Chronic sinusitis

Chronic sinusitis
Assistant Professor E.A. Sorokin
2022
Chronic rhinosinusitis (with or without nasal polyps)
in adults is defined as: the presence of two or more
symptoms, one of which must be either nasal
blockade/obstruction/nasal congestion or nasal
discharge (anterior/posterior nasal drops):
• ± facial pain / pressure;
• ± decrease or loss of odor; during ≥12 weeks; with
confirmation by phone or conversation.
Questions about allergic symptoms (e.g., sneezing,
watery rhinorrhea, itchy nose, and itchy, watery
eyes) should be included in the interview.
Etiology
• INFECTIOUS - viruses, bacteria, fungi
• LOCAL
* * craniofacial anomalies (choanal atresia, cleft palate),
* nasal obstruction (allergic and non-allergic rhinitis, polyps,
tumors, medicated rhinitis, foreign bodies)
• TRAUMA – barotrauma
• LOCAL INFECTION - local osteomyelitis
• FAILED SURGERY
• anatomic variants - deviated nasal septum, paradoxically twisted
middle concha, recession of maxillary sinus
MUCOCILIARY TRANSPORT DISORDERS
• SYSTEMIC FACTORS - bronchial asthma, polyposis, allergic fungal
sinusitis, systemic vasculitis, Wegener's granulomatosis
Chronic sinusitis pathogens
Aerobic infection
► Streptococci - 21%
► Haemophilus influenzae - 16%
► Staph aureus - 10%
► Ps. Aeruginosa - 15%
► Mor. Cataralis - 10%
Anaerobic infection
► Prevotella spp – 31%
► Streptococcus spp – 22%
► Fusobacter – 15%
► Mixed flora– 25%
Pathological and anatomical processes
Exudative develops in catarrhal, serous allergic
and purulent.
• Productive - with hyperplastic, polyposis, and
to some extent allergic inflammation.
• Alterative changes are characteristic of
atrophic and necrotic (osteomyelitic) forms of
chronic sinusitis.
• Mixed forms of the disease and
correspondingly mixed types of pathological
anatomical changes are common.
Classification
А. Exudative (acute or chronic) forms: 1)
catarrhal; 2) serous; 3) purulent.
B. Productive form: 1) parietal-hyperplastic; 2)
polyposis.
C. Alterative form: 1) atrophic; 2) necrotic; 3)
cholesteatous; 4) caseous.
D. Mixed forms. The formation of mixed forms
is caused by a combination of all the above
forms of sinusitis.
E. Vasomotor and allergic sinusitis.
Diagnostics
• Assessment of complaints, medical history.
• General clinical and otorhinolaryngological
examination.
• Bacteriological examination of sinus discharge.
• Endoscopic examination (endophotography),
sinusoscopy (if necessary).
• Biopsy and cytology (if indicated).
• X-ray examination of the paranasal sinuses,
including with contrast agents (as indicated).
• CT scan is the gold standard, magnetic resonance
imaging (MRI) (if necessary).
• Diagnostic puncture of sinuses (as indicated).
Левосторонний
полипозный в/ч синусит,
антрохоанальный полип
Maxillary sinusitis
Chronic maxillary sinusitis is a chronic
inflammation of the mucous membrane of the
maxillary sinus.
The most common forms of chronic maxillary
sinusitis are purulent, purulent-polyposic,
polyposic forms, less common are catarrhal,
parietal-hyperplastic, allergic.
The basis of chronic maxillary sinusitis is an
obstruction of the natural fistula of the
maxillary sinus with the violation of its drainage
and subsequent colonization by bacterial flora.
Maxillary sinusitis
The most common signs of chronic maxillary
sinusitis are :
- prolonged mucopurulent or mucopurulent nasal
discharge on the affected side or both sides,
- nasal breathing problems,
- periodic headaches of a limited or diffuse nature,
- decrease in sense of smell (hyposmia) up to its
complete loss (anosmia),
- dry mouth,
- increased in body temperature, general
intoxication symptoms
- Occasional tinnitus, possibly hearing loss
Maxillary sinusitis
• On anterior rhinoscopy: mucopurulent discharges
from under the middle nasal cavity are observed,
which may increase when tilting the head to the
opposite side, purulent discharge on the bottom and
walls of the nasal cavity, hyperemia of the mucosa,
anatomical changes in different areas of the
ostiomeatal complex.
• Diagnosis is based on the results of a comprehensive
general clinical and local examination, including
endoscopic.
