ParanasalSinuses
Pathology.
Lecture 2
Dr. Moiseeva Aleksandra Anatol’evna
1

Paranasal sinuses pathology
• Sinusitis
- Acute sinusitis
- Chronic sinusitis
- Chronic sinusitis with polyps

Thesinusesare:
• Cavities, or air-
fi
lled pockets, near the nasal passages
• Lined with mucous membrane continuous with that of nasal cavity
• All communicate with nasal fossa through their various ostia
•
3

Thesinusesare:
• Cavities, or air-
fi
lled pockets, near the nasal passages
• Lined with mucous membrane continuous with that of nasal cavity
• All communicate with nasal fossa through their various ostia
•
4
How many types of PNS
can you name?

Typesofsinuses:
• Ethmoid sinus. This sinus is located inside
the face, around the area of the bridge of
the nose.
• Maxillary sinus. This sinus is located inside
the face, around the area of the cheeks.
• Frontal sinus. This sinus is located inside
the face, in the area of the forehead.
• Sphenoid sinus. This sinus is located deep
in the face, behind the nose.
5

Typesofsinuses:
• Ethmoid sinus. This sinus is located inside
the face, around the area of the bridge of
the nose.
• Maxillary sinus. This sinus is located inside
the face, around the area of the cheeks.
• Frontal sinus. This sinus is located inside
the face, in the area of the forehead.
• Sphenoid sinus. This sinus is located deep
in the face, behind the nose.
6
Which sinuses are present
at birth?

Typesofsinuses:
• Ethmoid sinus. This sinus is located inside
the face, around the area of the bridge of
the nose. It is present at birth, and
continues to grow.
• Maxillary sinus. This sinus is located inside
the face, around the area of the cheeks. It is
also present at birth, and continues to
grow.
• Frontal sinus. This sinus is located inside
the face, in the area of the forehead. It does
not develop until around 7 years of age.
• Sphenoid sinus. This sinus is located deep
in the face, behind the nose. It does not
typically develop until adolescence.
7

Accordingtothe
damagedsinus
patientswillcomplain
onpaininspeci
f
icarea:
• Ethmoid sinus. This sinus is located inside
the face, around the area of the bridge of
the nose. It is present at birth, and
continues to grow.
• Maxillary sinus. This sinus is located inside
the face, around the area of the cheeks. It is
also present at birth, and continues to
grow.
• Frontal sinus. This sinus is located inside
the face, in the area of the forehead. It does
not develop until around 7 years of age.
• Sphenoid sinus. This sinus is located deep
in the face, behind the nose. It does not
typically develop until adolescence.
8

Thesinusesare:
• Cavities, or air-
fi
lled pockets, near the nasal passages
• Lined with mucous membrane continuous with that of nasal cavity
• All communicate with nasal fossa through their various ostia
• The sinuses are divided for Clinical Purposes into two groups:
- Anterior
- Posterior
• The line of attachment of middle turbinate to lateral wall of nose marks
division between the two.
9

Groupsofsinuses
10
The Posterior Group draining at several
locations above the middle turbinate is
made up of:
- Posterior Ethmoidal Cells
- Sphenoidal Sinuses
The Anterior Group draining below the
middle turbinate or near the infundibulum
and consists of:
- Frontal
- Maxillary
- Anterior and Middle Group of Ethmoidal
cells

Wheredothedischargego
• All the PNS are draining into nasal
cavity by speci
fi
c nasal meatus
(passage)
• Anterior group of sinuses ->
middle meatus
• Posterior group of sinuses ->
superior meatus
• The nasolacrimal duct is draining
to the inferior meatus

Functionsofthesinuses?
12

Functionsofthesinuses
• Give resonance to voice
• Sound protection from transmission
of one’s own speech to the ears
• May have a role in air-conditioning of
the inspired air
• May reduce skull weight
• Provide protection to orbits
• An hitherto unexplained function of
the PNS may be the supply of the
fresh, uncontaminated mucus to the
middle meatus.
13

Nasolacrimal duct – acts to
drain tears from the eye.
It opens into the inferior meatus.
14
Inadditiontotheparanasalsinuses,
otherstructuresopeninto
thenasalcavity:

Auditory (Eustachian) tube –
opens into the nasopharynx at
the level of the inferior meatus.
It allows the middle ear to
equalise with the atmospheric
air pressure.

