ACUTE SINUSITIS

DEPARTMENT OF ENT
JNMC, SAWANGI.
 Purpose statement
• At the end of the class the students will be
able to,
• Describe the pathophysiology, aetiology,
clinical features and management of acute
sinusitis.
 Learning objectives
• At the end of the class the final year
students should
s. Learning objectives Domain level criteria condition
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1. Enlist the various types of Cognitive Must All

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2. Enumerate the Cognitive Must

pathophysiology of acute know
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3. Enlist all the clinical features Cognitive Desired
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4. Out line the treatment options Cognitive Desired

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 ACUTE SINUSITIS
• Term Rhino sinusitis more apt
• Acute inflammation of mucous membrane
• One or more sinuses
• Pan sinusitis
• Recurrent
• 5% of URI lead to sinusitis
• Ethmoid sinus children ,maxillary in adult
 Sinusitis
• Inflammation of paranasal sinuses
 SALIENT FEATURES
• Osteo meatal complex is important
• FESS has changed concept-pathology
• Maxillary sinus –Conductor of orchestra
• Ostium is high , not gravity dependent
• Proximity to teeth is important
• Immunity, anatomy, virulence
• Ethmoidal in children , maxillary in adults
 PREDISPOSING FACTORS
• Mechanical obstruction
• Focal infection
• Fractured muco cilliary function
• Autoimmune, allergy, immune deficiency
• Hormonal balance
• Granulomatous conditions
• Trauma
• Idiopathic, itrogenic
OTHER FORMS OF SINUSITIS

• Nasocomial sinusitis (prolonged Intubation

• Barosinusitis ( Pressure changes –flying)

• Swimmer’s sinusitis
 CLASSIFICATION

• Acute sinusitis – Till 3 weeks

• Sub acute Sinusitis- 3 wks to 3 months

• Chronic sinusitis - 3 months or more

• Rhinogenic or Odontogenic
 PATHOGENESIS
• Viral or Bacterial acute infection
• Leucocytic infiltration
• Release of chemical mediators
• Vasodilatation and oedema
• Blockage of ostium
• Poor drainage – stagnation –infection
 Bacteria Involved in Acute
Bacterial Sinusitis

• Streptococcus pneumoniae 30%

• Haemophilus influenza 20%

• Moraxella catarrhalis 20%
• Sterile 30%
 STAGES
• Catarrhal stage

• Exudative stage

• Purulent stage

• Complication

• Resolution stage
 CLINICAL PRESENTATION
Nasal discharge – Mucopurulent
Foul smell (Dental)
Absent (close sinusitis)
Nasal obstruction
Headache –intense over affected sinus
History of previous infection
Fever, malaise
 ACUTE MAXILLARY
SINUSITIS
• Generally above 15 years

• Rhinogenic - 90%

• Odontogenic -8%

• Others – Blood borne, trauma, pollution

 CLINICAL FEATURES
• Pain over cheek- more on bending
• Discharge from nose
• Nasal blockage
• Anosmia
• Swelling over cheek
• Dry cough, epistaxis,malaise
 SIGNS
• Tenderness over canine fossa
• edema of cheek and lower eyelif
• Swollen congested nasal mucosa
• Discharge –Anteriorly (MM) Post. (PND)
• Signs of dental infection
• DNS or other structural abnormalities
 INVESTIGATIONS
• X ray PNS – Three basic view
(Occipitomental, occipitofrontal, Lateral)
• Mucosal thickening, opacity, fluid level
• Fallacies like
Shadow of upper lip
Thickening of bony wall
Post operative thickening
 OTHER INVESTIGATIONS
• Diagnostic nasal endoscopy
• Trans illumination (Cyst of maxillary sinus)
• USG – Children young females (Radiation)
• Nasal smear (eosinophillia)
• Nasal swab – Nose or antrum
• CT scan in select cases
Nasal and sinus endoscopy
 TREATMENT
• Medical –Mainstay antibiotics

• Surgical – Antral Puncture or FESS

• Dental treatment

• Treatment of complications (If any)

Diagnostic proof puncture
 FRONTAL SINUSITIS
• Generally secondary to ethmoidal sinus

