Rhinosinusitis

Mohamed Zaki Helal, M.D.

Professor of ORL,

Ain Shams University,

Cairo, EGYPT.

Email:                         mzhelal@mzhelal.com

Web Page:                  www.mzhelal.com

 

Definition:

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Sinusitis is inflammation of the mucoperiosteal lining of the paranasal sinuses. It may involve one or more of the PNS. Sinusitis is commonly associated with inflammation of the nasal mucosa, i.e. Rhinosinusitis.

Definition criteria for rhinosinusitis:

Rhinosinusitis is defined as:

Inflammation of the nose and the paranasal sinuses characterized by:

Two or more symptoms:

-     blockage/congestion;

-     discharge: anterior/post nasal drip;

-     facial pain/pressure,

-     reduction or loss of smell;

And at least one finding:

Either

Endoscopic signs:

o   polyps;

o   mucopurulent discharge from middle meatus;

o   edema/mucosal obstruction primarily in middle meatus,

And/or

CT changes:

o   Mucosal changes within ostiomeatal complex and/or sinuses.

Severity of the disease:

The disease can be divided into MILD and MODERATE/SEVERE based on total severity visual analogue scale (VAS) score (0-10 cm):

MILD = VAS 0-4

MODERATE/SEVERE = VAS 5-10

To evaluate the total severity the patient is asked to indicate on a VAS the question:

How troublesome are your symptoms of rhinosinusitis?

Duration of the disease:

Acute/Intermittent

         < 12 weeks

         Complete resolution of symptoms.

Chronic/Persistent

         >12 weeks symptoms

         No complete resolution of symptoms.

Acute Rhinosinusitis

Etiology & Pathogenesis:

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Causative Organisms:

In acute sinusitis, the commonest involved organisms are: Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. Hemolytic Streptococci, Staphylococcus aureus and anaerobic bacteria are less common organisms. Anaerobes (as B. necrodentalis) are involved heavily in sinusitis of dental origin.

Routes of Infection:

1-      Nasal route: i.e. through the natural ostium of the involved sinus.

This can be the route of infection in all of the paranasal sinuses. This may follow:

         Acute rhinitis (common cold or influenza) when 2ry bacterial infection involves both nasal and sinus mucosa.

         Diving in polluted water.

         Nasal packing, if prophylactic antibiotics are not used.

         Neglected foreign bodies.

2-      Dental route:

It is only in maxillary sinusitis. If the roots of the 2nd premolar or the 1st molar teeth extend into the sinus floor, dental infection (periodontitis or periapical abscess) may cause maxillary sinusitis. Furthermore, tooth extraction may be complicated by oroantral fistula which will allow infection.

3-      Trauma:

Examples are in compound fractures of the sinus bony walls or penetrating F.Bs (as gunshots).

4-      Hematogenous route:

It occurs mainly in immunocompromized patients e.g. acute necrotizing sinusitis complicating exanthemata.

Predisposing Factors:

General factors:

They render the individual more susceptible to upper respiratory infections, as:

         Bad hygienic conditions, bad housing, overcrowding

         Decreased general resistance as in diabetics and mal-nourished or immunocompromized individuals.

Local factors:

Sinus health depends upon proper aeration and drainage of secretions through its natural ostium. Condition that leads to obstruction of sinus ostia will predispose to infection (due to stasis of secretion and defective aeration) such as:

1-      Anatomical aberrations: as septal deviation or middle turbinate abnormalities e.g. concha bullosa (air cell in anterior end of middle turbinate) or concha paradoxica (with paradoxical curvature).

2-      Pathologic conditions: as allergic rhinitis and nasal polypi.

3-      Sinus barotrauma: negative pressure will cause edema and occlusion of the sinus ostium.

Pathology:

Acute sinusitis usually starts as a catarrhal inflammation with congestion and edema of the sinus mucosa with mucoid discharge. Edema adds more to ostial occlusion and stasis of secretions. Therefore, mucosa will be devitalized and catarrhal inflammation will proceed to suppurative inflammation with mucopurulent discharge. With severe damage to the sinus mucosa, ulcerations and granulations are formed and pure pus may be produced.

Clinical Picture:

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Symptoms:

Usually, there is a history of a recent attack of acute rhinitis. The duration of the disease is less than 12 weeks.

