Definition Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually...

Definition

Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.

Anatomical considerations:

Osteo-meatal complex

Types

• Depending on the site– Unilateral/ bilateral– Pansinusitis– Multisinusitis– Maxillary/ frontal/ ethmoidal/ sphenoidal

• Depending on whether the sinus is draining or not– Open type– Closed type

• Depending on the pathology– Suppurative– Non-suppurative

Etiology

• Rhinogenic- Commonest (85%)– Usually after viral rhinitis (Flu)– Any form of rhinitis

• Dental (Maxillary)

– Root abscess, dental procedure, etc.

• Trauma– RTA, Swimming and diving, FB, barotrauma, etc.– Iatrogenic- nasal packing, septal surgery

• Hematogenous- Rare

Predisposing factors for Acute rhinosinusitis

• Mucosal odema of MM– Any form of rhinitis: Viral, bacterial, Irritant, allergic, VMR,

atrophic, etc. (environmental factors play role)

• Mechanical (anatomical) obstruction of nose/ MM– DNS, spur, polyp, hypertrophic turbinate, any mass, FB, nasal

packing, etc.

• Pathological mucous– Thick mucous (mucoviscidosis, cystic fibrosis)

• Primary mucociliary dysfunction• Others: Poor general health, immunodeficiency states,

DM, nutritional deficiency, etc.

Bacteriology

• Str.Pneumoniae

• B-hemolytic streptococcus

• H.influenzae

• Stap. Aureus

• Klebsiella pneumoniae

• Others

Pathogenesis

• Obstruction to sinus ostium/ meatus• Stasis of secretions (serous-mucinous): Non-

suppurative• Secondary bacterial invasion: Suppurative• Severity and resolution depends on

– Open/ closed. May drain creating accessory opening.– Organism virulence– Host resistance– Treatment received

Pathology

• Acute inflammatory changes: Hyperemia, odema, acute infl. infliterate.

• Increased activity of the mucous glands• Severe suppuration Mucosal destruction Empyema Bony destruction Complications

Difference between healthy and inflammed Sinus

Clinical features: SymptomsDepends on the sinus involved

• Constitutional symptoms: Fever, malaise, lethargy• Headache/ facial pain: Dull ache, postural/diurnal.

– Max: Facial, forehead– Frontal: Forehead, “Office headache” – Ethmoid: Between the eyes, may > with eye movement– Sphenoid: Vertex, occipetal

• Nasal discharge– mucous/ mucopurulent/ purulent/ blood stained– Anterior/ postnasal

• Nasal obstruction• Cheek/ lid congestion, swelling

Clinical features: SignsDepends on the sinus involved

• Fever

• Tenderness

• Cheek swelling

• Lid odema: in ethmoid and frontal

• Inflamed nasal mucosa especially the meatus

• Discharge in MM/ SM as on anterior/posterior rhinoscopy

• Postural test

• Transillumination test

• Signs of complications

Endoscopic appearance of acute infective sinusitis, with pus exuding from under the right middle turbinate and down into the middle meatus.

Investigations

• Clinical diagnosis• Diagnostic nasal endoscopy (DNE)• Radiological

– X-ray PNS• Water’s view (Occipetomental)• Caldwel view (Occipetofrontal)• Lateral view• Base skull view (Submento-vertical)

– CT scan: indicated in impending complications

• C/S: rarely done

Acute Maxillary Sinusitis

Normal Sinuses

Treatment- Medical

• Antibiotics

• Nasal decongestants (Topical/systemic)

• Anti-inflammatory analgesics

• Medicated steam inhalation

• Mucolytics

• Hot fomentation

Surgical drainage

• If not responding to medical treatment

• Impending or manifest complications

• Depends on the sinus involved

Drainage procedures

• Acute maxillary: Antral washout/ endoscopic MMA

• Acute frontal: Frontal trefination/ endoscopic frontal recess clearance

• Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy

• Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy

Complications

• Chronic sinusitis• Acute sinusitis or acute exacerbations of

chronic sinusitis may give rise to following complications:

OrbitalIntracranial OsteomyelitisSeptic focus for other infections

Signs of impending/ manifest complications

Spiking feverLid odema, facial/orbital swellingProptosis, reduced vision, reduced extraoccular

movt.Severe headache and hyperirritableProjectile vomitingMeningeal signsHypothermiaAltered sensorium

Orbital complications• Common in acute ethmoiditis or

frontal sinusitis

• Direct spread/ ostitis/ thrombophlebitic

• Odema of the lids

• Subperiosteal abscess

• Orbitial cellulitis

• Orbital abscess

• Superior orbital fissure syndrome: Deep orbital pain, frontal headache, progressive paralysis of extraoccular movements

• Blindness

A patient with acute ethmoiditis threatening

vision

Intracranial

• Anterior cranial fossa and cavernous sinus closely related

• Meningitis

• Extradural abscess

• Subdural abscess

• Frontal lobe abscess

• Cavernous sinus thrombophlebitis, etc

LATERAL SINUS

THROMBOSIS

DELTA SIGN

BRAIN ABSCESS

Conclusion

“Acute sinusitis especially in a child should be treated adequately to prevent

consequent chronic sinusitis or other more severe complications which may

be even fatal”.