diseases of sinuses

DISEASES OF DISEASES OF SINUSES SINUSES

DISEASES OF SINUSESDISEASES OF SINUSES

The Para nasal sinuses are cavities in The Para nasal sinuses are cavities in various bones of the face and skull. They various bones of the face and skull. They are lined by the mucous membrane and are lined by the mucous membrane and communicate freely with the nasal cavity communicate freely with the nasal cavity through small openings, which are called through small openings, which are called "OSTIUM". On most of the sinuses, these "OSTIUM". On most of the sinuses, these openings are situated in unfavorable openings are situated in unfavorable positions. These sinuses contain air. positions. These sinuses contain air.

DISEASES OF SINUSESDISEASES OF SINUSES The various sinuses can be grouped as an anterior The various sinuses can be grouped as an anterior

group of sinuses and a posterior group of sinuses. The group of sinuses and a posterior group of sinuses. The anterior 3roup of sinuses consists of:anterior 3roup of sinuses consists of:

1.1. A pair of maxillary sinuses present in the body of A pair of maxillary sinuses present in the body of maxilla.maxilla.

2.2. A pair of frontal sinuses situated in the anterior part of A pair of frontal sinuses situated in the anterior part of the Frontal bone.the Frontal bone.

3.3. Ethmoidal sinuses, which are present in the ethmoid Ethmoidal sinuses, which are present in the ethmoid labyrinth On either sides. The anterior and middle labyrinth On either sides. The anterior and middle ethmoidal sinuses are Included in the anterior group. ethmoidal sinuses are Included in the anterior group. The posterior group of sinuses consists of: The posterior group of sinuses consists of: 1.1. Posterior ethmoidal sinus.Posterior ethmoidal sinus.

DISEASES OF SINUSESDISEASES OF SINUSES

2.2. A pair sphenoidal sinuses present in the body of A pair sphenoidal sinuses present in the body of sphenoid. All the sinuses develop as an outgrowth from sphenoid. All the sinuses develop as an outgrowth from the developing nasal cavity into the surrounding bones. the developing nasal cavity into the surrounding bones. Only the ethmoidal sinuses are present at birth. By the Only the ethmoidal sinuses are present at birth. By the age of 2-3 years the maxillary sinuses develop. By the age of 2-3 years the maxillary sinuses develop. By the age of 8 years the frontal sinuses develop. They are all age of 8 years the frontal sinuses develop. They are all fully developed at puberty.fully developed at puberty.

The walls of the sinuses are formed by thin bone, which The walls of the sinuses are formed by thin bone, which can be easily eroded by infection. The adjoining can be easily eroded by infection. The adjoining important organs or tissues are involved. The most important organs or tissues are involved. The most important structure related to the sinus is the orbit and important structure related to the sinus is the orbit and its contents.its contents.

FUNCTION OF THE SINUSES FUNCTION OF THE SINUSES

1.1. They make the skull and facial bones light.They make the skull and facial bones light.

2.2. The air cushion present in the sinuses act as a The air cushion present in the sinuses act as a buffer in weight transmission. Heavy jerks are buffer in weight transmission. Heavy jerks are decreased in intensity by air cushion.decreased in intensity by air cushion.

3.3. As air sinus is communicated with the nasal cavity As air sinus is communicated with the nasal cavity so it imparts resonance to the voice.so it imparts resonance to the voice.

4.4. Mucous membrane secrets mucous, which helps Mucous membrane secrets mucous, which helps to moisten the nasal mucous membrane. to moisten the nasal mucous membrane.

5.5. They give shape to the face. They give shape to the face.

MAXILLARY SINUS MAXILLARY SINUS

It is absent at birth or if present it is only It is absent at birth or if present it is only rudimentary. By the age of two years it is rudimentary. By the age of two years it is likely to develop. By the age of 4-6 years it likely to develop. By the age of 4-6 years it is well developed. At puberty it is fully is well developed. At puberty it is fully developed.developed.

In a fully developed maxillary sinus the In a fully developed maxillary sinus the capacity of holding water is 15-30 cc.capacity of holding water is 15-30 cc.

SURGICAL ANATOMY SURGICAL ANATOMY The maxillary sinus is present in the body of the The maxillary sinus is present in the body of the

maxilla. It is pyramidal or conical in shape. It has maxilla. It is pyramidal or conical in shape. It has roof; medial wall; lateral wall; anterior wall and roof; medial wall; lateral wall; anterior wall and posterior wall. The roof is related to the floor of the posterior wall. The roof is related to the floor of the orbit. In the floor of the orbit there is nerve and orbit. In the floor of the orbit there is nerve and vessel running called infraorbital nerve and vessel running called infraorbital nerve and vessel.vessel.

Occasionally bone is very thin and while operating Occasionally bone is very thin and while operating this nerve may be pulled. In the upper and medial this nerve may be pulled. In the upper and medial corner of the roof and media! Wall.corner of the roof and media! Wall.

There is ethmoidal labyrinth. Anterior and middle There is ethmoidal labyrinth. Anterior and middle ethmoidal sinuses are in close relation to it. ethmoidal sinuses are in close relation to it.

SURGICAL ANATOMY SURGICAL ANATOMY The medial wall is related to the nasal cavity. The medial wall is related to the nasal cavity.

Middle meatus, middle Turbinate, inferior Middle meatus, middle Turbinate, inferior meatus, inferior turbinate are all related to the meatus, inferior turbinate are all related to the medial wall. In the medial wall near the roof medial wall. In the medial wall near the roof there are openings of maxillary sinus, which are there are openings of maxillary sinus, which are situated, in the posterior part of the middle situated, in the posterior part of the middle meatus. There is main opening and accessory meatus. There is main opening and accessory opening just behind it.opening just behind it.

The drainage of the sinuses depends purely on The drainage of the sinuses depends purely on the ciliary activity of the sinuses because the the ciliary activity of the sinuses because the opening is near the roof. opening is near the roof.

SURGICAL ANATOMY SURGICAL ANATOMY Floor of the nasal cavity is higher than the floor Floor of the nasal cavity is higher than the floor

of the sinus, so infection can easily remain in the of the sinus, so infection can easily remain in the floor of the sinus. The floor of the sinus is floor of the sinus. The floor of the sinus is related to the upper surface of teeth, 1st molar, related to the upper surface of teeth, 1st molar, premolars and occasionally the canine. The premolars and occasionally the canine. The roots of the teeth are separated by 'a thin wall roots of the teeth are separated by 'a thin wall but occasionally bone is missing and roots are but occasionally bone is missing and roots are covered by thin mucous membrane. They are covered by thin mucous membrane. They are directly projecting into the sinus and infection directly projecting into the sinus and infection can easily reach the sinus. By extraction of the can easily reach the sinus. By extraction of the tooth there may be through and through opening tooth there may be through and through opening causing infection.causing infection.

SURGICAL ANATOMY SURGICAL ANATOMY Anterior wall is covered by periostium and the Anterior wall is covered by periostium and the

soft tissues of the cheek. Just below the roof soft tissues of the cheek. Just below the roof infra orbital nerve comes out and enters into the infra orbital nerve comes out and enters into the soft tissues of the cheek.soft tissues of the cheek.

