1. Sinusitis
Prepared by: Nibal Shawabkeh
Supervised by: Dr. Adel Adwan
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2. 2
They are hollow, air-
filled cavities that are
lined by respiratory
mucosa “
pseudostratified
ciliated columnar
epithelium”
Sinuses

3. 3
 There are four pairs of paranasal
sinuses;
 The frontal sinuses are located
above the eyes, in the frontal bone
 The maxillary sinuses are located in
the cheekbones, under the eyes.
 The ethmoid sinuses(6 – 10 per
side), also called ethmoid labyrinth
are located between the eyes and
the nose.
 The sphenoid sinuses(2) are
located in the body of sphenoid
bone, behind the nose and the
eyes.
THE PARANASAL SINUSES

4. 4
 Exact function unknown.
 Resonators of the voice.
Reduce the weight of the skull.
Protect the eye
Increasing the olfactory surface area.
Function Development
of sinuses
1. The ethmoid and maxillary
sinuses are present at birth.
2. The frontal sinus develops about
the seven year of age .
3. The sphenoid about the fifth
year.

5. Sinusitis is characterized by inflammation of the
lining of the paranasal sinuses.
Because the nasal mucosa is simultaneously
involved and because sinusitis rarely occurs without
concurrent rhinitis, RHINOSINUSITIS is now the
preferred term for this condition.
5 Sinusitis
Definition

6. Pathophysiology:
 The sinuses are lined by
respiratory epithelium
mucosa. Superficial
viscous layer and
underlying serous layers.
 Normal function
depends on
 Patent Ostia
 Ciliary Function
 Quality Of Mucosa.
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 The most important pathological process:
 Mucosal edema resulting from a viral rhinosinusitis→obstruction of
natural ostia → hypooxygenation → acidosis → vasodilation →
increased secretion by goblet cells → ciliary dysfunction with poor
mucous quality → retention of secretion and predisposition to
bacterial infection.

7. Risk factors:
 1. The common cold: major predisposing factor at all ages.
 2. Cystic fibrosis.
 3. Immunodeficiency, HIV infection.
 4. Nasogastric or nasotracheal intubation.
 5. Immotile cilia syndrome.
 6. Nasal polyps.
 7. Nasal foreign body.
 8. Cold air.
 9. Tumor.
 10. Rhinitis
Anything that blocks mucus from exiting the sinuses
predisposes them to inflammation.
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8. Etiology:
Ostial obstruction
Non-ostial obstruction
Direct extension
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9. Ostial obstruction:
 Inflammation
 - URTI
 - Allergy
 Mechanical
 - Septal deviation
 - Turbinate hypertrophy
 - Polyps
 - Tumors
 - Adenoid hypertrophy
 - Foreign body
 - Congenital abnormalities i.e. cleft palate
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10. Non-ostial obstruction:
 Immune
 - Wegener's granulomatosis
 - Lymphoma, leukemia
 - Immunosuppressed patients (e.g. neutropenics, diabetics, HIV)
 Systemic
 Cystic fibrosis
 Immotile cilia syndrome (Kartagener's)
 Triad of:
 1. Sinusitis
 2. Bronchiectasis
 3. Situs inversus
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11. Direct extension:
Dental
Infection
Trauma
Facial fractures
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12. Bacteria causing sinusitis include:
1. S. pneumoniae
2. Nontypable H. influenzae
3. Maroxella catarrhali
4. Less commonly: S. aureus, other streptococci, and anaerobes.
 Indwelling nasogastric and nasotracheal tubes predispose to
nosocomial sinusitis, which is often caused by gram-negative
bacteria (Klebsiella and Pseudomonas).
 Antibiotic therapy predisposes to infection with antibiotic-resistant
organisms.
 Sinusitis in neutropenic and immunocompromised persons may be
caused by Aspergillus and the Zygomycetes (e.g., Mucor,
Rhizopus).
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13. Fungal sinusitis is divided into:
1. Invasive: it is usually caused by Mucor, it has a very high mortality rate
because it causes
 destruction and necrosis to the bone and may reach the brain. It occurs in
immunocompromised patients
2. Non-invasive
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14. Classification According to duration:
Acute < 1 month.
Subacute 1-3 months.
Chronic > 3 month.
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15. Acute suppurative sinusitis
Definition:
 Acute infection and inflammation of the paranasal
sinuses.
 Clinical diagnosis requiring at least 2 major symptoms or
1 major symptom and 2 minor symptoms
 Major symptoms
 Facial pain/ pressure
 Facial fullness/ congestion
 Nasal obstruction
 Purulent/ discolored nasal discharge
 Hyposmia/ anosmia
 Fever
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 Minor symptoms
 Headache
 Halitosis
 fatigue
 Dental pain
 Cough
 Ear pressure/ fullness

