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
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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
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Str.Pneumoniae
B-hemolytic streptococcus
H.influenzae
Stap. Aureus
Klebsiella pneumoniae
Others
Pathogenesis
• Obstruction to sinus ostium/ meatus
• Stasis of secretions (serous-mucinous): Nonsuppurative
• Secondary bacterial invasion: Suppurative
• Severity and resolution depends on
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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: Symptoms
Depends on the sinus involved
• Constitutional symptoms: Fever, malaise, lethargy
• Headache/ facial pain: Dull ache, postural/diurnal.
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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: Signs
Depends on the sinus involved
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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
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Water’s view (Occipetomental)
Caldwel view (Occipetofrontal)
Lateral view
Base skull view (Submento-vertical)
– CT scan: indicated in impending complications
• C/S: rarely done
Normal Sinuses
Acute Maxillary
Sinusitis
Treatment- Medical
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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:
Orbital
Intracranial
Osteomyelitis
Septic focus for other infections
Signs of impending/ manifest
complications
Spiking fever
Lid odema, facial/orbital swelling
Proptosis, reduced vision, reduced extraoccular
movt.
Severe headache and hyperirritable
Projectile vomiting
Meningeal signs
Hypothermia
Altered 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”.