Paranasal sinuses pathology
• Sinusitis
- Acute sinusitis
- Chronic sinusitis
- Chronic sinusitis with polyps

Whatissinusitis?
Sinusitis is an in
fl
ammation of
the mucosa of one or several
paranasal sinuses.
The in
fl
ammation may be
• suppurative or non-suppurative;
• acute or chronic;
• with or without polyps.
17

1) Acute – duration
of symptoms lasts up to 12 weeks,
including 4-12 weeks of subacute
2) Recurrent acute – 2-4 acute cases
of sinusitis per year
3) Chronic – symptoms lasts over 12
weeks
1. Monosinusitis – one sinus is
damaged:
Maxillary sinusitis, frontitis,
ethmoiditis, sphenoiditis
2. Polysinusitis (more than 1 sinus are
damaged),
Hemisinusitis (sinuses of one side are
damaged),
Pansinusitis (all sinuses are damaged)
Duration Localisation
18
Classi
f
ication

Local
predisposing
factors • Upper respiratory tract infection (acute infective rhinitis, tonsillitis or
adenoiditis)
• Pre-existing rhinitis (allergic, vasomotor, rhinitis medicamentosa, etc)
• Nasal polyps
• Nasal foreign body
• Nasal anatomical variations (septal deviation, abnormal uncinate process,
middle turbinate or ethmoid bulla) which narrow the infundibulum and
predispose to its occlusion when there is intercurrent disease
• Nasal tumour
• Dental extraction or infection (diseases of the upper premolars and
molars)
• Fractures involving the sinuses
19

• Debilitation
• Immunocompromise patients
• Mucociliary disorders (e.g. Kartagener’s syndrome, cystic
fi
brosis)
• Atmospheric irritants(dust, fumes, tobacco smoking)
20
General
predisposing
factors

– is de
fi
ned as the sudden onset of two or
more symptoms, one of which is nasal
congestion/di
ffi
culty in nasal breathing or
discharge from the nose (out, into the
nasopharynx)
± pain / pressure in the face,
± decrease or loss of smell.
Symptoms persist for <12 weeks.
The latest series of guidelines on
rhinosinusitis from an
international cohort of experts
21
Acutesinusitis

Pathology
The majority of cases follow a viral upper respiratory tract infection which
involves all of the respiratory epithelium including the paranasal sinuses. Such
infections cause hyperaemia and oedema of the mucosa, which blocks the
ostia. There will be cellular in
fi
ltration and an increase in mucus production.
The infection will also paralyse the cilia, leading to stasis of secretions
predisposing to secondary bacterial infection. The usual causative organisms
are Streptococcus pneumoniae, Haemophilus in
fl
uenzae (pneumococcal and
haemophilus infections accounting for 70% of cases in adults), Streptococcus
pyogenes, Moraxella catarrhalis, and Staphylococcus aureus. Klebsiella pneumoniae,
Escherichia coli and Streptococcus faecalis may spread from a dental source.
Acute fungal infections (for example mucormycosis and aspergillosis) are rare,
but may develop in immunocompromised or elderly diabetic patients.
22

- pain over the infected sinus
- nasal congestion
- fullness in the face
- malaise and possibly a pyrexia
The symptoms usually occur several days after developing an upper
respiratory tract infection.
Speci
fi
c features may indicate the sinus that is infected.
Complaints
24

Maxillary sinus – pain developing in the cheek or upper teeth
Frontal sinusitis – pain in the forehead and tenderness below
the eyebrows
Ethmoid sinusitis – pain between the eyes accompanied by
frontal headache
Sphenoid sinus – pain anywhere across the vault or retro-
orbital pain
Speci
f
icfeatures
25

Diagnostic
• red oedematous nasal mucosa and turbinates
• pus in the middle meatus
26
• X-ray of paranasal sinuses is needed only if there is a clinic of complications, it
is better to make CT
• Also could be needed in di
ffi
cult cases for a di
ff
erential diagnosis
• In some cases – bacteriological examination of the discharge (puncture and
selection of antibioticterial treatment)
Anterior rhinoscopy:
Any other diagnostic needed?

Diagnosis:
Example of diagnosis
• Ill for 11 days, beginning with light nasal discharge
• Now there’s a temperature up to 37oC
• By anterior rhinoscopy – hyperaemia of nasal mucosa, white discharge in the left part of the nose
coming throw the middle nasal passage
• Pain in the left cheek
27

Diagnosis: Acuteleft-sidedmaxillarysinusitis
Example of diagnosis
• Ill for 11 days, beginning with light nasal discharge
• Now there’s a temperature up to 37oC
• By anterior rhinoscopy – hyperaemia of nasal mucosa, white discharge in the left part of the nose
coming throw the middle nasal passage
• Pain in the left cheek
28

Treatment ofacutesinusitis
• Only catarrhal changes – treating as acute rhinitis
•
29

Treatment ofacutesinusitis
• Only catarrhal changes – treating as acute rhinitis
• Acute bacterial sinusitis:
- antibacterial treatment
- washing the nasal cavity according to Proetz
- topical decongestants – up to 3-5 days
- topical corticosteroids (see Lecture 1)
+ mucolytics (see Lecture 1)
- puncture of maxillary sinus – better to be done after CT for out
fl
ow of
pus
30

