Approach to Sinusitis :Approach to Sinusitis Dr Nishit J Shah MS(ENT), DNB, DORL Hon ENT Surgeon Bombay Hospital & Breach Candy Hospital


Nasal & Sinus Anatomy :Dr Nishit Shah Nasal & Sinus Anatomy


What is Sinus - Sinusitis :Dr Nishit Shah What is Sinus - Sinusitis Anatomy Physiology Situation Affection – QOL Complications


Common Nasal Symptoms :Dr Nishit Shah Common Nasal Symptoms Nasal Obstruction Nasal Discharge Headache & Facial Pain Sneezing Epistaxis


Examination :Dr Nishit Shah Examination Anterior rhinoscopy Posterior rhinoscopy Mucosa, Septum, Turbinates, Pathology Diagnostic Nasal Endoscopy Ears Throat & Larynx


Examination :Dr Nishit Shah Examination


Diagnostic Nasal Endoscopy :Dr Nishit Shah Diagnostic Nasal Endoscopy


Diagnostic Nasal Endoscopy :Dr Nishit Shah Diagnostic Nasal Endoscopy Routine Anatomy Early Pathology Extent of Pathology Swab


Diagnostic Nasal Endoscopy :Dr Nishit Shah Diagnostic Nasal Endoscopy Complete view of the nasal passages Examination of the nasopharynx Inspection of the middle meatus Detect & Differentiate Pathology tumours, polyps, discharge, turbinates Painless, short office procedure Preoperative assessment


Diagnostic Nasal Endoscopy :Dr Nishit Shah Diagnostic Nasal Endoscopy Nasal obstruction Headache Epistaxis Anosmia Allergic rhinitis Suspected FB Documentation Nasal discharge Sinusitis Nasal mass Polyposis Post-operative CSF rhinorrhoea Nasopharynx, ET


Investigations :Dr Nishit Shah Investigations X-rays CTScan / MRI Swabs / Antral lavage Tissue from sinus (fungus) Blood tests


CT Scan / MRI :Dr Nishit Shah CT Scan / MRI Detailed look at nose and Paranasal sinuses Differentiate / confirm pathology tumours, polyps, sinusitis, CSF leak Assess extent of sino-nasal involvement Surgical anatomy for surgical planning Gauge present / possible complications Orbit, optic nerve, intracranial


Slide 13:Dr Nishit Shah


Nasal Obstruction :Dr Nishit Shah Nasal Obstruction Cyclic Adenoids, Foreign Body Deviated Nasal Septum (DNS), Turbinates Rhinitis & Sinusitis Coryza, Infective, Allergic, Atrophic Polyps Tumours


Nasal Obstruction – Polypoid IT :Dr Nishit Shah Nasal Obstruction – Polypoid IT


Deviated Nasal Septum :Dr Nishit Shah Deviated Nasal Septum Present in majority Types Symptomatic Medical treatment Surgery SMR v/s Septoplasty Associated surgery Turbinates, Sinuses


Nasal Discharge :Dr Nishit Shah Nasal Discharge Adenoids, Foreign Body Allergic Rhinitis Infective Rhinitis / Sinusitis CSF Rhinorrhoea


Allergic Rhinitis :Dr Nishit Shah Allergic Rhinitis Sneezing Rhinorrhoea (bilateral) Nasal obstruction Itching of nose, eyes & palate Paranasal pain, headache Anosmia, hyposmia Pharyngitis, hoarseness


Rx of Allergic Rhinitis :Dr Nishit Shah Rx of Allergic Rhinitis Evaluation History & examination Diagnosis Investigations Avoidance of Allergen Medical Rx Antihistamines, Decongestants, Steroids Immunotherapy


Rhino-Sinusitis :Dr Nishit Shah Rhino-Sinusitis Nasal Obstruction Discharge Headache & Facial Pain Swelling Hyperaemia - Swelling of nasal mucosa Purulent discharge Pathology or Structural variations


Acute Sinusitis - Rx :Dr Nishit Shah Acute Sinusitis - Rx Antibiotics Analgesics Antihistamines Decongestants systemic and topical Mucolytics Steroids Surgery if complications


Chronic Sinusitis :Dr Nishit Shah Chronic Sinusitis Headache & Facial pain Nasal block, Discharge Cough, Change in voice Antibiotics, Decongestants X-Ray, CTScan, Nasal Endoscopy Surgery Conventional – AP, CWL NEW - FESS


Complications of sinusitis :Dr Nishit Shah Complications of sinusitis Eye swelling Diminished eye movement Decreased vision / blindness Severe headaches Nausea & vomiting Drowsiness Death


Complications of sinusitis :Dr Nishit Shah Complications of sinusitis Orbital – preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and cavernous sinus thrombosis Osteomyelitis (and osteitis) are usually related to acute frontal sinusitis and may be associated subperiosteal abscess, the "Pott's puffy tumor"


Intracranial complications :Dr Nishit Shah Intracranial complications If the infection passes through this bone it may infect the tissue and fluid that lines the brain, causing "meningitis". In even more severe cases the infection may spread to the brain itself causing an "abscess", or collection of pus. These problems are life threatening and require prompt and aggressive treatment.