  1. General manifestations of acute infection as fever, malaise, headache
  2. Nasal obstruction: due to mucosal congestion and edema. Usually bilateral but may be unilateral.
  3. Nasal discharge: having the following characteristics:

a)      Character: may be mucoid, mucopurulent or purulent according to the stage of sinus pathology.

b)      Amount: may be profuse or scanty according to the degree of ostial occlusion.

c)      Odour: may be offensive in sinusitis of dental origin (bone necrosis or fermentation of food retained in the sinus through an oroantral fistula).

d)     Direction: may be nasal or postnasal depending on:

                                                                            i.     Its amount (small amounts are driven back and large amounts flow both anteriorly and posteriorly),

                                                                          ii.     Efficiency of the mucociliary mechanism, and

                                                                        iii.     Site of infection (infection of the posterior group of sinuses is accompanied mainly by postnasal discharge, but anterior group of sinuses infection causes both postnasal and anterior nasal discharge).

  1. Hyposmia or anosmia may be present (due to nasal obstruction). Cacosmia occurs in maxillary sinusitis of dental origin.
  2. Facial pain: Usually severe and increases with straining or leaning forwards. Frontal sinusitis may be accompanied by periodic pain that starts in the morning, intensifies at noon and gradually decreases at the end of the day. This can be explained by the fact that the frontal sinus is drained via the narrow vertically positioned frontonasal duct. During night sleep, the partially obstructed frontonasal duct becomes completely obstructed (postural congestion). By the morning, air inside becomes absorbed and the sinus will be full of discharge causing tension facial pain. After attaining the erect position, frontonasal duct partially reopens due to decongestion of its mucosal lining. Discharge will flow down the frontonasal duct helped by gravity, but air cannot flow in as the duct is narrowed. Negative pressure builds inside the sinus causing vacuum facial pain. This will be corrected when the sinus becomes completely drained, so air can refill the sinus and pain improves.

The site of facial pain varies according to the inflamed sinus:

    1. Maxillary sinus: over the cheek, may be referred to the ears or upper teeth.
    2. Ethmoid sinuses: in between the eyes.
    3. Frontal sinus: in the forehead, may be periodical.
    4. Sphenoid sinus: deep retro-orbital, may be referred to the vertex or back of the head.
  1. Facial swelling: Edema overlying the affected sinus may occur specially in infants and children. Its site differs according to the involved sinus.
    1. Maxillary sinus: over the cheek and lower eye lid.
    2. Ethmoid sinuses: intercanthal edema.
    3. Frontal sinus: forehead and upper eye lid.

Examination:

Apart from general signs as fever, the following is found:

         Externally, there is edema and tenderness over the affected sinuses.

         Nasal examination by anterior rhinoscopy: reveals diffuse congestion and edema of the nasal mucosa with discharge (mucoid, mucopurulent or purulent). Nasal examination after decongestion of nasal mucosa may allow visualization of the discharge to come from below the middle turbinate i.e. in the middle meatus (infection of anterior group of PNS), or coming from above the middle turbinate in posterior ethmoidal or sphenoidal sinusitis.

         Posterior rhinoscopy: may show postnasal discharge, or discharge from posterior ethmoid or sphenoid sinuses.

         Nasal endoscopic examination allows the best visualization of the above mentioned findings.

         In unilateral acute maxillary the teeth should be examined to exclude dental causes.

Investigations:

Generally, acute sinusitis is clinically diagnosed; however, the following may be needed.

         Culture and sensitivity test to detect the offending organism.

         Investigations to detect the predisposing factors in recurrent acute sinusitis.

         Investigations for dental problems causing unilateral maxillary sinusitis.

         In case of suspected complications CT scans and MRI for the PNS and the brain are requested.

Treatment:

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It is mainly medical. Surgical treatment is contraindicated as it may predispose to spread of infection or osteomyelitis or osteitis of sinus walls. However, surgery is indicated in case of failed medical treatment and in impending or occurrence of complications.

Medical Treatment:

Apart from general measures as bed rest and good nutrition, the following are given:

         Antibiotics: Start with a broad spectrum antibiotic till the result of culture and sensitivity is available, then one may shift to another antibiotic according to these results. Continue treatment for at least 10-14 days.

         Nasal decongestants: Both systemic and local forms may be used to open the occluded sinus ostia.

