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Brig Mirza Khizar Hameed

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2 Brig Mirza Khizar Hameed
Chronic Sinusitis Brig Mirza Khizar Hameed

3 Definition Inflammation of the Paranasal Sinuses lasting > 3 months

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

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

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

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

8 Physical signs Purulent Nasal discharge Anatomical anomalies
Transillumination ?

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

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

11 Operative procedures on Sinuses

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

13 1. Antral Washout Puncturing medial wall of sinus for pus aspiration and irrigation of sinus Indications - Ch sinusitis refractory to treatment 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 Hemorrhage Pain & swelling of cheek
Perforation of orbital floor Vasovagal shock Air embolism

18 2. Inferior Meatal Antrostomy
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 Hemorrhage Injury to Naso-lacrimal duct
Perforation of orbital floor

20 3. Caldwell-Luc’s Surgery
Anterior wall of the Maxillary sinus is entered through a Sub-labial incision A window is created in the medial wall through Antrostomy 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 Hemorrhage Cheek edema Numbness of cheek
Orbital hematoma Trauma to teeth roots Oro-antral fistula

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

25 Lynch Howarth Ethmoidectomy

26 Patterson Ethmoidectomy

27 Trans-antral ethmoidectomy

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

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

30 Frontal sinus trephination

31 Osteoplastic flap procedure

32 Complications Hematoma Frontal depression CSF leak Meningitis
Mucocoele formation Osteomyelitis

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

34 FESS 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
Uncinectomy (Infundibulotomy) Bullectomy & Anterior ethmoidectomy Middle meatal antrostomy Perforation of basal lamella Posterior ethmoidectomy Sphenoid sinus exploration Skull base disease clearance Frontal recess exploration

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

37 Fungal Sinusitis

38 Definition Inflammation of the sinuses due to a fungus

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

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

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



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

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


47 Fungus Ball- Treatment
Surgical clearance ? Anti fungal

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


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

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


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

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


56 CIFS- Treatment Aggressive surgical exenteration
Systemic anti fungal therapy

57 Thank you

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