Complications of sinusitis :Dr Nishit Shah Complications of sinusitis flare-ups of the sinusitis can lead to asthma attacks Sinusitis may diminish the senses of smell and taste Infections that involve either the carotid artery or cavernous sinus may lead to aneurysms or infected blood clots in the intracranial cavity, both of which are potentially fatal


What is FESS :Dr Nishit Shah What is FESS Anatomy Physiology Aetiology Pathology


Indications for ESS :Dr Nishit Shah Indications for ESS Chronic sinusitis Acute sinusitis Sphenoid pathology Polyposis Mucocoele/ Pyocoele Fungal sinusitis Allergic fungal sinusitis Septal spur Concha bullosa Asthma/ URTI Cystic fibrosis / AIDS Epistaxis Barotrauma FB, Rhinolith


FESS :Dr Nishit Shah FESS Uncinectomy Ethmoidectomy Maxillary Sinus Frontal Sinus Sphenoid Sinus


FESS - Sinusitis :Dr Nishit Shah FESS - Sinusitis


Extended Endoscopic Surgery :Dr Nishit Shah Extended Endoscopic Surgery CSF rhinorrhoea Pituitary surgery Nasal tumours / mass Nasopharynx tumours Choanal atresia Anterior skull base Clivus tumours Endoscopic DCR Orbital decompression Orbital complications Optic nerve decompression Orbital tumours Vidian neurectomy Cavernous sinus


Complications of FESS :Dr Nishit Shah Complications of FESS Bleeding Synechae Anosmia Diplopia Blindness CSF leak Epiphora Facial Pain Toothache Antrostomy Closure Subcutaneous Emphysema


Nasal Polyps :Dr Nishit Shah Nasal Polyps 2% of the population They are fluid filled sacs composed of an edematous tissue with infiltrating cells, including mast cells, eosinophils, lymphocytes and plasma cells surrounded by a ciliated airway epithelium- no true evidence of seromucinous glands An enigma !!!


Aetiology :Dr Nishit Shah Aetiology Inflammatory Infection – bacterial, fungal, viral Allergic, Histamine Drug sensitivity Mechanical obstruction Mucopolysaccharide abnormality Autonomic imbalance, Enzyme abnormality Proto-oncogene, Laryngopharyngeal reflux


Inflammation :Dr Nishit Shah Inflammation Polyps originate from the nasal mucosa and were consistently related to sinus ostia Inflammation mediators consistently elevated Most theories & studies in support Opacification of the paranasal sinuses can be seen in the absence of polyps Most pts with rhinosinusitis do not have polyps


Symptoms :Dr Nishit Shah Symptoms Nasal obstruction Recurrent sinusitis Hyposmia Headache Rhinorrhœa, Postnasal drip Sneezing Snoring


Extensive Polyps :Dr Nishit Shah Extensive Polyps Obstructive sleep apnœa Proptosis, hypertelorism, and diplopia Altered craniofacial structure Complications with AFS Optic nerves, Dura


Medical Rx :Dr Nishit Shah Medical Rx Steroids Oral – Topical Antibiotics Anti-fungals Oral – Topical Anti-histamines Decongestants Oral – Topical Anti-inflammatory


Surgery :Dr Nishit Shah Surgery Good pre-op preparation Decongest immediate pre-op Use debrider to restore anatomy Minimal trauma – bleeding Gentle with forceps – no pulling Use curette when in doubt Preserve normal mucosa Regular post-op


Antro choanal Polyp :Dr Nishit Shah Antro choanal Polyp


Polyps & FESS :Dr Nishit Shah Polyps & FESS


Surgery with a Debrider :Dr Nishit Shah Surgery with a Debrider


Recurrence :Dr Nishit Shah Recurrence The degree of tissue eosinophilia appears to be an important denominator of the recurrence rate of nasal polyps. In non-eosinophil dominated inflammation (cystic fibrosis, primary ciliary dyskinesia) other pathophysiological mechanisms may be of importance Complete surgical clearance Associated medical Rx


Complications :Dr Nishit Shah Complications Complications of FESS Poor pre-operative preparation Extensive disease Loss of Anatomy – Landmarks Bleeding Extension into Orbit Associated AFS with bone erosion Wrong diagnosis – Lack of investigations Poor surgeon preparation


Sinus endoscopy – Update Advanced applications :Dr Nishit Shah Sinus endoscopy – Update Advanced applications Endoscopic DCR Orbital & Apex Decompression Optic Nerve Decompression Endoscopic Hypophysectomy Endoscopic CSF Repair Angiofibroma & Tumour Excision Ear


Endo CSF repair :Dr Nishit Shah Endo CSF repair


Endoscopic Hypophysectomy :Dr Nishit Shah Endoscopic Hypophysectomy


Slide 48:Dr Nishit Shah Thank You