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Rhino-Sinusitis: Clinical Features, Diagnosis & Medical Treatment

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1 Rhino-Sinusitis: Clinical Features, Diagnosis & Medical Treatment
Dr. Vishal Sharma

2 Definitions Rhino-sinusitis: inflammation of lining mucosa of nose & paranasal sinuses Acute: infection lasting < 4 weeks Sub acute: infection lasting 4 to 12 weeks Chronic: infection lasting > 12 weeks Recurrent: > 3 episodes in 6 months or > episodes per year with asymptomatic intervals of > 10 days

3 Types of Sinusitis Acute / sub acute / chronic / recurrent
Open / Closed (depending on its drainage) Unilateral / bilateral Maxillary / frontal / ethmoidal / sphenoidal Single sinusitis / multi-sinusitis / pan-sinusitis Anterior group / posterior group Suppurative / hypertrophic Bacterial / fungal / allergic / occupational

4 Etiology Rhinogenic: commonest (85%) following any form of rhinitis
Dental: for maxillary sinusitis root abscess, dental procedures Trauma: R.T.A., swimming, diving, F.B., barotrauma Iatrogenic: nasal packing, septal surgery Hematogenous: rare

5 Predisposing factors Mucosal odema: viral, bacterial, allergic, irritant, vasomotor, barotrauma Mechanical obstruction: D.N.S. (spur), polyp, hypertrophic turbinate, concha bullosa, paradoxical middle turbinate, Haller cell, large bulla ethmoidalis, agger nasi, uncinate anomaly, nasal tumour, foreign body, nasal packing

6 Mucous abnormality: Young’s syndrome, cystic fibrosis, mucoviscidosis, dehydration
Mucociliary dysfunction: Kartagener’s syndrome, viral, bacterial, allergic, smoking, pollutants, hypoxia, dry air, extremes of temperature, synechiae Miscellaneous: Poor health, immunodeficiency, diabetes, nutritional deficiency




10 Bacteriology Chronic sinusitis Acute sinusitis  Staph. Aureus
 Streptococcus  H. influenzae  Bacteroides  Pseudomonas Acute sinusitis  Streptococcus pneumoniae  Haemophilus influenzae  Moraxella  Staphylococcus aureus  Neisseria

11 Progress Severity and resolution depends on Open / closed
Organism virulence Host resistance Treatment received

12 Ostio-meatal complex is key area for causation
of chronic anterior group sinusitis

13 Pathological variants of ostio-meatal complex

14 Concha bullosa

15 Concha bullosa

16 Paradoxically curved M.T.

17 Paradoxically curved M.T.

18 Medialized uncinate process

19 Large bulla ethmoidalis

20 Haller cell

21 Agger nasi cell

22 Nasal Septal Spur

23 Nasal Septal Spur

24 Mucosal disease

25 Symptoms Nasal discharge: mucoid / purulent / blood-stained
Nasal obstruction with hyposmia / anosmia Headache / facial pain Cheek / eyelid congestion + swelling Hawking, sore throat, cough Earache: associated Eustachian tube dysfunction Constitutional: fever, malaise, body ache

26 Location of facial pain
Maxillary: cheek, upper jaw, forehead (supra-orbital) that es on bending forward Frontal: forehead that es during morning & es by late afternoon (Office headache) Anterior Ethmoid: nasal bridge & peri-orbital, es with eye movement Posterior Ethmoid: retro-orbital Sphenoid: vertex, occipital, retro-orbital

27 Signs Congested & edematous nasal mucosa
Nasal discharge (anterior & posterior rhinoscopy): middle meatus: frontal, maxillary, anterior ethmoid superior meatus: posterior ethmoid, sphenoid Paranasal sinus tenderness present Postnasal drip, granular pharyngitis Cheek swelling: in maxillary sinusitis Lid edema: in ethmoid & frontal sinusitis

