Chronic sinusitis

1. Chronic Sinusitis
Dept of ENT

2. Recap -- Acute Sinusitis
• Acute inflammation of sinus mucosa
• Most common – Max  Ethmoidal 
Frontal  Sphenoidal
• Multisinusitis / pansinusitis
• ‘Open’ / ‘Closed’ Sinusitis

3. DEFINITIONS/ CONCEPTS
• Acute sinusitis- disease lasting less than one
month
• Subacute sinusitis - disease lasting 1 to 3
months
• Chronic sinusitis - disease lasting more than
three months; usually due to inadequately
treated acute or subacute disease
• Treatment concepts- Ac/subacute sinusitis
• - Chronic sinusitis

4. DEVELOPMENT
• Development of Sinuses
– At Birth – Max/ Ethmoidal
– Floor of nose higher than max sinus
floor till about 10 yrs
– Radiologically – Max (5m), Ethm (1yr),
Frontals (6 yrs)

5. ANTERIOR GROUP
POSTERIOR GROUP
MAXILLARY
FRONTAL
ANT ETH
POST ETH
SPHENOID
MIDDLE MEATUS
SUPERIOR MEATUS
SPHENOETHM RECESS
RELEVANT ANATOMY

6. PHYSIOLOGY
• Lining - pseudostratified, columnar epithelium
(respiratory epithelium)
• Mucous blanket is in two layers: a superficial
viscous layer and an underlying serous layer.
• Muco-ciliary blanket follows definite pathways
• Normal function depends on patent ostia,
ciliary function and quality of mucus

7. PATHOPHYSIOLOGY
• Vicious Cycle
• Obstruction leads to hypo-oxygenation
• Hypo-oxygenation leads to ciliary
dysfunction and poor mucous quality
• Ciliary dysfunction leads to retention of
secretions

8. RIGHT OBLIQUE VIEW OF SINUSES

9. OSTEOMEATAL COMPLEX
CONSISTS OF
•UNCINATE PROCESS
•HIATUS SEMILUNARIS
•BULLA ETHMOIDALIS
•CONVOLUTED ANATOMY
•NARROW VITAL AREA
•PATENCY CRUCIAL FOR HEALTHY SINUSES

10. ETIOLOGY
• Exciting causes
– Nasal Infections
– Swimming/ Diving
– Trauma/ Barotrauma
– Dental Infections
• Predisposing Causes
– Local
• Nasal Obstruction
– DNS, Hypertrophied turbs, ostial edema, polypi, ethmoidal cells, structural
abnormality, growths, packing
• Stasis of secretions
– Adenoids, growths, choanal atresia
• Recurrent Sinusitis
– Air Conditioning
– General
• Env pollution, Poor gen health

11. RADIOLOGY
• Plain films –more useful in acute
sinusitis, help in evaluating size and
integrity of the paranasal sinuses
• CT scan- the study of choice in chronic
sinusitis

12. PLAIN FILMS
• Three general views: Waters’,
Caldwell’s and lateral
• Waters’ view with nose and chin on film.
Useful for maxillary sinuses
• Caldwell view with nose and forehead
on film. Useful for frontal and ethmoid
sinuses
• Lateral film useful for sphenoid sinuses

13. RADIOLOGICAL VIEWS
OCCIPITOFRONTAL OCCIPITOMENTAL
SUBMENTOVERTICAL
WATER’S VIEW
CALDWELL’S VIEW

14. CHR MAXILLARY SINUSITIS
• Clinical Features
– Symptoms
• Constitutional symptoms
• Headache – Forehead
• Pain – Jaws/ teeth
• Aggravation – stooping, coughing, chewing
• Change in vocal resonance/ dry cough
• Blood stained rhinorrhoea

15. SITES OF PAIN

16. CHR MAXILLARY SINUSITIS
• Clinical Features--Signs
• Ant Rhinoscopy
– Cong & oedema of middle meatus
– ITs +
– Mucopus usually +
– Nasal Polypi +/-
• Post Rhinoscopy
– Mucopus +/-
• Throat exam – PN drip, post pharyngeal bands/
hypertrophied lymphoid tissue
• Sinus tenderness- only rarely

17. RADIOLOGY
• Translucency compared with orbit
• May show haziness/opacification/ fluid
level/polypi/ DNS
• Accuracy is less in children

18. RADIOLOGY – CT SCANS

19. MANAGEMENT
• Principles of Rx
– Reversible State
• Est drainage
• Control infection
– Antibiotics, Decongestants, Steam inhalation
– Lavages – if reqd - FESS
– Irreversible State
• Remove chr inf mucosa
• Est drainage
• Basically surgery reserved for severe chr
infections, mucosal changes ++, failure of
conservative Rx, sinusitis with complications

20. MANAGEMENT
• Proof Puncture
• Antral Lavage
– Therapeutic
– May repeat
– Indwelling catheter &
repeated washes
– Complication – perf
into cheek/ orbit

21. Ac Ethmoidal Sinusitis - Complications
• Orbital Cellulitis/ Abscess
• CST (Cavernous Sinus Thrombophlebitis)
• CNS Complications

22. Ac Frontal Sinusitis - Complications
• Orbital Cellulitis
• Osteomyelitis frontal bone
• Intracranial complications
• Chronic Frontal Sinusitis

23. • Why Max Sinus is infected commonly?
• In Multisinusitis/ Pansinusitis which sinus
should you focus on?
• In recurrent sinusitis in children, you should
aim to find out the cause. Commonest
cause?
• Why are orbital complications commonest
in children?
• Osteomyelitis of sinus bones is commonest
in maxilla & frontal bones. Why?
• Present concept of Surg Rx?