M.Mohammadi Ardehali,MD. Associate Professor of TUMS AMIRALAM HOSPITAL

Anatomy

Development MAXILLARY AND ETHMOID SINUSES DEVELOPS DURING 3RD & 4TH GESTATIONAL MONTH AND GROW IN SIZE UNTIL LATE ADOLESCENCE SPHENOID SINUS PRESENTS BY 2 YEARS OF AGE FRONTAL SINUS DEVELOPS DURING 5 AND 6 YRS.

Factors Predisposing To Obstruction Of Sinus Drainage. A. MUCOSAL SWELLING Systemic disorder Viral URI Allergic inflammation Cystic fibrosis Immune disorder Immotile cilia Local insult Facial trauma Swimming, diving Rhinitis medicamentosa B. MECHANICAL OBSTRUCTION Choanal atresia Deviated septum Nasal polyp Foreign body Tumor Ethmoid bullae C. MUCUS ABNORMALITIES Viral URI Allergic inflammation Cystic fibrosis

Pathophysiology Key Factors: The patency of the ostia Normal ciliary function The quality and quantity of secretion

The patency of the ostia Obstruction of the sinus ostium Negative pressure Intruduction of bacteria sinusitis

Normal ciliary function ciliary Dysfunction Impaired secretion clearance Sinusitis

The quality and quantity of secretion Antioxidan activiy Humidification of URT Entrapping microorganisms Immunologic antimicrobial functions Loss of: Sinusitis

Epidemiology Incidence Lifetime Incidence: 25% United States clinic office visits: 1% Attendance at Day Care Center Occurs during viral respiratory season School-age siblings in the household

Definitions: Acute Rhinosinusitis

Transition from Viral to Bacterial Infection Up to 2% of VRS complicated by bacterial infection Day 1-10: Can be difficult to distinguish VRS from ABRS. “Double Sickening” Pattern Pt initially gets better then gets worse Consistent with ABRS

Symptoms And Signs PERSISTENT >10 DAYS No appreciable improvement Nasal discharge of any quality Cough(must be present during day) Malodorous breath Facial Pain and headache are rare If fever then low grade May not appear very ill SEVERE High fever > 39 C Purulent nasal discharge And Present for at least 3-4 days Headaches may be present Periorbital swelling occasionally

Subacute Sinusitis 30 days to 4 months Mild to moderate and often intermittent symptoms Nasal discharge of any quality Cough often worse at night Low-grade fever may be periodic usually not prominent

Chronic Sinusitis Extremely protracted nasal symptoms Discharge or Congestion or Cough or both Some cases rhinorhhea minimal or absent Nasal congestion-mouth breathing-sore throat

Chronic Sinusitis Chronic headache usually on awakening Intermittent fever Malodorous breath Secondary affects –fatigue, impaired sleep –decreased appetite –irritability

Physical Findings Mucopurulent discharge in nose or posterior pharynx Nasal mucosa- erythematous Throat- moderate injection Ears- acute otitis or otitis with effusion Paranasal sinus tenderness- occasionally Periorbital edema-occasionally Malodorous breath

Differential Diagnosis-Purulent Nasal Discharge Uncomplicated viral URI Group A Strep infection Adenoiditis Nasal foreign body

Differential Diagnosis- Nasal Symptoms Persistent clear nasal discharge or nasal congestion –Allergic rhinitis: nasal discharge, congestion, sneezing, itchiness of eyes, nose, other mucous membranes, pale boggy mucosa, Dennies lines, allergic shiners, transverse crease on bridge of nose, headaches

Differential Diagnosis-Nasal Symptoms No allergic rhinitis -resemble allergic rhinitis children -specific allergens cannot be demonstrated, IgE levels normal, radioallergosorbent test negative Rhinitis Medicamentosa Vasomotor Rhinitis

Differential Diagnosis-Cough Reactive airway disease GER CF pertussis Mycoplasma bronchitis TB