- X-ray of the paranasal sinuses,
- CT scan of the paranasal sinuses,
- diagnostic puncture, taken at the puncture the
contents of the sinus are sent for examination of the
flora and sensitivity to antibiotics
Maxillary sinusitis
Treatment
• In catarrhal, serous, exudative (allergic),
purulent and vasomotor forms of chronic
maxillary sinusitis begin with conservative
treatment.
• In productive, alterative, mixed forms,
surgical treatment is indicated.
• Orbital and intracranial complications are
indications for urgent surgical intervention.
Radical surgery on the maxillary sinus
according to Caldwell-Luke :
а — incision under the lip;
b — trepanation of the anterior wall of the
maxillary sinus;
c— a spoon inserted into the maxillary sinus
through the formed junction with the nasal
cavity
Chronic frontal sinusitis
Chronic frontal sinusitis is chronic
inflammation of the mucous membrane of the
frontal sinus.
The most common cause of chronic frontal
sinusitis is undertreated acute frontitis, a
persistent violation of the patency of the frontal
sinus canal. A predisposing factor is
hypertrophy of the middle nasal concha,
deviation of the nasal septum, causing blocking
of the ostiomeatal complex, polyposis maxillary
osteoethmoiditis.
Chronic frontal sinusitis
Clinical picture
- periodic or constant headaches of varying intensity in
the forehead area,
- occasional nasal stuffiness,
- formation of mucopurulent nasal discharge,
- decreased sense of smell,
- pain in the orbital cavity when the eyeball moves,
exophthalmus, chemosis, and vision may be impaired.
On palpation and percussion, there is painfulness in the
projection of the anterior and inferior walls of the
frontal sinus.
Chronic frontal sinusitis
• Anterior rhinoscopy reveals swelling or hyperplasia of
the anterior parts of the middle nasal concha, causing
blockage of the frontal sinus canal, mucopurulent or
purulent discharge along the lateral wall of the nasal
cavity, polyposis-modified mucosa in the middle nasal
passage.
• The diagnosis is made on the basis of :
- anamnesis data, characteristic complaints of the
patient,
- the results of the clinical and instrumental
investigation,
- X-ray investigations.
Chronic frontal sinusitis
Treatment
• Exudative (catarrhal, serous, allergic) forms
are treated conservatively;
• Productive, alterative, mixed forms (polyposispurulent, hyperplastic, fungal, etc.) by surgery
Radical surgery on the frontal sinus.
а — skin incision;
b — Preobrazhensky drainage formation
Chronic ethmoiditis
Chronic
ethmoiditis is
a
chronic
inflammation of the mucous membranes of the
ethmoidal labyrinth.
Continuation of undiagnosed or untreated
acute ethmoiditis.
• catarrhal serous,
• purulent
• hyperplastic forms of chronic ethmoiditis
Polyps protruding from under the
nasal concha and obstructing the
common nasal passage.
а — endoscopic view;
b — polyp loop removal
Chronic ethmoiditis
Clinical picture
• It is often latent
• During relapse - nasal discharge of mucous or
purulent nature, headache, feeling of heaviness in the
area, increasing when bending the head.
• In a complicated course, the process may proceed to
the orbit: swelling of the upper eyelid, smoothing of
the upper inner corner of the eye, the eyeball shifts
forward.
• On palpation, there is pain in the area of the nasal
root and at the medial angle of the eye (periostitis).
• Infection can also enter the eyelid tissue through the
venous ducts (phlebitis).
Chronic ethmoiditis
• Rhinoscopy indicates swelling of the
mucous membrane of the middle nasal
concha and the middle nasal passage,
mucopurulent or purulent discharge from
under the middle nasal concha or from
the upper nasal passage in the olfactory
recess.
• Endoscopically: anterior ethmoiditis
under the middle nasal concha, posterior
ethmoiditis in the upper nasal passage or
on the posterior wall of the nasopharynx.
• Characterized by single or multiple
polypous formations of various sizes
around the outlet openings of the cells of
the ethmoid labyrinth.
X-rays of the paranasal sinuses or CT scans
reveal darkening on the corresponding side
of the cells of the ethmoidal labyrinth.
Chronic ethmoiditis
Treatment
• In case of uncomplicated course of chronic
ethmoiditis, first of all, conservative treatment is
carried out.
• In the absence of effect, conservative therapy is
combined with various surgical methods:
corrective intranasal surgeries, septoplasty, nasal
polypotomies, partial or total opening of the cells
of the labyrinth; partial resection of hyperplaced
areas of the middle nasal cavity, marginal
(sparing) resection or vasotomies of the inferior
nasal cavity, etc.
