The document discusses the anatomy, pathophysiology, diagnosis, and treatment of sinusitis. It notes that sinuses are air-filled cavities in the skull that may serve purposes like lightening the skull and adding resonance to the voice. Sinusitis is defined as inflammation of the sinus lining caused by infection, allergy, or structural issues. It can be acute (less than 2 weeks), chronic (over 2 weeks), or recurrent. Diagnosis involves examination of the nasal cavity and sinuses, transillumination, and imaging tests. Treatment focuses on restoring sinus drainage with medications like antibiotics, decongestants, saline irrigation, and surgery if medical management fails. Complications can include orbital and intracranial infections

1. Dr. Rizwan Elahi Chohan
Medical Officer
ENT Department

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Para-nasal Sinuses
They are paired, air filled chambers in the skull.
Several theories propose that they serve to
lighten the skull, protect the brain during head
trauma and add resonance to the voice.
Varieties-
Four pairs of para-nasal
sinuses:
 The Maxillary,
 The Frontal,
 The Ethmoid,
 The Sphenoid,

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Sinusitis-
Inflammation of the lining mucus membrane of a
sinus as a result of infection, allergy, structural or
mechanical abnormalities,
Multi- Sinusitis- If more than one sinus is infected,
Pan- Sinusitis- If all the sinuses are involved in the
inflammatory process,
Universal Law
“Where there is stasis, there is infection.”
Normally, secreted mucus is kept cleared off by the
action of gravity, of course aided by ciliary action
but when the ostium is obstructed, the mucus
collects in the sinus and gets infected, giving rise to
sinusitis,

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Classification
 Acute Sinusitis-
Infection of sinuses that lasts less than two weeks
and responds to antibiotic therapy,
 Chronic Sinusitis-
Infection of sinuses that lasts longer than two
weeks, require longer courses of medical
therapy, and may require surgery.
 Recurrent Sinusitis-
Either acute or chronic; it starts to resolve but
recurs because the treatment is either
inadequate or is stopped prematurely,

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…Classification
Catarrhal
Acute
Suppurative (Gram + cocci, i.e.
Sinusitis Strept./ Staph. /Pneumo. & H. influenzae)
Catarrhal
Chronic
Suppurative (Mix Gram + cocci &
Gram – bacilli)

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Pathogens
 Acute Sinusitis- Aerobic bacteria like
streptococcus pneumoniae, haemophilus influenzae,
moraxella catarrhalis; Anaerobic bacteria (10%)-; Viral
(10-20%)- rhinovirus, influenza virus;
 Chronic Sinusitis- Anaerobic bacteria like
peptococcus, streptococcus, either alone or in
combination with aerobic bacterium like
staphlococcus aureus;
 Nosocomial Sinusitis- commonly due to
pseudomonas aeruginosa, klebsiella pneumoniae,
enterobactor species & proteus mirabilis,
 Fungal Sinusitis- Aspergillosis, mucormycosis,

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Patho- physiology
Located in the cheeks, the maxillary sinuses are the
largest. The natural ostium of each maxillary sinus is
situated high above the floor of the sinus, and the
evacuating effect of gravity is unfortunately missing.
No wonder, therefore that this sinus is the most
commonly infected. Infection of other sinuses is
frequently secondary to the infection of maxillary
sinus. Thus, treatment directed towards the maxillary
sinus often cures the secondarily infected sinuses.
For these reasons, the maxillary sinus is often called
the ‘master’ sinus.
Contd…

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The mucus membranes of the nose and sinuses
normally produce 1 to 2 liters of mucus a day. If the
nasal passages become irritated by allergies, air
pollution, smoke or infection, more clear watery
mucus is produced to wash away irritants or
foreign substances. This profuse secretion is the
most common cause of postnasal drip. Bacterial
infections produce a thick, sticky mucus containing
pus, which is usually yellow or green.
This mucus blanket is
propelled backwards by the
metachronous movement of
cilia. Therefore lack of ciliary
movement will also result in
stasis and infection.

