ENT

DISEASES OF THE PARANASAL SINUSES

Dra. Karen
063009
Epidemiology
Rhinovirus, respiratory syncytial virus,
influenza virus, corona virus
One of the most frequent complaints
General considerations
Infection may affect the entire respiratory tract
Pathologic change determines by the
predominance of the infection in a particular
area
Concurrent exacerbation of sinus and
pulmonary disease SINUBRONCHIAL
SYNDROME
Sinusitis in Children
Maxillary and ethmoid sinuses are present at
birth
Frontal sinuses develop at 8y/o and is absent or
rudimentary in 20% of population
Etiologic agents
Acute
o Strep pneumonia
o H. influenzae
o Moraxella catarrhalis
*same pathogen with OM
Chronic sinusitis
o Bacteroides sp.*
o Anaerobic gm (+) streptococci*
o Fusobacterium sp.
o a-hemolytic streptococci
o Hemophilus sp.
*dental origin
Etiologic agents in chronic sinusitis
Acute symptomatic exacerbation may be due
to the same organisms as acute sinusitis
In quiescent stages, chronic sinus disease is
due to inadequate mucociliary function or
obstructed drainage
S. aureus in chronic that acute
Fungi in cases resistant to multiple antibiotic
courses (aspergillus)
Pseudomonas associated in chronic sinusitis
Cycle leading to sinusitis
Mucosal congestion or anatomical obstruction
blocks air flow drainage
Secretions stagnate and thicken
Ph changes
Mucosal gas metabolism changes
Cilia and epithelium are damaged
Retained secretions
*starts usually with a common cold
Key area Ostiomeatal complex
Where everything drains

DISEASES OF THE PARANASAL SINUSES

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Lamina papyracea thin egg shell like bone

that comprises the medial wall of the orbit
In children: infection can go easily to the eyes
ACUTE SINUSITIS
Sinus infection >7days to 12 weeks
(+) purulent discharge
NO residual mucosal damage
*will totally resolve
CHRONIC SINUSITIS
Persistent sinus disease >3months
(+)purulent discharge
WITH residual mucosal damage
MAXILLARY SINUSISTIS
Maxillary: 15ml
Follows a mild URTI
Predisposing factors:
o Chronic nasal allergies
o Nasal polyps
o Foreign body (NGT, ET, nasal packing)
o Nasal septal deviation
o Cleft palate
o Dentoalveolar abscess
Symptoms
o Fever
o Malaise
Signs
o Mucopurulent secretions from the nose
r postnasal drip
o May be foul smelling
o Tenderness upon palpation
Maxillary sinusitis of dental origin
Unilateral
Foul-smelling
o Bacterial flora form mouth can go
straight to sinus
Gram negative anaerobic infection
ETHMOID SINUSITIS
Common in children
May present as ORBITAL CELLULITIS
In adults, accompanies frontal sinusitis
May precede CAVERNOUS SINUS THROMBOSIS
o Cavernous valveless
Symptoms
o Pain between eyes
Signs
o Tenderness on palpation
FRONTAL SINUSITIS
Almost always associated with anterior
ethmoid infection
Predominantly seen in adults
Associated with a characteristic headache
Signs:
o Excruciating tenderness to pressure
pathognomonic sign
SPHENOID SINUSITIS
Most of the time group infection
Pain in the vertex of the skull

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DISEASES OF THE PARANASAL SINUSES

o
SINUS
-

HEADACHE
Frontal
Sphenoid
Ethmoid
Pain in orbital area

o
o

Complications of SINUSISTIS
Mucocoele
Orbital complications

NASAL POLYPS
Associated with allergy, cystic fibrosis,
Samters triad
o Samters triad asthma, nasal polyps,
aspirin intolerance
Originate at the lateral nasal wall/middle
meatus
Usually bilateral
Usually common in adults >20y/o
No gender predilection
Symptoms of nasal obstruction, rhinorrhea and
sinus facial syndrome
3 important factors
o Chronic recurrent mucosal
inflammation
o Abnormal vasomotor responses
o Mechanical problems related to
interstitial edema

Blockage to ostiomeatal
complex
Major basic protein from eosinophils damage
the BM allowing prolapse of the lamina propria
Mygind: histamine release
May occlude sinus ostia and drainage to
produce acute or chronic sinusitis
Benign disease, more of inflammatory
o Grows massively and can press on the
area

Complete ENT Exam

Anterior and posterior rhinoscopy
o Purulent discharge
Nasal endoscopy
o Unilateral nasal symptoms
o Suspecting tumors
Transillumination
Otoscopy
o OM with effusion
Oral cavity exam
o Purulent postnasal drip
Check neck
o For neck masses
*Nasal polyps gel-like
-

Sinuscopy
o Instances when doing biopsy

Diagnostic Examination
Paranasal Sinus X-ray

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Not routinely recommend in ACUTE

sinusitis
7-14day course of emphiric therapy
should be given initially
If no response: nasal endoscopy

Waters view
o Maxillary sinus
o Air-fluid level, mucosal thickening or
opacification
CT scan
o Acute: recurrent 4x
o Chronic: structural abnormalities

Management of Sinusitis
Antimicrobials
o Beta lactams
Topical nasal steroids
o Useful for recurrent acute or chronic
sinusitis, allergic rhinitis
o Nasonex momethasone
Antibiotics
o Acute: 7-14days
o Chronic: 3-4weeks
Topical decongestants
o Severe nasal obstruction (3-5days)
o Oxymethazoline-dixine
Topical steroids and anti-histamines
o Allergic background
Treatment failures
Non-compliance
Lack of drainage
Persistence of predisposing factors
Resistant organisms
Surgical options
Maximum medical treatment
Antral irrigation
Functional endoscopic sinus surgery
Caldwell-luc procedure
*polyps: very high recurrence rate, highly sensitive to
steroids
Endoscopic sinus Surgery
Chronic sinusitis with failed medical therapy
Nasal polyps or other mass lesions
Structural abnormalities
Management of Nasal Polyps
No permanent cure
Treatment complicated by high rate of
recurrence
Medical and surgical treatment are
complementary
Underlying factors should be identified and
eliminated
Medical treatment
o Decongestant
o Antibiotics

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Main line:

Topical and systemic

corticosteroids

Methylprednisone oral

Momethasone furoate
topical

DISEASES OF THE PARANASAL SINUSES

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