Chronic sphenoiditis
Chronic sphenoiditis— chronic inflammation of the
mucous membrane of the sphenoid sinus.
Clinical picture
• characteristic "sphenoidal" symptoms: headache of
different severity and duration (up to suffering) in the
occiput or deep in the head, sometimes in the orbital
cavity, parietal and temporal region
• pus discharge from the nasopharynx and down the
back of the pharynx
• formation of viscous discharge, crusts and difficulty
removing them from the nasopharynx
• the inflammatory process can spread to the visual
cross-sectional area - visual deterioration occurs
Chronic sphenoiditis
Surgical tactics are used in chronic sphenoiditis.
There are various methods of endonasal and
extranasal opening of the sphenoid sinus. Mainly
endonasal methods are used, transseptal opening
according to Hirsch, endonasal opening of the
sphenoid sinus according to Halle modified by A.F.
Ivanov, F.S. Bockstein and V.I. Voyacek, endonasal
operations according to Messerklinger and
Wiegand with the use of endoscopes and
microsurgical instruments.
Chronic sphenoiditis
The diagnosis is based on :
- characteristic complaints, objective examination
data,
- endoscopic and X-ray examinations.
- probing or puncture of the sphenoid sinus through
its anterior wall may be performed for diagnostic
and therapeutic purposes.
Thrombosis of the cavernous sinus
Thrombosis of the cavernous sinus is a
thrombus formation up to complete occlusion of
the sinus lumen, accompanied by inflammation
of its vascular wall.
• The disease is caused by the spread of
infection from the region of the nasolabial
triangle (with nasal furuncles) or with
purulent inflammation of the paranasal
sinuses.
Thrombosis of the cavernous sinus
Clinical picture
• General symptoms: severe general septic condition
accompanied by a high, remitting rise in body temperature,
combined with chills, profuse sweating, and weakness.
• General cerebral symptoms: increased intracranial pressure
and is manifested by headache, nausea, vomiting.
• Meningeal symptoms: stiffness of the occipital muscles
with negative Kernig and Brudzinski symptoms (dissociated
symptom complex).
• Local signs include bilateral eyelid edema, chemosis,
exophthalmos and ptosis of the eyeballs, paralysis of the
eye muscles. Dilated veins protrude through the thin skin
of the eyelids, in the forehead and the root of the nose.
Examination of the fundus shows congestion, edema of the
optic disc, sharply dilated veins, hemorrhages on the retina.
Thrombosis of the cavernous sinus
Diagnosis of cavernous sinus thrombosis is
based on general clinical data, CT and MRI
Rhinogenic sepsis
Sepsis is a pathological symptomcomplex caused by
constant or periodic inflow into the blood of
microorganisms from a focus of purulent inflammation.
• Rhinogenic sepsis is relatively rare and is
characterized by the fact that the primary focus of
purulent inflammation is located in the nose and
paranasal sinuses. Rhinogenic sepsis is usually
preceded by cavernous sinus thrombophlebitis or
orbital vein thrombosis. In cases of purulent processes
in the palatine tonsils and paratonsillar space there
may be cases of tonsillogenic sepsis, otogenic sepsis,
which occurs more often than others, is usually
associated with sigmoid and petrosal sinus
thrombophlebitis.
Rhinogenic sepsis
Clinical picture
• severe multi-organ disorders predominate, while local
inflammatory changes are weakly expressed.
There are two forms of sepsis - septicemic and septicopyemic.
Patients are characterized by severe general condition, high
body temperature of constant or hectic type, shaking chills,
headache, weakness, loss of appetite, tachycardia, changes in
psychoemotional status up to severe general brain disorders
(coma) are possible. Subsequently, inflammatory changes of
internal organs - kidneys, endocardium, liver, intestines,
spleen.
• Local changes are characterized by edema, hyperemia, and
infiltration of eyelids and paraorbital area of one or both
eyes with formation of dense vascular bands,
exophthalmos, eye mobility is sharply restricted, painful.
Rhinogenic sepsis
Diagnostics
• duration of fever for more than 5 days and
appearance of unmotivated rises in body
temperature to febrile, followed by a fall to
subfebrile.
• Laboratory blood tests are characterized by
leukocytosis or leukopenia,
thrombocytopenia; increased C-reactive
protein, procalcitonin, positive results of
bacteriological blood tests - detection of
hemoculture.
Rhinogenic sepsis
Treatment
Intensive therapy, including surgical sanation of
the causative focus and etiopathogenetic drug
treatment, is necessary. Empirical antibacterial
therapy in maximum dosage is carried out until
the results of bacteriological examination are
obtained.