chronic sinusitis

Chronic sinusitis

Prof. Ehab Taha Yaseen

Objectives

• To keep in mind for the rest of your life that facial pain is not the main symptoms in chronic sinusitis
• Hence, patient present with facial pain as the their chief complaint are usually not have chronic sinusitis
• 2. Usually present with other nasal features or ear and throat symptoms
• 3. The main type of surgery (FESS)






Definition



Better terms




Types

• Specific (TB, Fungal, etc…)
• Non specific 2 types
• Simple (infective) (repeated acute rs)
• Mixed type (infective and VMR) usually there is predisposing factor as obstruction of sinus ostia

Pathology:

Edema
Polyposis
chronic inflammatory cellular infiltration
fibrosis of submucosa
multiple small abscesses
metaplasia and glandular hypertrophy.

Symptoms:

Postnasal or nasal discharge.
Nasal obstruction
Recurrent pharyngitis (sore throat).
Headache.
Anosmia or cacosmia
Cough
Eustachian obstruction are common secondary effects
Constitutional symptoms are usually mild or absent.


Signs:
often unremarkable and non-specific,
you may see (endoscopy is important tool )
polyps
septal deviation
signs of allergic rhinitis (extrinsic rhinitis)
vasomotor rhinitis (intrinsic rhinitis)
postnasal drip
granular pharyngitis
you may notice bad smell
features of Eustachian obstruction.

Investigations:

Endoscopy (again)
CT scan is the gold standard investigation
• To prove the diagnosis
• Looking for predisposing factors (anatomical variation or pathological findings)
• To address the anatomy (if surgery is decided)
• To exclude the presence of complications (especially orbital and intracranial complications)

Treatment:

Medical: for 4-6 weeks, this will include:
Antibiotics are given orally and should cover both aerobic, anaerobic, gram positive and gram negative bacteria e.g. amoxicillin + metronidazol or amoxicillin + calvulonic acid.
Steroids as nasal spray
Antihistamines especially when there is allergy.
Analgesic usually not needed.
Surgical : treatment is indicated when there is failure of medical treatment, and these may include:
Intranasal antrostomy. (obsolete)
Caldwell – Luc operation. (only one indication)
Internal and external ethmoidectomy. (obsolete)
Internal ethmoidectomy. (obsolete)
external fronto – ethmoidectomy. (obsolete)
frontal sinus obliteration. (obsolete)
Sphenoid surgery is usually part of surgery on the other sinuses.
Functional endoscopic sinus surgery (FESS).


The gold standard operation nowadays is the FESS:
Aims of FESS are to
Remove diseased mucosa, polyps, bones and widen sinus ostia
Restore sinus ventilation
Restore normal mucocilliary clearance
What are the indications of FESS
• Chronic rhinosinusitis after failure of medical therapy
• Recurrent acute rhinosinusitis (more than 3 attacks per year in the presence of predisposing anatomical variation)
Chronic Specific Sinusitis ( Fungous infection)
Usually due to aspergilli, common in immune compromised patients as diabetic or uraemic patients. Treated by evacuation surgery and systemic antifungal agents as amphotericin B.

Case

35 y old man seeking advice to remove his tonsils because of recurrent infection that affect his QOL. How you will approach the diagnosis in this patient?
History
Examination
Investigation
Treatment