chronic sinusitis

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Presentation Transcript

CHRONIC SINUSITIS : 

CHRONIC SINUSITIS

SPECIFIC LEARNING OBJECTIVES : 

SPECIFIC LEARNING OBJECTIVES Define : Chronic sinusitis Explain the etiopathology of chronic sinusitis Describe the pathogenesis of chronic sinusitis Detail the clinical features of chronic sinusitis Mention the differential diagnosis of chronic sinusitis Enumerate the investigations for chronic sinusitis Outline the treatment for chronic sinusitis 2

DEFINITION : 

DEFINITION Chronic (≥12 weeks) inflammation of the mucosa of 1 or more sinuses with of two or more of the following symptoms: Anterior or posterior muco-purulent drainage Nasal obstruction Facial-pain-pressure-fullness Decreased sense of smell With one of the following evidence Purulent mucus or edema in the middle meatus or ethmoid region Polyps in the nasal cavity or middle meatus Imaging showing inflammation of the paranasal sinuses [Executive summary published in Otolaryngology - Head and Neck Surgery on adult sinusitis (2007)]

RECURRENT ACUTE SINUSITIS : 

RECURRENT ACUTE SINUSITIS 4 or more episodes of acute bacterial rhinosinusitis per year without signs and symptoms of rhinosinusitis between episodes. [Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg. Sep 2007;137(3):365-77. [Medline]

ETIOPATHOLOGY : 

ETIOPATHOLOGY Mechanical obstruction Focal infection Decreased mucociliary function Allergy Immunodeficiency state Granulomatous conditions Iatrogenic Autoimmune Hormonal imbalance Idiopathic 5

Pathogenesis of Chronic Sinusitis : 

Pathogenesis of Chronic Sinusitis Persistent venous & lymphatic obstruction Mucosal hyperplasia & polypoidal changes Polyp/edema blocking ostia Obstruction at ostiomeatal complex >> further infection 6

Pathology of Chronic Sinusitis : 

Pathology of Chronic Sinusitis Edema / inflammatory infiltration Epithelial hyperplasia Squamous metaplasia Increased Goblet cells Ciliary damage Subepithelial interstitial fibroblastic proliferation & lymphatic obstruction Frank polyposis 7

BACTERIOLOGY OF CHRONIC SINUSITIS : 

BACTERIOLOGY OF CHRONIC SINUSITIS Microbiologic studies of chronic sinusitis often show that the infection is polymicrobial Staphylococcus aureus (both methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA] strains) Coagulase-negative staphylococci H influenzae, M catarrhalis, S pneumoniae, Streptococcus intermedius P aeruginosa, Nocardia species Anaerobic bacteria (Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides, Fusobacterium species)

SYMPTOMS : 

SYMPTOMS Headache- dull Nasal obstruction - ↑ at night Smell disturbances (hyposmia/ cacosmia) Taste disturbances Nasal discharge – thick, foul smelling Hawking sensation Cough Halitosis

MAJOR SYMPTOMS : 

MAJOR SYMPTOMS Purulent anterior/ posterior nasal drainage Nasal obstruction or blockage Facial congestion or fullness Facial pain or pressure Hyposmia or anosmia

MINOR SYMPTOMS : 

MINOR SYMPTOMS Headache Ear pain or fullness Halitosis Dental pain Cough Fever Fatigue

OTHER HISTORY : 

OTHER HISTORY Duration of symptoms Exacerbating and relieving factors History of previous nasal or paranasal sinus surgery Current medications Previous treatments and their duration Other confounding health problems (including asthma, allergy, and immuno-compromising disorders) Active or passive tobacco smoke

SIGNS : 

SIGNS Tenderness Mucosal congestion Discharge – mucoid/mucopurulent Post-nasal discharge

OTHER EXAMINATION : 

OTHER EXAMINATION Neck examination for lymphadenopathy Ear examination for the presence of middle ear fluid oropharynx examination -for evidence of postnasal drip Ocular examination for spread of disease

Differential Diagnoses : 

