M.H BARADARANFAR M.

D
professor of otolaryngology
Head & Neck surgery

Acute
Rhinosinusitis

Physilogy of the sinuses

1- Paterncy of the ostia
2- Function of the cilia
3- Quality of the glandular secretions

Siliary function
Double layer of mucus include
1- superficial viscid gel layer
2- underlying serous or sol layer

Pathophysiology of the sinusitis

- Mucosal edema in and around the sinus ostium the most significant
pathophysiology
- The abstruction of the sinus ostium
Cllary function

O2
mucus blanket?

Local host resistence factors

Secretions within sinus

transient intrasinus pressure

Negative intrasinus pressure

Mucosal edema

O2

nasal breathing

Obstruction of the sinus

ostium products
O2
Vasodilati
on

Ciliary

Mucous gland

dysfunctio
n

dysfunction

Transudation

Viscid fluid
Retained thick
secretions

Protection against infection

1. Nostril hair
2. Sticky mucoid layer
secreted by the goblet cells and the mucoid
glands particles carried posteriorly at a rate of approximately 6-7 mm/
mimute to be swallowed
3. Phagosytose: particels that penetrate to the muscosal layer are
phagocytose
particles 5-10 microns are most efficiently trapped in the nose
particles 2-4 microns may be carried through on air currents to the lung
4. Lysozymes: which are mucolytic enzymes that can cause swelling and
lysis of some microorganisms
5. Antibodies: lgA. lgG
Ration 3:1 in nasal secretions
Ration 1:5 in serum

Protection against infection

The principal immunolobulin in nasal secretions is IgA
The highest circulating antibody against respiratory viruses is IgG

IgA antibody dose not combine with complement and therefore is unable
to lyse bacteria, however, effective as a viral neutralizing substance.
IgA dose note speed clinical recovery, but renewed local specific IgA
antibody stores provide protection agaist reinfection
IgA in viral cold is two stage
a: stage I:

during the first 24 hours increase specific and

nonspecific IgA

b: stage II:

a second rise in the IgA titer will be seen at

approximately 1 week peaking at 2 weeks

sinusitis
1. Acute sinusitis occurs secondary to the extension of nasal
and dental infection into the pathogen- free milieu of the
paranasal sinuses
2. Type of sinusitis
a: acute

:associated with onset of a purulent airfluid

level or sinus opacification

b: sub acute

:if the infection fails to resolve within a month

and the mucosa has become increasingly
thickened by the inflammatory process

c: chronic

:these pathologic changes become

sinusitis
1. Hypertrophic sinusitis
2. Atrophic or sclerosing sinusitis with areas of squamous
metaplasia
both conditions are associated with thickened secretions,
reduced blood flow, and low oxygen tension and PH, thus
providing the atmosphere for anaerobic bacterial growth
3. Normal bacterial flora of the ant. part of nose and
nasopharynx frequently include, staph, strep pneumonia
H. influenzae and beta- hemolytic strep

Predisposing factors in sinusitis

1. Common cold
2. Mucosal hypertrophy from allergic or vasomotor rhinitis
3. Septal deviation
4. polyps
5. obstructing adenoidal tissue
6. Tumors
7. Foreign bodies
8. Unilateral choanal atresia

Acute frontal sinusitis

1. It presents with pain over the frontal sinus that is increased
by trapping or bending forward
2. The sinus will fail to transilluminate, will have fluid level and
will be opaque on radiographs
3. All forms of sinusitis frequently follow viral upper respiratory
tract infections and are particularly common in patients with
septal deviations and nasal polyps
4. If A.F.S goes untreated, the patient may present with fever,
swelling, and redness over the sinus associated with edema of
upper eyelid and diffuse headache

Acute frontal sinusitis

5. Pus may not be present in the nose
6. Complications A.F.S
a: meningitis
b: epidural, subdural or brain abscess (extension bacteria
intracranialy through phlebitic diploic veins
c: potts puffy tumor
7. Bacterial include S. peneumoniae and H. influenzae
8. A.F.S frequently requires hospitalization, intravenous
antibiotics should be administered, along with opical nasal
decogestant or %4 cocaine packings, three times a day to
induce drainge