Antibacterialtreatmentofacutesinusitis
Major bacterial
pathogens
Drugs of the 1 step Drugs of the 2 step Drugs of the 3 step
Duration
of therapy
S. Pneumoniae
H. In
fl
uenzae
b-hem streptococci
(not A)
M. Catarrhalis
Doc. of GM
(mild and uncomplicated forms):
Amoxicillin per os 0,5
3 times a day or
1,0 2 times a day
ENT
(moderate and complicated
forms):
Amoxicillin/Сlavulanate per os
0,625 3 times a day or
1,0 2 times a day
Ce
fi
xim
per os 0,4
ones a day
Cefditoren
per os 0,2
twice a day
Josamicin per os 1,0
twice a day
Clarithromycin per os
0,5 twice a day
Levo
fl
oxacin
per os
0,75 once a day
Moxi
fl
oxacin
per os
0,4 once a day
5-7 days
31

WashingthenasalcavityaccordingtoProetz
32
The washing of the sinuses is popularly called the
«cuckoo». This term was chosen for a reason,
since during the procedure the patient is asked to
repeat “cuckoo-cuckoo” all the time to provide
protection of respiratory tract from the ingress of
liquid, since during the pronunciation of these
sounds a soft palate rises and thereby closes the
nasopharynx, the epiglottis also blocks the
entrance to the larynx.

WashingthenasalcavityaccordingtoProetz
• The patient is o
ff
ered to lie on his back (sitting position is
acceptable). He/she needs to breathe smoothly and calmly.
• The next step is the anemization of the mucosa (using
vasoconstrictive drops)
• The doctor heats the solution, with the help of which the Proetz
method will be carried out (saline solutions, NaCl 0,9% or
solutions with antibiotics or corticosteroids)
33

WashingthenasalcavityaccordingtoProetz
• The otolaryngologist pours the prepared solution into one nostril,
and using a special vacuum apparatus sucks it from the other half
of the nose.
• Under the in
fl
uence of vacuum, negative pressure is created, which
helps to clear the sinuses from pathological contents.
• «Cuckoo» sound during such washing can be carried out up to 5
times in 10 minutes.
34

Maxillarysinuspuncture(Antralwashout)
• The maxillary sinus is irrigated with
0,9% NaCl solution by a cannula
introduced through the inferior
meatus.
• The solution circulates inside the
sinus cavity and comes out together
with accumulated discharge through
the natural ostium in the middle
meatus.
• Before procedure – anemisation with
decongestant; anaesthesia (lidokain)
35

• Is a chronic in
fl
ammation of the mucous
membrane which has resulted in irreversible
and usually degenerative changes.
• Symptoms persist for >12 weeks.
- odontogenic – treating by dentist
- associated with systemic diseases
- associated with tumor process
- chronic atelectasis of the maxillary sinus
Speci
fi
c forms:
36
Chronicsinusitis

Signs
• persistent nasal discharge
• di
ffi
culty in nasal breathing
• headache or pain in the projection of the sinuses
• postnasal syndrome (a feeling of constant
fl
ow of viscous secretions along
the back wall of the nasopharynx)
•Examination, palpation and percussion, anterior rhinoscopy
•Assessment of clinical manifestations, anamnesis and complaints
•CT of paranasal sinuses – not at exacerbation!
•Results of laboratory studies
37
Diagnostic

Treatment
• Antibacterial treatment
• Intranasal corticosteroids during ~ 3
months
• Irrigation therapy (according to
Proetz)
• Mucolytics
• Surgical treatment: puncture and
revision of paranasal sinuses Endoscopic view of the removal of the left
posterior maxillary bone and polypoid tissue
with through-cut forceps.
38

Antibacterial treatment of exacerbation of chronic sinusitis
Major bacterial
pathogens
Drugs of the 1step Drugs of the 2 step Drugs of the 3 step
Duration of
therapy
Polyetiologic:
S. Pnemoniae
H. In
fl
uenzae
Staphylococcus
aureus,
Enterobacteria
etd,
+ Anaerobes
Amoxicillin/
Сlavulanate per os
0,625 3 times a day
or
1,0 twice a day
Ce
fi
ximum per os
0,4 ones a day
Levo
fl
oxacin
per os
0,75 once a day
Moxi
fl
oxacin
per os
0,4 once a day
10-14 days
39

Patients usually present with:
• nasal obstruction
• persistent nasal discharge (rhinorrhea)
• sinus infection
• loss of the sense of smell (anosmia) of prolonged duration
Polyp formation in the nasal cavity is due to chronic allergic rhinitis, chronic
sinusitis, and, less commonly, underlying disease such as cystic
fi
brosis.
Often combined with bronchial asthma.
40
Chronicsinusitiswithpolyps

41

Tactics
• The presence of obstruction – polypectomy
• The presence of changes in the mucous membrane and
deformation of the intranasal structures – conservative therapy
and surgical treatment of anatomical anomalies
• The presence of anatomical changes and diagnosed bronchial
asthma – combined treatment of an ENT specialist and an allergist
42

43