28 Para-nasal sinus tenderness

29 Para-nasal sinus tenderness
Maxillary: palpate over canine fossa Anterior ethmoid: palpate medial to medial canthus Frontal: palpate floor of sinus or tap over its anterior wall

30 Para-nasal sinus tenderness

31 Sinus trans-illumination test

32 Sinus trans-illumination test
Performed in a dark room. High-intensity light source placed inside patient’s mouth or against the cheek (for maxillary sinus) & under medial aspect of supra-orbital ridge (for frontal sinus). Trans-illumination normal = no sinusitis Trans-illumination absent = sinus filled with pus Trans-illumination dull = equivocal result

33 Postural test Performed in acute sinusitis (active nasal discharge)
Pus cleaned in supine position & pt sits upright Pus appears = frontal or ethmoid sinusitis Pus appears on stooping forwards = sphenoid sinusitis No discharge  pt lies in lateral position with affected side up. Pus appears = maxillary sinusitis

34 Rhinosinusitis Task Force Criteria
Major Minor 1. Facial pain / pressure Headache 2. Nasal obstruction Fever (non-acute sinusitis) 3. Nasal discharge or Halitosis discolored postnasal drip 4. Fatigue 4. Hyposmia / anosmia Dental pain 5. Purulence on examn Cough 6. Fever (acute sinusitis) Ear pain / pressure / fullness Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

35 Investigations

36 Diagnostic nasal endoscopy (D.N.E.)
Maxillary Sinoscopy X-ray of P.N.S. U.S.G. of maxillary sinus (Rhinoscan) C.T. scan of P.N.S. M.R.I. of P.N.S.: rarely done Allergic tests Proof puncture (antral wash): for maxillary sinus Endoscopic microswab for culture & sensitivity Fungal culture: of cheesy nasal discharge

37 Diagnostic Nasal Endoscopy

38 Indications for D.N.E. 1. Patients not responding to medical therapy
2. Anatomic factor preventing adequate examination by anterior rhinoscopy 3. Collection of pus from hiatus semilunaris for culture & sensitivity 4. Objective monitoring of patients 5. Peri-operative nasal inspection & cleaning

39 Pus in middle meatus in D.N.E.

40 Maxillary sinoscopy

41 Maxillary sinoscopy Anterior sinus wall perforated directly (in canine fossa between roots of 3rd & 4th teeth) with maxillary sinus trocar & cannula Trocar removed & sinoscope introduced through cannula

42 X-ray paranasal sinus Water’s view (Occipito-mental)  maxillary
Caldwell’s view (Occipito-frontal)  frontal Rhese’s view (lateral oblique)  ethmoid Base skull view (Submento-vertical)  sphenoid Lateral view Pierre’s view (occipito-mental with mouth open) Air-fluid level: acute sinusitis Mucosal thickening chronic sinusitis

43 Acute maxillary sinusitis

44 Chronic maxillary sinusitis

45 Frontal sinusitis

46 Pierre’s view

47 Lateral view

48 Para-nasal sinus sonography
Bony anterior wall is seen as hyper-echoic line. Maxillary cavity filled with air appears as hyper-echoic hence posterior sinus margin not seen. Fluid in sinus, cyst & mucosal thickening are hypoechoic so posterior sinus margin is visible. B mode sonogram differentiates between fluid in sinus, cyst & mucosal thickening.

49 Normal sinus sonography (A-mode)

50 A-mode sonography of sinusitis

51 C.T. scan: maxillary sinusitis

52 C.T. scan: ethmoid sinusitis

53 C.T. scan: frontal sinusitis

54 C.T. scan: sphenoid sinusitis

55 C.T. scan paranasal sinus
Coronal & axial cuts, plain (without contrast) Coronal planes, cuts of 4 mm or less Indications: In recurrent acute / chronic sinusitis not responding to medical therapy Before endoscopic surgery Impending complications of sinusitis

