Diseases of the Paranasal Sinuses

Janrus Y. Abello, MD

ANATOMY

Thick Anterior Table

Frontal sinus

Thin Posterior Table

Sphenoid sinus

CORONAL SECTION

AXIAL SECTION

INFECTION
Viral Bacterial Fungal

Acute Sinusitis VS Chronic Sinusitis

ACUTE SINUSITIS
Usually follow an URTI, but may also
follow trauma, allergic edema, swimming, dental procedures, altitude changes, poor ventilation.

ACUTE SINUSITIS
PATHOPHYSIOLOGY: inflammation and edema
lead to increased secretions retained in the sinuses impaired mucociliary clearance obstruction of the ostia bacterial overgrowth on the retained secretions Offending organisms: Strep. pneumoniae,

Haemophilus influenzae, Moraxella catarrhalis, Staph. aureus, as well as anaerobes

ACUTE SINUSITIS
Symptoms:
Nasal congestion/obstruction Purulent yellowish or greenish nasal discharge Facial or sinus pain Headaches or heaviness over the sinuses Fever Foul breath Mouth breathing Cough and fatigue Anosmia/hyposmia

ACUTE SINUSITIS
Physical Exam:
Tenderness over the sinus involved Congested turbinates and nasal mucosa Purulent nasal discharge Congested oropharynx or post-nasal discharge

ACUTE SINUSITIS
Diagnostics:
Paranasal radiographic views may reveal haziness, air-fluid levels or total opacification of the sinuses CT scan of the PNS is still reserved for more complicated or unresponsive cases The gold standard is an antral puncture to obtain discharge for culture However, usually, treatment is empiric

ACUTE SINUSITIS
Management:
Antibiotics Decongestants Antihistamines (if warranted) Analgesics Mucolytics Saline douche

CHRONIC SINUSITIS
Most common predisposing factor is an
untreated or poorly-treated acute infection Other predisposing factors are trauma, structural deformities, allergic edema The offending organisms are mixed: gram positive, gram negative and anaerobes

CHRONIC SINUSITIS
Symptoms:
Chronic nasal obstruction Less pain and heaviness than that seen in acute infections Chronic purulent foul-smelling nasal discharge Chronic foul breath and mouth-breathing Chronic anosmia/hyposmia Throat symptoms of pharyngitis

CHRONIC SINUSITIS

CHRONIC SINUSITIS
Diagnostics and Management:
Depends on the predisposing factor Radiography is reserved for complicated and unresponsive cases

CHRONIC SINUSITIS
Medical treatment may have to be more long-term: saline douching, intranasal steroids Surgical treatment may be considered to correct underlying problems like nasal polyps, septal deviation, anatomic variations

COMPLICATIONS OF SINUS INFECTIONS

Orbital Complications Intracranial Complications Bony/Local Complications

ORBITAL COMPLICATIONS
Sinonasal disease accounts for the
majority of orbital infections (up to 85%). Ethmoid sinuses are almost always implicated in orbital disease; maxillary and frontal sinuses may also be involved. Spread may be direct with erosion of the lamina or through a prior fracture or by thrombophlebitic spread into the orbit.

ORBITAL COMPLICATIONS
Orbital complications as staged by
Chandler (1970) are:
preseptal cellulitis orbital cellulitis subperiosteal abscess orbital abscess cavernous sinus thrombosis

Cavernous Sinus Thrombosis

ORBITAL COMPLICATIONS
Symptoms of orbital disease include:
erythema or edema of the eyelids (common to all orbital infections) proptosis and ophthalmoplegia (suggestive of orbital cellulitis or orbital or subperiosteal abscess) decreased visual acuity (associated with advanced infection and may be irreversible)

ORBITAL COMPLICATIONS
Evaluation should include a thorough ophthalmologic examination and thin slice CT of the orbits and paranasal sinuses with contrast .

ORBITAL COMPLICATIONS
All patients with orbital complications
managed medically should be closely observed with frequent visual checks. Patients who experience a decrease in visual acuity, worsening extraocular muscle function or failure to improve in 48-72 hours should undergo surgical sinus drainage.

INTRACRANIAL COMPLICATIONS
Meningitis, subdural empyema, epidural
abscess and cerebral abscess may complicate acute and chronic sinusitis. The ethmoids, frontal, and sphenoid sinusitis primarily responsible. Infection is spread via thrombophlebitis or less commonly via direct extension of infection.