16. Acute suppurative sinusitis
Etiology:
 Viral vs. bacterial
 Children are more prone to a bacterial etiology than adults, but viral is still more
common
 Maxillary sinus most commonly affected
 Must rule out fungal causes (mucormycosis) in immunocompromised hosts (especially if
painless, bloodless mucosa on examination)
 Organisms:
 Viral (most common): rhinovirus, influenza, parainfluenza
 Bacterial: S. pneumoniae (35%), H. influenzae (35%), M. catarrhalis, anaerobes (dental)
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17. Acute suppurative sinusitis
Management:
 Anterior rhinoscopy
 x-ray/ CT scan not recommended
unless complications are suspected
(i.e. sub-periorbital abscess or
intracranial) spread – Pitt's Puffy
tumor.
 Symptoms improving within 5 days:
symptomatic relief "such as
decongestant" and expectant
management.
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18. Acute suppurative sinusitis
Management: cont.
 Moderate symptoms that worsen or persist beyond 5
days:
 institute an intranasal corticosteroid spray and continue
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
(INCS):
 Augmentin (Drug of choice) or clarithromycin therapy ±
INCS ± referral to a specialist or if there is a late
complication.
 Surgery if medical therapy fails:
1. FESS
2. Antral washout
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19. Acute suppurative sinusitis
Complications:
 Consider hospitalization if any of the following
are suspected:
 1. Orbital (Chandler's classification)
 a. Periorbital cellulitis
 b. Orbital cellulitis
 c. Subperiosteal abscess
 d. Orbital abscess
 e. Cavernous sinus thrombosis (The most
important sign is pulsating proptosis)
 2. Intracranial
 a. Meningitis
 b. Abscess
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 3. Bony
 a. Subperiosteal frontal
bone abscess (Pott's
Puffy tumor)
 b. Osteomyelitis
 4. Neurologic
 a. Superior orbital
fissure syndrome (CN
III/IV/VI palsy, immobile
globe, dilated pupils,
ptosis)
 b. Orbital apex
syndrome (as "a" above
plus neuritis,
papilledema,
decreased acuity)

20. 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.
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21. Chronic sinusitis
Definition:
Inflammation of the paranasal sinuses lasting > 3 months.
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22. Chronic sinusitis
Etiology:
 Can result from any of the following:
 - Inadequate treatment of acute sinusitis
 - Untreated nasal allergy
 - Allergic fungal rhinosinusitis
 - Anatomic abnormality e.g. deviated septum (predisposing factor)
 - Underlying dental disease
 - Ciliary disorder e.g. cystic fibrosis, Kartagener's
 - Chronic inflammatory disorder e.g. wegener's
 Organisms:
 - Bacterial: S. pneumonia, H. influenza, M. catarrhalis, S.pyogenes, S.aureus,
anaerobes
 - Fungal: Aspergillus
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23. Chronic sinusitis
Clinical features:
(similar to acute, but less severe)
 Chronic nasal obstruction
 Purulent nasal discharge
 Pain over sinus or headache
 Halitosis
 Yellow-brown post-nasal discharge
 Chronic cough
 Maxillary dental pain
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Sinobronchial syndrome:
Post nasal drip in chronic sinusitis
causing lower respiratory tract
symptoms such as chronic cough
Allergic fungal rhinosinusitis is a chronic sinusitis affecting mostly young, immunocompetent,
atopic individuals. Treatment options include FESS ± intranasal topical steroids, antifungals
and immunotherapy.

24. Chronic sinusitis
Diagnosis:
 Cultures of the nasal mucosa in not useful.
 Sinus aspirate culture is the most accurate
diagnostic method but is not practical or
necessary.
 Transillumination: show evidence of fluid,
difficult to perform in children and is not
reliable.
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25. 25
Conventional Radiographs, 4
views:
1. Water's view
(Occipitomental view):
"with opened mouth"
Shows maxillary sinuses,
frontal sinuses, anterior
ethmoidal sinuses & via the
mouth, the sphenoidal
sinuses. Best for maxillary
sinuses.
2. Caldwell view
(Occipitofrontal view):
Shows frontal, maxillary &
anterior ethmoidal
sinuses. Best for frontal
sinuses.

26. 26 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.
4. Submentovertical
view (bucket-handle):
Shows ethmoidal
sinuses.

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Signs of sinusitis on
X ray:
1. Air-fluid level
2. Sinus opacity or clouding
3. Mucosal thickening, but it is not specific for sinusitis, it may
occur in simple rhinitis.
CT: The gold standard for sinuses.
MRI

28. Chronic sinusitis
Treatment:
 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), macrolide (clarithromycin), fluoroquinolone
(levofloxacin), clindamycin, Flagyl TM
 Topical nasal steroid, saline therapy
 Surgery if medical therapy fails or fungal sinusitis
 Removal of all diseased soft tissue and bone, post-op drainage
and obliteration of pre-existing sinus cavity
 FESS
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29. Chronic sinusitis
Complications:
1. Polyps
2. Mucocele (frontal and ethmoid)
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30. End of Lecture
March 2014
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