• Blockage of frontal recess

• Isolated frontal sinusitis is rare

• Generally rhinogenic
 SYMPTOMS
• Headache – severe, periodic frontal
More in morning subsides by afternoon
“Office headache/Vaccume frontal
• Swelling of upper eyelid
• Nasal discharge , nasal obstruction
• Fever, anosmia, hyposmia
• Altered taste sensation
 SIGNS
• Congested nasal mucosa
• Purulent discharge in middle meatus
• Tenderness over frontal sinus
( Medial to supra orbital notch and above
inner canthus)
• Edema of upper eyelid
 TREATMENT
• Medical treatment – Antibiotics

• Trephination frontal sinus (Beek puncure)

• Endoscopic frontal sinus clearance

 ETHMOIDAL SINUSITIS
• Commonest sinus affected in children

• Isolated acute ethmoiditis is rare

• Pain between eyes ,frontal headache

• Discharge from nose, PND

• Nocturnal cough, fever

 SIGNS
• Tenderness over inter canthal region

• Anterior rhinoscopy – Discharge in MM

• Posterior rhinoscopy – Discharge from

middle and superior meatus
 TREATMENT
• Diagnostic nasal endoscopy

• CT scan

• Conservative treatment with antibiotics

• Rarely surgical treatment –Complications

 Acute sphenoidal sinusitis
• Isolated cases are rare

• Generally pansinusitis

• Follows acute ethmoiditis

• Secondary to # skull base

 SYMPTOMS AND SIGNS
• Headche –Vertex, frontal, occipital,central

• Pain may radiate to temporal region

• Presence of pus discharge in SE recess

• “Supratubal stream of discharge”

 INVESTIGATIONS
TREATMENT
• Diagnostic nasal endoscopy
• X ray PNS Water’s view with mouth open
(Pierre’s View)
• CT scan
• Medical treatment
• Endoscopic Sphenoidotomy
 Summary

• Definition and classification of different types of

rhinosinusitis discussed.
• Described the Pathophysiology of acute
sinusitis.
• Formulated the diagnostic criteria(clinical
features) of Acute sinusitis.
• Discussed different treatment options of Acute
sinusitis.
 References
• Diseases of Ear Nose Throat
fifth Ed. P. L. Dhingra, Shruti Dhingra
• Scott Brown’s Otolaryngology- Sixth
Edition A short text book of ENT K.B.
Bhargava .
• Logar Turners Diseases of the Nose
Throat and Ear 10th Edition
Edited by AGD Maran
 Sinusitis
• Inflammation of paranasal sinuses
 Sinusitis

Infectious or noninfectious inflammation of

1 or more sinuses

• 4 paranasal sinuses, each lined with

pseudostratified ciliated columnar epithelium
and goblet cells
– Frontal
– Maxillary
– Ethmoid
– Sphenoid
 Viral Rhinosinusitis

• Most upper respiratory infections are viral

• Short lived, last less than 10 days

• Sinus mucosa as well as nasal mucosa is

involved
• Most will clear without antibiotics

• Treatment: decongestants, nasal lavage, rest,

fluids
 Classification of Bacterial Sinusitis
• Acute bacterial sinusitis- infection lasting 4
weeks, symptoms resolve completely
(children 30 days)
• Subacute bacterial sinusitis- infection lasting
between 4 to 12 weeks, yet resolves
completely (children 30-90 days)
• Chronic sinusitis- symptoms lasting more
than 12 weeks (children >90 days)
• Some guidelines add treatment failure + a
positive imaging study
 Recurrent Acute Bacterial Sinusitis

• Episodes lasting fewer than 4 weeks and

separated by intervals of at least 10 days
during which the patient is totally
asymptomatic
• 3 episodes in 6 months or 4/year
 Acute Sinusitis Imposed on
Chronic Sinusitis

• Patients with chronic, low grade symptoms

experience increase in mucous flow, change
in viscosity or color, or secretions
• Treated

• New symptoms resolve but chronic symptoms

continue
 Pathophysiology of Sinusitis
• Lined by respiratory epithelium

• Mucous blanket is in two layers: a superficial

viscous layer and an underlying serous layer.

• Cilia beat in the serous layer, moving the blanket

towards the natural ostia.

