ACUTE SINUSITIS, ENT Seminar, College of Medicine, King Faisal University Al-Ahsa, Saudi Arabia

1. ACUTE SINUSITIS
Abdullatif Sami Al Rashed
ENT Block 5.6
College of Medicine, King Faisal University
Al Ahsa, Saudi Arabia

2. Introduction
• The sinus most commonly involved is the maxillary followed in
turn by ethmoid, frontal and sphenoid.
• Very often, more than one sinus is infected (multisinusitis).
Sometimes, all the sinuses of one or both sides are involved
simultaneously (pansinusitis unilateral or bilateral)
• Sinusitis may be “open” or “closed ” type depending on whether
the inflammatory products of sinus cavity can drain freely into
the nasal cavity through the natural ostia or not.
• A “closed” sinusitis causes more severe symptoms and is also
likely to cause complications.

3. AETIOLOGY OF SINUSITIS IN
GENERAL
1. Nasal infections.
• Most common cause of acute sinusitis is viral rhinitis followed by bacterial invasion.
2. Swimming and diving.
3. Trauma.
4. Dental infections.
• This applies to maxillary sinus
5. Obstruction to sinus ventilation and drainage
• (a) Nasal packing
• (b) Deviated septum
• (c) Hypertrophic turbinates
• (d) Oedema of sinus ostia due to allergy or vasomotor rhinitis
• (e) Nasal polypi
• (f) Structural abnormality of ethmoidal air cells
• (g) Benign or malignant neoplasm.
6. Stasis of secretions in the nasal cavity.
7. Previous attacks of sinusitis
8. Environment.
• Sinusitis is common in cold and wet climate.
9. Poor general health

4. BACTERIOLOGY
• Most cases of acute sinusitis start as viral infections
followed soon by bacterial invasion such as:
• Streptococcus pneumoniae, Haemophilus influenzae, Moraxella
catarrhalis,
• Streptococcus pyogenes, Staphylococcus aureus and Klebsiella
pneumoniae.
• Anaerobic organisms and mixed infections are seen in sinusitis of
dental origin.

5. ACUTE MAXILLARY
SINUSITIS

6. Introduction
• Clinical features depend on:
• (i) severity of inflammatory process and
• (ii) efficiency of ostium to drain the exudates.
• Closed ostium sinusitis is of greater severity and leads
more often to complications.

7. Pain
situated over the upper jaw, but may be referred to the gums
or teeth
Pain is aggravated by stooping, coughing or chewing.
Occasionally, pain is referred to the ipsilateral supraorbital
region and thus may simulate frontal sinus infection.
Headache
is confined to forehead and may thus be confused with frontal sinusitis
Constitutional symptoms
fever, general malaise and body ache. They are the result of toxaemia.
Clinical features

8. Postnasal discharge.
Pus may be seen on the upper soft palate on posterior rhinoscopy or nasal endoscopy.
Nasal discharge
Anterior rhinoscopy/nasal endoscopy shows pus
or mucopus in the middle meatus.
Postural test. If no pus seen in the middle
meatus
Redness and edema of cheek
Commonly seen in children. The lower eyelid may become puffy.
Tenderness
Pressure or tapping over the anterior wall of antrum produces pain
Clinical features

9. DIAGNOSIS
• Transillumination test:
• Affected sinus will be found opaque.
• X-rays.
• Waters’ view will show either an opacity or a fluid level in the
involved sinus.
• Computed tomography (CT) scan
• is the preferred imaging modality to investigate the sinuses.

10. TREATMENT
• Medical TTT:
• Antimicrobial drugs
• Nasal decongestant drops
• Steam inhalation
• Analgesics
• Hot fomentation
• Surgical TTT:
• Antral lavage  if medical TTT failed

11. COMPLICATIONS
1. Acute maxillary sinusitis may change to subacute or
chronic sinusitis.
2. Frontal sinusitis. Due to obstruction of frontal sinus
drainage pathway because of oedema.
3. Osteitis or osteomyelitis of the maxilla.
4. Orbital cellulitis or abscess.