Differential Diagnoses Allergic Fungal Sinusitis Malignant Tumors of the Nasal Cavity / Sinuses / Nasopharynx Allergic Rhinitis / Nonallergic Rhinitis Cystic Fibrosis Foreign Bodies of the Airway Juvenile Nasopharyngeal Angiofibroma Skull Base, Benign Tumors Turbinate Dysfunction Nasal polyposis / Antral-choanal polyp Inverting papilloma /Dental abscess Chronic headache of other etiology

INVESTIGATIONS : 

INVESTIGATIONS Diagnostic Nasal Endoscopy CT Scan Nose & PNS (Axial & Coronal images) X-Ray PNS (Water’s or Occipito-mental view) MRI scan

X-Ray PNS : 

X-Ray PNS Plain radiographs have very less role in chronic rhinosinusitis (CRS) The clinical role of plain films is limited to documentation of acute maxillary or frontal sinusitis and the ostiomeatal complex May show mucosal thickenings or sinus opacities

CT Scan Nose & PNS : 

CT Scan Nose & PNS after failure of maximal medical therapy before surgical planning for evaluation of suspected complications when a neoplasm is a possibility limited sinus CT scans [screening CT scans] 5-12 coronal cuts Radiation effect & cost about the same as a plain radiography but provide more information

Normal CT Nose / PNS : 

Normal CT Nose / PNS Coronal cut Axial image

Anatomical variation causing disease : 

Anatomical variation causing disease CONCHA BULLOSA blocking the ostiomeatal complex

Pre-operative CT scan : 

Pre-operative CT scan Anatomic relationships of the key structures to the diseased areas orbital contents optic nerve carotid artery Defines the extent of disease in any individual sinus Any underlying anatomic abnormalities that may predispose to sinusitis

MUCOSAL THICKENING & EARLY POLYPOIDAL / POLYP : 

MUCOSAL THICKENING & EARLY POLYPOIDAL / POLYP

Slide 24: 

Concha bullosa with posterior ethmoidal involvement both sides Right sided DNS, concha bullosa left side and blockade of osteomeatal unit both sides

Slide 25: 

Left sided DNS with concha bullosa right side & anterior ethmiodal invovement –CORONAL IMAGE Axial images of the anterior and posterior ethmoid air cells. The presence of massive sinonasal polyps

Slide 26: 

Coronal view demonstrating the blockage of the ostiomeatal complex by a large concha bullosa (CB). Axial image at the level of the inferior turbinates demonstrating maxillary mucoceles and mucosal thickening

Anatomic relationships of the key structures to the diseased areas : 

Anatomic relationships of the key structures to the diseased areas Axial view demonstrating opacification of the anterior and posterior ethmoid cells, mucosal thickening in the right aspect of sphenoid Dehiscent petrous carotid canals (arrow) at the level of the sphenoid sinus

Diagnostic Nasal Endoscopy : 

Diagnostic Nasal Endoscopy

The Nasal Telescope : 

The Nasal Telescope Nasal endoscopy provides a detailed examination of both the nasal cavity and sinuses & also used during surgical procedures in the office and operating room Endoscopes have diameters of 4mm and 2.7mm and come in varying angles of vision from 0 degrees to 30, 45, 70, 90, and 120 degrees

MRI : 

MRI MRI is generally reserved for complex cases of paranasal sinus tumors cases with orbital and cranial base involvement Fungal sinusitis

Other investigations-Laboratory Studies : 

Other investigations-Laboratory Studies Nasal swab and culture Radio Allergo Sorbent assay Test (RAST) or skin testing for allergens Sweat test for cystic fibrosis -children with nasal polyposis and chronic rhinosinusitis Evaluation of cilia function with a brush biopsy or turbinate biopsy Total immunoglobulin E (IgE) levels -to evaluate for allergic fungal sinusitis

MEDICAL MANAGEMENT : 

MEDICAL MANAGEMENT An adequate antibiotic trial in chronic rhino-sinusitis (CRS) - 3-4 weeks (preferably culture directed) Intranasal Corticosteroids, Short Courses Of Oral Steroids, Decongestants, Topical Vasoconstrictors, Mucolytics

FIRST-LINE ANTIBIOTICS : 