Posterior wall is thin and is related to the narrow Posterior wall is thin and is related to the narrow space called pterygo-palatine fossa. In the space called pterygo-palatine fossa. In the pterygo-palatine fossa there are important pterygo-palatine fossa there are important structures i.e. Maxillary nerve and terminal structures i.e. Maxillary nerve and terminal branches of the maxillary artery. In cases of branches of the maxillary artery. In cases of intractable bleeding the maxillary artery is intractable bleeding the maxillary artery is legated through the posterior wall. legated through the posterior wall.

SURGICAL ANATOMY SURGICAL ANATOMY Lateral wall is related to the zygomatic Lateral wall is related to the zygomatic

bone and the pterigoid muscle.bone and the pterigoid muscle.

The lining of the sinuses is mucous The lining of the sinuses is mucous membrane, which is thin, has columnar membrane, which is thin, has columnar ciliated epithelium. The ciliary activity is ciliated epithelium. The ciliary activity is towards the ostiumtowards the ostium ofof the sinus. the sinus.

NERVE SUPPLY NERVE SUPPLY

By the maxillary division of the fifth cranial By the maxillary division of the fifth cranial nerve.nerve.

DISEASES OF THE MAXILLARY DISEASES OF THE MAXILLARY SINUS SINUS

The diseases of the maxillary sinus are The diseases of the maxillary sinus are

mainly two.mainly two.

1.1. Infection ............. Maxillary Sinusitis.Infection ............. Maxillary Sinusitis.

2.2. New growth ... Carcinoma of maxillary sinus.New growth ... Carcinoma of maxillary sinus.

MAXILLARY SINUSITIS MAXILLARY SINUSITIS

Types:Types:

1.1. Infective type ........ Infective maxillary sinusitis.Infective type ........ Infective maxillary sinusitis.

2.2. Allergic type ........... Allergic maxillary sinusitis.Allergic type ........... Allergic maxillary sinusitis.

3.3. Mixed type.Mixed type.

ACUTE INFECTIVE MAXILLARY ACUTE INFECTIVE MAXILLARY SINUSITIS SINUSITIS

Infection of maxillary sinus is the Infection of maxillary sinus is the commonest infection to occur in Para commonest infection to occur in Para nasal sinuses. The reasons are: -nasal sinuses. The reasons are: -

1.1. The ostium of the sinuses is situated in The ostium of the sinuses is situated in unfavorable position even mild infection of unfavorable position even mild infection of its own does not clear as the ciliary activity its own does not clear as the ciliary activity is disturbed due to infection. From maxillary is disturbed due to infection. From maxillary sinuses.sinuses.

ACUTE INFECTIVE MAXILLARY ACUTE INFECTIVE MAXILLARY SINUSITIS SINUSITIS

2.2. Infection from other sinuses can infect the maxillary Infection from other sinuses can infect the maxillary sinus. The reason is that the frontal sinus, anterior sinus. The reason is that the frontal sinus, anterior and middle ethmoidal sinus open in the middle and middle ethmoidal sinus open in the middle meatus. Infection from these sinuses can go to the meatus. Infection from these sinuses can go to the maxillary sinus (descending inf). Becausemaxillary sinus (descending inf). Because the the opening of maxillary sinus is behind.opening of maxillary sinus is behind.

3.3. The nasal cavity and teeth are immediately related The nasal cavity and teeth are immediately related to the sinuses; especially the teeth are potential to the sinuses; especially the teeth are potential source of infection of the maxillary sinus.source of infection of the maxillary sinus.

CAUSES OF ACUTE INFECTION CAUSES OF ACUTE INFECTION

a) Nasal:a) Nasal:1.1. an extension from the nasal cavity. An ordinary an extension from the nasal cavity. An ordinary

acute Rhinitis can easily reach the maxillary acute Rhinitis can easily reach the maxillary sinus.sinus.

2.2. In swimmers while diving the infected water In swimmers while diving the infected water rushes into the nose and infects the maxillary rushes into the nose and infects the maxillary sinus.sinus.

3.3. When there is an obstruction in the nasal cavity When there is an obstruction in the nasal cavity i.e. Presence of foreign body. Growth, packing i.e. Presence of foreign body. Growth, packing or even D.N. S. Will interfere with the drainage or even D.N. S. Will interfere with the drainage of the sinus and infection can occur.of the sinus and infection can occur.

CAUSES OF ACUTE INFECTION CAUSES OF ACUTE INFECTION

b)b) Dental: Dental: Apical abscess and carries of teeth can Apical abscess and carries of teeth can cause infection called dental type of sinusitis. cause infection called dental type of sinusitis. Main characters foul smelling in nasal cavity.Main characters foul smelling in nasal cavity.

c)c) Anterior wall:Anterior wall: Infection occurs in compound Infection occurs in compound fractures in blow and bullet injuries.fractures in blow and bullet injuries.

d)d) Roof:Roof: Very rarely infection occurs through the Very rarely infection occurs through the orbit.orbit.

e)e) Barotraumas or Aero sinusitis.Barotraumas or Aero sinusitis.

PREDISPOSING FACTORS PREDISPOSING FACTORS

Nasal obstruction due to D.N.S. polypus, Nasal obstruction due to D.N.S. polypus, allergyallergy or or

Local: Local: hypertrophied turbinate. hypertrophied turbinate. Neighboring infection from other sinuses.Neighboring infection from other sinuses.

General:General: Chill, Fatigue / atmospheric Chill, Fatigue / atmospheric conditions such as sudden change in conditions such as sudden change in temperature.temperature.

PATHOLOGY PATHOLOGY

As a result of infection the mucous membrane of As a result of infection the mucous membrane of lining gets inflamed; it becomes congested, lining gets inflamed; it becomes congested, swollen or edematous. There is outpouring of swollen or edematous. There is outpouring of secretion first of all in the sinus mucosa and secretion first of all in the sinus mucosa and finally into the sinus cavity. The sinus cavity finally into the sinus cavity. The sinus cavity starts filling with the inflammatory exudates. The starts filling with the inflammatory exudates. The ostium is partially blocked. If inflammation ostium is partially blocked. If inflammation process is severe the ostium is completely process is severe the ostium is completely blocked. The secretions, which are mucoid in the blocked. The secretions, which are mucoid in the beginning, easily become mucopurulent and beginning, easily become mucopurulent and finally become frank pus.finally become frank pus.

PATHOLOGY PATHOLOGY The pressure inside the sinus increases because the sinus is full The pressure inside the sinus increases because the sinus is full

of pus. This pressure exerts its force to the surrounding of pus. This pressure exerts its force to the surrounding structures and the pain is felt in the teeth, orbit and cheek. structures and the pain is felt in the teeth, orbit and cheek. Because of absorption of toxins From collected pus there is Because of absorption of toxins From collected pus there is toxemia. The drainage is established artificially or naturally and toxemia. The drainage is established artificially or naturally and the pus starts coming out. If drainage is not established the the pus starts coming out. If drainage is not established the complications start which Are:complications start which Are:

Pressure necrosis of the wall.Pressure necrosis of the wall. Infection can go into the orbit, orbital cellulitis, or go to theInfection can go into the orbit, orbital cellulitis, or go to the Maxilla, osteomyelitis.Maxilla, osteomyelitis. Infection products may enter the blood vessels causingInfection products may enter the blood vessels causing Retrograde thrombophlebitis reaching the cavernous sinus.Retrograde thrombophlebitis reaching the cavernous sinus. Spread to the sinuses i.e. to the ethmoid sinus. Spread to the sinuses i.e. to the ethmoid sinus.

PATHOLOGYPATHOLOGY

In children these complications occur In children these complications occur easily. easily.