56 M.R.I. of P.N.S.

57 Medical Treatment Systemic Antibiotics
Nasal decongestants: topical & systemic Anti-histamines Analgesic-anti-inflammatory drugs Medicated steam inhalation & nasal douching Mucolytics: Ambroxol Anti-allergy treatment Hot fomentation

58 Amoxicillin-clavulanate duo: 625 mg B.D. X 7 days
Ciprofloxacin: 500mg B.D. X 7 days Doxycycline: 100 mg B.D. X 7 days Cefadroxil: 500 mg B.D. X 7 days Cefaclor: 500 mg T.I.D. X 7 days Cefuroxime: 250 mg B.D. X 7 days Cefixime: 200 mg B.D. X 7 days Cefpodoxime: 200 mg B.D. X 7 days Azithromycin: 500 mg O.D. X 3-5 days Clarithromycin: 250 mg B.D. X 7 days

59 Antihistamines Systemic: Cetirizine: 10 mg OD Fexofenadine: 120 mg OD
Loratidine: 10 mg OD Levocetrizine: 5 mg OD Desloratidine: 5 mg OD Topical: Azelastine spray (0.1%): 1-2 puff BD

60 Nasal Decongestants Systemic decongestants  Phenylephrine
 Pseudoephedrine Topical decongestants  Xylometazoline  Oxymetazoline  Saline

61 Anti-cold preparations
Name Chlorpheniramine Decongestant Paracetamol COLDIN 4 mg PsE 60 mg 500 mg SINAREST DECOLD PhE 7.5 mg SUPRIN 2 mg PhE 5 mg PsE = Pseudoephedrine; PhE = Phenylephrine

62 Topical Decongestants
Oxymetazoline 0.05 %: 2-3 drops BD (NASIVION) Oxymetazoline %: 2 drops BD (NASIVION-P) Xylometazoline 0.1 %: 3 drops TID (OTRIVIN) Xylometazoline 0.05 %: 2 drops BD (OTRIVIN-P) Saline 2 %: 3 drops TID Saline 0.67 %: 2 drops BD (NASIVION-S)

63 Fungal Sinusitis A. Invasive (hyphae present in submucosa)
Acute invasive or fulminant (< 4 weeks) Chronic invasive or indolent (> 4 weeks) B. Non-invasive Allergic Fungal ball or mycetoma Saprophytic Aspergillosis & Mucormycosis are common

64 Acute invasive fungal sinusitis
Usually mucormycosis Predisposing factors: Immune-compromise: AIDS, Lymphoma, Cyto-toxic drugs, chronic use of steroid, aplastic anemia Insulin dependent diabetes mellitus Long term use of broad-spectrum antibiotics C/F: Unilateral nasal discharge with black crusts due to ischaemic necrosis. Cerebral & vascular invasion present. Absence of significant inflammation.

65 Black crusting

66 Chronic invasive fungal sinusitis
Treatment: Remove precipitating factors Surgical debridement of necrotic debris Anti-fungal drugs: Amphotericin B infusion for 1-2 months Itraconazole 100 mg BD for 6-12 months Chronic invasive fungal sinusitis Significant inflammation with fibrosis & granuloma formation Locally destructive with minimal bone erosion Tx: Debridement + Anti-fungal agents

67 Surgical debridement

68 Allergic fungal sinusitis
Associated with ethmoid polyps & asthma Unilateral thick yellow nasal discharge with mucin, eosinophils & Charcot Leyden crystals C.T. scan: radio-opaque mass with central area of hyper density (due to hyphae) Tx: Surgical debridement + anti-histamines steroids (oral & topical)

69 Allergic fungal sinusitis

70 Allergic fungal sinusitis

71 C.T. scan coronal cuts

72 C.T. scan axial cuts

73 Fungal ball (Mycetoma)
Refractory sinusitis with foul smelling cheesy material in maxillary sinus Tx: Surgical removal. No anti-fungal drugs. Saprophytic fungal sinusitis Seen after sino-nasal surgery due to proliferation of fungal spores on mucous crusts

74 Thank You

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