• Normal function depends on patent ostia, ciliary

function and quality of mucous
Pathophysiology of Sinusitis, continued
• Most important pathologic process in disease is
obstruction of natural ostia

• Obstruction leads to hypooxygenation

• Hypooxygenation leads to ciliary dysfunction and

poor mucous quality

• Ciliary dysfunction leads to retention of secretions

 Pathophysiology of Sinusitis, continued

• Local factors can impair ciliary function. Cold air

“stuns” the epithelium, resulting in retained
secretions. Dry air dessicates the blanket.

• Anatomical factors, ie, polyps, tumors, foreign

bodies and rhinitis, block the ostia

• Kartagener’s Syndrome (immotile cilia

syndrome)
 Road to Bacterial Sinus Infections
• Obstruction of the various ostia

• Impairment in ciliary function

• Increased viscosity of secretions

• Impaired immunity

• Mucus accumulates

• Decrease in oxygenation in the sinuses

• Bacterial overgrowth
 Pathogenesis of Nasal Obstruction

• Viral upper respiratory infections

– Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
– Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
– Deviated septum, concha bullosa, polyps
 Allergic Stimuli Causing Rhinosinusitis
• Pollens

– Tree, grass, weeds

• House dust mite

• Animal danders

– Cat, dog, mice, gerbil, other animals with

fur
• Molds

• Allergic foods and beverages

 Causes of Ciliary Dysfunction
• Immotile cilia syndrome
• Prolonged exposure to cigarette smoke
• Common cold viruses causing URI
• Increased viscosity of mucus
• Medications
– First generation antihistamines (non
sedating do not affect)
– Anticholinergics
– Aspirin
– Anesthetic agents
– Benzodiazepines
 Diseases Slowing Ciliary Function

• Allergic and nonallergic rhinitis

• Rhinosinusitis

• Aging rhinitis

• Cystic fibrosis

• Any disease causing obstruction, crusting of

the mucosa
 Causes of Mechanical Obstruction

• Deviated nasal septum

• Concha bullosa
• Foreign body
• Nasal polyps
• Congenital atresia
• Lymphoid hyperplasia
• Nasal structural changes found in Downs
syndrome
 Other Predisposing Conditions

• Physical trauma

• Scuba diving

• Foreign body

• Cleft palate

• Dental disorders

• Any patient with chronic fatigue, fever, general

malaise/aching or headaches should be evaluated for
sinusitis
 Acute Bacterial Sinusitis

• Usually begins with viral upper respiratory illness

• Symptoms initially improve, but then …
• Symptoms become persistent or severe
• Persistent… 10-14 days but fewer than 4 weeks
• Severe…temperature of 102°, purulent nasal
discharge for 3-4 days, child appears ill
• Disease clears with appropriate medical treatment
 Treatment of Acute Sinusitis

• Antihistamines recommended if allergy present

– Oral or topical
• Decongestants
– Oral or topical

• Antibiotic when indicated (bacteria)

• Nasal irrigation

• Guaifenesin 200-400 mg q4-6 hrs

• Hydration
 Decongestants
• Topical nasal sprays (limit use to 3-7 days)
– Phenylephrine
– Oxymetazoline
– Naphthazoline
– Tetrahydrozoline
– Xylometazoline

• Topical nasal spray (unlimited daily use)

– Ipratropium

• Oral
– Pseudoephedrine 30-60 mg
– Phenylephrine 2-4 times/day
Normal Water’s and Towne’ s Views of
the Sinuses
X-Ray Image of Sinuses with Maxillary
Sinusitis
 Bacteria Involved in Acute
Bacterial Sinusitis

• Streptococcus pneumoniae 30%

• Haemophilus influenza 20%

• Moraxella catarrhalis 20%
• Sterile 30%
Diagnostic proof puncture
Nasal and sinus endoscopy
 Summary

• Definition and classification of different types of

rhinosinusitis discussed.
• Described the Pathophysiology of acute
sinusitis.
• Formulated the diagnostic criteria(clinical
features) of Acute sinusitis.
• Discussed different treatment options of Acute
sinusitis.
 References
• Diseases of Ear Nose Throat
fifth Ed. P. L. Dhingra, Shruti Dhingra
• Scott Brown’s Otolaryngology- Sixth
Edition A short text book of ENT K.B.
Bhargava .
• Logar Turners Diseases of the Nose
Throat and Ear 10th Edition
Edited by AGD Maran