Understanding Sinus and Sinusitis: Physiology and Pathophysiology

1. بسْمِ اللهِ الرَحمنِ الرَحِيمِ

2. SINUS & SINUSITIS

3. Acute Rhinosinusitis

4. Physilogy of the sinuses 1- Paterncy of the ostia 2- Function of the cilia 3- Quality of the glandular secretions

5. Siliary function Double layer of mucus include 1- superficial viscid gel layer 2- underlying serous or sol layer

6. - Mucosal edema in and around the sinus ostium the most significant pathophysiology - The abstruction of the sinus ostium O2 Cllary function mucus blanket? Local host resistence factors Secretions within sinus transient intrasinus pressure Negative intrasinus pressure nasal breathing Mucosal edema O2 Pathophysiology of the sinusitis

7. O2 Mucous gland dysfunction Vasodilation Ciliary dysfunction Transudation Viscid fluid Retained thick secretions Obstruction of the sinus ostium products

8. 1. Nostril hair 2. Sticky mucoid layer secreted by the goblet cells and the mucoid glands particles carried posteriorly at a rate of approximately 6-7 mm/ mimute to be swallowed 3. Phagosytose: particels that penetrate to the muscosal layer are phagocytose particles 5-10 micronsare most efficiently trapped in the nose particles 2-4microns may be carried through on air currents to the lung 4. Lysozymes: which are mucolytic enzymes that can cause swelling and lysis of some microorganisms 5. Antibodies:lgA. lgG Ration 3:1 in nasal secretions Ration 1:5 in serum Protection against infection

9. Protection against infection The principal immunolobulin in nasal secretions isIgA The highest circulating antibody against respiratory viruses is IgG  IgA antibody dose not combine with complement and therefore is unable to lyse bacteria, however, effective as a viral neutralizing substance.  IgA dose note speed clinical recovery, but renewed local specific IgA antibody stores provide protection agaist reinfection IgA in viral cold is two stage a: stage I: during the first 24 hours increase specific and nonspecific IgA b: stage II: a second rise in the IgA titer will be seen at approximately 1 week peaking at 2 weeks

10. sinusitis 1. Acute sinusitis occurs secondary to the extension of nasal and dental infection into thepathogen- free milieu of the paranasal sinuses 2.Type of sinusitis a: acute :associated with onset of a purulent airfluid level or sinus opacification b: sub acute :if the infection fails to resolve withina month and the mucosa has become increasingly thickenedby the inflammatory process c: chronic :these pathologic changes become irreversible and include two forms

11. sinusitis 1. Hypertrophic sinusitis 2. Atrophic or sclerosing sinusitis with areas of squamous metaplasia both conditions are associated withthickened secretions, reduced blood flow,andlow oxygen tension and PH, thus providing the atmosphere for anaerobic bacterial growth 3.Normal bacterial floraof the ant. part of nose and nasopharynx frequently include, staph, strep pneumonia H. influenzae and beta- hemolytic strep

12. Predisposing factors in sinusitis 1. Common cold 2. Mucosal hypertrophy from allergic or vasomotor rhinitis 3. Septal deviation 4. polyps 5. obstructing adenoidal tissue 6. Tumors 7. Foreign bodies 8. Unilateral choanal atresia

13. Acute frontal sinusitis 1. It presents withpainover the frontal sinus that isincreased by trapping or bending forward 2. The sinus will fail to transilluminate, will havefluid leveland will beopaque on radiographs 3. All forms of sinusitis frequently follow viral upper respiratory tract infections and are particularly common in patients with septal deviations and nasal polyps 4. If A.F.S goes untreated, the patient may present withfever, swelling, and redness over the sinusassociated with edemaof upper eyelid and diffuse headache

14. Acute frontal sinusitis 5. Pus may not be present in the nose 6. Complications A.F.S a: meningitis b: epidural, subdural or brain abscess (extension bacteria intracranialy through phlebitic diploic veins c: potts puffy tumor 7. Bacterial include S. peneumoniae and H. influenzae 8. A.F.S frequently requires hospitalization, intravenousantibiotics should be administered, along with opical nasal decogestant or %4 cocaine packings, three times a day to induce drainge

15. Acute frontal sinusitis 9. The choice of antibiotic should be based on the presumed appropriate bacterial coverage and good C.N.S penetration (third generation cephalosporinesuchas cefuroxime or ceftriaxone) patients who have had rash- type allergic reaction to penicillin, but they should be avoided in patients who have had anaphylactic reaction to penicillin 10. If the sinus fails to drain and patients condition has not improved in24 hours, surgical drainage followed by saline irrigationof the sinus should be under taden

16. Chronic frontal sinusitis C.F.S occurs in two form A:Low gradefrontal sinusitis with thickened sinus lining and retained secretions This form is characterized bymild tendernessandchronic headachewith associatedintermittent drainage into the nose Rediographs demonstrate anopacified sinus with sclerosisof the surrounding bone  These infections result from an inadequately functioning nasofrontal duct system caused by allergic or hyperplastic mucosa, scarring or traumatic ductal injury  Most cultures aremixed and most orevalent pathogenes areanaerobesthat respong to high dose penicillin or cephalosporins such as cefoxitic,for oenocillin allergic individuals,clindamycin or chloramphenicolare choices, combination withtobramycin  H. Influenzaeis the most important aerobe