There will be orbital cellulitis, meningitis There will be orbital cellulitis, meningitis etc. Organisms which cause infection are etc. Organisms which cause infection are Streptococcus, haemolyticus; Streptococcus, haemolyticus; Staphyllococus pneumococcus, E.Coli.Staphyllococus pneumococcus, E.Coli.

CLINICAL PICTURE CLINICAL PICTURE Symptoms may be general or local.Symptoms may be general or local.General:General: Symptoms of acute toxemia (temp. etc) Symptoms of acute toxemia (temp. etc) Local:Local: History of cold few weeks ago.History of cold few weeks ago. Pain in the cheek, or in the teeth or in the orbit.Pain in the cheek, or in the teeth or in the orbit. There is thick excessive mucopurulent discharge from the There is thick excessive mucopurulent discharge from the

Nose. It may be profuse if the drainage is established. Nose. It may be profuse if the drainage is established. As a result of inflammation of mucous membrane and As a result of inflammation of mucous membrane and

Closure of ostium the voice of the patient is changed and Closure of ostium the voice of the patient is changed and resonance is lost.resonance is lost.

There may be headache and excessive lacrimation.There may be headache and excessive lacrimation.

CLINICAL PICTURE CLINICAL PICTURE Often there is epistaxis. Signs may also be divided into Often there is epistaxis. Signs may also be divided into

general and local.general and local.

General:General: Signs of acute toxaemia. Signs of acute toxaemia.

Local:Local:

Tenderness over the cheek along with local swelling.Tenderness over the cheek along with local swelling.

In children there will be edema over lower eyelid. In children there will be edema over lower eyelid.

On anterior rhinos copy the nasal mucosa is intensely On anterior rhinos copy the nasal mucosa is intensely congested, there is presence of mucopurulent secretion in the congested, there is presence of mucopurulent secretion in the middle meatus collecting in the floor of the nasal cavity. middle meatus collecting in the floor of the nasal cavity. Posterior rhinos copy reveals pus in the middle meatus. Posterior rhinos copy reveals pus in the middle meatus.

DIAGNOSIS DIAGNOSIS

Diagnosis is confirmed by local Diagnosis is confirmed by local examination, by doing a examination, by doing a transillumination test in which the transillumination test in which the infected side will be dull; by X-ray of infected side will be dull; by X-ray of Para nasal sinuses complete opacity Para nasal sinuses complete opacity or fluid level in the affected sinus can-or fluid level in the affected sinus can-be seen. be seen.

DIFFERENTI L DIAGNOSIS DIFFERENTI L DIAGNOSIS

1.1. Trigeminal Neuralgia: NoTrigeminal Neuralgia: No H/o cold, no H/o cold, no toxaemia, H/o long duration trigger spots.toxaemia, H/o long duration trigger spots.

2.2. Migraine:Migraine: The attack comes in intervals and is The attack comes in intervals and is associated with the H/o allergy or family history associated with the H/o allergy or family history there is vomiting, eyes are congested, fever, there is vomiting, eyes are congested, fever, the nasal mucosa is normal.the nasal mucosa is normal.

3.3. An ordinary infection is differentiated by looking An ordinary infection is differentiated by looking at teeth or by X-ray at teeth or by X-ray ofof teeth. teeth.

4.4. Malignancy of the maxillary sinus. Malignancy of the maxillary sinus.

TREATMENT OF ACUTE TREATMENT OF ACUTE MAXILLARY SINUSITIS MAXILLARY SINUSITIS The basic treatment is: -The basic treatment is: -

1.1. To control infection as quickly as To control infection as quickly as possible.possible.

2.2. To drain the infected material from the To drain the infected material from the sinus cavity either Through the natural sinus cavity either Through the natural openings or though an artificially openings or though an artificially created Opening.created Opening.

3.3. Fomentation by application of heat Fomentation by application of heat from outside or by infrared treatment.from outside or by infrared treatment.

SURGICAL TREATMENT SURGICAL TREATMENT

In some cases if treatment fails (the pain is not In some cases if treatment fails (the pain is not relieved, temperature is not lowered and sinus is relieved, temperature is not lowered and sinus is not draining) an artificial drainage in established not draining) an artificial drainage in established by putting a needle or trochar and cannula either by putting a needle or trochar and cannula either through the inferior meatus or cannula is put through the inferior meatus or cannula is put through the ostium. With the help of these through the ostium. With the help of these instruments the sinus cavity is washed and the instruments the sinus cavity is washed and the infected material is drained out. This procedure infected material is drained out. This procedure is called Antrum wash or Antrum puncture or is called Antrum wash or Antrum puncture or proof puncture plus Antrum wash out (P.P. + A. proof puncture plus Antrum wash out (P.P. + A. W. 0.). This is mostly carried out through W. 0.). This is mostly carried out through inferior meatus.inferior meatus.

SURGICAL TREATMENT SURGICAL TREATMENT

It should never be carried out in acute It should never be carried out in acute cases unless the patient has received at cases unless the patient has received at least 72 hours antibiotic therapy. It is the least 72 hours antibiotic therapy. It is the last resort to be carried out in acute cases last resort to be carried out in acute cases but it is first in chronic cases because the but it is first in chronic cases because the mucous membrane is acutely inflamed mucous membrane is acutely inflamed and chances of spreading the infection to and chances of spreading the infection to bone (osteomyelitis) are more. One bone (osteomyelitis) are more. One Antrum wash with normal saline is more Antrum wash with normal saline is more than enough in acute cases.than enough in acute cases.

ANTRUM PUNCTURE ANTRUM PUNCTURE

It is an outpatient’s procedure in which It is an outpatient’s procedure in which trochar and cannula is inserted through trochar and cannula is inserted through the inferior meatus. After with drawing the the inferior meatus. After with drawing the trochar cannula remains in the sinus trochar cannula remains in the sinus cavity. Drainage is done and fluid comes cavity. Drainage is done and fluid comes out through the ostium. out through the ostium.

INDICATIONS FOR ANTRUM INDICATIONS FOR ANTRUM PUNCTURESPUNCTURES

1.1.Diagnostic indications: -Diagnostic indications: - To establish the To establish the

cause of hazy and opaque sinus cause of hazy and opaque sinus

appearance in x-ray. If pus comes out, it is appearance in x-ray. If pus comes out, it is

chronic sinusitis, if mucous fluid comes chronic sinusitis, if mucous fluid comes

out, cyst is present in the sinus, andout, cyst is present in the sinus, and If If

blood comes out there is a growth. blood comes out there is a growth.

Indications for Antrum punctures Indications for Antrum punctures

2.2.Therapeutic indications: -Therapeutic indications: - To treat, and To treat, and drain out the fluid or pus in the sinus drain out the fluid or pus in the sinus cavity. To introduce lhe medicine through cavity. To introduce lhe medicine through the cannula, into The cavity. the cannula, into The cavity.

Contraindications Contraindications

Presence of fulminating infection.Presence of fulminating infection.A recent fracture of maxilla.A recent fracture of maxilla.

TECHNIQUE OF OPERATIONTECHNIQUE OF OPERATION

It is carried out under local anesthesia or in It is carried out under local anesthesia or in children under general anesthesia. The local children under general anesthesia. The local anesthesia is achieved by spraying the nasal.anesthesia is achieved by spraying the nasal.

