By

Dr. Hazem El-Mehairy

Prof. Otorhinolaryngology and Head & Neck Surgery Ain-Shams University Cairo-EGYPT

Definition
The condition manifested by inflammatory response involving the mucous membrane (possibly involving the neuroepithelium) of the nose and para-nasal sinuses , fluids within these cavities and / or underlying bone.

Why called Rhinosinusitis ?

The mucous membrane of the nose and paranasal sinuses are anatomically and embryologically contiguous.
Clinical symptoms are inseparable . They respond similarly to medical and surgical therapy. CT study showed that the mucosal lining of the nose and the sinuses are simultaneously involved in common cold.

Rhinosinusitis
Rhinosinusitis is defined as inflammation of the nose and the
paranasal sinuses resulting in:

AND either 2 MAJOR SYMPTOMS ENDOSCOPIC SIGNS of Polyps or Blockage/congestion Mucopurulent discharge from Loss of smell middle meatus or Discharge anterior/postnasal drip Edema/mucosal obstruction Facial pain/pressure primarily in middle meatus
OR CT CHANGES Mucosal changes within ostiomeatal complex and/or sinuses
EAACI. Rhinol Suppl. 2005;18:1. Fokkens et al. Allergy. 2005;60:583.

Rhinosinusitis

Severity
Mild = VAS 0-4 Moderate/severe = VAS 5-10
10 cm

Duration Acute/intermittent
<12 weeks Complete resolution of symptoms

Persistent/chronic
Worst possible >12 weeks No complete resolution of symptoms

No

VAS = visual analogue scale.

EAACI. Rhinol Suppl. 2005;18:1. Fokkens et al. Allergy. 2005;60:583.

ROUTES OF INFECTION

1- Nasal route: through the natural ostium of the involved sinus

2- Dental route (only in maxillary sinusitis) 3- Trauma 4- Hematogenous ( in immuno-compromized patient)

Rhinosinusitis Intensity of Symptoms and Signs

Acute rhinosinusitis Chronic rhinosinusitis Recurrent acute rhinosinusitis Acute exacerbations of chronic rhinosinusitis

Adults Children

Intensity of symptoms and signs

Acute rhinosinusitis
Chronic rhinosinusitis Recurrent acute rhinosinusitis Acute exacerbation of chronic rhinosinusitis 12 Weeks

Classification
(Lanza and Kennedy,1997)
Acute Rhinosinusitis: rapid onset, following viral UR infection,
lasts 4 weeks, 2 major factors or 1 major & 2 minor factors. Histologically, exudative process associated with necrosis, hemorrhage and / or ulceration in which neutrophils predominate. Complete resolution after effective medical treatment.

Subacute Rhinosinusitis:
unresolved acute rhinosinusitis. Symptoms are identical but less severe, persists more than 4 weeks (4-11 weeks).

Recurrent Acute Rhinosinusitis:

Acute RS occurs in patients 4 or more times per year. Each lasts 7-10 days. Patients symptoms completely resolve with antibiotic therapy.

Chronic Rhinosinusitis:
persists more than 12 weeks, symptoms identical to acute. Histologically, there is proliferative process associated with fibrosis of the lamina propria in which lymphocytes, plasma cells and eosinophils predominate along with changes in bone.

Acute exacerbation of chronic rhinosinusitis:

sudden worsening of chronic RS, with return to baseline after treatment

Etiology
The development of Rhinosinusitis depends on variety of enviromental and host factors.

Environmental factors:Infectious / viral agents, trauma, noxious chemicals, iatrogenic (medications & surgery).

Host factors:Genetic/ Congenital conditions, cystic fibrosis, immobile cilia syndrome allergy/ immune conditions, anatomic abnormalities, systemic diseases, endocrine, metabolic, neuromechanisms and neoplasms.

Acute Rhinosinusitis
Spectrum of acute rhinosinusitis based on clinical criteria
Increasing symptom severity

Mild rhinosinusi tis

Moderate to severe acute rhinosinusitis Allergic Viral Bacterial

Fulminant bacterial rhinosinus itis

Clinical Diagnosis
Major factor:
Facial pain / pressure, facial congestion / fullness, nasal obstruction / blockage, hyposmia / anosmia , purulence in nasal cavity and fever.

