Chronic Sinusitis

Question 1

CHRONIC SINUSITIS

Answer 1

Sinus infection lasting for months or years is called chronic sinusitis

Question 2

cause of chronic sinusitis

Answer 2

failure of acute infection to resolve.

Question 3

PATHOPHYSIOLOGY of CHRONIC SINUSITIS

Answer 3

Acute infection ➡️destroys normal ciliated epithelium ➡️impairing drainage from the sinus➡️ Pooling and stagnation of secretions in the sinus ➡️ infection ➡️mucosal changes, such as loss of cilia, oedema and polyp formation, thus continuing the vicious cycle

Question 4

PATHOLOGY CHRONIC SINUSITIS

Answer 4

In chronic infections, process of destruction and attempts at healing proceed simultaneously. Sinus mucosa becomes thick and polypoidal (hypertrophic sinusitis) or under- goes atrophy (atrophic sinusitis). Surface epithelium may show desquamation, regeneration or metaplasia. Submu- cosa is infiltrated with lymphocytes and plasma cells and may show microabscesses, granulations, fibrosis or polyp formation.

Question 5

BACTERIOLOGY

Answer 5

Mixed aerobic and anaerobic organisms

Question 6

CLINICAL FEATURES

Answer 6

• often vague and similar to those of acute sinusitis but of lesser severity
• Purulent nasal discharge
• Foul-smelling discharge
• Local pain and headache
• nasal stuffiness and anosmia.

Question 7

commonest complaint

Answer 7

Purulent nasal discharge

Question 8

Foul-smelling discharge sug- gests

Answer 8

anaerobic infection

Question 9

Local pain and headache are often not marked except in

Answer 9

acute exacerbations

Question 10

DIAGNOSIS

Answer 10

• X-ray
• X-rays after injection of contrast material
• Computed tomography (CT) scan
• Aspiration and irrigation:

Question 11

X-ray of the involved sinus may show

Answer 11

mucosal thickening or opacity.

Question 12

X-rays after injection of contrast material may show

Answer 12

soft tissue changes in the sinus mucosa.

Question 13

Computed tomography (CT) scan is particularly useful in

Answer 13

ethmoid and sphenoid sinus infections and has replaced studies with contrast materials

Question 14

Aspiration and irrigation

Answer 14

Finding of pus in the sinus is confirmatory.

Question 15

TREATMENT

Answer 15

• search for underlying aetiological factors which obstruct sinus drainage and ventilation
• A work-up for nasal allergy
• Culture and sensitivity of sinus discharge ➡️ proper selection of an antibiotic.
• conservative rx ➡️antibiotics, decongestants, antihistaminics and sinus irrigations
• surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases so as to provide wide drainage or to obliterate the sinus.

Question 16

SURGERY FOR CHRONIC MAXILLARY SINUSITIS

Answer 16

Antral puncture and irrigation
Intranasal antrostomy
Caldwell–Luc operation

Question 17

Antral puncture and irrigation

Answer 17

Sinus cavity is irrigated with a cannula passed through the inferior meatus. Removal of pus and exudates helps the sinus mucosa to revert to normal.

Question 18

Intranasal antrostomy

Answer 18

is indicated if sinus irrigations fail to resolve infection. A window is created in the infe- rior meatus to provide aeration to the sinus and its free drainage.

Question 19

Caldwell–Luc operation

Answer 19

In this operation, antrum is entered through its anterior wall by a sublabial incision. All irreversible diseases are removed and a window is cre- ated between the antrum and inferior meatus.

Question 20

SURGERY FOR CHRONIC FRONTAL SINUSITIS

Answer 20

• Intranasal drainage operations
• Trephination of frontal sinus
• External frontoethmoidectomy (Howarth’s or Lynch operation
• Osteoplastic flap operation

Question 21

Intranasal drainage operations

Answer 21

Correction of deviated septum, removal of a polyp or anterior portion of middle turbinate, or intranasal ethmoidectomy provide drainage through the frontonasal duct. Treatment of associated max- illary sinusitis also helps to resolve chronic frontal sinusitis

Question 22

External frontoethmoidectomy (Howarth’s or Lynch
operation)

Answer 22

The frontal sinus is entered through its floor by a curvilinear incision round the inner margin of the orbit. Diseased mucosa is removed, ethmoid cells exen- terated and a new frontonasal duct created.