Cavity with 4% xylocaine in which equal amount Cavity with 4% xylocaine in which equal amount of adrenaline has been added 1:1000 strength of adrenaline has been added 1:1000 strength After waiting for five minutes the nasal cavity After waiting for five minutes the nasal cavity and the inferior meatus are packed with solution, and the inferior meatus are packed with solution, complete anesthesia is achieved in 30 minutes.complete anesthesia is achieved in 30 minutes.

STEPS OF OPERATION STEPS OF OPERATION

Let the patient sit on the stool. Remove Let the patient sit on the stool. Remove the packs.the packs.

INSTRUMENTS REQUIRED ARE:INSTRUMENTS REQUIRED ARE:

1. Trochar and cannula.1. Trochar and cannula.

2. Higgonson's rubber syringe.2. Higgonson's rubber syringe.

3. Bucket containing warm normal saline. 3. Bucket containing warm normal saline.

STEPS OF OPERATION STEPS OF OPERATION

PROCEDURE:PROCEDURE: Take the trochar and cannula in the right hand, Take the trochar and cannula in the right hand,

introduce it through the nose. Through the inferior introduce it through the nose. Through the inferior meatus. The direction of trochar and cannula meatus. The direction of trochar and cannula should be upwards, backwards and laterally. should be upwards, backwards and laterally. (U.B.L), towards the outer canthus of the eyeball, (U.B.L), towards the outer canthus of the eyeball, or tragus of the pinna. The site of puncture is in or tragus of the pinna. The site of puncture is in the inferior meatus about 1/2 to 3/4 from the the inferior meatus about 1/2 to 3/4 from the anterior end of inferior turbinate (where the inferior anterior end of inferior turbinate (where the inferior turbinate joins the lateral wall). turbinate joins the lateral wall).

STEPS OF OPERATION STEPS OF OPERATION Here the bone is thinnest and very little force is needed to pierce Here the bone is thinnest and very little force is needed to pierce

the wall. Thus the trochar and cannula introduced through the the wall. Thus the trochar and cannula introduced through the wall till it enters the sinus cavity where resistance disappears. wall till it enters the sinus cavity where resistance disappears. Then trochar is taken out and cannula remains in. The rubber Then trochar is taken out and cannula remains in. The rubber syringe is connected to the cannula; the other end of the syringe syringe is connected to the cannula; the other end of the syringe is dipped in the bucket containing warm normal saline. The sinus is dipped in the bucket containing warm normal saline. The sinus is washed out till the solution in return is clear. The cannula is is washed out till the solution in return is clear. The cannula is then withdrawn and the patient is asked to hold his nose with a then withdrawn and the patient is asked to hold his nose with a gauze piece, for fifteen minutes. Washout can be repeated at an gauze piece, for fifteen minutes. Washout can be repeated at an interval of fifteen days. If 6-8 washings fail to clear the Antrum a interval of fifteen days. If 6-8 washings fail to clear the Antrum a little more advanced surgery is done. Antrum puncture should little more advanced surgery is done. Antrum puncture should not be done through middle meatus, which is nearer to the orbit not be done through middle meatus, which is nearer to the orbit and has closer relations to the other sinuses also.and has closer relations to the other sinuses also.

COMPLICATIONS AND COMPLICATIONS AND DANGERS OF THE OPERATION DANGERS OF THE OPERATION 1. Anesthesia complications: -1. Anesthesia complications: - The patient may The patient may

be sensitive to xylocaine. There might be sever be sensitive to xylocaine. There might be sever reaction causing collapse and shock.reaction causing collapse and shock.

2. Operative complications: -2. Operative complications: - These are due to These are due to two reasons.two reasons.

A) Fault in the technique: -A) Fault in the technique: -i). Spread of infection beyond the sinus.i). Spread of infection beyond the sinus.ii) Instead of going in the sinus, mucous ii) Instead of going in the sinus, mucous

membrane of the inferior turbinate can be membrane of the inferior turbinate can be injured, causing profuse bleeding. injured, causing profuse bleeding.

GENERAL TREATMENT GENERAL TREATMENT

The patient who has acute maxillary sinusitis, The patient who has acute maxillary sinusitis, having temp. Feeling ill and has severe pain having temp. Feeling ill and has severe pain should be looked after. Advise analgesic for should be looked after. Advise analgesic for pain, rest in bed and antibiotic in the form of pain, rest in bed and antibiotic in the form of injections or oral therapy to control fever. Start injections or oral therapy to control fever. Start with crystalline penicillin or procaine penicillin; if with crystalline penicillin or procaine penicillin; if the patient does not show any response within the patient does not show any response within 24-48 hours, change the antibiotics. The choice 24-48 hours, change the antibiotics. The choice depends upon the culture and sensitivity tests. depends upon the culture and sensitivity tests.

LOCAL TREATMENT LOCAL TREATMENT

The local treatment is as important as general. It The local treatment is as important as general. It may be. Either medicinal or conservative. In may be. Either medicinal or conservative. In most of the cases, the local medicinal treatment most of the cases, the local medicinal treatment is enough to drain the sinuses. The aim of this is enough to drain the sinuses. The aim of this treatment is to establish the natural drainage treatment is to establish the natural drainage through ostium. Thus edema and inflammation through ostium. Thus edema and inflammation of mucous membrane is corrected.of mucous membrane is corrected.

1.1. Medicated steam inhalation, menthol and Medicated steam inhalation, menthol and tincture benzene should be carried out thrice tincture benzene should be carried out thrice daily. daily.

LOCAL TREATMENT LOCAL TREATMENT

2.2. Mild decongestant drops like 1/2 - 1% Ephedrine in Mild decongestant drops like 1/2 - 1% Ephedrine in

normal saline 5-10 drops are used. As it is mild normal saline 5-10 drops are used. As it is mild

one it does not cause any damage to the cilia or one it does not cause any damage to the cilia or

any rebound vasodilatatation effect. The mucous any rebound vasodilatatation effect. The mucous

membrane shrinks and drug may enter sinus membrane shrinks and drug may enter sinus

through ostia. Antibiotics like penicillin or any through ostia. Antibiotics like penicillin or any

broad acting can be added to decongestant drops. broad acting can be added to decongestant drops.

This local therapy is enough in most cases. This local therapy is enough in most cases.

B) Fault in sterilization of the instruments:B) Fault in sterilization of the instruments:Following complications can occur: Following complications can occur:

i)i) Osteomyelitis.Osteomyelitis.

ii)ii)Retrograde thrombophilebitis leading to Retrograde thrombophilebitis leading to cavernous sinus thrombosis.cavernous sinus thrombosis.

iii) Acute fulminating infection.iii) Acute fulminating infection.

PROPHYLACTIC TREATMENT: PROPHYLACTIC TREATMENT:

As the chances of recurrence of acute maxillary As the chances of recurrence of acute maxillary sinusitis are more, prophylactically the following sinusitis are more, prophylactically the following precautions should be done.precautions should be done. Avoid swimming during heavy cold.Avoid swimming during heavy cold. Avoid any blow on cheeks.Avoid any blow on cheeks. Any local pathology in the nose e.g. D.N.S., Any local pathology in the nose e.g. D.N.S.,

Adenoids, polyps, and Allergy etc should be treated.Adenoids, polyps, and Allergy etc should be treated. General health of the patient should be built up. General health of the patient should be built up.

QUESTIONS QUESTIONS

Describe signs, symptoms and treatment of Describe signs, symptoms and treatment of Acute Maxillary sinusitis in detail?Acute Maxillary sinusitis in detail?

What are the indications of Antrum Puncture? What are the indications of Antrum Puncture? Describe The technique in detail.Describe The technique in detail.