FIRST-LINE ANTIBIOTICS Amoxicillin-clavulanate Erythromycin-sulfasoxazole Cefixime(III) -H influenzae or M catarrhalis, but poor against Streptococcus pneumoniae Cefuroxime(II), Cefaclor (II), Cefprozil(II), Cefpodoxime(III) Clarithromycin and azithromycin Clindamycin - reserved for resistant S pneumoniae

SUPPORTIVE TREATMENT : 

SUPPORTIVE TREATMENT Nasal cavity irrigation using buffered normal saline Steam inhalation Smoking cessation

Surgical Management : 

Surgical Management Functional Endoscopic Sinus Surgery (FESS) Balloon sinuplasty Antral Lavage Inferior Meatal Antrostomy Caldwell-Luc Operation Intranasal ethmoidectomy

Slide 41: 

Transantral ethmoidectomy (Jansen Horgan) Trephination of the frontal sinus or sphenoid washout External Fronto-ethmosphenoidectomy (Lynch-Howarth , Patterson) Osteoplastic flap (± obliteration)

Functional Endoscopic Sinus Surgery : 

Functional Endoscopic Sinus Surgery Minimally invasive technique in which sinus air cells and sinus ostia are opened under direct visualization to restore the ventilation and normal function Recurrent acute or chronic infective sinusitis in whom medical treatment has failed Under general or local anesthesia The goal of FESS is to return the mucociliary drainage of the sinuses to normal function

BASIC STEPS OF F.E.S.S. : 

BASIC STEPS OF F.E.S.S. UNCINECTOMY MIDDLE MEATAL ANTROSTOMY / MAXILLARY OSTIAL WIDENING ANTERIOR ETHMOIDECTOMY Opening of Bulla Ethmoidalis Decapitation of other anterior ethmoidal air cells

BASIC STEPS OF F.E.S.S. : 

BASIC STEPS OF F.E.S.S.

advantage of FESS : 

advantage of FESS Less invasive Minimal postoperative discomfort / scars (synechiae) Damage to the nerve supply of the teeth are also avoided Better view of the surgical field Lower rate of complications

Postoperative Care : 

Postoperative Care nasal toilet performed 2-3 times a week by the surgeon simple nasal douching -several times a day by the patient a short course of systemic steroids combined with antibiotics (gross inflammation or polyps)

Complications : 

Complications Cerebrospinal fluid leak (single most common major complication of FESS- 0.2% of cases) Blindness -damage to the optic nerve Orbital hematoma Nasolacrimal duct stenosis, adhesion formation, anosmia, hyposmia Orbital haemorrhage, abscess Meningitis, Brain abscess, Intracranial haemorrhage

MICRODEBRIDER assisted FESS : 

MICRODEBRIDER assisted FESS The microdebrider facilitates preservation of mucosa / vital structures by resecting only diseased & simultaneous continuous suction at the operative site with very limited blood loss meticulous cutting, a near bloodless field, unimpaired vision, and continuous removal of resected tissue

Complications : 

Complications superimposed acute sinusitis Adenoiditis, secondary serous or purulent otitis media Dacryocystitis and laryngitis Orbital complications preseptal cellulitis subperiosteal abscess orbital cellulitis orbital abscess cavernous sinus thrombosis

Slide 54: 

Intracranial complications Meningitis epidural abscess subdural abscess brain abscess. osteomyelitis / mucocele formation.

Pitfalls : 

Pitfalls Failure to identify and treat sinusitis >> progress to more serious infections Failure to consider malignancy >> unilateral sinusitis >> demonstrate a nasal mass on examination or imaging Pediatric patients with chronic rhinosinusitis (CRS) with nasal polyps >> cystic fibrosis / immunodeficiency

Balloon Sinuplasty : 

Balloon Sinuplasty This technology is an endoscopic, small, flexible catheter-based system to open up blocked sinus passageways, restoring normal sinus drainage. When the sinus balloon is inflated, it gently restructures and widens the walls of the passageway while maintaining the integrity of the sinus lining.

Merits of Balloon Sinuplasty : 

Merits of Balloon Sinuplasty less invasive pain and bleeding is minimal No swelling or bruising speedier recovery after surgery