         Analgesic-antipyretic drugs.

         Saline douches and sprays.

         Anti-inflammatory drugs: To reduce edema of the sinonasal mucosa and to open the sinus ostia.

         Mucolytic agents: To liquify viscid discharge so, it will be easily drained.

Surgical Treatment:

It aims at draining an obstructed sinus via making an opening in the sinus wall under cover of antibiotics.

         Maxillary sinus: Endoscopic widening of its ostium; an operation called endoscopic Middle Meatal Antrostomy. If there are no facilities for endoscopic surgery, maxillary sinus puncture and lavage may be done.

         Frontal sinus: Local decongestion of the frontal recess under endoscopic control in outpatient clinic is done. If it fails to give relief Endoscopic Frontal Sinusotomy operation is needed. If there are no facilities for endoscopic surgery, external approach is used to make an opening in the sinus floor just below the eye brow, and then a small tube is inserted for drainage. It is called frontal trephine operation.

         Ethmoid sinuses: Endoscopic ethmoidectomy operation may be done; however, an external ethmoidectomy operation may be resorted to if there are no facilities for endoscopic surgery.

         Sphenoid sinus: Endoscopic sphenoidotomy (widening of the ostium) has replaced the older operation of external spheno-ethmoidectomy.

Chronic Rhinosinusitis

Commonly, chronic inflammation involves more than one paranasal sinus.

Causative Organisms:

Commonly isolated bacteria in patients with rhinosinusitis include Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. However, Staph. aureus and Gram ve bacteria (e.g. Proteus, Pseudomonas) are frequently isolated in chronic sinusitis. Anaerobic bacteria may also be involved.

Etiology:

Almost all cases of chronic sinusitis follow recurrent acute episodes, only a few are chronic from the start as those following a single attack of necrotizing sinusitis of exanthemata. A healthy sinus needs proper aeration and drainage via its natural ostium. Persistent obstruction of the sinus ostium leads to defective aeration and drainage of the sinus causing retention of secretions and, therefore, rendering the sinus a good medium for bacterial colonization i.e. infection. Inflammation induces edema and possible damage of the cilia of the sinus epithelium adding more to the defective aeration and drainage, so, a chronic disease is the result with inflammatory cellular infiltrates rich in neutrophils, lymphocytes and esinophils and their products of mediators like leukotrienes, prostaglandin D2, and cytokines.

Causes of chronicity include:

  1. Causes for persistent ostial obstruction:

                             i.     Anatomical causes as septal deviation, concha bullosa or paradoxical middle concha.

                           ii.     Pathological causes as allergic rhinitis and nasal polypi.

  1. Incomplete resolution of recurrent acute sinusitis (inadequate treatment, resistant organism or impaired patients resistance).
  2. Persistent source of infection especially dental causes as oro-antral fistula.

Pathology:

Chronic non-specific inflammatory reaction of the sinus mucosa usually progresses in a hypertrophic way rather than an atrophic one. In the former, there is edema of the mucosa with polypoidal changes. Damage of the cilia of the mucosa with ulceration and granulation tissue formation may be present. On the other hand, atrophic changes are similar to those of atrophic rhinitis with excessive fibrosis and the formation of crusts.

Clinical Picture:

Apart from manifestations of a septic focus (as joint and muscle pains), chronic sinusitis presents mainly with local symptoms and signs.

Symptoms:

Long term symptoms (>12 weeks) with bouts of exacerbations (acute attacks):

  1. Nasal obstruction: mild to moderate, may be alternating.
  2. Nasal discharge: usually postnasal but anterior nasal discharge is present in many cases. It may be mucoid, mucopurulent or pure pus.
  3. Headache or facial pain: may be of tension, vacuum or toxic types. Periodic headache may occur with chronic frontal sinusitis.
  4. Hyposmia: may be present. Cacosmia is present in sinusitis of dental origin.

Signs:

Tenderness on deep pressure over the same sites as in acute sinusitis may be found.

Nasal examination by anterior rhinoscopy, posterior rhinoscopy and endoscopy reveals:

  1. Edema and congestion of the nasal mucosa mainly in the area of the meati (middle meatus, superior meatus, and spheno-ethmoidal recess). In some cases of chronic ethmoiditis, small polyps may be seen in meati.
  2. Discharge coming from the middle meatus indicates anterior group sinusitis, and discharge from above the middle turbinate indicates posterior group infection. Nasal endoscopic examination gives a precise confirmation on this issue.
  3. Crusts are found if dryness or atrophic changes have taken place.
  4. Predisposing factors may be found as DS, aberrations of the middle turbinates, allergic rhinitis or polypi.