Enumerate the complications of the operation. Enumerate the complications of the operation.

For vivaFor viva

Describe the anatomy of the maxillary Describe the anatomy of the maxillary sinus, Sites of Antrum puncture.sinus, Sites of Antrum puncture.

Harm of operating through the middle Harm of operating through the middle meatus.meatus.

Direction of the cannula.Direction of the cannula.

CHRONIC CHRONIC MAXILLARY MAXILLARY SINUSITIS SINUSITIS

CHRONIC MAXILLARY CHRONIC MAXILLARY SINUSITIS SINUSITIS

It is the commonest infection of the It is the commonest infection of the

Para nasal sinuses due to the Para nasal sinuses due to the

following reasons following reasons

ANATOMICAL REASONS ANATOMICAL REASONS

1.1.The drainage of the sinuses depends The drainage of the sinuses depends purely on the cilia activity. The drainage of purely on the cilia activity. The drainage of the sinus is present near its roof; the sinus is present near its roof; secretions can only be expelled out of the secretions can only be expelled out of the sinus by the cilia activity. Due to chronic sinus by the cilia activity. Due to chronic infection the ciliary activity is diminished or infection the ciliary activity is diminished or the cilia are destroyed and secretions will the cilia are destroyed and secretions will remain in the sinus cavity. remain in the sinus cavity.


2.2. The natural opening of the sinus is situated in The natural opening of the sinus is situated in the posterior part of the middle meatus. In the the posterior part of the middle meatus. In the anterior end and in the mid of the middle anterior end and in the mid of the middle meatus, there are openings of the Frontal sinus meatus, there are openings of the Frontal sinus and anterior and middle group of the Ethmoidal and anterior and middle group of the Ethmoidal sinuses. The openings of the maxillary sinus is sinuses. The openings of the maxillary sinus is situated behind them, so the infection from situated behind them, so the infection from Frontal and Ethmoidal sinuses can go backward Frontal and Ethmoidal sinuses can go backward in the maxillary sinus. in the maxillary sinus.


3.3.The floor of the sinus is closely related to The floor of the sinus is closely related to

the roots of the premolars and molars. the roots of the premolars and molars.

There may be an intervening thin bone or There may be an intervening thin bone or

a mucous membrane; dental infection can a mucous membrane; dental infection can

easily infect the maxillary sinus. easily infect the maxillary sinus.

AETIOLOGY AETIOLOGY

Local CausesLocal Causes1.1.A persistent source of infection in the A persistent source of infection in the

neighborhood, which may be other neighborhood, which may be other sinuses, nasal cavity, nasopharynx, sinuses, nasal cavity, nasopharynx, pharynx, adenoids in children, chronic pharynx, adenoids in children, chronic tonsillitis or dental sepsis.tonsillitis or dental sepsis.

2.2.A persistent source of obstruction of the A persistent source of obstruction of the drainage. The cause of obstruction may be drainage. The cause of obstruction may be anatomical or pathological. anatomical or pathological.

AETIOLOGY AETIOLOGY

a)a) Anatomical causes of obstruction: - Anatomical causes of obstruction: - D.N.S. pressing upon the middle turbinate.D.N.S. pressing upon the middle turbinate. Hypertrophied middle turbinate.Hypertrophied middle turbinate.

b)b) Pathological causes of obstruction: Pathological causes of obstruction: Simple edema of the mucosa. Simple edema of the mucosa. Allergy of the nose and Para nasal sinuses. Allergy of the nose and Para nasal sinuses. Formation of the polyp in middle meatus.Formation of the polyp in middle meatus. Foreign bodies in the nose.Foreign bodies in the nose. Growths in the nasal cavity or nasopharynx that may Growths in the nasal cavity or nasopharynx that may

be Benign or Malignant. be Benign or Malignant.

General causes General causes

1.1.Low resistance of the patient due to ill Low resistance of the patient due to ill health, which may be due to Nutritional health, which may be due to Nutritional deficiency or following some chronic deficiency or following some chronic illness.illness.

2.2.Overcrowding, bad sanitation and bad Overcrowding, bad sanitation and bad atmospheric condition.atmospheric condition.

3.3.A persistent source of infection in the lung A persistent source of infection in the lung e.g. Brochiectasis (rare). e.g. Brochiectasis (rare).

PATHOLOGY PATHOLOGY

The changes occur in the sinus, nasal The changes occur in the sinus, nasal

cavity, and lower respiratory tract and in cavity, and lower respiratory tract and in

the body as a whole. the body as a whole.

PATHOLOGY PATHOLOGY

1. Change in the mucosa of the sinus cavity: -1. Change in the mucosa of the sinus cavity: - The mucous membrane is chronically inflamed and The mucous membrane is chronically inflamed and

thickened.thickened. In some cases it may show polypoid outgrowth whereas In some cases it may show polypoid outgrowth whereas

in other cases the Mucous membrane may be atrophied.in other cases the Mucous membrane may be atrophied. Microscopically the changes are that of chronic Microscopically the changes are that of chronic

inflammation. The cavity of the sinus is full of secretion inflammation. The cavity of the sinus is full of secretion which are mucopurulent or Frank foul smelling pus, filling which are mucopurulent or Frank foul smelling pus, filling partially or completely the sinus cavity.partially or completely the sinus cavity.

In very chronic cases this pus becomes sticky, thick and In very chronic cases this pus becomes sticky, thick and assumes a cheesy Appearance that is extremely difficult assumes a cheesy Appearance that is extremely difficult to drain out. to drain out.

PATHOLOGY PATHOLOGY 2.2. Change in the Nasal cavity: -Change in the Nasal cavity: - Congestion in the middle meatus, presence of Congestion in the middle meatus, presence of

pus in he middle meatus or over the inferior pus in he middle meatus or over the inferior turbinate and collecting in the floor of the nasal turbinate and collecting in the floor of the nasal cavity.cavity.

3.3. Change in the lower respiratory tract: -Change in the lower respiratory tract: - In the nasopharynx and pharynx the changes are: In the nasopharynx and pharynx the changes are:

the pus' going backward can infect the middle ear the pus' going backward can infect the middle ear through Eustachian tube, can infect oropharynx through Eustachian tube, can infect oropharynx chiefly the tonsils, and may still go further down chiefly the tonsils, and may still go further down and involves larynx, trachea and bronchial tree. and involves larynx, trachea and bronchial tree.

PATHOLOGY PATHOLOGY 4.4. Change In the body as a whole: -Change In the body as a whole: - These changes are as a result of absorption of These changes are as a result of absorption of

toxins from the pool of pus that is present in toxins from the pool of pus that is present in sinus. The symptoms may be due to the focal sinus. The symptoms may be due to the focal sepsis, which are:sepsis, which are: Repeated which are:Repeated which are: Repeated joint lesions (arthritis).Repeated joint lesions (arthritis). Mental retard ness (poor functioning of brain cells).Mental retard ness (poor functioning of brain cells). Gastrointestinal upsets. Gastrointestinal upsets.

ORGANISMS ORGANISMS

The organisms involved are The organisms involved are

Staphylococcus, Streptococcus and Staphylococcus, Streptococcus and

B. Coli. B. Coli.

CLINICAL FEATURES CLINICAL FEATURES

Symptoms: -Symptoms: -1. Local Symptoms: -1. Local Symptoms: - They are very few and not They are very few and not

definite.definite.a) Excessive nasal drainage may or may not be a) Excessive nasal drainage may or may not be foul smelling. There may be no discharge in foul smelling. There may be no discharge in some cases.some cases.b) Sense of heaviness at the site of infection.b) Sense of heaviness at the site of infection.c) Headache.c) Headache.d) Occasionally repeated episodes of bleeding. d) Occasionally repeated episodes of bleeding.