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Aetiology
 All cases of rhinitis by continuity of mucosa through
sinus ostia,
 Acue infectious fevers, concerned with the
respiratory tract/ or through blood stream,
 Trauma (accidental)- e.g. RTAs, gun shot injuries,
and trauma (operative)- e.g. SMR, polypectomy,
 Severe deflected septum pressing on the lateral
wall,
 Nasal polypi, adenoids, tonsillitis tend to cause stasis,
 Infections in the pharynx, the larynx, the tracheo-
bronchial tree and the lungs,
Contd…

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 Root abscess in Teeth (bicuspid & tricuspid)/ dental
extraction leading to oro-antral fistula- 10% of all
cases are dental in origin,
 Bathing and diving in infected water,
 Poor state of health with lowered body resistance,
an imbalanced diet with excess of starches & little
proteins/ vitamins; dark, damp, overcrowded living
conditions, favour cross- infection,
 Wet and cold weather,
 Sedentary occupations & working conditions with
dusty, polluted atmosphere,

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Pathology
 Acute catarrhal stage- Hyperema and
swelling of sinus mucosa with exudation of some
thin mucoid discharge; under microscope,
blood vessels are seen dilated with slight
leucocytic infiltration, cilia present on lining
mucosa,
 Acute suppurative stage- Mucosal swelling
increases, cilia may be shed off with gross
leucocytic infilteration- polymorphs and
eiosinophilia, retension of discharge in the sinus
cavity due to blocked ostia,
Contd…

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 Chronic suppurative stage- Gross hypertrophy
of sinus mucosa leading to polypoidal
excrescences, easily seen on x-ray examination;
mucosa may be shed off in places or may have
undergone stratified squamous metaplasia; in late
cases, erosion of the wall of the sinus in some
places and thickening in others; At some places,
there may be polypus or cyst formation in the
mucus membrane and in other places, sinus
mucosa may have undergone atrophy.

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Symptoms
Local-
 A sense of fullness or tension around
the affected sinus, aggravated on
stooping & coughing,
 Pain in cheek below the eye and
upper teeth on affected side, may
refer to supra-orbital region,
 Puffiness over the face, forehead or
the eyelids,
 Nasal discharge- muco-purulent or
purulent, moderate in amount,
General-
 Rise of temperature, rise of pulse rate,
and other symptoms of generalized
toxemia,

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Examination
 First of all, see pt. as such:
looks very toxic with raised
temperature & pulse, flushed
face, appear in agony,
On local exam.-
 Ant. Rhinoscopy shows
congestion and swelling of
nasal mucosa, septum seen in
contact with swollen turbinals,
with thin or thick discharge,
 Post. Rhinoscopy shows
generalized congestion and
discharge sticking to the
boundaries of post. nares &
walls of naso-pharynx,
Contd…

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 Palpation elicits tenderness over
the affected sinus. with
comparison to the opposite side,
provided it is healthy. Tapping over
the sinus is also helpful,
Hyperasthesia tested with wool or
pin prick gives additional
information,
 Trans-illumination test- a small bulb
placed in pt.’s mouth in a dark
room lits the skull and sinuses. If
both sides illuminate equally, either
both sides are healthy or they are
equally diseased. If one side
illuminates less than the other, that
side may be at fault from
collection of pus, blood or growth
in the antrum. Test is not carried
out below the age of nine, and is
only 50% trustworthy,
Palpation of Max. sinus
Contd…

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X-rays are trustworthy in 90% cases when taken in suitable
positions, False haziness of a sinus means thickened
mucosa, growth or blood in the sinus, thick normal bones
or swollen overlying tissues unless fluid level can be seen in
the suspected sinus; therefore, x-rays should be
considered in association with history & clinical
examination.
Lt. Max. SinusitisPansinusitis

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Fluid level in the Lt. max.
sinus in a case of Acute
Max. Sinusistis.
Bil. Hazy Max. Sinuses
in a case of Chronic
Max. Sinusitis.