Acute frontal sinusitis

9. The choice of antibiotic should be based on the
presumed appropriate bacterial coverage and good
C.N.S penetration (third generation cephalosporine
such as cefuroxime or ceftriaxone)
patients who have had rash- type allergic reaction to
penicillin, but they should be avoided in patients who
have had anaphylactic reaction to penicillin
10. If the sinus fails to drain and patients condition has
not improved in 24 hours, surgical drainage followed by
saline irrigation of the sinus should be under taden

Chronic frontal sinusitis

C.F.S occurs in two form
A: Low grade frontal sinusitis with thickened sinus lining and retained
secretions
This form is characterized by mild tenderness and chronic headache
with associated intermittent drainage into the nose
Rediographs demonstrate an opacified sinus with sclerosis of the
surrounding bone
These infections result from an inadequately functioning nasofrontal
duct system caused by allergic or hyperplastic mucosa, scarring or
traumatic ductal injury
Most cultures are mixed and most orevalent pathogenes are anaerobes
that respong to high dose penicillin or cephalosporins such as cefoxitic, for
oenocillin allergic individuals, clindamycin or chloramphenicol are choices,
combination with tobramycin
H. Influenzae is the most important aerobe

Chronic frontal sinusitis

B: Mucocele,

or mucopyocele

These lesions are often painless but they gradually expand and
erode the walls of the sinus and swelling of the upper eyelid
and at times exphthalmos and diplopia
Osteoplastic frontal fat obliteration of the sinus is the treatment
of choice
Baterial studes should include routine culture, anaerobic
culture and smear
Penicillin G or cefoxitin are good choices for postoperative
antibiotic choices for postoperative antibiotic coverage until the
cultures are returned

Acute & Chronic maxillary sinusitis

1. Acute maxillary sinusitis may follow viral respitatory infection
2. Bacteria most frequently cultured
a: H. influenzae
b: S. pneumoniae
c: Bronhamella catarrhalis
d: S. aureus
3. Anaerobes are also common cultured from a chronically
infected sinus
4. A Unilaterally opacified maxillary antrum on sinus xray film:
A. potential sinus tumor until proved otherwise
B. apical root abscess draining into the sinus

Acute & Chronic maxillary sinusitis

Evaluation should include
a: sinus Xray film (waters)
b: C.T. Scan, if necessary
c: Dental bite wing views
d: Panorex
If the diagnosis remains in doubt, the sinus should be explored
5. Osteomyelitis of the maxilla is unusual but rarely may result in
fistula formation to the cheek, palate or pterygoid fossa

Acute & Chronic maxillary sinusitis

6. Treatment: for 3 weeks or more
a: Amoxicillin, Augmentin, cefaclor
b: for penicillin- allergic erythromycin together cotrimaxazole
c: vasoconstrictors spray by head positioning maneuvers
d: doist air inhalation
7. An antral wash should not be attempted in untreated acute
sinusitis but should be used after a week or more of antibiotic
therapy

Acute & Chronic Ethmoiditis

1. Acute viral ethmoiditis is commonly associated with viral
rhinitis
2. Scondary bacterial infection can be recognized by a change
from mucoid to mucopurulent nasal drainage
3. Ethmoidal sinusitis is the form of sinusitis most frequently
seen among pediatric patients
4. Chronic ethmoiditis is often seen in patients with allergic or
hyperplastic sinusitis
5. Because of mucous stasis and poor vascularity of polypoid
tissue, infection is often difficult to treat in this situation
6. Ethmoidal surgery may be required to control chronic
infection

Acute & Chronic Sphenoidal sinusitis

1. Sphenoidal sinusitis occures alone only occasionally,
more often it is seen in pansinusitis
2. Isolated bacterial or rarely fungal infections occur in
debiliated elderly persons
3. Patients complain of a deep headache behind the
eyes with pain referred to the vertex of the skull
4. Diagnosis requires a high index suspicion

Acute & chronic sphenoidal sinusitis

5. Un complicated acute sphenoidal sinusitis usually responds
briskly to appropriate antibiotic treatment
6. If treatmentt fails, surgical drainage of the sinus is
accomplished by resection of the ant.wall sphenidal by external
ethmoidectomy or transseptal approach
7. Complications of sphenoidal sinusitis
a: Osteomyelitis of sphenoid bone
b: Cavernous sinus thrombosis
c: Panhypopituitarism
d: Blindness

