1、sinusitis 12lAnterior sinus :maxillary sinus maxillary sinus frontal sinus frontal sinus anterior ethmoidal sinusethmoidal sinusThey all open in the middle meatus.They all open in the middle meatus.3lPosterior sinus:posterior ethmoidal sinus:open in ethmoidal sinus:open in the superior meatusthe sup
2、erior meatus sphenoid sinus:open in sphenoid sinus:open in sphenoethmoidal recesssphenoethmoidal recess4 overviewlSinusitis has been defined Sinusitis has been defined as an inflammation of the as an inflammation of the mucous membrane of the mucous membrane of the sinuses.sinuses.ltwo types-acute s
3、inusitis two types-acute sinusitis and chronic sinusitis.and chronic sinusitis.5lAcute inflammation of sinus mucosa lThis commonly follows a cold.lThe sinus most commonly involved is the maxillary followed in turn by ethmoid,frontal and sphenoid.lMultisinusitis:lPansinusitis:6lAetiology of sinusitis
4、 in general7lNasal infectionlSwimming and divinglTraumalDental infection8lPredisposing causes9lObstruction to sinus ventilation and drainage101、nasal packing112、deviated septum123、hypertrophic turbinates134、nasal polypi145、oedema of sinus ostia due to allergy or vasomotor rhinitis 6、benign or malign
5、ant neoplasm15lEnvironment:atmospheric pollution,smoke,dustlPoor general health nutritional deficiencies systemic disorders(diabets,immune deficiency syndromes)16lViral infection-bacterial invasionlpneumococci,streptococci,H.influenzaelAnaerobic organisms and mixed infections 17lAcute inflammation o
6、f sinus mucosa causes hyperaemia,exudation of fluid,outpouring of polymorphonuclear cells and increased activity of serous and mucous glands.lDepending on the virulence of organisms,defences of the host and capability of the sinus ostium to drain the exudates,the disease may be mild(none-suppurative
7、)or severe(suppurative)18lInitially,the exudate is serous;later it may become mucopurulent or purulent.lSevere infections cause destruction of mucosal lining.lFailure of ostium to drain results in empyema of the sinus and destruction of its bony walls leading to complications.19Acute maxillary sinus
8、itis20lMost commonly,it is viral rhinitis which spreads to involve the sinus mucosa.This is followed by bacterial invasion.lDiving and swimming in contaminated water.lDental infections are important source of maxillary sinusitis.lTrauma 21lClinical features depend on severity of inflammatory process
9、 and efficiency of ostium to drain the exudates.lClosed ostium sinusitis is of greater severity and leads more often to complications.22lConstitutional symptoms consist of fever,general malaise and body ache.They are the result of toxaemia.lHeadache lPainlTendernesslRedness and oedema of cheek.lNasa
10、l discharge lPost nasal discharge23X-rays or CT scan:an opacity or a fluid level in the involved sinus.242526Antimicrobial drugslAmpicillin or amoxicillinlErythromycin or doxycycline or cotrimoxazolel-lactamase-producing strains of influenzae may necessitate the use of amoxicillin/clavulanic acid ls
11、parfloxacin27Nasal decongestant dropsl1%ephedrine 28steroidslAs nasal sprayslAvoid long-term systemic steroids29Steam inhalationlSteam alone provides symptomatic relief and encourage sinus drainage.lInhalation should be given 15 to 20 minutes after decongestion for better penetration.30AnalgesicslPa
12、racetamol 31Hot fomentationlLocal heat to the affected sinus is often soothing and helps in the resolution of inflammation.32lAntral puncture and irrigationMost cases of acute maxillary sinusitis respond to medical treatment.Antral puncture and irrigation is rarely necessary.It is done only when med
13、ical treatment has failed and only under cover of antibiotics.3334lChronic sinusitislOsteomyelitis of the maxillalOrbital cellulitis or abscess35lAcute frontal sinusitis36Usually follows viral infections of upper respiratory tract followed later by bacterial invasion.Entry of water into the sinus du
14、ring diving or swimming.External trauma to the sinus.Oedema of middle meatus,secondary to associated maxillary or ethmoid sinus infection.37lFrontal headachelTendernesslOedema of upper eyelid with suffused conjunctiva and photophobia.lNasal discharge3839lThis is same as for acute maxillary sinusitis
