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Chronic Sinusitis Brig Mirza Khizar Hameed Definition Inflammation of the Paranasal Sinuses lasting > 3 months Inflammation of the Paranasal Sinuses.

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Presentation on theme: "Chronic Sinusitis Brig Mirza Khizar Hameed Definition Inflammation of the Paranasal Sinuses lasting > 3 months Inflammation of the Paranasal Sinuses."— Presentation transcript:

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2 Chronic Sinusitis Brig Mirza Khizar Hameed

3 Definition Inflammation of the Paranasal Sinuses lasting > 3 months Inflammation of the Paranasal Sinuses lasting > 3 months

4 Etiology l Anatomical variations l Deviated Nasal Septum l Concha Bullosa l Bulla Ethmoidalis l Underlying diseases l Cystic Fibrosis l Ciliary Dyskinesia l Immuno-deficiency l Granulomatous diseases

5 Microbiology Anaerobes Anaerobes Staphylococcus aureus Staphylococcus aureus Streptococcus Streptococcus H. Influenzae H. Influenzae M. catarrhalis M. catarrhalis

6 Pathophysiology Obstruction of Osteomeatal complex region Obstruction of Osteomeatal complex region Impaired mucociliary clearance Impaired mucociliary clearance↓ Stagnation & pooling of secretions Stagnation & pooling of secretions Infection  Vicious cycle Infection  Vicious cycle

7 Symptoms l Chronic nasal obstruction l Purulent post nasal discharge l Pain over sinuses/ Headache l Halitosis l Chronic cough

8 Physical signs l Purulent Nasal discharge l Anatomical anomalies l Transillumination ?

9 Investigations X-ray PNS X-ray PNS CT Scan PNS CT Scan PNS Proof puncture/ Sinus lavage Proof puncture/ Sinus lavage Sinus aspirate/ Pus swab for C/S Sinus aspirate/ Pus swab for C/S

10 Treatment Antibiotics – Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, Metronidazole Antibiotics – Ciprofloxacin, Augmentin, Clarithromycin, Cefuroxime, Clindamycin, Metronidazole Decongestants Decongestants Antihistamines Antihistamines Steroid Nasal Drops/ Sprays Steroid Nasal Drops/ Sprays Surgery- To provide drainage & ventilation Surgery- To provide drainage & ventilation

11 Operative procedures on Sinuses

12 Maxillary Sinusitis l Antral Washout l Inferior Meatal Antrostomy l Caldwell-Luc’s Operation l FESS

13 1. Antral Washout l Puncturing medial wall of sinus for pus aspiration and irrigation of sinus l Indications - Ch sinusitis refractory to treatment l Contraindications - Age < 3 yrs - Hypoplastic maxilla with thick bony walls - Acute maxillary sinusitis untreated by antibiotics

14 Tilley Lichwitz Trocar & Cannula

15 Higginson Syringe

16 Trocar directed towards I/L tragus

17 Complications l Hemorrhage l Pain & swelling of cheek l Perforation of orbital floor l Vasovagal shock l Air embolism

18 2. Inferior Meatal Antrostomy l A window is created in medial wall of Maxillary antrum by perforating it in the Inferior meatus with Tilley’s Antrum Harpoon & enlarged (1.5-2 cm) with Myle’s perforator

19 Complications l Hemorrhage l Injury to Naso-lacrimal duct l Perforation of orbital floor

20 3. Caldwell-Luc’s Surgery l Anterior wall of the Maxillary sinus is entered through a Sub-labial incision l A window is created in the medial wall through Antrostomy l Indications - Ch sinusitis refractory to treatment - Repair of Oro-antral fistula - Reccurrent AC polyp - Blow out fracture of floor of orbit - Approach to ethmoids/ PPF

21 Sublabial Incision

22 Hole made in anterior wall followed by Inferior Meatal Antrostomy

23 Complications l Hemorrhage l Cheek edema l Numbness of cheek l Orbital hematoma l Trauma to teeth roots l Oro-antral fistula

24 Ethmoid Sinusitis l Intranasal Ethmoidectomy l External Ethmoidectomy - Lynch Howarth procedure - Patterson transorbital procedure - Jansen Horgan transantral procedure l FESS

