Definition

Acute bacterial infection of the mucosa of one or more paranasal sinuses, usually rhinogenic in origin and is characterized by acute facial pain/ head ache and purulent nasal discharge.

Anatomical considerations:

Osteo-meatal complex

Types

• Depending on the site– Unilateral/ bilateral– Pansinusitis– Multisinusitis– Maxillary/ frontal/ ethmoidal/ sphenoidal

• Depending on whether the sinus is draining or not– Open type– Closed type

• Depending on the pathology– Suppurative– Non-suppurative

Etiology

• Rhinogenic- Commonest (85%)– Usually after viral rhinitis (Flu)– Any form of rhinitis

• Dental (Maxillary)

– Root abscess, dental procedure, etc.

• Trauma– RTA, Swimming and diving, FB, barotrauma, etc.– Iatrogenic- nasal packing, septal surgery

• Hematogenous- Rare

Predisposing factors for Acute rhinosinusitis

• Mucosal odema of MM– Any form of rhinitis: Viral, bacterial, Irritant, allergic, VMR,

atrophic, etc. (environmental factors play role)

• Mechanical (anatomical) obstruction of nose/ MM– DNS, spur, polyp, hypertrophic turbinate, any mass, FB, nasal

packing, etc.

• Pathological mucous– Thick mucous (mucoviscidosis, cystic fibrosis)

• Primary mucociliary dysfunction• Others: Poor general health, immunodeficiency states,

DM, nutritional deficiency, etc.

Bacteriology

• Str.Pneumoniae

• B-hemolytic streptococcus

• H.influenzae

• Stap. Aureus

• Klebsiella pneumoniae

• Others

Pathogenesis

• Obstruction to sinus ostium/ meatus• Stasis of secretions (serous-mucinous): Non-

suppurative• Secondary bacterial invasion: Suppurative• Severity and resolution depends on

– Open/ closed. May drain creating accessory opening.– Organism virulence– Host resistance– Treatment received

Pathology

• Acute inflammatory changes: Hyperemia, odema, acute infl. infliterate.

• Increased activity of the mucous glands• Severe suppuration Mucosal destruction Empyema Bony destruction Complications

Difference between healthy and inflammed Sinus

Clinical features: SymptomsDepends on the sinus involved

• Constitutional symptoms: Fever, malaise, lethargy• Headache/ facial pain: Dull ache, postural/diurnal.

– Max: Facial, forehead– Frontal: Forehead, “Office headache” – Ethmoid: Between the eyes, may > with eye movement– Sphenoid: Vertex, occipetal

• Nasal discharge– mucous/ mucopurulent/ purulent/ blood stained– Anterior/ postnasal

• Nasal obstruction• Cheek/ lid congestion, swelling

Clinical features: SignsDepends on the sinus involved

• Fever

• Tenderness

• Cheek swelling

• Lid odema: in ethmoid and frontal

• Inflamed nasal mucosa especially the meatus

• Discharge in MM/ SM as on anterior/posterior rhinoscopy

• Postural test

• Transillumination test

• Signs of complications

Endoscopic appearance of acute infective sinusitis, with pus exuding from under the right middle turbinate and down into the middle meatus.

Investigations

• Clinical diagnosis• Diagnostic nasal endoscopy (DNE)• Radiological

– X-ray PNS• Water’s view (Occipetomental)• Caldwel view (Occipetofrontal)• Lateral view• Base skull view (Submento-vertical)

– CT scan: indicated in impending complications

• C/S: rarely done

Acute Maxillary Sinusitis

Normal Sinuses

Treatment- Medical

• Antibiotics

• Nasal decongestants (Topical/systemic)

• Anti-inflammatory analgesics

• Medicated steam inhalation

• Mucolytics

• Hot fomentation

Surgical drainage

• If not responding to medical treatment

• Impending or manifest complications

• Depends on the sinus involved

Drainage procedures

• Acute maxillary: Antral washout/ endoscopic MMA

• Acute frontal: Frontal trefination/ endoscopic frontal recess clearance

• Acute ethmoiditis: External ethmoidectomy/ endoscopic ethmoidectomy

• Acute sphenoiditis: External sphenoethmoidectomy/ endoscopic sphenoidotomy

Complications

• Chronic sinusitis• Acute sinusitis or acute exacerbations of

chronic sinusitis may give rise to following complications:

OrbitalIntracranial OsteomyelitisSeptic focus for other infections

Signs of impending/ manifest complications

Spiking feverLid odema, facial/orbital swellingProptosis, reduced vision, reduced extraoccular

movt.Severe headache and hyperirritableProjectile vomitingMeningeal signsHypothermiaAltered sensorium

Orbital complications• Common in acute ethmoiditis or

frontal sinusitis

• Direct spread/ ostitis/ thrombophlebitic

• Odema of the lids

• Subperiosteal abscess

• Orbitial cellulitis

• Orbital abscess

• Superior orbital fissure syndrome: Deep orbital pain, frontal headache, progressive paralysis of extraoccular movements

• Blindness

A patient with acute ethmoiditis threatening

vision

Intracranial

• Anterior cranial fossa and cavernous sinus closely related

• Meningitis

• Extradural abscess

• Subdural abscess

• Frontal lobe abscess

• Cavernous sinus thrombophlebitis, etc

LATERAL SINUS

THROMBOSIS

DELTA SIGN

BRAIN ABSCESS

Conclusion

“Acute sinusitis especially in a child should be treated adequately to prevent

consequent chronic sinusitis or other more severe complications which may

be even fatal”.