rhinosinusitis

presentation on ENT

1. Rhinosinusitis by : Sameer S. Sawaed - MD

2. Inflammation of the mucous membrane of nose and paranasal sinuses since the nasal cavity & sinuses have the same MM, so any pathological changes affecting the nasal mucosa can spread to the paranasal sinuses. Definition

3. Anatomy The paranasal sinuses are a group of air containing spaces that surround the nasal cavity Each sinus is name for the bone in which it is located: Maxillary (one sinus located in each cheek) Ethmoid (approximately 6-12 small sinuses per side, located between the eyes) Frontal (one sinus per side, located in the forehead) Sphenoid (one sinus per side, located behind the ethmoid sinuses, near the middle of the skull )

4. The ethmoid and maxillary sinuses are present at birth . The frontal & sphenoid sinuses are not … they will develop later

5. Ethmoid sinuses As u go posteriorly become: Larger Less in no.

6. Sinuses have small orifices ( ostia ) which open into recesses ( meati ) of the nasal cavities. Meati are covered by turbinates ( conchae ). Turbinates consist of bony shelves surrounded by erectile soft tissue. There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior). The drainage of the sinuses Frontal , maxillary , anterior ethmiod  middle meatus Posterior ethmoid  superior meatus Sphenoid  sphenoethmoidal recess

7. Solid facial skeletal elements surrounding the nose are invaded by respiratory mucosa and subsequently pneumatized . Begins in 3 rd - 4 th mon th of fetal life and further development takes place after birth The Ethmoid sinuses are present at birth , reach adult size by age 12. The Maxillary present at birth . Frontal sinus rarely present at birth; usually not visible until age 2 , great variability in size; congenitally absent in 5% Sphenoid sinuses are rarely present at birth, usually seen around age 4 . Development of sinuses

8. Pathogenesis Sinuses are normally sterile, but their proximity to nasopharyngeal flora allows bacterial and viral inoculation following rhinitis. Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia become occluded, leading to mucosal congestion . The mucociliary transport system becomes impaired, leading to stagnation of secretions and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth .

9. Why pain ?? Air trapped within a blocked sinus, along with pus or other secretions may cause pressure on the sinus wall that can cause the  intense pain of a sinus attack .

10. Acute Rhinosinusitis … up to 4 weeks Sub acute Rhinosinusitis … 4 to 12 weeks Chronic Rhinosinusitis .. > 12 weeks Recurrent acute Rhinosinusitis Classification

11. It is an inflammatory condition of one or more of the para -nasal cavities Lasts up to 4 weeks Can range from acute viral rhinitis (common cold) to acute bacterial rhino-sinusitis Acute Rhinosinusitis

12. lasts 4-12 weeks Sub-acute rhino-sinusitis usually involves one or two pairs of the paranasal cavities. Sub acute Rhinosinusitis

13. It is the inflammatory and infection that concurrently affects the nose and para -nasal sinuses Lasts for longer than 12 weeks Chronic Rhinosinusitis

14. 4 or more recurrences of acute disease within a 12-month period, With resolution of symptoms between each episode lasts greater than 2 months . In most cases, each episode lasts for at least 7 days Recurrent acute Rhinosinusitis

15. Predisposing Factors URTI Cold weather Day care attendance Smoking in the home Anatomic abnormalities ( nasal polyps , ciliary disorder, septal deviation , concha bullosa , turbinate hypertrophy, tumors, congenital abnormalities i.e. cleft palate) Immunesupressed Direct extension : dental infection , facial fractures Inflammatory disorder: Wegener's Granulomatosis Sarcoidosis Mucosal disorder CF Allergic Rhinitis and other hyperreactivity Samter syndrome Asthma Nasal Polyps Aspirin intolerance .

16. Etiology Viral (10-15%) - Rhinovirus (most common viral sinusitis cause), Influenza, Parainfluenza , Adenovirus Bacterial Acute Sinusitis: S.Pneumoniae , H.Influenzae , Moraxella , Streptococcus Pyogenes Chronic Sinusitis: Anaerobes (>50%) Bacteroides , Anaerobic Gram Positive Cocci , Fusobacterium species Other less common causes Staphylococcus aureus , Hemophilus Influenzae , Pseudomonas aeruginosa , Escherichia coli, Beta-hemolytic Streptococcus, Neisseria causes Fungal ( Immunocompromised or DM) Aspergillus , Mucormycosis …

17. Allergic Rhinitis

18. Hypersensitivity of the nasal mucosa due to exposure to allergens Acute & seasonal or chronic & perennial Definition

19. What happens in allergic rhinitis? Exposure to allergen IgE production by the body Formation of allergen IgE complex Binding of the complex to mast cells Degranulation of the mast cells and release of inflamatory mediators including histamine. Vasodilation Increase in capillary permability .