25 Lynch Howarth Ethmoidectomy

26 Patterson Ethmoidectomy

27 Trans-antral ethmoidectomy

28 Complications l Hemorrhage l Injury to Lamina papyracea  Periorbital hematoma, proptosis, visual loss l Injury to Medial palpebral ligament l CSF leak l Meningitis l Mucocoele formation

29 Frontal Sinusitis l Trephination l Osteoplastic flap procedure - Coronal incision - Brow incision l FESS

30 Frontal sinus trephination

31 Osteoplastic flap procedure

32 Complications l Hematoma l Frontal depression l CSF leak l Meningitis l Mucocoele formation l Osteomyelitis

33 Sphenoid Sinusitis l Trans-nasal trans-septal approach l Sublabial trans-septal approach l External ethmoidectomy approach l FESS

34 FESS l Indications - Ch sinusitis refractory to treatment - Nasal polyps - Fungal sinusitis - Antro choanal polyp - Fronto-ethmoidal mucocoele - Repair of CSF leak - DCR - Orbital decompression

35 Functional Endoscopic Sinus Surgery l Uncinectomy (Infundibulotomy) l Bullectomy & Anterior ethmoidectomy l Middle meatal antrostomy l Perforation of basal lamella l Posterior ethmoidectomy l Sphenoid sinus exploration l Skull base disease clearance l Frontal recess exploration

36 Complications Major Major epistaxis Orbital hematoma Diplopia Blindness or  visual acuity Internal carotid injury Intracranial hemorrhage CSF leak / Meningitis Pneumocephalus Anosmia Nasolacrimal duct trauma Minor Minor epistaxis Hyposmia Adhesions (synechiae) Headache Periorbital echhymosis Periorbital hematoma Dental / facial pain

37 Fungal Sinusitis

38 Definition l Inflammation of the sinuses due to a fungus

39 Classification l Non Invasive Fungal Sinusitis - Allergic - Fungus Ball (Mycetoma) l Invasive Fungal Sinusitis - Acute - Chronic

40 Allergic Fungal Sinusitis l Most common form l Warm humid climate l Among younger, immuno-competent, atopic l Hypersensitivity reaction to inhaled fungus organism l Presents with Nasal polyps & thick greenish mucus

41 Investigations l Total IgE -  l CT Scan PNS- Sinus filled with high signal intensity soft tissue with calcium deposits, thinning/ pressure bony erosion & remodelling l Histology of greasy mucous- branching, non invasive fungal hyphae, eosinophils & Charcot- Leyden crystals

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44 Treatment l Surgical clearance of sinuses l Topical Steroids l Antihistamines l Immunotherapy l ? Antifungal

45 Fungus Ball (Mycetoma) l Older individuals, usually females l Immunocompetent l Asymptomatic/ Cacosmia/ Chronic sinusitis l Fungal mass limited to one sinus l CT Scan- Hyperdense mass with punctate calcifications

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47 Fungus Ball- Treatment l Surgical clearance l ? Anti fungal

48 Acute Invasive Fungal Sinusitis l Most lethal form l Immunocompromised/ Diabetics l Caused by Mucorales, Aspergillus, Fusarium, Phaeohyphomycosis l Angio invasion, hematogenous spread l Local necrosis, orbital & intracranial spread l Fever, pain, nasal congestion, epistaxis, proptosis, headaches, seizures

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50 AIFS- CT Findings l Unilateral nasal soft tissue thickening l Bony erosions l Unilateral involvement of PNS l Proptosis l Cavernous sinus thrombosis

51 Unilateral ethmoid involvement with bone destruction, intraorbital spread and proptosis Acute Invasive Fungal Sinusitis - CT

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53 AIFS- Treatment l Aggressive surgical debridement l Systemic anti fungal therapy l Treatment of underlying cause of immunosuppression

54 Chronic Invasive Fungal Sinusitis l Immunocompetent with H/o Ch sinusitis l Progressin over months to years l Maxillofacial soft tissue swelling l Orbital involvement  proptosis, visual loss l Intracranial extension with cranial neuropathies, headaches seizures l CT Scan- Hyperdense mass, bone erosion

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56 CIFS- Treatment l Aggressive surgical exenteration l Systemic anti fungal therapy

57 Thank you


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