Diagnosis

Diagnosis-Imaging 4 Standard views –Anterioposterior –Lateral –Occipitomental 4 Sinus XRay (Rarely indicated) Sinus XRay  Complicated Acute Sinusitis  Suspected Chronic SinusitisChronic Sinusitis 4 Significantly abnormal in 88% of children younger than 6

Imaging

Imaging

Imaging

Diagnosis- CT Scans Frequent abnormalities are found in patients with a “fresh common cold” Indications complicated sinus disease(either orbital or CNS complications) numerous recurrences protracted or nonresponsive symptoms(surgery is being contemplated)

Axial CTScan

4 Limitations of CT: –Radiation may be 10x that of plain films –lack of specificity for bacterial infection Diagnosis- CT Scans

DIAGNOSIS 4 The diagnosis is based largely on symptoms with confirmation by nasendoscopy

Are endoscopically-directed cultures of the middle meatus an acceptable means of documenting microbiological diagnosis of acute sinusitis?

4 Talbot et al. (1995) –47 evaluable patients with acute maxillary sinusitis –overall sensitivity = 65%, specificity =40% –better performance with Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis –increased isolation of staphylococcal species with endoscopic cultures

ABRS Microbiology Streptococcus pneumoniae 30-40% Haemophilus influenzae 20% Moraxella catarrhalis 20% Strep pyogenes 4% Respiratory viral isolates 10% –adenovirus –parainfluenzae –influenzae –rhinovirus Other rarer isolates- group A strep, group C strep, viridians strep, peptostrep, Moraxella species, Eikenella corrodens

CRS Microbiology: Anaerobes gm+ cocci, bacteroides, corynebacteria Staphylococcus aureus Streptococcus H. Influenzae M. catarrhalis

Complications

Complications of Acute Bacterial Sinusitis 4 Preseptal cellulitis 4 Orbital cellulitis 4 Osteomyelitis 4 Subperiosteal orbital abscess 4 Subdural or Epidural Empyema 4 Meningitis 4 Brain abscess 4 Cortical thrombophlebitis 4 Cavernous or sagittal sinus thrombophlebitis

6 weeks post op.

Treatment

Choice of Antibiotic for ABRS Wright & Frankel

Symptomatic Relief of Acute Bacterial Rhinosinusitis 4 Adjunctive treatments for rhinosinusitis that may aid in symptomatic relief include –decongestants (  -adrenergic) –corticosteroids (topical?) –saline irrigation –Mucolytics –**None of these products have been specifically approved by the FDA for use in acute rhinosinusitis (as of February 2007), and few have data from controlled clinical studies supporting this use.

4 In patients with acute sinusitis 40-50% have spontaneous clinical cure rate 4 Hospitalization- systemic toxicity or unable to take oral antimicrobials –cefuroxime –ampicillin/sulbactam –cefotaxime and vanco. if suspecting penicillin- resistant strep pneumoniae Treatment: cont,

4 Clinical improvement is prompt 4 If no reduction of nasal discharge or cough in 48 hours reevaluate 4 Patients with brisk response- 10 days of treatment 4 If respond more slowly- treat until patient is symptom free plus 7 more days

Recurrent Sinusitis Most common cause is recurrent viral URIs –day care attendance –presence of other school age siblings in house Other predisposing conditions –allergic and nonallergic rhinitis –CF –immunodeficiency disorder –ciliary dyskinesia –anatomical problem

Absolute Indications for Surgery Failure of maximal medical therapy Causing brain abscess or meningitis, subperiosteal/orbital abscess, cavernous sinus thrombosis, another contiguous infection, or an impending complication (Pott’s tumor) Sinus mucocele or pyocele Fungal sinusitis (all types( Nasal polyps (massive ) Neoplasm or suspected neoplasm

Surgery 4 Functional endoscopic sinus surgery (FESS) 4 Rarely required in children 4 Consider if anatomical variations causing local obstruction,

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