15、:antimicrobials,decongestion,analgesics,steroid.lPlacing a pledget of cotton soaked in a vasoconstrictor in the middle meatus,once or twice daily,helps to relieve ostial oedema and promotes sinus drainage and ventilation.40lIf patient shows response to medical treatment and pain is relieved,treatmen
16、t is continued for full 10 days to 2 weeks.41lTrephination of frontal sinus.If there is persistence of pain or pyrexia in spite of medical treatment for 48 hours,or if the lid swelling is increasing,frontal sinus is drained externally.4243lOrbital cellulitislOsteomyelitis of frontal bone lMeningitis
17、,extradural abscess or frontal lobe abscess.lChronic frontal sinusitis.44lAcute ethmoid sinusitis45lAcute ethmoiditis is often associated with infection of other sinuses.Ethmoid sinuses are more often involved in infants and young children.46lPain lOedema of lidslNasal dischargelSwelling of the midd
18、le turbinate47lMedical treatment is the same as for acute maxillary sinusitis.lVisual deterioration and exophthalmos indicate abscess in the posterior orbit and may require drainage of the ethmoid sinuses into the nose.48lOrbital cellulitis and abscesslVisual deterioration and blindness due to invol
19、vement of optic nerve.lCavernous sinus thrombosis.lExtradural abscess,meningitis or brain abscess.49lAcute sphenoid sinusitis50lIsolated involvement of sphenoid sinus is rare.It is often a part of pansinusitis or is associated with infection of posterior ethmoid sinuses.51lHeadache:occiput or vertex
20、lPostnasal discharge52l neoplasms of the sphenoid sinus may clinically simulate features of acute infection of sphenoid sinus and should always be excluded in any case of isolated sphenoid sinus involvement.5354lChronic sinusitis55lSinus infection lasting for months or years is called chronic sinusi
21、tis.Most important cause of chronic sinusitis is failure of acute infection to resolve.56lPersistence of infection causes mucosal changes,such as loss of cilia,oedema and polyp formation,thus continuing the vicious cycle.57lIn chronic infections,process of destruction and attempts at healing proceed
22、 simultaneously.lSinus mucosa becomes thick and polypoidal or undergoes atrophy.58lMixed aerobic and anaerobic organism are often present59lClinical features are often vague and similar to those of acute sinusitis but of lesser severity.lPurulent nasal discharge is commonest complaint.lFoul-smelling
23、 discharge suggests anaerobic infection.60lLocal pain and headache are often not marked.lSome patients complain of nasal stuffiness and anosmia.61lX-ray or CT scan:mucosal thickening or opacitylAspiration and irrigation:finding of pus in the sinus is confirmatory.62lIt is essential to search for und
24、erlying aetiological factors which obstruct sinus drainage and ventilation.lA workup for nasal allergy may be required.lCulture and sensitivity of sinus discharge helps in the proper selected of an antibiotic.63lInitial treatment of chronic sinusitis is conservative,including antibiotics,decongestan
25、ts,antihistaminics and steroids.lSome form of surgery is required either to provide free drainage and ventilation or radical surgery to remove all irreversible diseases.64lRecently,endoscopic sinus surgery is replacing radical operations on the sinuses and provides good drainage and ventilation.It a
26、lso avoids external incisions.6566Chronic maxillary sinusitis67686970Chroic frontal sinusitis71lCorrection of deviated septum lRemove of a polyplRemove of anterior portion of middle turbinate lIntranasal ethmoidectomy727374lThe ethmoid air cells and diseased tissue is removed between middle turbinat
27、e and the medial wall of orbit by the intranasal route.7576lAcess to the sphenoid sinus can be obtained by removal of its anterior wall.77lostiomeatal complex,OMC78uncinectomy79Open anterior ethmoid sinus80Enlarge maxillary ostium81Open posterior ethmoid sinus82Open sphenoid sinus83Open frontal siuns84question85
