ENT DISEASES OF THE PARANASAL SINUSES Page 1 of 3

DISEASES OF THE PARANASAL SINUSESDra. Karen063009

Epidemiology- Rhinovirus, respiratory syncytial virus,

influenza virus, corona virus- One of the most frequent complaints

General considerations- Infection may affect the entire respiratory tract- Pathologic change determines by the

predominance of the infection in a particular area

- Concurrent exacerbation of sinus and pulmonary disease SINUBRONCHIAL SYNDROME

Sinusitis in Children- Maxillary and ethmoid sinuses are present at

birth- Frontal sinuses develop at 8y/o and is absent

or rudimentary in 20% of population

Etiologic agents- Acute

o Strep pneumoniao H. influenzaeo Moraxella catarrhalis

*same pathogen with OM- Chronic sinusitis

o Bacteroides sp.*o Anaerobic gm (+) streptococci*o Fusobacterium sp.o a-hemolytic streptococcio Hemophilus sp.

*dental origin

Etiologic agents in chronic sinusitis- Acute symptomatic exacerbation may be due

to the same organisms as acute sinusitis- In quiescent stages, chronic sinus disease is

due to inadequate mucociliary function or obstructed drainage

- S. aureus in chronic that acute- Fungi in cases resistant to multiple antibiotic

courses (aspergillus)- Pseudomonas – associated in chronic sinusitis

Cycle leading to sinusitis- Mucosal congestion or anatomical obstruction

blocks air flow drainage- Secretions stagnate and thicken- Ph changes- Mucosal gas metabolism changes- Cilia and epithelium are damaged- Retained secretions

*starts usually with a common cold

Key area – Ostiomeatal complex- Where everything drains

- Lamina papyracea – thin egg shell like bone that comprises the medial wall of the orbit

- In children: infection can go easily to the eyesACUTE SINUSITIS

- Sinus infection >7days to 12 weeks- (+) purulent discharge- NO residual mucosal damage

*will totally resolve

CHRONIC SINUSITIS- Persistent sinus disease >3months- (+)purulent discharge- WITH residual mucosal damage

MAXILLARY SINUSISTIS- Maxillary: 15ml- Follows a mild URTI- Predisposing factors:

o Chronic nasal allergieso Nasal polypso Foreign body (NGT, ET, nasal packing)o Nasal septal deviationo Cleft palateo Dentoalveolar abscess

- Symptomso Fever o Malaise

- Signso Mucopurulent secretions from the nose

r postnasal dripo May be foul smelling o Tenderness upon palpation

Maxillary sinusitis of dental origin- Unilateral- Foul-smelling

o Bacterial flora form mouth can go straight to sinus

- Gram negative anaerobic infection

ETHMOID SINUSITIS- Common in children- May present as ORBITAL CELLULITIS- In adults, accompanies frontal sinusitis- May precede CAVERNOUS SINUS THROMBOSIS

o Cavernous – valveless- Symptoms

o Pain between eyes- Signs

o Tenderness on palpation

FRONTAL SINUSITIS- Almost always associated with anterior

ethmoid infection- Predominantly seen in adults- Associated with a characteristic headache- Signs:

o Excruciating tenderness to pressure – pathognomonic sign

SPHENOID SINUSITIS- Most of the time group infection- Pain in the vertex of the skull

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SINUS HEADACHE- Frontal- Sphenoid- Ethmoid- Pain in orbital area

Complications of SINUSISTIS- Mucocoele- Orbital complications

NASAL POLYPS- Associated with allergy, cystic fibrosis,

Samter’s triado Samter’s triad – asthma, nasal polyps,

aspirin intolerance- Originate at the lateral nasal wall/middle

meatus- Usually bilateral- Usually common in adults >20y/o- No gender predilection- Symptoms of nasal obstruction, rhinorrhea and

sinus facial syndrome- 3 important factors

o Chronic recurrent mucosal inflammation

o Abnormal vasomotor responseso Mechanical problems related to

interstitial edema Blockage to ostiomeatal

complex- Major basic protein from eosinophils damage

the BM allowing prolapse of the lamina propria- Mygind: histamine release- May occlude sinus ostia and drainage to

produce acute or chronic sinusitis- Benign disease, more of inflammatory

o Grows massively and can press on the area

Complete ENT Exam- Anterior and posterior rhinoscopy

o Purulent discharge- Nasal endoscopy

o Unilateral nasal symptomso Suspecting tumors

- Transillumination- Otoscopy

o OM with effusion- Oral cavity exam

o Purulent postnasal drip- Check neck

o For neck masses

*Nasal polyps – gel-like

- Sinuscopyo Instances when doing biopsy

Diagnostic Examination- Paranasal Sinus X-ray

o Not routinely recommend in ACUTE sinusitis

o 7-14day course of emphiric therapy should be given initially

o If no response: nasal endoscopy

- Water’s viewo Maxillary sinuso Air-fluid level, mucosal thickening or

opacification- CT scan

o Acute: recurrent 4xo Chronic: structural abnormalities

Management of Sinusitis- Antimicrobials

o Beta lactams- Topical nasal steroids

o Useful for recurrent acute or chronic sinusitis, allergic rhinitis

o Nasonex – momethasone- Antibiotics

o Acute: 7-14dayso Chronic: 3-4weeks

- Topical decongestantso Severe nasal obstruction (3-5days)o Oxymethazoline-dixine

- Topical steroids and anti-histamineso Allergic background

Treatment failures- Non-compliance- Lack of drainage- Persistence of predisposing factors- Resistant organisms

Surgical options- Maximum medical treatment- Antral irrigation- Functional endoscopic sinus surgery- Caldwell-luc procedure

*polyps: very high recurrence rate, highly sensitive to steroids

Endoscopic sinus Surgery- Chronic sinusitis with failed medical therapy- Nasal polyps or other mass lesions- Structural abnormalities

Management of Nasal Polyps- No permanent cure- Treatment complicated by high rate of

recurrence- Medical and surgical treatment are

complementary- Underlying factors should be identified and

eliminated- Medical treatment

o Decongestanto Antibiotics

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o Main line: Topical and systemic

corticosteroids Methylprednisone –

oral Momethasone furoate –

topical