anatomy

1. Sinusitis

2. Paranasal Sinuses: Anatomy
• There are four pairs of paranasal sinuses.
• The Frontal sinuses, above the eyes in the frontal bone
• The Maxillary sinuses, in the cheekbones, under the eyes.
• The Ethmoid sinuses (Anterior, Middle and Posterior) also called
ethmoid labyrinth are located between the eyes and the nose.
• The Sphenoid sinuses (1 or 2) are located in the body of sphenoid
bone, behind the nose and the eyes.
• They are lined by:
Pseudostratified ciliated
columnar epithelium.

3. • Anterior group : Maxillary, Anterior Ethmoidal and frontal sinuses.
• Posterior group : Sphenoidal and posterior Ethmoidal sinuses.
• Anterior group they open at the hiatus semilunaris in the middle meatus.
• Posterior group open at the spheno-ethmoidal recess above the superior
turbinate into the superior meatus.

4. Function of the paranasal sinuses
• Exact function unknown, But:
1. Act as resonance to the voice.
2. Reduce the weight of the skull.
3. Protect the eyes.
4. Humidifying and warming inspired air.

6. Sinusitis
• Inflammation of the lining of the paranasal sinuses.
• Rhinosinusitis is now the preferred term for this condition.
• According to duration:
1. Acute < 1 month.
2. Subacute 1-3 months.
3. Chronic > 3 month.
• Recurrent sinusitis: Episodes of paranasal sinuses infection, each
lasting less than 30 days and separated by intervals of at least 10
days during which the patient is asymptomatic. (4 per yr).

7. Pathophysiology:
• The sinuses are lined by respiratory epithelium mucosa. Superficial viscous layer
and underlying serous layers.
• Normal function depends on patent Ostia, Ciliary function and quality of mucosa.

8. Risk Factors
• Common Cold
• Cystic Fibrosis
• Immotile cilia syndrome
• Nasogastric or Nasotracheal tube
• Immunodeficiency
• Nasal polyps or tumors
• Nasal foreign bodies
• Structural problems

9. Ostial
obstruction:
Inflammation
URTI
Allergy
Mechanical
Septal deviation
Turbinate
hypertrophy
Polyps
Tumors
Adenoid
hypertrophy
Congenital
abnormalities
Foreign
body
Non-ostial
obstruction
Direct extension
Dental
Trauma
Systemic
Cystic fibrosis
Immotile cilia
syndrome
Immune
Lymphoma,
leukemia
Wegener's
granulomatosis
Immunosuppres
sed patients
ETIOLOGY:

10. Acute Sinusitis:
• Etiology
• Viral (most common): Rhinovirus, influenza, parainfluenza.
• Bacterial: S.pneumoniae (35%), nontypable H.influenza (35%), Moroxella catarrhali, less common
(S.aureus, anaerobics (dental).
• Must rule out fungal causes in immunocompromised patients. (Aspergillus, Zygomycetes; Mucor
Rhizopus)
• Nosocomial sinusitis caused by gram –ve bacteria (Klebsiella and Pseudomonas), are common in
cases of nasogastric and nasotracheal tubes.
• Viral infection can progress to acute bacterial sinusitis. ( most common risk factor for bacterial
sinusitis).
• Acute sinusitis is a clinical diagnosis.

11. Diagnosis
• 2 or more major factors
• 1 major & 2 minor factors
• Major factors:
• Facial pain/pressure
• Facial fullness/congestion
• Nasal obstruction
• Purulent nasal discharge
• Hyposmia/anosmia
• Fever
• Minor Factors:
• Headache
• Halitosis
• Fatigue
• Dental pain
• Cough
• Ear pressure/ fullness
 Acute Viral infection lasts for <10 days, if symptoms increase after 5 days or
last longer than 10 days, consider bacterial etiology.
 Anterior rhinoscopy can be done.
 X-ray/ CT scan not recommended unless complications are suspected.