20. Symptoms : Nasal obstruction with sneezing Clear rhinorrhea (containing increased eosinophils ) Itching of eyes with tearing Frontal headache and pressure Signs : Mucosa  edematous , pale or violet in color Allergic salute  transverse nasal skin crease from rubbing the nose Clinical features

21. Allergic salute

22. Allergic Rhinitis

23. Allergic Rhinitis

24. 2 Types: Seasonal (summer, spring, early autumn) Tree pollens, grass pollens, mold spores Lasts several weeks Disappears and recurs following year at the same time Perennial I nhaled : house dust, wool, feathers, foods, tobacco, hair Ingested : wheat, eggs, milk, nuts  occurs intermittently for years with no pattern or may be constantly present Types

25. Chronic sinusitis Polyps (swollen edematous nasal mucosal tissue, they can cause complete nasal obstruction) Serous otitis media Complications

26. Diagnosis History ( atopy & family history) Physical examination : Redness , swelling of the mucosa (particularly the turbinates ) & mucoid discharge . Check for structural anomalies ( septal deviation or nasl polyps). Sensitivity test for specific allergen (skin prick tests)

27. Identification and avoidance of allergen During the acute attack : Antihistamine (systemic or intranasal) Local steroids Decongestant (ephedrine) Sodium cromoglycate ( mast cell stabilizer used as prophyaxis ) Desensitization (we keep exposing the body to gradually increased amounts of allergen until the body fails to produce IgE as a result to exposure). Treatment

28. Allergic Rhinitis

29. Vasomotor Rhinitis

30. Very common Non-inflammatory , non-allergic rhinitis Characterized by a combination of symptoms that includes nasal obstruction and rhinorrhea Vasomotor rhinitis is a diagnosis of exclusion reached after taking a careful history, performing a physical examination, and, in select cases, testing the patient with known allergens 2 types ; eosinophilic & non- eosinophilic (according to the number of eosinophils found in the nasal secretion) Definition

31. Temp erature change Alcohol , dust, smoke Stress , anxiety, neurosis Endocrine – hypothyroidism, pregnancy, menopause Parasympathomimetic drugs Causes

32. Symptoms : Chronic intermittent nasal obstruction Rihinorhea (thin, watery) Signs : Mucosa & turbinates : swollen , pale between exposure Clinical features

33. Elimination of irritant factor Symptomatic relief with exercise Parasympathetic blocker Steroids Surgery Treatment

34. Acute Suppurative Sinusitis

35. Acute infection and inflammation of paranasal sinuses Defenition

36. Diagnosis Major sx Fever Facial pain / pressure Facial fullness Nasal obstruction Nasal dicharge Hyposmia / anosmia Minor sx Headache Fatigue Ear pressure/ fullness Halitosis Dental pain Cough At least 2 major symptoms or 1 major and 2 minor symptoms

37. Viral : Rhinovirus, Influenza, Parainfluenza Bacterial : Streptococcus Pneumoniae , Haemophilus Influenzae , Moraxella catarhalis , anaerobes Etiology

38. Sudden onset of : Facial pain or pressure Nasal blockage & or nasal discharge / posterior nasal drip Hyposmia Signs more suggestive of a bacterial etiology: Erythematus nasal mucosa Mucopurulent discharge Pus originating from middle meatus Presence of nasal polyps of a deviated septum Acute viral rhinsinusitis lasts < 10 days. Clinical features

39. History & PE Anterior rhinoscopy X-ray / CT scan not recomnded unless complications are suspected Diagnosis

40. Symptoms relieved within 5 days  symptomatic relief and expectant management Moderate symptoms that worsen or persist beyond 5 days  intranasal corticosteroid spray Severe symptoms that worsen or persist beyond 5 days and refractory to intranasal corticosteroid  Clarythromycin , INCS , referral to specialist Surgery if medical treatment fails Management

41. Chronic Sinusitis

42. Inflammation of the paranasal sinuses lasting >3months Defintion

43. Inadequate treatment of acute sinusitis Untreated nasal allergy Allergic fungal rhinosinusitis Anatomic abnormality e.g. deviated septum Underlying dental disease Cilliary disorder e.g. CF Chronic inflammatory disorder e.g. wegener’s Etiology

44. Bacterial : S. Pneumoniae , H. Influenzae , M. catarhalis , S.pyogenes , S.auereus , anaerobes Fungal : Aspergillus Organisms

45. Chronic nasal obstruction Purulent nasal discharge Headache & Pain over sinuses Halitosis Yellow - brown post-nasal discharge Chronic cough Maxillary dental pain Clinical features

46. Antibiotics for 3 to 6 weeks for infectious etiology Augmented penicillin ( Clavulin ™) Macrolide ( clarithromycin ) Fluoroquinolone ( levofloxacin ) Clindamycin , FlagyjTM Topical nasal steroid , saline spray Surgery if medical therapy fails or fungal sinusitis Surgical Treatment Removal of all diseased soft tissue and bone Post-op drainage Obliteration of pre-existing sinus cavity FESS : functional endoscopic sinus surgery Treatment

47. Benign to potentially fatal The incidence of complications from both acute and chronic rhinosinusitis has decreased as a result of the use of antibiotics. Complications can be divided into 3 categories: Orbital Intracranial Bony Complications

48. Most commonly involved in complicated sinusitis. Orbital extension is usually the result of ethmoid sinusitis . Children are more prone to orbital complications, probably secondary to high incidence of URI and sinusitis. Orbital complications

49. Uncommon but devastating. 2 major mechanism: Direct extension . Retrograde thrombophlebitis via valveless diploe veins. * Frontal sinus is rich in diploe veins especially during adolescence IC complications

50. Meningitis  Sphenoid, ethmoid Epidural abscess  Frontal Subdural abscess  Frontal Intracerebral abscess  Frontal Superior sagittal sinus thrombosis  Frontal Cavernous sinus thrombosis  Sphenoid, ethmoid Proptosis Chemosis Opthalmoplegia Complications

51. X-ray