M.H BARADARANFAR M.DM.H BARADARANFAR M.Dprofessor ofprofessor of otolaryngologyotolaryngology

Head & Neck surgeryHead & Neck surgery

AcuteAcute

RhinosinusitisRhinosinusitis

Physilogy of the sinusesPhysilogy of the sinuses

1- Paterncy of the ostia

2- Function of the cilia

3- Quality of the glandular secretions

Siliary functionSiliary function

Double layer of mucus include

1- superficial viscid gel layer

2- underlying serous or sol layer

Pathophysiology of the sinusitisPathophysiology of the sinusitis

- Mucosal edema in and around the sinus ostium the most significant pathophysiology

- The abstruction of the sinus ostium O2

Cllary function mucus blanket?

Local host resistence factors

Secretions within sinus transient intrasinus pressure

Negative intrasinus pressure nasal breathing

Mucosal edema O2

Obstruction of the sinus Obstruction of the sinus ostium productsostium products

Vasodilation

Ciliary

dysfunction

Mucous gland

dysfunction

Transudation

Retained thick secretions

Viscid fluid

O2

1. Nostril hair

2. Sticky mucoid layer secreted by the goblet cells and the mucoid glands particles carried posteriorly at a rate of approximately 6-7 mm/ mimute to be swallowed

3. Phagosytose: particels that penetrate to the muscosal layer are phagocytose

particles 5-10 microns are most efficiently trapped in the nose

particles 2-4 microns may be carried through on air currents to the lung

4. Lysozymes: which are mucolytic enzymes that can cause swelling and lysis of some microorganisms

5. Antibodies: lgA. lgG

Ration 3:1 in nasal secretions

Ration 1:5 in serum

Protection against infectionProtection against infection

Protection against infectionProtection against infection

The principal immunolobulin in nasal secretions is IgA

The highest circulating antibody against respiratory viruses is IgG

IgA antibody dose not combine with complement and therefore is unable to lyse bacteria, however, effective as a viral neutralizing substance.

IgA dose note speed clinical recovery, but renewed local specific IgA antibody stores provide protection agaist reinfection

IgA in viral cold is two stage

a: stage I: during the first 24 hours increase specific and

nonspecific IgA

b: stage II: a second rise in the IgA titer will be seen at

approximately 1 week peaking at 2 weeks

sinusitissinusitis1. Acute sinusitis occurs secondary to the extension of nasal and dental infection into the pathogen- free milieu of the paranasal sinuses

2. Type of sinusitis

a: acute :associated with onset of a purulent airfluid

level or sinus opacification

b: sub acute :if the infection fails to resolve within a month

and the mucosa has become increasingly

thickened by the inflammatory process

c: chronic :these pathologic changes become

irreversible and include two forms

sinusitissinusitis1. Hypertrophic sinusitis

2. Atrophic or sclerosing sinusitis with areas of squamous metaplasia

both conditions are associated with thickened secretions, reduced blood flow, and low oxygen tension and PH, thus providing the atmosphere for anaerobic bacterial growth

3. Normal bacterial flora of the ant. part of nose and nasopharynx frequently include, staph, strep pneumonia

H. influenzae and beta- hemolytic strep

Predisposing factors in sinusitisPredisposing factors in sinusitis

1. Common cold

2. Mucosal hypertrophy from allergic or vasomotor rhinitis

3. Septal deviation

4. polyps

5. obstructing adenoidal tissue

6. Tumors

7. Foreign bodies

8. Unilateral choanal atresia

Acute frontal sinusitisAcute frontal sinusitis1. It presents with pain over the frontal sinus that is increased by trapping or bending forward

2. The sinus will fail to transilluminate, will have fluid level and will be opaque on radiographs

3. All forms of sinusitis frequently follow viral upper respiratory tract infections and are particularly common in patients with septal deviations and nasal polyps

4. If A.F.S goes untreated, the patient may present with fever, swelling, and redness over the sinus associated with edema of upper eyelid and diffuse headache

Acute frontal sinusitisAcute frontal sinusitis5. Pus may not be present in the nose

6. Complications A.F.S

a: meningitis

b: epidural, subdural or brain abscess (extension bacteria

intracranialy through phlebitic diploic veins

c: potts puffy tumor

7. Bacterial include S. peneumoniae and H. influenzae

8. A.F.S frequently requires hospitalization, intravenous antibiotics should be administered, along with opical nasal decogestant or %4 cocaine packings, three times a day to induce drainge