12. Management
• Mild Symptoms improving within 5 days: symptomatic relief "decongestant" and
watchful management.
• Moderate symptoms that worsen or persist beyond 5 days: intranasal corticosteroid
spray for 14 days if symptomatic relief is noted within 48 hours.
• Severe symptoms that worsen or persist beyond 5 days and refractory to intranasal
corticosteroid: Augmentin (Drug of choice) or clarithromycin therapy ± INCS ± referral
to a specialist or if there is a late complication.

13. Secondary Antibiotics for Acute Sinusitis
• No response to TX within 3-5 days
• Symptoms present for more than 30 days
• Recurrent sinus infections
• Can give:
• 2nd or 3rd generation cephalosporins (eg, cefuroxime, cefpodoxime, cefdinir)
• macrolides (ie, clarithromycin)
• fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin)
• clindamycin.

14. • Surgical if medical
therapy fails:
• Functional endoscopic
sinus surgery (FESS) :
Opening of the entire
OMC to facilitate
drainage.
• Antral washout:
Irrigation of the
maxillary sinus through
its natural ostium or
through a puncture of
the inferior meatus
(careful of
nasolacrimal duct)

15. Complications
1.Orbital (Chandler's classification)
• Periorbital cellulitis
• Orbital cellulitis
• Sub periosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis (The most
important sign is pulsating proptosis)
2.Intracranial
• Meningitis
• Abscess
3.Bony
• Sub periosteal frontal bone abscess- Pott's
Puffy tumor
• Osteomyelitis
4.Neurologic

16. Pott’s puffy tumors
• Characterized by an osteomyelitis of the frontal bone with
frontal breakthrough.
• This results in a swelling on the forehead.
• The infection can also spread inwards, leading to an
intracranial abscess.
• Although it can affect all ages, it is mostly found among
teenagers and adolescents.

17. Chronic sinusitis
Results from:
• Inadequate treatment of acute sinusitis
• Untreated nasal allergy
• Allergic fungal rhinosinusitis
• Anatomic abnormality e.g. deviated septum
• Underlying dental disease
• Ciliary disorder e.g. cystic fibrosis, Kartagener's
• Chronic inflammatory disorder e.g. Wegener's

18. Diagnosis
• Sinus aspirate culture is the most accurate but is not practical or
necessary.
• Trans illumination can show fluid but its not reliable.
• CT is the gold standard for sinuses
• MRI
• Conventional Radiology( 4 views):
• Water's view (Occipitomental view): best for Maxillary.
• Caldwel view (Occipitofrontal view): best for Frontal.
• Lateral soft tissue view show adenoid, Sphenoidal sinus and sella turcica.
• Submentovertical view (bucket-handle) show Ethmoidal sinuses.

19. 1.Water's view "with opened mouth" Shows maxillary sinuses, frontal sinuses, anterior
ethmoidal sinuses & via the mouth, the sphenoidal sinuses. Best for maxillary sinuses.

20. 2. Caldwel view (Occipitofrontal view): Shows frontal, maxillary & anterior
ethmoidal sinuses. Best for frontal sinuses.

21. • 3. Lateral soft tissue view: Shows adenoids, sphenoidal sinuses & sella
turcica. Lateral soft tissue view of the neck and upper thoracic region is
ordered if there is suspicion of foreign body

22. •
4. Submentovertical view (bucket-handle): Shows ethmoidal
sinuses.

25. Management
• Antibiotics for 3 to 6 weeks for infectious etiology
• Augmentin (40-50 mg/kg/day).
• Amoxicillin is the best in children (80-90 mg/kg/day).
• Macrolides, Fluroquinolone, clindamycin, flagyl.
• Topical nasal steroid
• Nasal irrigation
• Decongestants
• Surgery, if medical therapy fails or fungal infection
• Remove all disease soft tissue and bone, and obliterate pre-existing sinus
cavity.
• FESS

26. Thank you