesis Usually Rhinogenic. Other routes- rare.
Unresolved acute sinusitis
Any form of rhinitis Mucosal odema in OMC Pathological obstruction
Any anatomical variation Anatomical obstruction
Stagnation and secondary chronic sinusitis

8. Infective / reactive rhinitis
Mechanical: DNS, anatomical variations in the MM/ OMC, etc.
Pathological mucous/ mucociliary dysfunction
Mucosal odema/ polyp formation
Anatomical obstruction
Pathological obstruction
Impaired drainage of sinuses in the MM/ OMC
Stagnation and secondary infection
Chronic sinusitis

9. Pathogenesis : Mucosal odema Mechanical obstruction (anatomical)
Mucous- thick
Primary mucociliary dysfunction
Anterior ethmoids is the key area for causation of chronic anterior group sinusitis because
Ostiomeatal complex is situated within it
Acts as reservoir of infection

10. Types & Mucosal changes
Open/ closed type
Mucosal changes:
Hyperemia
Hypertrophy
Increased mucosal glands
Polypoidal changes
Mucopurulent secretions
Microabscesses
Fibrosis, hyalinization
Atrophy, squamous metaplasia, granulations

11. Bacteriology Mixed infection
Streptococcus pneumoniae, Hemolyticus, Staph
aureus, gram negative bacteriae,etc.
Anaerobic infection> fowl smelling discharge

12. Clinical features: Symptoms
Mucopurulent/ purulent post nasal discharge
Cachosmia- anaerobic
Headache/ facial pain- depending on the site and
type- usually dull aching.
Nasal obstruction
Aural and throat symptoms

13. Clinical features: Signs
Discharge in the MM on anterior rhinoscopy
Mucosal changes in the MM
Discharge in MM/ SM on posterior rhinoscopy
Tenderness in acute excerbations
Postural/ Transillumination tests
Prominent lateral pharyngeal band

14. Investigations Plain radiographs “Water’s”
Mucosal thickening, haziness, opacity, polyp
CT scan of OMC/ paranasal sinuses (coronal cuts)
X-ray nasopharynx in children
Diagnostic nasal endoscopy
Allergic tests if suspected
Proof puncture for maxillary sinus
Culture and sensitivity- rarely done
Fungal culture of cheesy discharge, if present

15. CHRONIC
Sinusitis

17. Endoscopic appearance of mucosal changes in CHRONIC sinusitis

18. Treatment: Medical Antibiotics Nasal decongestants- topical/ systemic
Antihistaminics
Analgesic-antiinflammatory
Medicated steam inhalation
Alkaline nasal douches
Steroid nasal spray/ short course of systemic
steroids
Antiallergy treatment

19. Treatment: Surgical When refractory to medical treatment
Surgery for predisposing causes like DNS, polyp, etc.
Surgical procedure depends on the sinus involved
All sinuses may be surgically
accessed endoscopically

20. Chronic maxillary sinusitis
Surgical options
Antral puncture
Intranasal antrostomy
Caldwel-Luc operation
FESS (Functional endoscopic sinus surgery)

21. CALDWELL LUC SURGERY Opening through canine fossa
Counter opening into inferior meatus
Radical mucosal debridement
CALDWELL LUC SURGERY

22. Chronic ethmoiditis Intranasal ethmoidectomy
Blind & dangerous
Trans-antral ethmoidectomy
Via Caldwel-Luc operation
External ethmoidectomy (Howarth operation)
Endoscopic ethmoidectomy (FESS)

23. Chronic frontal sinusitis
External frontoethmoidectomy (Lynch-Howarth
operation)
Osteoplastic operation
Obliteration of frontal sinus
Endoscopic frontal sinusostomy

24. Chronic sphenoidal sinusitis
Intranasal sphenoethmoidectomy
External sphenoethmoidectomy
Endoscopic sphenoidotomy

25. Functional endoscopic sinus surgery (FESS)
Uncinectomy (infundibulotomy)
Middle meatal antrostomy
Frontal recess clearance
Anterior ethmoidectomy