Chronic Sinusitis
Brig Mirza Khizar Hameed
Definition
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Inflammation of the Paranasal Sinuses
lasting > 3 months
Etiology
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Anatomical variations
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Deviated Nasal Septum
Concha Bullosa
Bulla Ethmoidalis
Underlying diseases
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Cystic Fibrosis
Ciliary Dyskinesia
Immuno-deficiency
Granulomatous diseases
Microbiology
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Anaerobes
Staphylococcus aureus
Streptococcus
H. Influenzae
M. catarrhalis
Pathophysiology
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Obstruction of Osteomeatal complex
region
Impaired mucociliary clearance
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Stagnation & pooling of secretions
Infection  Vicious cycle
Symptoms
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Chronic nasal obstruction
Purulent post nasal discharge
Pain over sinuses/ Headache
Halitosis
Chronic cough
Physical signs
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Purulent Nasal discharge
Anatomical anomalies
Transillumination ?
Investigations
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X-ray PNS
CT Scan PNS
Proof puncture/ Sinus lavage
Sinus aspirate/ Pus swab for C/S
Treatment
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Antibiotics – Ciprofloxacin, Augmentin,
Clarithromycin, Cefuroxime, Clindamycin,
Metronidazole
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Decongestants
Antihistamines
Steroid Nasal Drops/ Sprays
Surgery- To provide drainage & ventilation
Operative procedures on
Sinuses
Maxillary Sinusitis
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Antral Washout
Inferior Meatal Antrostomy
Caldwell-Luc’s Operation
FESS
1. Antral Washout
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Puncturing medial wall of sinus for pus
aspiration and irrigation of sinus
Indications
- Ch sinusitis refractory to treatment
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Contraindications
- Age < 3 yrs
- Hypoplastic maxilla with thick bony walls
- Acute maxillary sinusitis untreated by antibiotics
Tilley Lichwitz Trocar & Cannula
Higginson Syringe
Trocar directed towards I/L tragus
Complications
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Hemorrhage
Pain & swelling of cheek
Perforation of orbital floor
Vasovagal shock
Air embolism
2. Inferior Meatal Antrostomy
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A window is created in
medial wall of Maxillary
antrum by perforating it
in the Inferior meatus
with Tilley’s Antrum
Harpoon & enlarged
(1.5-2 cm) with Myle’s
perforator
Complications
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Hemorrhage
Injury to Naso-lacrimal duct
Perforation of orbital floor
3. Caldwell-Luc’s Surgery
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Anterior wall of the Maxillary sinus is entered
through a Sub-labial incision
A window is created in the medial wall
through Antrostomy
Indications
- Ch sinusitis refractory to treatment
- Repair of Oro-antral fistula
- Reccurrent AC polyp
- Blow out fracture of floor of orbit
- Approach to ethmoids/ PPF
Sublabial Incision
Hole made in anterior wall followed
by Inferior Meatal Antrostomy
Complications
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Hemorrhage
Cheek edema
Numbness of cheek
Orbital hematoma
Trauma to teeth roots
Oro-antral fistula
Ethmoid Sinusitis
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Intranasal Ethmoidectomy
External Ethmoidectomy
- Lynch Howarth procedure
- Patterson transorbital procedure
- Jansen Horgan transantral procedure
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FESS
Lynch Howarth Ethmoidectomy
Patterson Ethmoidectomy
Trans-antral ethmoidectomy
Complications
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Hemorrhage
Injury to Lamina papyracea  Periorbital
hematoma, proptosis, visual loss
Injury to Medial palpebral ligament
CSF leak
Meningitis
Mucocoele formation
Frontal Sinusitis
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Trephination
Osteoplastic flap procedure
- Coronal incision
- Brow incision
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FESS
Frontal sinus trephination
Osteoplastic flap procedure
Complications
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Hematoma
Frontal depression
CSF leak
Meningitis
Mucocoele formation
Osteomyelitis
Sphenoid Sinusitis
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Trans-nasal trans-septal approach
Sublabial trans-septal approach
External ethmoidectomy approach
FESS
FESS
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Indications
- Ch sinusitis refractory to treatment
- Nasal polyps
- Fungal sinusitis
- Antro choanal polyp
- Fronto-ethmoidal mucocoele
- Repair of CSF leak
- DCR
- Orbital decompression
Functional Endoscopic Sinus Surgery
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Uncinectomy (Infundibulotomy)
Bullectomy & Anterior ethmoidectomy
Middle meatal antrostomy
Perforation of basal lamella
Posterior ethmoidectomy
Sphenoid sinus exploration
Skull base disease clearance
Frontal recess exploration
Complications
Major
 Major epistaxis
 Orbital hematoma
 Diplopia
 Blindness or  visual acuity
 Internal carotid injury
 Intracranial hemorrhage
 CSF leak / Meningitis
 Pneumocephalus
 Anosmia
 Nasolacrimal duct trauma
Minor
 Minor epistaxis
 Hyposmia
 Adhesions (synechiae)
 Headache
 Periorbital echhymosis
 Periorbital hematoma
 Dental / facial pain
Fungal Sinusitis
Definition
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Inflammation of the sinuses due to a
fungus
Classification
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Non Invasive Fungal Sinusitis
- Allergic
- Fungus Ball (Mycetoma)
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Invasive Fungal Sinusitis
- Acute
- Chronic
Allergic Fungal Sinusitis
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Most common form
Warm humid climate
Among younger, immuno-competent, atopic
Hypersensitivity reaction to inhaled fungus
organism
Presents with Nasal polyps & thick greenish
mucus
Investigations
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Total IgE - 
CT Scan PNS- Sinus filled with high signal
intensity soft tissue with calcium deposits,
thinning/ pressure bony erosion & remodelling
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Histology of greasy mucous- branching, non
invasive fungal hyphae, eosinophils & CharcotLeyden crystals
Treatment
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Surgical clearance of sinuses
Topical Steroids
Antihistamines
Immunotherapy
? Antifungal
Fungus Ball (Mycetoma)
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Older individuals, usually females
Immunocompetent
Asymptomatic/ Cacosmia/ Chronic sinusitis
Fungal mass limited to one sinus
CT Scan- Hyperdense mass with punctate
calcifications
Fungus Ball- Treatment
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Surgical clearance
? Anti fungal
Acute Invasive Fungal Sinusitis
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Most lethal form
Immunocompromised/ Diabetics
Caused by Mucorales, Aspergillus,
Fusarium, Phaeohyphomycosis
Angio invasion, hematogenous spread
Local necrosis, orbital & intracranial spread
Fever, pain, nasal congestion, epistaxis,
proptosis, headaches, seizures
AIFS- CT Findings
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Unilateral nasal soft tissue thickening
Bony erosions
Unilateral involvement of PNS
Proptosis
Cavernous sinus thrombosis
Acute Invasive Fungal Sinusitis - CT
Unilateral ethmoid involvement with bone destruction,
intraorbital spread and proptosis
AIFS- Treatment
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Aggressive surgical debridement
Systemic anti fungal therapy
Treatment of underlying cause of
immunosuppression
Chronic Invasive Fungal Sinusitis
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Immunocompetent with H/o Ch sinusitis
Progressin over months to years
Maxillofacial soft tissue swelling
Orbital involvement  proptosis, visual loss
Intracranial extension with cranial
neuropathies, headaches seizures
CT Scan- Hyperdense mass, bone erosion
CIFS- Treatment
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Aggressive surgical exenteration
Systemic anti fungal therapy
Thank you