Complication of sinus infection

A. local complications
a: chronic mucosal inflammmation:

The most common complication of acute sinusitis

There is intermittent thick yellow- green drainage

b: Mucocele or mucopyocele
It arises most commonly in the frontal sinus, less
commonly in the ethmoidal sinus and rarely in the
sphenoidal sinus

A mucocele of the frontal sinus can present in the

supero medial aspect of the ornbit as a painless soft mass
that may displace the eye inferiorly and laterally

Complication of sinus infection

c: Osteomyelitis
It is quite unusal, it occurs most commonly
following trauma, radiation, or debilitating diseases

In the maxillary sinus, osteomyelitis can occur

subsequent to a dental root abscess or dental extraction

The frontal sinus is the most commmon site of

this type of osteomyelitis, which occurs secondary to
periostitis and cause edema over the sinus (potts puffy
tumor)

Potts puffy tumor is a red, tender swelling of the

foreheade skin with associated fever

Complication of sinus infection

d: Orbital complications
1. Pneumocele of the orbit
It may result from a small bony defect between the orbit and

maxillary or ethmoidal sinuses following forceful blowing of the nose

2. Orbital cellulitis:
It is a frequent complication of acute ethmoiditis in children

(less in adults) secondray to spread of infection either directly through

the lamina papyracea or via phlebitic veins
It characterized by lid swelling, chemosis and proptosis, pain

is variable but maybe sever, mild to markly restricted eye motion

In uncomplicated cases, vision remains good and pupillary

reflexes are normal

Complication of sinus infection

3. Dacryocystitis:
It is manifested by localized, painful, red welling
below the medial can thus over the lacrimal sac

this complication occurs more often in elderly

patients and generally responds well to antibiotics

Surgical drainge is required only occasionally

4. Sup. Orbital fissure synd.

It is a rare complication of sphenoidal sinusitis

The symptoms consist of deep orbital and

unilateral frontal headache with progressive III, IV, VI palsies

Complication of sinus infection

B. Systemic complication
a: C.N.S complication
1. Meningitis:
The most common bactera are strep. Pyogenes,
S. pneumonia, staph aures and H. influenzae

Treatment consists of immediate initiation of

intensive antibiotic therapy for 2 weeks or longer in addition
to through surgical drainage of the involoved sinus

Surgical drainge is required only occasionally

2. Brain abscess:
One clue is a high C. S. F protein concentration

Complication of sinus infection

3. Cavernous sinus thrombosis:
This infection is chracterized by high spiking fever in a patient
with high toxicity
There is a rapid on set of oculomotor involvement including
almost simultaneous involvemnt of III, IV,VI cranial nerve, resulting in a
painful pan opthalmoplegia or fixed-eye
Pupillary responses are usually lacking and a large pupil is
common
Optic nerve involvement is manifested by congestion of the
optic disc, field cuts, or complete less of vision
In a responsive patient, sensation in volving the first division
of V nerve maybe diminished of lacking
Treatment consists of intensive antibiotic therapy, drainage of
the contiguous, infected ethmoidal and sphenoidal sinuses and anti
coagulation

Nasocomial sinus infections

1. Bacteria pseudomonas, S.aurens (penicillin resistant)
2. This is aparticulary important consideration for patients
with cystic fibrosis.
3.Sinus infections in ill patient or in the patient in ICU are
precipitated by foreign objects placed through the nose, N.G
Tube nasopharyngeal airway tube, and packing
4. Treatment
a: removal of nasal tube
b: administration of IV antibiotics
c: especially in life- threatening

sinus- drainage

Fungal sinus infection

A. Non opportunistic infection
1. Aspergillus fumigatus is the most common cousative
agent
2. In nonivasive fungal sinusitis, fungus lives
saprophytically as a, small mycetoma on the mucosa of
the sinus floor
Treatment is the removal of the fungus and
improved sinus ventilation

This disease often begins as a dental infection

or follows an oroantral fistula

Fungal sinus infection

3. Allergic aspergillus sinusitis:
The disease, which often affects young adult, is characterized by
recurrent polyoid rhinosinusitis, a history of asthma, and pansinusitis
documented by Xray
The diagnosis is made histologically byexamination of
mucinous material for eosinophils, septate hyphae, and charcot.
Leyden crystals and by immunologic Testing for an lgG - mediated
positive skin test or by antigen specific serum IgE- elevation
There is no tissue invasion by the fungi
Treatment:
a: surgical extirpation and earation
b: long- term oral steroid therapy