12. ACUTE FRONTAL
SINUSITIS

13. Clinical Features
• Usually severe and localized over the affected sinus.
• It shows characteristic periodicity
• It is also called “office headache” because of its presence
only during the office hours.
Frontal Headache
• It can also be elicited by tapping over the anterior wall of frontal sinus in the
medial part of supraorbital region.
Tenderness
Edema of upper eyelid with suffused conjunctiva and
photophobia
• A vertical streak of mucopus is seen high up in the anterior part of the middle
meatus
Nasal discharge

14. Investigations
• X-rays.
• Opacity of the affected sinus or fluid level can be seen. Both
Waters’ and lateral views should be taken.
• CT scan
• is the preferred modality

15. Treatment
• Medical TTT:
• Same as ACUTE MAXILLARY SINUSITIS
• treatment is continued for full 10 days to 2 weeks.
• Surgical TTT:
• Trephination of frontal sinus:
• If there is persistence or exacerbation of pain or pyrexia in spite of
medical treatment for 48 h,
• or if the lid swelling is increasing and threatening orbital cellulitis, frontal
sinus is drained externally.

16. COMPLICATIONS
1. Orbital cellulitis.
2. Osteomyelitis of frontal bone and fistula formation.
3. Meningitis, extradural abscess or frontal lobe abscess,
• if infection breaks through the posterior wall of the sinus.
4. Chronic frontal sinusitis,
• if the acute infection is neglected or improperly treated.

17. ACUTE ETHMOID
SINUSITIS

18. Introduction
• Acute ethmoiditis is often associated with infection of
other sinuses.
• Ethmoid sinuses are more often involved in infants and
young children.

19. CLINICAL FEATURES
1. Pain
• It is localized over the bridge of the nose, medial and deep to the
eye. It is aggravated by movements of the eye ball
2. Edema of lids
• Both eyelids become puffy and swollen. There is increased
lacrimation. Orbital cellulitis is an early complication in such cases
3. Nasal discharge
• On anterior rhinoscopy, pus may be seen in middle or superior
meatus depending on the involvement of anterior or posterior group
of ethmoid sinuses.
4. Swelling of the middle turbinate

20. TREATMENT
• Medical treatment is the same as for acute maxillary
sinusitis.
• Visual deterioration and exophthalmos indicate abscess in
the posterior orbit and may require:
• drainage of the ethmoid sinuses into the nose through an external
ethmoidectomy incision.

21. COMPLICATIONS
1. Orbital cellulitis and abscess.
2. Visual deterioration and blindness due to involvement of
optic nerve.
3. Cavernous sinus thrombosis.
4. Extradural abscess, meningitis or brain abscess.

22. ACUTE SPHENOID
SINUSITIS

23. Introduction
• Isolated involvement of sphenoid sinus is rare. It is often a
part of pansinusitis or is associated with infection of
posterior ethmoid sinus

24. CLINICAL FEATURES
• Headache.
 Usually localized to the occiput or vertex. Pain may also be
referred to the mastoid region.
• Postnasal discharge.
 It can only be seen on posterior rhinoscopy. A streak of pus may
be seen on the roof and posterior wall of nasopharynx or above the
posterior end of middle turbinate.

25. Investigations
• X-rays.
• Opacity or fluid level may be seen in the sphenoid sinus. Lateral
view of the sphenoid sinus is taken in supine or prone position and
is helpful to demonstrate the fluid level
• CT scan
• is the preferred modality

26. DIFFERENTIAL DIAGNOSIS
• Mucocele of the sphenoid sinus or its neoplasms may
clinically simulate features of acute infection of sphenoid
sinus and should always be excluded in any case of
isolated sphenoid sinus involvement.

27. Treatment
• Treatment is the same as for acute infection of other
sinuses.

28. Reference

29. Thank You 