Acute frontal sinusitisAcute frontal sinusitis

9. The choice of antibiotic should be based on the presumed appropriate bacterial coverage and good C.N.S penetration (third generation cephalosporine such as cefuroxime or ceftriaxone)

patients who have had rash- type allergic reaction to penicillin, but they should be avoided in patients who have had anaphylactic reaction to penicillin

10. If the sinus fails to drain and patients condition has not improved in 24 hours, surgical drainage followed by saline irrigation of the sinus should be under taden

Chronic frontal sinusitisChronic frontal sinusitisC.F.S occurs in two form

A: Low grade frontal sinusitis with thickened sinus lining and retained secretions

This form is characterized by mild tenderness and chronic headache with associated intermittent drainage into the nose

Rediographs demonstrate an opacified sinus with sclerosis of the surrounding bone

These infections result from an inadequately functioning nasofrontal duct system caused by allergic or hyperplastic mucosa, scarring or traumatic ductal injury

Most cultures are mixed and most orevalent pathogenes are anaerobes that respong to high dose penicillin or cephalosporins such as cefoxitic, for oenocillin allergic individuals, clindamycin or chloramphenicol are choices, combination with tobramycin

H. Influenzae is the most important aerobe

Chronic frontal sinusitisChronic frontal sinusitis

B: Mucocele, or mucopyocele

These lesions are often painless but they gradually expand and

erode the walls of the sinus and swelling of the upper eyelid

and at times exphthalmos and diplopia

Osteoplastic frontal fat obliteration of the sinus is the treatment

of choice

Baterial studes should include routine culture, anaerobic

culture and smear

Penicillin G or cefoxitin are good choices for postoperative

antibiotic choices for postoperative antibiotic coverage until the

cultures are returned

Acute & Chronic maxillary sinusitisAcute & Chronic maxillary sinusitis

1. Acute maxillary sinusitis may follow viral respitatory infection

2. Bacteria most frequently cultured

a: H. influenzae

b: S. pneumoniae

c: Bronhamella catarrhalis

d: S. aureus

3. Anaerobes are also common cultured from a chronically infected sinus

4. A Unilaterally opacified maxillary antrum on sinus xray film:

A. potential sinus tumor until proved otherwise

B. apical root abscess draining into the sinus

Acute & Chronic maxillary sinusitisAcute & Chronic maxillary sinusitis

Evaluation should include

a: sinus Xray film (waters)

b: C.T. Scan, if necessary

c: Dental bite wing views

d: Panorex

If the diagnosis remains in doubt, the sinus should be explored

5. Osteomyelitis of the maxilla is unusual but rarely may result in fistula formation to the cheek, palate or pterygoid fossa

6. Treatment: for 3 weeks or more

a: Amoxicillin, Augmentin, cefaclor

b: for penicillin- allergic erythromycin together cotrimaxazole

c: vasoconstrictors spray by head positioning maneuvers

d: doist air inhalation

7. An antral wash should not be attempted in untreated acute sinusitis but should be used after a week or more of antibiotic therapy

Acute & Chronic maxillary sinusitisAcute & Chronic maxillary sinusitis

1. Acute viral ethmoiditis is commonly associated with viral rhinitis

2. Scondary bacterial infection can be recognized by a change from mucoid to mucopurulent nasal drainage

3. Ethmoidal sinusitis is the form of sinusitis most frequently seen among pediatric patients

4. Chronic ethmoiditis is often seen in patients with allergic or hyperplastic sinusitis

5. Because of mucous stasis and poor vascularity of polypoid tissue, infection is often difficult to treat in this situation

6. Ethmoidal surgery may be required to control chronic infection

Acute & Chronic EthmoiditisAcute & Chronic Ethmoiditis

1. Sphenoidal sinusitis occures alone only occasionally, more often it is seen in pansinusitis

2. Isolated bacterial or rarely fungal infections occur in debiliated elderly persons

3. Patients complain of a deep headache behind the eyes with pain referred to the vertex of the skull

4. Diagnosis requires a high index suspicion

Acute & Chronic Sphenoidal sinusitisAcute & Chronic Sphenoidal sinusitis

5. Un complicated acute sphenoidal sinusitis usually responds briskly to appropriate antibiotic treatment

6. If treatmentt fails, surgical drainage of the sinus is accomplished by resection of the ant.wall sphenidal by external ethmoidectomy or transseptal approach

7. Complications of sphenoidal sinusitis

a: Osteomyelitis of sphenoid bone

b: Cavernous sinus thrombosis

c: Panhypopituitarism

d: Blindness

Acute & chronic sphenoidal sinusitisAcute & chronic sphenoidal sinusitis

A. local complications

a: chronic mucosal inflammmation:

The most common complication of acute sinusitis

There is intermittent thick yellow- green drainage

b: Mucocele or mucopyocele

It arises most commonly in the frontal sinus, less commonly in the ethmoidal sinus and rarely in the sphenoidal sinus

A mucocele of the frontal sinus can present in the supero medial aspect of the ornbit as a painless soft mass that may displace the eye inferiorly and laterally

Complication of sinus infectionComplication of sinus infection

Complication of sinus infectionComplication of sinus infection

c: Osteomyelitis

It is quite unusal, it occurs most commonly following trauma, radiation, or debilitating diseases

In the maxillary sinus, osteomyelitis can occur subsequent to a dental root abscess or dental extraction

The frontal sinus is the most commmon site of this type of osteomyelitis, which occurs secondary to periostitis and cause edema over the sinus (potts puffy tumor)

Potts puffy tumor is a red, tender swelling of the foreheade skin with associated fever

Complication of sinus infectionComplication of sinus infectiond: Orbital complications

1. Pneumocele of the orbit

It may result from a small bony defect between the orbit and maxillary or ethmoidal sinuses following forceful blowing of the nose

2. Orbital cellulitis:

It is a frequent complication of acute ethmoiditis in children (less in adults) secondray to spread of infection either directly through the lamina papyracea or via phlebitic veins

It characterized by lid swelling, chemosis and proptosis, pain is variable but maybe sever, mild to markly restricted eye motion

In uncomplicated cases, vision remains good and pupillary reflexes are normal

Complication of sinus infectionComplication of sinus infection

3. Dacryocystitis:

It is manifested by localized, painful, red welling below the medial can thus over the lacrimal sac

this complication occurs more often in elderly patients and generally responds well to antibiotics

Surgical drainge is required only occasionally

4. Sup. Orbital fissure synd.

It is a rare complication of sphenoidal sinusitis

The symptoms consist of deep orbital and unilateral frontal headache with progressive III, IV, VI palsies

Complication of sinus infectionComplication of sinus infection

B. Systemic complication

a: C.N.S complication

1. Meningitis:

The most common bactera are strep. Pyogenes, S. pneumonia, staph aures and H. influenzae

Treatment consists of immediate initiation of intensive antibiotic therapy for 2 weeks or longer in addition to through surgical drainage of the involoved sinus

Surgical drainge is required only occasionally

2. Brain abscess:

One clue is a high C. S. F protein concentration

Complication of sinus infectionComplication of sinus infection3. Cavernous sinus thrombosis:

This infection is chracterized by high spiking fever in a patient with high toxicity

There is a rapid on set of oculomotor involvement including almost simultaneous involvemnt of III, IV,VI cranial nerve, resulting in a painful pan opthalmoplegia or fixed-eye

Pupillary responses are usually lacking and a large pupil is common

Optic nerve involvement is manifested by congestion of the optic disc, field cuts, or complete less of vision

In a responsive patient, sensation in volving the first division of V nerve maybe diminished of lacking

Treatment consists of intensive antibiotic therapy, drainage of the contiguous, infected ethmoidal and sphenoidal sinuses and anti coagulation

Nasocomial sinus infectionsNasocomial sinus infections1. Bacteria pseudomonas, S.aurens (penicillin resistant)

2. This is aparticulary important consideration for patients with cystic fibrosis.

3.Sinus infections in ill patient or in the patient in ICU are precipitated by foreign objects placed through the nose, N.G Tube nasopharyngeal airway tube, and packing

4. Treatment

a: removal of nasal tube

b: administration of IV antibiotics

c: especially in life- threatening sinus- drainage

Fungal sinus infectionFungal sinus infectionA. Non opportunistic infection

1. Aspergillus fumigatus is the most common cousative agent

2. In nonivasive fungal sinusitis, fungus lives saprophytically as a, small mycetoma on the mucosa of the sinus floor

Treatment is the removal of the fungus and improved sinus ventilation

This disease often begins as a dental infection or follows an oroantral fistula

Fungal sinus infectionFungal sinus infection3. Allergic aspergillus sinusitis:

The disease, which often affects young adult, is characterized by recurrent polyoid rhinosinusitis, a history of asthma, and pansinusitis documented by Xray

The diagnosis is made histologically byexamination of mucinous material for eosinophils, septate hyphae, and charcot. Leyden crystals and by immunologic Testing for an lgG - mediated positive skin test or by antigen specific serum IgE- elevation