Symptoms: -Symptoms: -2. General Symptoms: -2. General Symptoms: - They are more marked and definite. They are more marked and definite.

a)a) Ottorrhoea.Ottorrhoea.b)b) Repeated sore throat.Repeated sore throat.c)c) Post nasal trickling.Post nasal trickling.d)d) Chronic cough.Chronic cough.e)e) Repeated attacks of hoarseness.Repeated attacks of hoarseness.f)f) Mental retard ness, inability to concentrate, lack of Mental retard ness, inability to concentrate, lack of

memory.memory.g)g) Repeated eye infection (irritis).Repeated eye infection (irritis).h)h) Repeated joint pain (Arthritis).Repeated joint pain (Arthritis).I)I) Poor appetite.Poor appetite.


SIGNS:SIGNS:

1.1. Presence of pus in the meddle meatus and Presence of pus in the meddle meatus and

the floor of nose. In some cases pus has the floor of nose. In some cases pus has

dried up and crusts are formed.dried up and crusts are formed.

2.2. Middle meatus is congested.Middle meatus is congested.

3.3. In the nasopharynx pus is found in the In the nasopharynx pus is found in the

floor floor or in the upper surface of soft palate. or in the upper surface of soft palate.

DIAGNOSIS: DIAGNOSIS:

It is confirmed by the following It is confirmed by the following investigations:investigations:

1.1. Transillumination.Transillumination.2.2. X-ray (sub-mento vertical view, 45 X-ray (sub-mento vertical view, 45

degrees tilt). In the cases of infection fluid degrees tilt). In the cases of infection fluid will be present in the sinus or in some or will be present in the sinus or in some or in some cases ostium may be completely in some cases ostium may be completely opaque and full of fluid. Thickened opaque and full of fluid. Thickened polypoid mucosa may also be seen. polypoid mucosa may also be seen.

DIAGNOSIS: DIAGNOSIS:

3.3. Diagnostic Antrum Puncture: -Diagnostic Antrum Puncture: - Trochar Trochar and cannula is inserted in the sinus and cannula is inserted in the sinus through the inferior meatus, if the pus through the inferior meatus, if the pus comes out it shows chronic sinusitis.comes out it shows chronic sinusitis.

4.4. For the purpose of identifying the For the purpose of identifying the organisms swab is taken for organisms swab is taken for Bacteriological examination. Bacteriological examination.

TREATMENT TREATMENT

It may be conservative or surgical. It may be conservative or surgical.

CONSERVATIVE TREATMENTCONSERVATIVE TREATMENT It is the local o general use of drugs.It is the local o general use of drugs. To control the infection by systemic or local antibiotics.To control the infection by systemic or local antibiotics. To promote natural drainage by reducing edema and To promote natural drainage by reducing edema and

inflammation,inflammation, Systemically anti-allergies and locally vasoconstrictor Systemically anti-allergies and locally vasoconstrictor

drops. (1/2% Ephedrine in normal saline) are used.drops. (1/2% Ephedrine in normal saline) are used. Improve the general health of the patient (supportive Improve the general health of the patient (supportive

treatment). treatment).

SURGICAL TREATMENT SURGICAL TREATMENT It is establishment of drainage either by temporary It is establishment of drainage either by temporary

or permanent means.or permanent means.1.1. The simplest way is by "Antrum Puncture and The simplest way is by "Antrum Puncture and

wash out". Repeated puncture (6-8 times) can wash out". Repeated puncture (6-8 times) can safely be done at every week’s interval. Antibiotic safely be done at every week’s interval. Antibiotic solution can be introduced through the Puncture solution can be introduced through the Puncture into the sinus cavity. If repeated punctures failed into the sinus cavity. If repeated punctures failed to drain infection, a little bigger operation is to drain infection, a little bigger operation is performed in which a permanent window is made performed in which a permanent window is made into the inferior meatus that opens into the nasal! into the inferior meatus that opens into the nasal! Cavity, an opening is made lateral to inferior Cavity, an opening is made lateral to inferior turbinate in the nose that is called turbinate in the nose that is called

SURGICAL TREATMENT SURGICAL TREATMENT 2.2. ""Intra Nasal AntrostomyIntra Nasal Antrostomy". This operation is ". This operation is

quite effective if it fails a "radical Extra nasal or quite effective if it fails a "radical Extra nasal or Intra Nasal Antrostomy" is done.Intra Nasal Antrostomy" is done.

3.3. This operation is called "Cald well Luc's This operation is called "Cald well Luc's operation". operation".

TECHNIQUE OF "CALD WELL TECHNIQUE OF "CALD WELL LUC'S OPERATION”LUC'S OPERATION” The Maxillary sinus is approached from outside The Maxillary sinus is approached from outside

from gingivo-labial fold by elevating the upper lip from gingivo-labial fold by elevating the upper lip a curved incision is given in the mucous a curved incision is given in the mucous membrane above the canine and premolar teeth.membrane above the canine and premolar teeth.

A bone is exposed and an opening is made in A bone is exposed and an opening is made in the anterior wall by means of a gouge or bur. the anterior wall by means of a gouge or bur. The opening is enlarged, the diseased mucous The opening is enlarged, the diseased mucous membrane, Polyp and Pus is removed from the membrane, Polyp and Pus is removed from the sinus cavity. After this a counter opening is sinus cavity. After this a counter opening is made in the inferior rneatus of the nose for Intra made in the inferior rneatus of the nose for Intra nasal drainage.nasal drainage.

INDICATIONS OF CALD WELL INDICATIONS OF CALD WELL LUC'S OPERATEONLUC'S OPERATEON1. Intra-sinus indications: -1. Intra-sinus indications: -

a)a) Chronic maxillary sinusitis that has failed to clear by Chronic maxillary sinusitis that has failed to clear by conservative means.conservative means.b) To take a Biopsy in suspected growths.b) To take a Biopsy in suspected growths.c)c) To remove a foreign body from the sinus. To remove a foreign body from the sinus.d)d) To remove Antro-choanal Polypus. To remove Antro-choanal Polypus.e) To remove from the sinuse) To remove from the sinus

2. Extra-sinus indications: -2. Extra-sinus indications: -a)a) To repair Oro-antrum fistula. To repair Oro-antrum fistula.b)b) To tie to Maxillary art: To tie to Maxillary art:c)c) To elevate the fractured Zygomatic bone. To elevate the fractured Zygomatic bone.d)d) To eradicate the infection of Ethmoidal sinus. To eradicate the infection of Ethmoidal sinus.e)e) To avulse the infraorbital nerve. To avulse the infraorbital nerve.f)f) Transantral approach to Pituitary. Transantral approach to Pituitary.

PROPHYLACTIC TREATMENT PROPHYLACTIC TREATMENT

Eradicate the infection or relieve Eradicate the infection or relieve obstruction in the immediate neighborhood obstruction in the immediate neighborhood like D.N.S. Polypus, Adenoids Tonsils etc. like D.N.S. Polypus, Adenoids Tonsils etc. Improve the general health of the patient.Improve the general health of the patient.