INTRACRANIAL COMPLICATIONS
Watch out for symptoms of increased
intracranial pressure (ICP):
Headache Altered mental status or restlessness Drowsiness Fever Vomiting Nuchal rigidity or meningismus

INTRACRANIAL COMPLICATIONS
The offending organisms are the same
ones implicated in sinusitis (Strep, Staph, gram negatives and anaerobes). Streptococcal species are most commonly responsible for CNS complications.

INTRACRANIAL COMPLICATIONS
The treatment for each of these
complications is similar:
A CT scan to evaluate for other CNS complications and cerebral midline shift or mass effect is necessary. In cases of meningitis, this is followed by lumbar puncture and culture if safe. High dose IV antibiotics with CSF penetration are begun.

INTRACRANIAL COMPLICATIONS
Neurosurgical consultation is strongly
recommended, even in cases that are not clearly immediately surgical. Management of ICP and seizure prevention are necessary.

BONY COMPLICATIONS
The spread of infection from the sinus is
either by the hematogenous route (retrograde thrombophlebitis) or direct spread (via erosion or through existing fractures or dehiscences.) CT scan can delineate the extent of disease and evaluate for other CNS complications.

LOCAL COMPLICATIONS
Formation of mucocoeles and pyocoeles cystic
masses that cause expansion of the bony walls of the sinuses caused by retained secretions and edema when there is obstruction Pharyngeal complications pharyngitis, tonsillitis, laryngitis, tracheitis and bronchitis occur when purulent secretions from active sinusitis drip down into the oropharynx and larynx

NEOPLASMS
Benign Neoplasms Malignant Neoplasms

NEOPLASMS
Why is it important to check the NOSE?
Extension of mass into nasal cavity May be easier to biopsy Character of mass is easily distinguished: friable, infected-looking, smooth, tends to bleed easily

DO NOT BIOPSY IF JUVENILE ANGIOFIBROMA IS SUSPECTED BASED ON PATIENTS AGE AND SEX AND PRESENTATION OF THE MASS!

NEOPLASMS
Why is it important to check the EYES?
Extension of mass into orbital cavity To find out whether mass has possibly infiltrated into periorbita (proptosis), extraocular muscles (limitation of motion) or optic nerve (decrease in visual acuity)

NEOPLASMS
Why is it important to check the EYES?
If surgical excision is contemplated, the extent of the surgery may have to include the eye involved, depending on whether mass is malignant or not.

NEOPLASMS
Why is it important to check the EARS?
A unilateral ear discharge or serous otitis media behind an intact TM may point towards extension of a paranasal sinus mass into the area of the eustachian tube, causing blockage.

NEOPLASMS
Why is it important to check the ORAL
CAVITY AND OROPHARYNX?
A maxillary sinus mass may present with a downward growth, causing a palatal bulge or extension into oropharynx A maxillary sinus malignancy may cause maxillary teeth to loosen and fall off There may be bleeding seen coming down the posterior pharyngeal wall

NEOPLASMS
Why is it important to check the SKIN
OVERLYING THE MAXILLA?
In malignancy, the skin overlying the area may become indurated or ulcerated, signifying tumor involvement Decreased sensation may signify involvement of the infraorbital nerve

REMEMBER:
The maxillary sinus may be the site of a silent malignancy. A tumor in this area may have a subtle presentation and may only be discovered during its late or advanced stage.

BENIGN NEOPLASMS

CASE: 12 year old male with Dentigerous Cyst

CASE: 29 year old female with Trigeminal Schwannoma

CASE: 18 year old male with Juvenile Nasopharyngeal Angiofibroma extending to Left Maxillary, Orbital, and Intracranial Areas

Magnetic Resonance Image of a Juvenile Nasopharyngeal Angiofibroma

MALIGNANT NEOPLASMS

Maxillary sinus CA may present with subtle signs and may reach a significant size before it is discovered.

Let us avoid LATE DETECTION

REFERENCES:
Caparas, Lim, Ejercito, Chiong, Enriquez, and Jamir.

BASIC OTOLARYNGOLOGY. Copyright 1993. Bobby R. Alford Department of Otorhinolaryngology-Head and Neck Surgery Baylor College of Medicine Grand Rounds. COMPLICATIONS OF SINUSITIS www.bcm.edu/oto/grand/71395.html