There is no tissue invasion by the fungi

Treatment:

a: surgical extirpation and earation

b: long- term oral steroid therapy

Fungal sinus infectionFungal sinus infectionB. Opportunistic infections

1. Invasive fungal infections occurs under diabetic keto acidosis, immune alteration secondary to antibiotic and steroid therapy and profound granulocytopenia

2. The earliest clinical presentation:

a: Unexplained fever

b: A slight cloudy rhinorea

c: Facial tenderness

3. Xray film: the patients impaired inflammatory response dose note produce sign of sinusitis on Xray films until the disease is advanced

Fungal sinus infectionFungal sinus infection

4. Nasal examination: gray non sensate areas may represent early tissue invasion and infarction

5. Biopsy

a: Nonseptate hyphae tissue mucormycosis

b: septate hyphae with branching at 45 degrees aspergillosis

c: other opportunistic infections include candida, herpes simplex, and pseudomona

6. Treatment:

Surgical excision should be performed as quickly advance rapidly

Amphoteripcin -B is administers

The best hope for survival is an improved granulocyte count

Mucor MycosesMucor Mycoses

1. It is a fluminant opportunistic infection usually caused by Rhizopus oryzae

2. The infection, by fever and increased obtundation, usually arises in the nose and ethmoidal sinus, however, it can arise in the lung or bowel

3. If uncontrolled, it is fatal in a period of days to weeks.

4. Clinical presentation

a: headache

b: nasal blockage

c: sero sanguinous nasal discharge

d: invading and penetrating the walls and causing thrombosis and necrosis

e: panophthalmoplegia and proptosis

f: extend intracranially seizure, coma, death

Mucor MycosesMucor Mycoses

5. The prognosis is grave

6. The diagnosis by biopsy demonstrates non septate, branching hyphae

7. Treatment:

a: Amphoteripcin-B should be initiated as soon as

possible intravenously

b: surgical debridment of infected tissue

AspergillosisAspergillosis

1. Although aspergillosis occurs most commonly as a chronic pulmonary disease, it may also be a chronic granulomatous infection of M.E,E.A.c, nose and paranasal sinuses

2. The fungus may be part of the normal orophryngeal flora, but, in debilitated or mmunosuppressed patients, acute aspergillosis may become a very aggressive nasal and sinus infection

3. Extension from the nose and oaranasal sinuses can quickly involve the orbit and C.N.S

AspergillosisAspergillosis

4. Diagnosis: by biopsy, culture and exmination of nasal secretions for mycelial forms

5. Treatment:

a: In chronic form, It is not life threatning and shold be treated by debridment and local therapy

b: In acute form, it is life threatening disease, prompt debridemnt is requred

systemic amphotericin- B therapyy is occasionally effective

Diagnostic EvaluationDiagnostic Evaluation

1. History

2. Physical examination

3. X-ray film

4. C.T.Scan

5. Biopsy & culture

Waters

Caldwell

Management of sinusitis Management of sinusitis (duration)(duration)

1- clinical improvemement usually occurs within 48 to 72 hours of inltiation of antimicrobial therapy

2- the antibiotic therapy should be continued for a minimum of 7 days afer the symproms have disappeared

3- the average duration of treatment should be 10 days and often 2 weeks

Surgical ManagmentSurgical Managment

A. Maxillary sinus

1. Antral irrigation

2. Fenestration (inf. Meatus)

3. Caldwell-Luc

4. F.E.S.S (antrostomy of M.M)

B. Frontal sinus

a: acute frontal sinusitis

1. Trephination

b: chronic frontal sinusitis

1. Lynch

2. Reidel

3. Killian

4. Lothrop

5. Osteoplastic

6. F.E.S.S

Surgical ManagmentSurgical Managment

Surgical ManagmentSurgical Managment c: Ethmoidal sinus

1. Intranasal ethmoidectomy

2. External ethmoidectomy

3. F.E.S.S

d: Sphenoid sinus

1. Transseptal sphenoidectomy

2. Trans ethmoidal sphenoidectomy

3.F.E.S.S

Ant. Ethmoidectomy

Post. ethmoidectomy

Spheno ethmoidal yecess

Trans ethmoidal

Indication for external Indication for external ethmoidectomyethmoidectomy

1. Extensive polypoid sinus and nasal disease

2. Chronic ethmoid sinus infection

3. Approach to tumor of the frontal, ethmoidal and sphenoidal sinuses

4. Searching for and repairing C.S.F leaks in the cribriform, ethmoidal and sphenoidal regions

5. Extracranial approach in hypophhysectomy

6. Orbital decompression