ACUTE FRONTAL ACUTE FRONTAL SINUSITIS SINUSITIS

FRONTAL SINUSES ARE PRESENTFRONTAL SINUSES ARE PRESENT in the anterior part of frontal bone, in the anterior part of frontal bone, they are paired and separated from they are paired and separated from each other by a septum. They are each other by a septum. They are absent at birth and slowly develop absent at birth and slowly develop from two years onwards. At the age of from two years onwards. At the age of eight years they are partially eight years they are partially developed and at puberty they are developed and at puberty they are developed fully.developed fully.

They may have various shapes and sizes.They may have various shapes and sizes. FRONTAL SINUSFRONTAL SINUS open in the anterior open in the anterior part of the meddle meatus through a part of the meddle meatus through a narrow long tortuous duct which is closely narrow long tortuous duct which is closely related to the Ethmoidal sinuses, infection related to the Ethmoidal sinuses, infection of the frontal sinus is common because of of the frontal sinus is common because of the long narrow and tortuous duct. It can the long narrow and tortuous duct. It can easily get blocked on its way into the easily get blocked on its way into the middle meatus, although the opening of middle meatus, although the opening of the duct is situated in the floor of the sinus.the duct is situated in the floor of the sinus.

The frontal sinus is related to the following The frontal sinus is related to the following structures: Floor of the frontal sinus is structures: Floor of the frontal sinus is related to the orbit, the bone intervening related to the orbit, the bone intervening the bone, leading to orbital infection.the bone, leading to orbital infection.

The Posterior wall is related to anterior The Posterior wall is related to anterior cranial fossa.cranial fossa.

The Anterior wall is related to soft tissue The Anterior wall is related to soft tissue structures of the forehead. The bone of the structures of the forehead. The bone of the anterior wall is very thick and infection can anterior wall is very thick and infection can easily reach the bone causing easily reach the bone causing osteomyelitis. osteomyelitis.

AETIOLOGY AETIOLOGY

The commonest causes are as follows:The commonest causes are as follows:1.1. Ascending infection from the nasal cavity in Ascending infection from the nasal cavity in

cases of severe rhinitis. The infection is usually cases of severe rhinitis. The infection is usually associated with maxillary sinusitis.associated with maxillary sinusitis.

2.2. Infection can also reach the frontal sinus, in Infection can also reach the frontal sinus, in cases of entrance of infected material through cases of entrance of infected material through the duct during diving and swimming especially the duct during diving and swimming especially in common cold.in common cold.

3.3. Infection can also reach as in the case of Infection can also reach as in the case of fracture of the frontal! Bone.fracture of the frontal! Bone.

4.4. Infection from posterior wall and orbit (rare). Infection from posterior wall and orbit (rare).

PREDISPOSING CAUSES PREDISPOSING CAUSES

1.1. Obstruction in the nasal cavity, egg.Obstruction in the nasal cavity, egg. D.N.S. pressing upon the middle turbinate and middle D.N.S. pressing upon the middle turbinate and middle

meatus. Thus blocking the drainage.meatus. Thus blocking the drainage. Pressure of hypertrophied turbinate.Pressure of hypertrophied turbinate. Polyps and growths.Polyps and growths.

2.2. Presence of infection in the other sinuses, Presence of infection in the other sinuses, commonest is the maxillary sinus. Chronic commonest is the maxillary sinus. Chronic infection will lead to edema of the middle infection will lead to edema of the middle meatus, the opening is obstructed or blocked or meatus, the opening is obstructed or blocked or a repeated infection of frontal sinus.a repeated infection of frontal sinus.

PATHOLOGY PATHOLOGY An ordinary picture of inflammation will be seen in the An ordinary picture of inflammation will be seen in the

frontal sinusitis.frontal sinusitis. The mucous membrane is congested, edematous and The mucous membrane is congested, edematous and

swollen. The inflammatory process also involves the swollen. The inflammatory process also involves the long narrow duct that gets blocked very quickly. The long narrow duct that gets blocked very quickly. The secretions start collecting in the sinus cavity that is secretions start collecting in the sinus cavity that is mucopus or frank pus. If the duct is partially opened the mucopus or frank pus. If the duct is partially opened the secretions may drain out, but inmost of the cases, the secretions may drain out, but inmost of the cases, the duct is already blocked by inflammatory process, the duct is already blocked by inflammatory process, the inflammatory exudates cannot drain out and start filling inflammatory exudates cannot drain out and start filling the sinus cavity. the sinus cavity.

PATHOLOGY PATHOLOGY As the inflammatory process spreads, As the inflammatory process spreads,

pressure continue to raise which is exerted pressure continue to raise which is exerted on the inflamed mucosa, leading to intense on the inflamed mucosa, leading to intense pain. As the pressure increases further, the pain. As the pressure increases further, the pressure necrotic changes in the mucous pressure necrotic changes in the mucous membrane occur. The inflammation reaches membrane occur. The inflammation reaches the bone directly or the infection may go to the bone directly or the infection may go to the mucous membrane causing thrombosis the mucous membrane causing thrombosis of the vessels. of the vessels.

PATHOLOGY PATHOLOGY The pressure necrosis of the bone occurs, the infection The pressure necrosis of the bone occurs, the infection

go outside the sinus cavity, reaching the orbit causing go outside the sinus cavity, reaching the orbit causing orbital cellulites giving an orbital abscess; going towards orbital cellulites giving an orbital abscess; going towards the other sinuses, may go to the bone causing the other sinuses, may go to the bone causing osteomyelitis, may go to the cranium causing intracranial osteomyelitis, may go to the cranium causing intracranial complications. The thrombotic processes extend to the complications. The thrombotic processes extend to the normal veins causing thrombophlebitis, either in sagital normal veins causing thrombophlebitis, either in sagital sinus or cavernous sinus.sinus or cavernous sinus.

Due to all these complications acute frontal sinusitis is Due to all these complications acute frontal sinusitis is severe and danger pus condition than Maxillary sinusitis.severe and danger pus condition than Maxillary sinusitis.

The common organism involved is Streptococcus, The common organism involved is Streptococcus, Pneumococcus, and M. Catarrhalis. Pneumococcus, and M. Catarrhalis.

CLINICAL FEATURES CLINICAL FEATURES SYMPTOMS:SYMPTOMS:

1.1. Heaviness in head followed by severe pain. Pain is in Heaviness in head followed by severe pain. Pain is in the forehead Usually on one side quickly increases in the forehead Usually on one side quickly increases in intensity. The pain has a typical Periodicity. The pain intensity. The pain has a typical Periodicity. The pain comes; say for about half an hour after getting up to comes; say for about half an hour after getting up to from bed in the morning, gradually increases become from bed in the morning, gradually increases become worst at midday. At 12' 0 ' Clock it become severe, worst at midday. At 12' 0 ' Clock it become severe, unbearable and by 4 'o' clock it subsides. unbearable and by 4 'o' clock it subsides. InIn some some cases this periodicity is lost and pain become cases this periodicity is lost and pain become continuous throughout day and night. continuous throughout day and night.

