Para-nasal Sinuses

They are paired, air filled chambers in the skull.

Several theories propose that they serve to
lighten the skull, protect the brain during head
trauma and add resonance to the voice.
Varieties-
Four pairs of para-nasal
sinuses:
 The Maxillary,
 The Frontal,
 The Ethmoid,
 The Sphenoid,
Sinusitis-
Inflammation of the lining mucus membrane of a
sinus as a result of infection, allergy, structural or
mechanical abnormalities,
Multi- Sinusitis- If more than one sinus is infected,
Pan- Sinusitis- If all the sinuses are involved in the
inflammatory process
Universal Law
“Where there is stasis, there is infection.”
Normally, secreted mucus is kept cleared off by the
action of gravity, of course aided by ciliary action but
when the ostium is obstructed, the mucus collects in
the sinus and gets infected, giving rise to sinusitis
Classification
Acute Sinusitis-
Infection of sinuses that lasts less than two weeks and
responds to antibiotic therapy,
Chronic Sinusitis-
Infection of sinuses that lasts longer than two weeks,
require longer courses of medical therapy, and may
require surgery.
Recurrent Sinusitis-
Either acute or chronic; it starts to resolve but recurs
because the treatment is either inadequate or is stopped
prematurely
…Classification
Sinusitis:
Acute:
Catarrhal

Suppurative (Gram + cocci, i.e.Strept./

Staph. /Pneumo. & H. influenzae)

Chronic:
Catarrhal

Suppurative (Mix Gram + cocci &Gram

– bacilli)
Pathogens
Acute Sinusitis- Aerobic bacteria like
streptococcus pneumoniae, haemophilus
influenzae, moraxella catarrhalis; Anaerobic
bacteria (10%)-; Viral(10-20%)- rhinovirus, influenza
virus;
Chronic Sinusitis- Anaerobic bacteria like
peptococcus, streptococcus, either alone or in
combination with aerobic bacterium like
staphlococcus aureus
Nosocomial Sinusitis- commonly due to
pseudomonas aeruginosa, klebsiella pneumoniae,
enterobactor species & proteus mirabilis,