Question 23

Osteoplastic flap operation

Answer 23

It may be unilateral or bilat- eral. A coronal or a brow incision is used. The anterior wall of frontal sinus is reflected as an osteoplastic flap, based inferiorly. The diseased tissues are removed and the sinus drained through a new frontonasal duct. If it is desired to obliterate the sinus, all diseased as well as healthy mucosa are stripped off and the sinus obliterated with fat

Question 24

SURGERY FOR CHRONIC ETHMOID SINUSITIS

Answer 24

Intranasal ethmoidectomy

External ethmoidectomy

Question 25

Intranasal ethmoidectomy

Answer 25

This operation is done for chronic ethmoiditis with polyp formation. The ethmoid air cells and the diseased tissue are removed between the middle turbinate and the medial wall of orbit by the intranasal route. The frontal and sphenoid sinuses can also be drained by this operation.

Question 26

External ethmoidectomy

Answer 26

In this operation, ethmoid sinuses are approached through medial orbital incision. Access can also be obtained to sphenoid and frontal sinuses and the operation is called fronto-spheno-ethmoidectomy.

Question 27

SURGERY FOR CHRONIC SPHENOIDITIS SINUSITIS

Answer 27

Sphenoidotomy. Access to the sphenoid sinus can be obtained by removal of its anterior wall. This is accomplished by external ethmoidectomy or trans-septal approach, usu- ally the former, because of the coexistence of ethmoid dis- ease with chronic sphenoiditis.

Question 28

FUNGUS CAUSING SINUSITIS

Answer 28

Aspergillus, Alternaria, Mucor or Rhizopus They may involve single or multiple sinuses.

Question 29

Fungal ball is due to

Answer 29

implantation of fungus into an otherwise healthy sinus which on CT shows a hyperdense area with no evidence of bone erosion or expansion

Question 30

most commonly involved sinus in Fungal ball

Answer 30

Maxillary sinus >sphenoid>ethmoid >frontal

Question 31

Treatment for Fungal ball

Answer 31

surgical removal of the fungal ball and adequate drainage of the sinus. No antifungal therapy is required

Question 32

Allergic fungal sinusitis

Answer 32

allergic reaction to the causative fungus

Question 33

Presentation of Allergic fungal sinusitis

Answer 33

presents with sinunasal polyposis and mucin

Question 34

mucin of Allergic fungal sinusitis contains

Answer 34

- eosinophils - Charcot- Leyden crystals - fungal hyphae

Question 35

CT scan of Allergic fungal sinusitis shows

Answer 35

mucosal thickening with hyperdense areas

Question 36

How many sinus are involved in Allergic fungal sinusitis

Answer 36

There is no invasion of the sinus mucosa with fungus. Usually more than one sinus are involved on one or both sides.

Question 37

Treatment of Allergic fungal sinusitis

Answer 37

endoscopic surgical clearance of the sinuses with provision of drainage and ventilation. This is combined with pre and postoperative systemic steroids.

Question 38

Chronic invasive sinusitis

Answer 38

Here the fungus invades into the sinus mucosa. There is bone erosion by fungus

Question 39

In Chronic invasive sinusitis Patient presents with

Answer 39

chronic rhinosinusitis

Question 40

CT scan of Chronic invasive sinusitis shows

Answer 40

thick- ened mucosa with opacification of sinus and bone erosion. Patient may have intracranial or intraorbital invasion.

Question 41

Histopathology of Chronic invasive sinusitis shows

Answer 41

fungal invasion of submucosa and granulomatous reaction with multinucleated giant cells.

Question 42

Treatment for Chronic invasive sinusitis

Answer 42

surgical removal of the involved mucosa, bone and soft tissues followed by antifungal ther- apy

Question 43

antifungal ther- apy for Chronic invasive sinusitis

Answer 43

i.v. amphotericin B. Up to a total of 2–3 g of the drug is given. followed by itraconazole therapy for 12 months or more monitored by serial CT or MRI scans.

Question 44

Fulminant fungal sinusitis

Answer 44

It is an acute presentation and is mostly seen in immunocompromised or dia- betic individuals.

Question 45

Common fungal species for Fulminant fungal sinusitis

Answer 45

Mucor Aspergillus

Question 46

Mucor causes which disease

Answer 46

rhinocerebral disease

Question 47

How does mucor causes black eschar of inferior turbi- nate, palate or the sinus

Answer 47

invasion of the blood vessels, mucor fungus causes ischaemic necro- sis presenting as a black eschar, involving inferior turbi- nate, palate or the sinus

Question 48

Where does mucor spreads to

Answer 48

face, eye, skull base and the brain

Question 49

Treatment for mucor

Answer 49

Treatment is surgical debridement of necrotic tissue and i.v. amphotericin B.

Question 50

Aspergillus infection can also cause

Answer 50

acute fulminant sinusitis with tissue invasion.

Question 51

acute fulminant sinusitis due to Aspergillus presentation

Answer 51

acute sinusitis and develop sepsis and other sinus com- plications. Unlike Mucor infection, there is no black eschar.

Question 52

For for acute fulminant sinusitis due to Aspergillus presentation

Answer 52

antifungal therapy and surgery.