Investigations:

1.      CT scans for the nose and PNS are the method of choice in investigating chronic sinusitis. They show the extent of the disease and the presence of any possible cause for chronicity specially aberrations of the middle turbinate.

2.      Plain X-ray films are now used only for screening purposes.

3.      Culture and sensitivity test for swabs from nasal discharge.

4.      Investigations for possible predisposing factors (e.g. allergic rhinitis, DM).

Treatment:

Unlike acute sinusitis, the treatment of chronic sinusitis is mainly surgical. That is because of the presence of mechanical obstruction of the sinus ostia in almost all cases. On the other hand, there is a limited role for medical treatment.

Medical Treatment:

         Antibiotics:

-        Short course (14 days) with a broad spectrum antibiotic for acute on top attacks.

-        Long term (3 months) Macrolide antibiotic in half recommended dose for age is needed in a trial to avoid surgery.

         Anti-inflammatory drugs such as Topical corticosteroid Sprays: To reduce inflammatory reactions and edema of the sinonasal mucosa and to open the sinus ostia.

         Nasal decongestants: Both systemic and local forms may be used to open the occluded sinus ostia in acute episodes of illness and for short duration i.e. few days.

         Saline douches and sprays.

         Mucolytic agents: To liquify viscid discharge so, it will be easily drained.

         Anti-allergic medications can be tried as a line of treatment of chronic sinusitis on top of allergic rhinitis.

Surgical Treatment:

It aims at:

1) Correcting a predisposing factor as DS and

2) Clearance of the sinus disease itself.

Several surgical procedures have been practiced in treating chronic sinusitis. These include:

A.     Functional Endoscopic Sinus Surgery (FESS):

It is the treatment of choice for chronic sinusitis as it targets the cause of the disease and preserves the function of the nose and sinuses. It is based on the fact that clearance of ostial obstructing lesions together with polypoidal mucosa and granulation tissues will allow for free ventilation and drainage of the affected sinus and will eventually lead to resolution of inflammation. The surgical procedure is performed using sinoscopes of different sizes and angles, and it can be tailored according to the extension of the sinus disease. That is to say:

1) For maxillary sinus, endoscopic middle meatal antrostomy is done. It widens the sinus natural ostium and respects the natural upward direction of the mucociliary drainage of the sinus.

2) For frontal sinus, endoscopic clearance of the frontonasal recess or frontal sinusotomy can be done.

3) Endoscopic ethmoidectomy is done for isolated ethmoiditis and endoscopic sphenoethmoidectomy for combined ethmoid and sphenoid sinus disease.

4) For sphenoid sinus, endoscopic sphenoidotomy is done.

5) Any combinations of these procedures would be performed if needed.

B. Conventional Surgery:

It is uncommonly practiced nowadays because endoscopic surgery has better results and preserves nasal functions. They include:

                               I.            For maxillary sinusitis:

         Repeated puncture and lavage under local anesthesia.

         Intranasal antrostomy (creating an artificial opening for the sinus in the inferior meatus). It depends on gravitational drainage of sinus secretion rather than the respect of the natural mucociliary drainage of the sinus directed upwards towards the sinus natural ostium. Therefore, it has inferior results than endoscopic middle meatal antrostomy.

         Radical antrostomy i.e. Caldwell-Luc operation (via a sublabial incision a hole in the anterior sinus wall is made, through which the diseased sinus mucosa is removed). It is a form of radical surgery with no respect to mucociliary drainage and sinus physiology.

                            II.            For frontal sinusitis:

         External fronto-ethmoidectomy operation through a facial skin incision.

         Osteoplastic flap operation with sinus obliteration.

                         III.            For ethmoidal sinusitis:

         External ethmoidectomy is done alone for isolated ethmoiditis.

         External fronto-ethmoidectomy or spheno-ethmoidectomy is done if the frontal or sphenoid sinuses are involved respectively.

                         IV.            For sphenoidal sinusitis: External spheno-ethmoidectomy.