Fungal Sinusitis- Aspergillosis, mucormycosis

Patho- physiology:
Located in the cheeks, the maxillary sinuses are the
largest. The natural ostium of each maxillary sinus is
situated high above the floor of the sinus, and the
evacuating effect of gravity is unfortunately missing. No
wonder, therefore that this sinus is the most commonly
infected. Infection of other sinuses is frequently secondary
to the infection of maxillary sinus. Thus, treatment
directed towards the maxillary sinus often cures the
secondarily infected sinuses. For these reasons, the
maxillary sinus is often called the ‘master’ sinus.
The mucus membranes of the nose and sinuses
normally produce 1 to 2 liters of mucus a day. If the
nasal passages become irritated by allergies, air
pollution, smoke or infection, more clear watery
mucus is produced to wash away irritants or
foreign substances. This profuse secretion is the
most common cause of postnasal drip. Bacterial
infections produce a thick, sticky mucus containing
pus, which is usually yellow or green.
This mucus blanket is
propelled backwards by the
metachronous movement of
cilia. Therefore lack of ciliary
movement will also result in
stasis and infection.
Aetiology
 All cases of rhinitis by continuity of mucosa through
sinus ostia,
 Acue infectious fevers, concerned with the
respiratory tract/ or through blood stream,
 Trauma (accidental)- e.g. RTAs, gun shot injuries,
and trauma (operative)- e.g. SMR, polypectomy,
 Severe deflected septum pressing on the lateral
wall,
 Nasal polypi, adenoids, tonsillitis tend to cause stasis,
 Infections in the pharynx, the larynx, the
tracheobronchial
tree and the lungs,
Root abscess in Teeth (bicuspid & tricuspid)/ dental
extraction leading to oro-antral fistula- 10% of all
cases are dental in origin,
 Bathing and diving in infected water,
 Poor state of health with lowered body resistance,
an imbalanced diet with excess of starches & little
proteins/ vitamins; dark, damp, overcrowded living
conditions, favour cross- infection,
 Wet and cold weather,
 Sedentary occupations & working conditions with
dusty, polluted atmosphere
Pathology
 Acute catarrhal stage- Hyperema and
swelling of sinus mucosa with exudation of some
thin mucoid discharge; under microscope,
blood vessels are seen dilated with slight
leucocytic infiltration, cilia present on lining
mucosa,
 Acute suppurative stage- Mucosal swelling
increases, cilia may be shed off with gross
leucocytic infilteration- polymorphs and
eiosinophilia, retension of discharge in the sinus
cavity due to blocked ostia,
Chronic suppurative stage- Gross hypertrophy of
sinus mucosa leading to polypoidal excrescences,
easily seen on x-ray examination; mucosa may be
shed off in places or may have undergone stratified
squamous metaplasia; in late cases, erosion of the
wall of the sinus in some places and thickening in
others; At some places, there may be polypus or cyst
formation in the mucus membrane and in other
places, sinus mucosa may have undergone atrophy.
Symptoms
Local-
 A sense of fullness or tension around the affected
sinus, aggravated on stooping & coughing,
 Pain in cheek below the eye and upper teeth on
affected side, may refer to supra-orbital region,
 Puffiness over the face, forehead or the eyelids,
 Nasal discharge- muco-purulent or purulent,
moderate in amount,
General-
 Rise of temperature, rise of pulse rate, and other
symptoms of generalized toxemia,
Examination
 First of all, see pt. as such:
looks very toxic with raised temperature & pulse,
flushed face, appear in agony,
On local exam.-
 Ant. Rhinoscopy shows
congestion and swelling of nasal mucosa, septum seen
in contact with swollen turbinals, with thin or thick
discharge,
 Post. Rhinoscopy shows
generalized congestion and discharge sticking to the
boundaries of post. nares & walls of naso-pharynx
Palpation elicits tenderness over
the affected sinus. with
comparison to the opposite side,
provided it is healthy. Tapping over
the sinus is also helpful,
Hyperasthesia tested with wool or
pin prick gives additional
information,
X-rays are trustworthy in 90% cases when taken in
suitable positions, False haziness of a sinus means
thickened mucosa, growth or blood in the sinus, thick
normal bones or swollen overlying tissues unless fluid
level can be seen in the suspected sinus; therefore, x-
rays should be considered in association with history &
clinical examination.
Fluid level in the Lt. max. sinus in a case of Acute Max.
Sinusistis.
Laboratory workup
 CBC with a differential white blood count provides
useful information regarding infection,
 ESR monitors the course of infection,
 Culturing of sinus discharge, ideally when the patient
is not being treated with antibiotics, is the most
important test.
Recent sinus investigations
 Sinogram- Ultrasonic examination of a sinus to
differentiate fluid or mucosal thickening from a solid
growth,
 Sinocopy- Physical examination of a sinus by a
fibroptic sinoscope, now performed in the physician’s
office; clarifies the diagnosis in patients who are not
responding adequately to medical treatment
CT Scan- Imaging studies are indicated for refractory
or recurrent sinusitis; sinusitis with complications and
preparations for surgery to build a `road map` that the
surgeon follows during surgery,
 MRI Scan- used to access soft tissue changes and to
evaluate the extent of sinus tumor.
COMPLICATIONS
Orbital Complications
 Inflammatory oedema
 Orbital cellulitis
 Subperiosteal abscess
 Orbital abscess
 Cavernous sinus thrombosis
 Intracranial Complications
 Meningitis
 Epidural abscess
 Subdural abscess
 Brain abscess
 Misc.Complications
 Osteomyelitis of the Skull
 Osteomyelitis of superior Maxilla
 Mucocele or pyocele
Signs of Complications
 Generalized persistent headache
 Vomiting
 Convulsions
 Chills or high fever
 Edema or increasing swelling of the forehead or
eyelids
 Blurring of vision, diplopia, or persistent retroocular
pain
 Signs of increased intracrial pressure
 Personality changes or dulling of the sensorium
Treatment
Inflammatory sinus disease is first treated
conservatively with medication.
GOAL OF MEDICAL TREATMENT
“Re-establish patency of the sinus ostea & restore
normal mucociliary clearance”
CAUSE OF THE INFLAMMATION OR OBSTRUCTION
MUST BE TARGETTED FOR MEDICAL THERAPY TO
BE SUCCESSFUL
 Allergy
 Nasal polypi etc.
General
“Complete rest in bed, easily digestible nourishing diet,&
analgesia for the relief of pain is usually rewarding.”
 Antibiotics:
Acute and chronic sinus infections should be treated with
antibiotic to eradicate causative bacteria.
Ideally antibiotic is chosen after a nasal swab for C/S or
sinus aspirate for C/S.
Generally treatment is started with broad spectrum
antibiotics, i.e. ampicillin or amoxicillin, given 14 days for
acute sinusitis or 3-4 weeks for chronic Sinusitis, they are
effective against the most likely pathogens; if ineffective, a
second generation cephalosporin may be used for 3-6
weeks.
Anti-histamines are effective in relieving the allergic
symptoms, use of topical or oral corticosteroids may
help reduce inflammation and secretions.
Allergic Desensitization- In patients with seasonal
allergies, desensitization (allergy shots) may help
relieving chronic symptoms,
 Sinus drainage & irrigation- With clogged sinus
ostia and failed drainage system, nasal decongestant
sprays to open up sinus channels are more helpful
than antihistamines and corticosteroids & help
restore normal drainage
Oral
decongestants reduce nasal and sinus mucosal
congestion and can be used over a long period of time.
Saline nasal douches are also helpful in restoring nasal
mucociliary function and in return improve sinus
drainage. When medical treatment fails, mechanical
irrigation and aspiration is undertaken.
 Antifungal Chemotherapy- Is sometimes required
especially in cases of rhinocerebral mucormycosis or
aspergillosis with or without surgical removal of disease
depending on the extent of disease.