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Laboratory workup
 CBC with a differential white blood count
provides useful information regarding infection,
 ESR monitors the course of infection,
 Culturing of sinus discharge, ideally when the
patient is not being treated with antibiotics, is the
most important test.

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Recent sinus investigations
 Sinogram- Ultrasonic examination of a sinus to
differentiate fluid or mucosal thickening from a solid
growth,
 Sinocopy- Physical examination of a sinus by a
fibroptic sinoscope, now performed in the physician’s
office; clarifies the diagnosis in patients who are not
responding adequately to medical treatment,
 CT Scan- Imaging studies are indicated for refractory
or recurrent sinusitis; sinusitis with complications and
preparations for surgery to build a `road map` that
the surgeon follows during surgery,
 MRI Scan- used to access soft tissue changes and to
evaluate the extent of sinus tumor.

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Clinical correlation of radiological findings
is essential

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 Orbital Complications
 Inflammatory oedema
 Orbital cellulitis
 Subperiosteal abscess
 Orbital abscess
 Cavernous sinus thrombosis
 Intracranial Complications
 Meningitis
 Epidural abscess
 Subdural abscess
 Brain abscess
 Misc.Complications
 Osteomyelitis of the Skull
 Osteomyelitis of superior Maxilla
 Mucocele or pyocele
Complications

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…Complications
Because of these serious consequences, physician
must learn to diagnose the disease and be ready to
treat it aggressively. Any sign of intra-orbital or
intracranial spread demands contrast enhanced CT
scan of the head in both axial and coronal planes.
Complications of sinusitis usually follow the acute
stage of the disease or occur during an acute
exacerbation of a chronic infection

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Signs of Complications
 Generalized persistent headache
 Vomiting
 Convulsions
 Chills or high fever
 Edema or increasing swelling of the forehead
or eyelids
 Blurring of vision, diplopia, or persistent
retroocular pain
 Signs of increased intracrial pressure
 Personality changes or dulling of the
sensorium.

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Treatment
Inflammatory sinus disease is first treated
conservatively with medication.
GOAL OF MEDICAL TREATMENT
“Re-establish patency of the sinus ostea &
restore normal mucociliary clearance”
CAUSE OF THE INFLAMMATION OR OBSTRUCTION
MUST BE TARGETTED FOR MEDICAL THERAPY TO BE
SUCCESSFUL
 Allergy
 Nasal polypi etc.

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 General
“Complete rest in bed, easily digestible nourishing diet,&
analgesia for the relief of pain is usually rewarding.”
 Antibiotics:
Acute and chronic sinus infections should be treated with
antibiotic to eradicate causative bacteria.
Ideally antibiotic is chosen after a nasal swab for C/S or
sinus aspirate for C/S.
Generally treatment is started with broad spectrum
antibiotics, i.e. ampicillin or amoxicillin, given 14 days for
acute sinusitis or 3-4 weeks for chronic Sinusitis, they are
effective against the most likely pathogens; if ineffective, a
second generation cephalosporin may be used for 3-6
weeks.
 Anti-histamines are effective in relieving the allergic
symptoms, use of topical or oral corticosteroids may help
reduce inflammation and secretions.
contd…

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 Allergic Desensitization- In patients with seasonal allergies,
desensitization (allergy shots) may help relieving chronic
symptoms,
 Sinus drainage & irrigation- With clogged sinus ostia and
failed drainage system, nasal decongestant sprays to open
up sinus channels are more helpful than antihistamines and
corticosteroids & help restore normal drainage. Oral
decongestants reduce nasal and sinus mucosal congestion
and can be used over a long period of time. Saline nasal
douches are also helpful in restoring nasal mucociliary
function and in return improve sinus drainage. When
medical treatment fails, mechanical irrigation and
aspiration is undertaken.
 Antifungal Chemotherapy- Is sometimes required
especially in cases of rhinocerebral mucormycosis or
aspergillosis with or without surgical removal of disease
depending on the extent of disease.

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