CLINICAL FEATURES CLINICAL FEATURES Causes of periodicity:Causes of periodicity: WHILE the patient is sleeping opening of the WHILE the patient is sleeping opening of the

frontonasal duct is not frontonasal duct is not inin the dependent position. But the dependent position. But as he gets up from the bed, the opening become as he gets up from the bed, the opening become dependent and the secretions that are present in the dependent and the secretions that are present in the cavity exert their pressure on the inflamed. Partially cavity exert their pressure on the inflamed. Partially blocked opening of the Sinus, the secretions are blocked opening of the Sinus, the secretions are constantly poured out the pressure goes on constantly poured out the pressure goes on increasing, by the midday as the pressure is increasing, by the midday as the pressure is maximum, the pain become worst. Pain aggravates by maximum, the pain become worst. Pain aggravates by the pull of gravity that make the duct open the pull of gravity that make the duct open

CLINICAL FEATURES CLINICAL FEATURES Slightly and the secretions start pouring out by drop by Slightly and the secretions start pouring out by drop by

drop and by 4drop and by 4 'o' 'o' clock, the sinus empties completely. If clock, the sinus empties completely. If the sinus opening cannot be opened out, the periodicity the sinus opening cannot be opened out, the periodicity is lost and pain becomes continuous, as there is no is lost and pain becomes continuous, as there is no place for secretion to get out, the pain becomes severe place for secretion to get out, the pain becomes severe and unbearable.and unbearable.

2.2. Nasal discharge:Nasal discharge: Extensive thick mucopurulent Extensive thick mucopurulent discharge.discharge.

3.3. Nasal obstruction.Nasal obstruction.

4.4. Excessive lacrimation and photophobia, both are reflex Excessive lacrimation and photophobia, both are reflex symptoms.symptoms.

5.5. Constitutional symptoms like temperature, toxemia. Constitutional symptoms like temperature, toxemia.

CLINICAL FEATURESCLINICAL FEATURES

SIGNS:SIGNS:

1.1. Tenderness in the area of frontal sinus:Tenderness in the area of frontal sinus: It may be over It may be over the forehead or towards the floor.the forehead or towards the floor.

2.2. Swelling:Swelling: Mild degree of periosteal activity leads to edema Mild degree of periosteal activity leads to edema and swelling of forehead’ or swelling of the Roof of the orbit, and swelling of forehead’ or swelling of the Roof of the orbit, edema of the upper eyelid. In advanced cases there is soft, edema of the upper eyelid. In advanced cases there is soft, fluctuant swelling.fluctuant swelling.

3.3. On anterior rhinos copy middle meatus is congested. On anterior rhinos copy middle meatus is congested. Secretions are present in the middle meatus collected in the Secretions are present in the middle meatus collected in the anterior part of middle turbinate and in the floor of the cavity. anterior part of middle turbinate and in the floor of the cavity.

DIAGNOSISDIAGNOSIS

History of severe attack of acute rhinitis. History of severe attack of acute rhinitis.

History of swimming or diving. Presence of History of swimming or diving. Presence of

above mentioned signs and symptoms. above mentioned signs and symptoms.

The diagnosis is confirmed by taking X-ray The diagnosis is confirmed by taking X-ray

of frontal sinuses. The sinus is either of frontal sinuses. The sinus is either

opaque or fluid is present in the sinus opaque or fluid is present in the sinus

cavity. cavity.

DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS

Other causes of half headache / (Migrain):Other causes of half headache / (Migrain):

1.1. Migraine.Migraine.

2.2. Neuralgia of supra-orbital nerve.Neuralgia of supra-orbital nerve.

3.3. Intracranial lesions.Intracranial lesions.

There will be no pathology in the nasal There will be no pathology in the nasal cavity and sinuses, X-ray clear in all the cavity and sinuses, X-ray clear in all the above conditions. above conditions.

TREATMENT TREATMENT

It should be adequate, as early as It should be adequate, as early as

possible; infection should be controlled possible; infection should be controlled

immediately and should be taken to drain immediately and should be taken to drain

the sinus as early as possible. The the sinus as early as possible. The

treatment is divided is General, Local and treatment is divided is General, Local and

Prophylactic treatment. Prophylactic treatment.

TREATMENTTREATMENT

1. 1. GENERAL TREATMENT:GENERAL TREATMENT:

Resin bed.Resin bed.

Control of infection by giving adequate and Control of infection by giving adequate and appropriate Antibiotics. Start with Procaine appropriate Antibiotics. Start with Procaine Penicillin that should be Changed when the Penicillin that should be Changed when the bacteriological and cultural report is Available or bacteriological and cultural report is Available or there is no relief in 24 hours.there is no relief in 24 hours.

To relieve pain, give ordinary analgesics even To relieve pain, give ordinary analgesics even Pethidine and Morphia can be given.Pethidine and Morphia can be given.

TREATMENTTREATMENT2. 2. LOCAL TREATMENT:LOCAL TREATMENT: Principles of local treatment are to establish natural Principles of local treatment are to establish natural

drainage with the help of which frontonasal duct is drainage with the help of which frontonasal duct is opened.opened.

Vasoconstrictor drugs like 1% Ephedrine with normal Vasoconstrictor drugs like 1% Ephedrine with normal saline along with steam inhalation three times a day, this saline along with steam inhalation three times a day, this is mild decongestant therapy. The mucous membrane is mild decongestant therapy. The mucous membrane shrinks and drainage is established.shrinks and drainage is established.

If mild decongestant therapy fails go on to intense potent If mild decongestant therapy fails go on to intense potent decongestant therapy, by putting cotton wool packs, decongestant therapy, by putting cotton wool packs, swabs soaked in certain drugs into the middle meatus. swabs soaked in certain drugs into the middle meatus. Adrenaline hydrochloride pack isAdrenaline hydrochloride pack is

TREATMENTTREATMENT Inserted in the middle meatus and left for 1/2 an Inserted in the middle meatus and left for 1/2 an

hour and then taken out.hour and then taken out. This therapy is repeated for 3-4 times a day.This therapy is repeated for 3-4 times a day. If this measure also fails to establish drainage, If this measure also fails to establish drainage,

minor surgery is done. The simplest minor minor surgery is done. The simplest minor surgery is Antrum Puncture and wash out of the surgery is Antrum Puncture and wash out of the Maxillary Sinus. (In most of the cases infection is Maxillary Sinus. (In most of the cases infection is also present in the maxillary sinus which give also present in the maxillary sinus which give rise to edema. As maxillary sinus is drained, rise to edema. As maxillary sinus is drained, edema subsides, drainage occurs). edema subsides, drainage occurs).

TREATMENTTREATMENT If this minor surgery fails then drain the frontal sinus If this minor surgery fails then drain the frontal sinus

directly i.e. by swabs. This is done by opening the directly i.e. by swabs. This is done by opening the floor of frontal sinus by making a tiny hole in the floor of frontal sinus by making a tiny hole in the frontal sinus. Put a polythene tube and drain the frontal sinus. Put a polythene tube and drain the sinus. Another polythene tube is put by the side of sinus. Another polythene tube is put by the side of the first for washing purposes (through one the first for washing purposes (through one introduce penicillin for wash and fluid comes out of introduce penicillin for wash and fluid comes out of the other tube). No major surgery is done in acute the other tube). No major surgery is done in acute frontal sinusitis because of the danger of infection, frontal sinusitis because of the danger of infection, tube may remain as long as necessary till whole of tube may remain as long as necessary till whole of the pus is drained and sinus becomes clear. the pus is drained and sinus becomes clear.

TREATMENTTREATMENT

3.3. PROPHYLACTIC TREATMENT:PROPHYLACTIC TREATMENT:

Eradicate infection in other sinuses.Eradicate infection in other sinuses.

Release the nasal obstruction.Release the nasal obstruction.

Form the patient to dive and swim.Form the patient to dive and swim.

diseases of sinuses

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