Minor factors:
Headache, halitosis, fatigue, dental pain, cough, otalgia / fullness and fever.

Criteria for Clinical Diagnosis

Patient history and physical examination is sufficed for routine diagnosis of most forms.

Endoscopy and C T scans are essential in diagnosis of difficult, recalcitrant or complicated cases.

EXAMINATION

1- External. 2- Nasal examination by anterior rhinoscopy. 3- Posterior rhinoscopy. 4- Nasal endoscopy. 5- Dental examination.

EP3OS - Acute/Intermittent Rhinosinusitis

Common Cold/Viral Rhinosinusitis Acute/Intermittent Rhinosinusitis

Increase in symptoms after 5 days

Symptoms

persistent symptoms after 10 days

5 Days

10

15

Adapted from Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.

12 Week s

Common Cold/Acute Rhinosinusitis

Viral rhinosinusitis/common cold Acute rhinosinusitis/increase after 5 days Acute rhinosinusitis/persist after 10 days

Symptoms

No need for antibiotic therapy

Consider treatment with antibiotics and/or steroids

10

15

Days

Fokkens et al. EP3OS Guidelines. Rhinol Suppl. 2005;18:1.

Microbiology
Viral colds lead to 0.5 2.5% of adult RS, 10% in children RS and 15% of Sinus aspirate contain viruses mainly rhinovirus, influenza and parainfluenza viruses.

Acute rhinosinusitis:
Strept. Pneumoniae 31%, Haemophilus influenza 21% , Anearobes 6%, Staph. aureus 4%, Strept.pyogenes 2% and Moreaxalla catarrhalis 2%.

Chronic Rhinosinusitis:
Coagulase- negative Staph. 51% , Staph. aureus 20% , Anearobes 3% and Strept.pneumoniae 4%. Allergic fungal sinusitis 2-7% of chronic rhinosinusitis, but seems to be increasing in frequency.

Staging of Rhinosinusitis
- C.T. scan parameters. - Pattern of involvement of the sinuses. - Numerical score of each sinus group. - Actual measurement of the mucosal thickness. - C.T.findings with other factors (immune system, surgery,infection).

Lund Mackay system (1993):

Structure Right Left
Maxillary Anterior Ethmoid Posterior Ethmoid Sphenoid Frontal Osteomeatal sinus Total points for each side Scoring for sinuses: 0 =No abnormality 1=Partial opacification 2= Total opacification For osteomeatal complex: 0=not occluded 2= occluded

Radiology
Ultrasound. Plain sinus radiography. Coronal CT (3- 4 mm sections). Magnetic resonance imaging (MRI).

Pharmacotherapy
The crus of the treatment is the compromised mucociliary clearance, for if the sinuses can regain normal clearance, this defense mechanism will tend to prevent recurrence of infection in the normal manner. If the normal mucociliary clearance can not be achieved and the mucosa may be denuded to be irreversibly damaged and complete removal of the lining mucosa will be the only alternative.

Saline nasal sprays & nasal irrigation.

Mucoevacuants.

Decongestants (systemic & topical)

Topical nasal steroids .

Systemic corticosteroids.

Antiobiotics. The optimal duration for antimicrobial therapy is 10 14

days in acute cases. For chronic rhinosinusitis, the duration of therapy should be at least 4 weeks. The use of antibiotics in CRS is a topic of controversy. Its efficacy , duration of therapy and agents to be use have been extensively debated.

Antihistamines

Antireflux regime:
There is a new trend of research in the involvement of GERD in upper airway pathologies. Reflux is said to be associated to chronic rhinosinusitis. It is though that the reflux of acid content reach the nasopharynx and nasal cavities leading to chronic mucosal irritation and rhinosinusitis. Adult patients with history of heartburn can benefit from antireflux regimen including precautions and medications

Immunotherapy

An important adjunct in the management of those with atopy who develops chronic rhinosinusitis or recurrent acute rhinosinusitis.

Reduction of mucosal edema and secretions by suppression of the atopic response, would diminish the persistence or recurrence of sinus disease.