Fungal sinus infection

B. Opportunistic infections
1. Invasive fungal infections occurs under diabetic keto
acidosis, immune alteration secondary to antibiotic and
steroid therapy and profound granulocytopenia
2. The earliest clinical presentation:
a: Unexplained fever
b: A slight cloudy rhinorea
c: Facial tenderness
3. Xray film: the patients impaired inflammatory response
dose note produce sign of sinusitis on Xray films until the
disease is advanced

Fungal sinus infection

4. Nasal examination: gray non sensate areas may represent early tissue
invasion and infarction
5. Biopsy
a: Nonseptate hyphae tissue

mucormycosis

b: septate hyphae with branching at 45 degrees

aspergillosis

c: other opportunistic infections include candida, herpes simplex, and

pseudomona
6. Treatment:
Surgical excision should be performed as quickly advance rapidly

Amphoteripcin -B is administers
The best hope for survival is an improved granulocyte count

Mucor Mycoses
1. It is a fluminant opportunistic infection usually caused by Rhizopus oryzae
2. The infection, by fever and increased obtundation, usually arises in the
nose and ethmoidal sinus, however, it can arise in the lung or bowel
3. If uncontrolled, it is fatal in a period of days to weeks.
4. Clinical presentation
a: headache
b: nasal blockage
c: sero sanguinous nasal discharge
d: invading and penetrating the walls and causing thrombosis and necrosis
e: panophthalmoplegia and proptosis
f: extend intracranially

seizure, coma, death

Mucor Mycoses
5. The prognosis is grave
6. The diagnosis by biopsy demonstrates non septate,
branching hyphae
7. Treatment:
a: Amphoteripcin-B should be initiated as soon as
possible intravenously
b: surgical debridment of infected tissue

Aspergillosis
1. Although aspergillosis occurs most commonly as a
chronic pulmonary disease, it may also be a chronic
granulomatous infection of M.E,E.A.c, nose and
paranasal sinuses
2. The fungus may be part of the normal orophryngeal
flora, but, in debilitated or mmunosuppressed patients,
acute aspergillosis may become a very aggressive
nasal and sinus infection
3. Extension from the nose and oaranasal sinuses can
quickly involve the orbit and C.N.S

Aspergillosis
4. Diagnosis: by biopsy, culture and exmination of nasal
secretions for mycelial forms
5. Treatment:
a: In chronic form, It is not life threatning and shold be
treated by debridment and local therapy
b: In acute form, it is life threatening disease, prompt
debridemnt is requred
systemic amphotericin- B therapyy is occasionally

effective

Diagnostic Evaluation
1. History
2. Physical examination
3. X-ray film
4. C.T.Scan
5. Biopsy & culture

Waters
Caldwell

Management of sinusitis
(duration)
1- clinical improvemement usually occurs within 48
to 72 hours of inltiation of antimicrobial therapy
2- the antibiotic therapy should be continued for a
minimum of 7 days afer the symproms have
disappeared
3- the average duration of treatment should be 10
days and often 2 weeks

Surgical Managment
A. Maxillary sinus
1. Antral irrigation
2. Fenestration (inf. Meatus)
3. Caldwell-Luc
4. F.E.S.S (antrostomy of M.M)

Surgical Managment
B. Frontal sinus
a: acute frontal sinusitis
1. Trephination
b: chronic frontal sinusitis
1. Lynch
2. Reidel
3. Killian
4. Lothrop
5. Osteoplastic
6. F.E.S.S

Surgical Managment
c: Ethmoidal sinus
1. Intranasal ethmoidectomy
2. External ethmoidectomy
3. F.E.S.S
d: Sphenoid sinus

Ant. Ethmoidectomy
Post. ethmoidectomy

1. Transseptal sphenoidectomy
2. Trans ethmoidal sphenoidectomy
3.F.E.S.S
Spheno ethmoidal yecess
Trans ethmoidal

Indication for external

ethmoidectomy
1. Extensive polypoid sinus and nasal disease
2. Chronic ethmoid sinus infection
3. Approach to tumor of the frontal, ethmoidal and
sphenoidal sinuses
4. Searching for and repairing C.S.F leaks in the
cribriform, ethmoidal and sphenoidal regions
5. Extracranial approach in hypophhysectomy
6. Orbital decompression