sinusitis & its complications sami alharethy
TRANSCRIPT
SINUSITIS & ITS
COMPLICATIONS
Sami Alharethy
DEFINITIONS
• Acute – the persistence of upper respiratory symptoms for greater than a 7-day course but lasts less than 4 weeks.
• Subacute - nasal symptoms lasting 4 weeks to 12 weeks
• Chronic– persistence mucosal inflammation for > 12 consecutive weeks despite medical therapy or occurrence of more than 4 episodes a year
Rhinosinusitis
Acute
• Less then 3 months• S. Pneumo, H. Flu, M.
Catarrhalis• More severe symptoms• General stems from acute
viral infection
Chronic
• Greater than 3 months• S. Aureus,Anerobes• α-hemolytic strep, m.
catarrhalis• Milder symptoms• Additional symptoms
present: – chronic cough,
bronchitis, fatigue, malaise, and depression
Signs and Symptoms
• Day and night cough• Purulent nasal discharge• Nasal airway obstruction• Headache, irritability, or facial pain• Fever• Postnasal drip
AnatomyMaxillary Sinus
• Largest and first sinus to develop • Natural ostium drains into Middle M• First and second molar roots dehiscent
in 2%
AnatomyEthmoid Sinus
• First seen at 5 months gestation• Adult size by 12-15 years• Between 10-15 cells• Drainage
– Anterior cells via Middle meatus– Posterior cells via Superior M
AnatomyFrontal Sinus
• Not present at birth– Starts developing at 4 years
• Development not complete until 12-20 years
• Drainage via frontal recess to MM
AnatomySphenoid Sinus
• Pneumatization begins in middle childhood• Reaches adult size by 12-18 years
Pathophysiology
Systemic:
• Viral URI
• Allergy
• Immotile cilia
• Cystic fibrosis
• Immune disorder
Pathophysiology
Local:
Trauma Swimming/Diving Rhinitis Medicamentosa
Pathophysiology
Mechanical:
Choanal Atresia Deviated Septum Polyps/Foreign Body Turbinate/Adenoid Hypertrophy
MUCOCILIARY CLEARANCE
Mucociliary clearance
• Ciliary function very important
• Ostia are small and located in locations not conducive to spont-drainage
Mucociliary clearance
Cilia work best: Temp of 37° Humidity near 100%
Respiratory Epithelium Goblet cells (20%) produce mucus Ciliated cells (80%)
Decreased MCC
• Kartagener syndrome (Primary ciliary dyskinesia)
• Cystic fibrosis
• Radiotherapy
• GERD
• Rhinosinusitis
Primary ciliary dyskinesia
• Autosomal recessive
• Dynein arm defects
• Kartagener syndrome (Associated with dextrocardia, sinusitis, rhinitis, pneumonia, and otitis media)
• Male infertility is common
Cystic Fibrosis
• Autosomal recessive
• Decreased chloride secretion with resultant thicker/stickier mucus adherent to bacteria
• Viscosity leads to dysfunction:– Resp tract Sweat glands – Pancreas Other exocrine glands– GI tract
Treatment principles
• Irrigation and drainage of secretions improve local defense mechanisms
• Antimicrobials
Surgical treatment
• Conservative FESS
Complications of Sinusitis
• Three main categories– Orbital (60-75%)– Intracranial (15-20%)– Bony (5-10%)
• Radiography– Computed tomography (CT) best for orbit– Magnetic resonance imaging (MRI) best for intracranium
Orbital ComplicationsChandler Criteria
• Five classifications– Preseptal cellulitis– Orbital cellulitis– Subperiosteal abscess– Orbital abscess– Cavernous sinus thrombosis
Orbital ComplicationsPreseptal Cellulitis
Orbital ComplicationsOrbital Cellulitis
Orbital ComplicationsSubperiosteal Abscess
• Surgical drainage– Worsening visual acuity or extraocular movement– Lack of improvement after 48 hours
Orbital ComplicationsSubperiosteal Abscess
• Approaches– External ethmoidectomy (Lynch incision) is
most preferred– Endoscopic ideal for medial abscesses– Transcaruncular approach
Orbital ComplicationsOrbital Abscess
• Similar approaches as with subperiosteal abscess– Lynch incision– Endoscopic
Orbital ComplicationsCavernous Sinus Thrombosis
• Symptomatology– Orbital pain
– Proptosis and chemosis
– Ophthalmoplegia
– Symptoms in contralateral eye
– Associated with sepsis and meningitis
• Radiology– Better visualized on MRI
Orbital ComplicationsCavernous Sinus Thrombosis
• Mortality rate up to 30%• Surgical drainage• Intravenous antibiotics
Complications of SinusitisIntracranial
Intracranial ComplicationsTypes
• Five types– Meningitis– Epidural abscess– Subdural abscess– Intracerebral abscess– Cavernous sinus, venous sinus thrombosis
Complications of SinusitisBony
• Pott’s puffy tumor– Frontal sinusitis with acute osteomyelitis
– Subperiosteal pus collection leads to “puffy” fluctuance
• Rare complication