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Diseases of PNS/Sinusitis

  1. Acute sinusitis:-
    Sinuses involved in order of frequency: Maxillary > Frontal > Ethmoid > Sphenoid
  2. Etiology:-                                
    1. Secondary bacterial infection following viral rhinitis
    2. Swimming/diving         
    3. Trauma eg. Fractures  
    4. Dental infections
  3. Predisposing factors
    1. Cold, wet climate
    2. Poor general condition
    3. Systemic illness eg. Anemia, diabetes mellitus
  4. Causative organisms: -
    1. Streptococcus pneumonia
    2. Hemophilus influenzae
    3. Moraxella catarrhalis
    4. Staph aureus
    5. Pseudomonas
  5. Anaerobes (dental origin)                          
    1. Fusobacteria
    2. Anaerobic streptococci
    3. Bacteroides
  1. Maxillary Sinusitis.
    1. Constitutional symptoms : Fever, body ache
    2. Headache → Frontal region (thus confused with frontal sinusitis)
    3. Pain → Upper jaw with radiation to the gums and teeth aggravated
    4. by coughing
    5. Redness and oedema of cheek
    6. Nasal discharge
    7. Postnasal drip                              
  1. Posture Test (decongest and place effected sinus uppermost)
  2. Transillumination
  3. X-rays
  4. CT Scan
  1. Frontal Sinusit1s:-
    1. Headache:-
      Over the frontal sinus area
    2. Office Headache (starts in the morning, increases in midday, decreases by evening)
    3. Nasal discharge
    4. Tenderness:- Along the frontal sinus floor just above the medical canthus
    5. Oedema of upper eyelid

Extra Edge: Office headache, which is maximum during office hours & reduces by evening.



Extra Edge. Most common organism responsible for acute bacterial sinusitis is Strep. pneumoniae followed by H. influenzae.

Extra Edge. Anaerobic and mixed infections are seen in sinusitis of dental origin.

Extra Edge. Non-invasive forms of fungal sinusitis are (i) fungal ball and (ii) fungal allergic sinusitis presenting with polyps. They do not require antifungal treatment.

  1. Ethmoid Sinusitis:-
    1. Clinical Features:
      1. More often seen in infants and young children
      2. Pain:-  Over the nasal bridge, medially deep to the eye
      3. Oedema of the upper and lower eyelids (orbital cellulitis
      4. Cavernous sinus thrombosis are early complications)
      5. Nasal discharge
      6. Swelling of middle turbinate
  2. Sphenoiditis:-
    1. Rare entity on its own
    2. Subsequent to ethmoiditis/ Pansinusitis
    3. Severe headache:- retro orbital → Referred to vertex , temple or occiput
    4. Post - nasal drip: Seen on posterior rhinoscopy
    5. d/d : tumor of sphenoid sinus
  1. Radiological views for each sinus:
Maxillary        Frontal Ethmoid Sphenoid
- Water’s view - Caldwell’s view Caldwell’s & Basal Views Lateral & Basal View
  1. Treatment
    1. Antibiotics ; minimum - 2 weeks
    2. Nasal decongestants : For not more than 2 weeks else patient may develop Rhinitis medicamentosa
    3. Analgesics
    4. Steam inhalation
    5. Antrum puncture for maxillary and trephining for frontal
    6. FESS or older techniques
    7. Caldwell-Luc for maxillary
    8. Howarth/Lynch for frontal
    9. Osteoplastic flap for frontal
    10. Ethmoidectomy for ethmoid
      When symptoms of sinusitis persist for more than 3 weeks Chronic State develops. Commonest cause is incomplete resolution of acute episode.
      - Organism: Mixed aerobic & anaerobic
      - Treatment (Medical line)
      1. Antibiotics
      2. Mucolytic
      3. Nasal Irrigation
      4. Corticosteroids: to reduce mucosal swelling associated with the inflammatory response
      5. If maximal treatment for a period of 3-4 weeks : surgical treatment
  1. Functional Endoscopic Surgery of Sinuses
    Better understanding of the pathophysiology of recurrent and chronic sinusitis and the fact that most of the changes are reversible, if proper drainage and ventilation is provided to the sinuses has, in more recent years, led to the development of endoscopic surgery of sinuses.(a) Rigid endoscopes, which provide better illumination and magnification and permit visualisation of struc­tures situated at different angles.
    (b) Microsurgical instruments, which permit precise and limited surgery, directed at specific sites, to remove obstruction to the sinus ostiA. 
  2. Functional endoscopic surgery of paranasal sinuses
    1. Endoscopes can also be passed through a cannula into the maxillary sinus to visualise its interior and take accu­rate biopsies or deal with certain pathological conditions such as small cysts and polyps.
    2. With endoscopic surgery, it is now possible to cure selected cases of chronic and recurrent infections of the frontal, maxillary, ethmoid and sphenoid sinuses without resort to external operations
  3. Complications of sinusitis
    1. Most common organism known to produce complication of sinusitis: staphylococcus aureus
      1. Orbital
      2. Osteomyelitis
      3. Intracranial
      4. Descending (otitis media, tonsillopharyngitis, laryngitis, tracheobronchitis)
      5. Focal (associated with polyarthritis, tenosynovitis)
Orbital Complication
  1. Routes of spread
  1. Superior orbital syndrome:
    - Infection of sphenoid sinus
    - Deep orbital pain
    - Frontal headache
    - Cranial Nerves VI, III and IV paralysis (in that order)
  2. Orbital Apex Syndrome
    - Above plus
    - Optic nerve paralysis
    - Maxillary division of trigeminal nerve paralysis
  1. ​Types of Orbital Complications:-
    1. 1 Preseptal cellulitis
    2. 2 Orbital cellulitis without abscess
    3. 3 Orbital cellulitis with sub or extra periosteal abscess
    4. 4 Orbital cellulitis with intraperiosteal abscess
    5. 5 Cavernous sinus thrombosis (posterior ethmoiditis/ sphenoiditis)
  2. Treatment of Orbital Complications
    - i.v antibiotics
    - Analgesics and nasal decongestants
    - Visual loss : Surgical decompression

Extra Edge:

  • The Cranial nerves involved in sup. orbital syndrome III, IV & VI.
  • The nerves involved in orbital apex syndrome are II, III, IV, V-2 and VI


P. S :- IN children the orbital complication of sinusitis is due to ethmoiditis, in adult. it is due frontal sinusitis.
Fig.: Orbital complications of sinusitis: (A) Normal (B) Subperiosteal abscess (C) Orbital abscess

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