Chronic Rhinosinusitis

Symptoms of Chronic Rhinosinusitis

Major symptoms
Facial pain/pressure Facial congestion/fullness Nasal obstruction/ blockage Nasal discharge/ purulence/postnasal drip Hyperosmia/anosmia Fever

Minor symptoms
Headache Fever Halitosis Fatigue Dental pain Cough Ear pain/pressure/fullness

Differential Diagnosis of Chronic Rhinosinusitis

Infectious rhinitis (eg; viral upper respiratory tract infections) Allergic rhinitis: seasonal, perennial, occupational Nonallergic rhinitis: vasomotor rhinitis, nonallergic rhinitis eosinophilia syndrome, aspirin sensitivity, Rhinitis medicamentosa Rhinitis secondary to pregnancy, hypothyroidism Anatomical abnormalities: severe septal deviation, foreign body Nasal polyps Inverted papilloma, benign and malignant tumours Cerebrospinal fluid leak, meningoencephaloceles Mucoceles Morbus wegener Cocaine abuse Atrophic rhinitis Specific or tropic infections Fungal sinus disease Ophthalmologic or neurologic diseases

Symptoms Suggestive of Chronic Rhinosinusitis

Special indications (differential diagnosis and underlying disease) Allergy tests
Microbiology (eventually sinus puncture) Challenge test for aspirin sensitivity Nasal cytology (eosinophils, neutrophils) MRI Ciliary function studies Biopsy Blood examinations (Morbus wegener, immunodeficiencies) Sweat chloride test Electron microscopy Genetic analyses Consultations of other specialties (ophthalmologist, neurologist, etc)

Initial evaluation
Medical history: major, minor symptoms General examination Anterior rhinoscopy, nasal endoscopy Evaluation of underlying disease and comorbidities CT scan (after treatment, not in acute episode)

Chronic Rhinosinusitis: Bacteriology

Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis

Staphylococcus aureus
Coagulase-negative Staphylococcus Pseudomonas aeruginosa Anaerobes Mixed infections

Pathogenic? All fungus?

Management of Chronic Rhinosinusitis

Diagnosis Medical treatment

Topical CT scan

Systemic

Surgery

Medical Treatment
Steroids
Topical Systemic

Antibiotics: short/long courses Douching Mucolytics, immunomodulators, immunostimulants, bacterial lysates Antifungals

Possible Strategies for Treating CRS

Treat Etiology

Infectious
Anatomic Allergy

Allergen Avoidance Antibiotics Surgery

Attenuate Inflammation

Steroids Immunotherapy Antileukotrienes Macrolides?

IL-5, IL-4 IL-8, IF- GM-CSF

CRS

Indications for Surgery

Absolute indications:
Massive nasal polyposis, acute complicated rhinosinusitis, mucocele, mucopyocele, invasive or allergic fungal rhinosimusitis, suspected tumor causing nasal/sinus obstruction and cerebrospinal fluid rhinorrhea.

Relative indications:
Chronic rhinosinusitis refractory to an appropriate length of therapy and recurrent acute RS in which a source of anatomic, micropolyp, or similar obstruction to sinus drainage can be identified. Most consider failure of 4 6 weeks of aggressive pharmacotherapy (documented by nasal endoscopy or coronal CT) to be an indication of surgery in adults, whereas 2 3 months of similar therapy is usually delivered before consideration of surgery in children.

SURGICAL TREATMENT
Aims at : - Correcting predisposing factor e.g. D.S - Clearance of sinus disease itself.

A- Functional Endoscopic sinus surgery FESS

For maxillary sinus, endoscopic middle meatal antrostomy. For frontal sinus, endoscopic clearance of frontonasal recess or frontal sinosotmy. For ethmoids, endoscopic ethmoidecytomy. For sphenoid, endoscopic sphenoidectomy. Combinations of all.

B- Conventional surgery
1-For maxillary sinusitis: * Repeated puncture and lavage under local anesthesia . * Intranasal antrosotomy. * Radical antrosotomy ( Caldwell Lucs) operation.
2- For frontal sinusitis: external frontoethmoidectomy or osteoplastic flap operation with obliteration

3- For ethmoiditis : external ethmoidectomy or external fronto-ethmoidectomy or spheno-ethmoidectomy operations.

4- For sphenoditis: external spheno-ethmoidectomy operation

FUNGAL RHINOSINUSITIS
Noninvasive Fungal RS 1- Fungal Ball
-Fungal ball occurs in adults, in immunocomptent patients without invasion of the mucus membrane on histopathology. -Unilateral postnasal discharge is the most frequent symptom. -C.T scan is helpful in diagnosis ( heterogeneous opacification ). -Aspergillus is the most common agent involved -Surgery is the most effective treatment.

2- Allergic fungal RS
Immunocomptent patient with an allergy to fungus. The most common fungi reported are dematiaceous species. The clinical and biological criteria for diagnosis are under debate including nasal polyps, thick mucin , hypersensitivity type I for fungus, oesinophilic mucin . C.T scan show sinus opacities with bone erosion. Treatment is controversial. Removal of all mucin is recommended. Recurrences are common, so combination with medical therapy (prednisone) is suggested.

Invasive Fungal RS 1- Chronic or indolent invasive FTS

Two forms: granulomatous and non-granulomatous. Occurs in healthy individuals. Pain is the main symptom, but chronic headache, proptosis and cranial nerve defects were reported. Aspergillus is the most frequent agent isolated and histopathology reveals fungus invasion of the tissue ( bone , mucus membrane , vessels). MRI confirm extension to soft tissues. Most patients are treated with combination of surgery and anitfungal chemotherapy.

2- Acute fulminant FRS

Occurs in immuno-compromised patients (AIDs, hematologic disease, chemotherapy, diabetius) . Fatal outcome Mycotic infiltrations of the mucus membranes of the nasal cavity and / or paranasal sinuses. Fever of unknown cause and rhinorrhoea are the most common first symptoms. Later proptosis , ophthalmoplegia and focal neurological signs occur. Nasal endoscopy is the crux of early diagnosis ( discoloration , black necrosis, granulations or crusts). Fungi show marked predilection for vascular invasion with direct nvasion of the large and small arteries . Mucur and aspergillus most frequently isolated. C.T scan is commonest imaging modality, but MRI for intracranial extension. Treatment combination of anti fungal chemotherapy , aggressive surgergical debridement and reversal of immuno-compromised condition.

Pediatric Rhinosinusitis
Children have a higher rate of exposure to viral infections and their immune systems are not as mature. Children anatomy is significantly different. Frontal and sphenoid sinuses are not usually developed. Also, adenoid hypertrophy and allergic rhinitis are common in children.

The main symptoms in children are rhinorrhoea, nasal obstruction,mouth breathing, hyponasal speech and snoring.

The use of saline nasal sprays or trial of allergen avoidance and ageappropriate topical nasal anti-inflammatory sprays should be tried.

Rhinosinusitis in children is not a surgical disease and watchful waiting is advised. It is likely that growth and maturation of the immunological response play a major role in the resolution of the disease.

The few exceptions to this principle are nasal polyps and periorbital cellulites, where an assessment of vision, parenteral antibiotics and there is concern about the possibility of subperiosteal abscess, CT and drainage of any pus is indicated.

COMPLICATIONS OF SINUSITS
ORBITAL Pre-& post septal cellulitis Orbital abscess Subperiosteal abscess Cavernous sinus thrombosis Hematoma Enophthalmous Mucocele blindness NON ORBITAL CRANIAL BONY GENERAL

ROUTS OF EXTENSION
Suture lines Congenital bony dehiscences Natural pathways as AEC PEC Necrosis of bone by acute infection or Bone erosion by chronic infection Retrograde thrombophlebitis

SOF IOF

ON FR

Complications of sinusitis
Periorbital cellulitis Intraorbital abscess Osteomyelitis Meningitis Intracranial abscess Cavernous sinus thrombosis

MUCOCELE

Staging Of Orbital infections

1. Stage I - preseptal cellulitis 2. Stage II - orbital cellulitis 3. Stage III - subperiosteal abscess (which may arise from orbital cellulitis or paranasal sinusitis) 4. Stage IV - orbital abscess (a complication

Orbital Cellulitis

SUBPERIOSTEAL ABSCESS

ORBITAL ABSCESS