17. Chronic frontal sinusitis B:Mucocele, or mucopyocele These lesions are often painless but they gradually expand and erode the walls of the sinus and swelling of the upper eyelid and at times exphthalmos and diplopia  Osteoplastic frontal fat obliteration of the sinus is the treatment of choice Baterial studes should include routine culture, anaerobic culture and smear  Penicillin G or cefoxitin are good choices for postoperative antibiotic choices for postoperative antibiotic coverage until the cultures are returned

18. Acute & Chronic maxillary sinusitis 1. Acute maxillary sinusitis may follow viral respitatory infection 2. Bacteria most frequently cultured a: H. influenzae b: S. pneumoniae c: Bronhamella catarrhalis d: S. aureus 3. Anaerobes are also common cultured from a chronically infected sinus 4. A Unilaterally opacified maxillary antrum on sinus xray film: A. potential sinus tumor until proved otherwise B. apical root abscess draining into the sinus

19. Acute & Chronic maxillary sinusitis  Evaluation should include a: sinus Xray film (waters) b: C.T. Scan, if necessary c: Dental bite wing views d: Panorex  If the diagnosis remains in doubt,the sinus should be explored 5. Osteomyelitis of the maxilla is unusual but rarely may result in fistula formation to the cheek, palate or pterygoid fossa

20. Acute & Chronic maxillary sinusitis 6. Treatment:for 3 weeks or more a: Amoxicillin, Augmentin, cefaclor b: for penicillin- allergic erythromycin together cotrimaxazole c: vasoconstrictors spray by head positioning maneuvers d: doist air inhalation 7.An antral washshould not be attempted in untreated acute sinusitis but should be usedafter a week or moreof antibiotic therapy

21. Acute & Chronic Ethmoiditis 1. Acute viral ethmoiditis is commonly associated with viral rhinitis 2. Scondary bacterial infection can be recognized by a change from mucoid to mucopurulent nasal drainage 3. Ethmoidal sinusitis is the form of sinusitis most frequently seen among pediatric patients 4. Chronic ethmoiditis is often seen in patients with allergic or hyperplastic sinusitis 5. Because of mucous stasis and poor vascularity of polypoid tissue, infection is often difficult to treat in this situation 6. Ethmoidal surgery may be required to control chronic infection

22. Acute & Chronic Sphenoidal sinusitis 1. Sphenoidal sinusitis occures alone only occasionally, more often it is seen in pansinusitis 2. Isolated bacterial or rarely fungal infections occur in debiliated elderly persons 3. Patients complain of a deep headache behind the eyes with pain referred to the vertex of the skull 4. Diagnosis requires a high index suspicion

23. Acute & chronic sphenoidal sinusitis 5. Un complicated acute sphenoidal sinusitis usually responds briskly to appropriate antibiotic treatment 6. If treatmentt fails, surgical drainage of the sinus is accomplished by resection of the ant.wall sphenidal by external ethmoidectomy or transseptal approach 7. Complications of sphenoidal sinusitis a: Osteomyelitis of sphenoid bone b: Cavernous sinus thrombosis c: Panhypopituitarism d: Blindness

24. Complication of sinus infection A. local complications a: chronic mucosal inflammmation:  The most common complication of acute sinusitis  There is intermittent thick yellow- green drainage b: Mucocele or mucopyocele  It arises most commonly in the frontal sinus, less commonly in the ethmoidal sinus and rarely in the sphenoidal sinus  A mucocele of the frontal sinus can present in the supero medial aspect of the ornbit as a painless soft mass that may displace the eye inferiorly and laterally

25. Complication of sinus infection c: Osteomyelitis  It is quite unusal, it occurs most commonly following trauma, radiation, or debilitating diseases  In the maxillary sinus, osteomyelitis can occur subsequent to a dental root abscess or dental extraction  The frontal sinus is the most commmon site of this type of osteomyelitis, which occurs secondary to periostitis and cause edema over the sinus (potts puffy tumor)  Potts puffy tumor is a red, tender swelling of the foreheade skin with associated fever

26. Complication of sinus infection d: Orbital complications 1. Pneumocele of the orbit  It may result from a small bony defect between the orbit and maxillary or ethmoidal sinuses following forceful blowing of the nose 2. Orbital cellulitis:  It is a frequent complication of acute ethmoiditis in children (less in adults) secondray to spread of infection either directly through the lamina papyracea or via phlebitic veins  It characterized by lid swelling, chemosis and proptosis, pain is variable but maybe sever, mild to markly restricted eye motion  In uncomplicated cases, vision remains good and pupillary reflexes are normal

27. Complication of sinus infection 3. Dacryocystitis:  It is manifested by localized, painful, red welling below the medial can thus over the lacrimal sac  this complication occurs more often in elderly patients and generally responds well to antibiotics  Surgical drainge is required only occasionally 4. Sup. Orbital fissure synd.  It is a rare complication of sphenoidal sinusitis  The symptoms consist of deep orbital and unilateral frontal headache with progressive III, IV,VI palsies

28. Complication of sinus infection B. Systemic complication a: C.N.S complication 1. Meningitis:  The most common bactera are strep. Pyogenes, S. pneumonia, staph aures and H. influenzae  Treatment consists of immediate initiation of intensive antibiotic therapy for 2 weeks or longer in addition to through surgical drainage of the involoved sinus  Surgical drainge is required only occasionally 2. Brain abscess:  One clue is a high C. S. F protein concentration

29. Complication of sinus infection 3. Cavernous sinus thrombosis:  This infection is chracterized by high spiking fever in a patient with high toxicity  There is a rapid on set of oculomotor involvement including almost simultaneous involvemnt of III, IV,VI cranial nerve, resulting in a painful pan opthalmoplegia or fixed-eye  Pupillary responses are usually lacking and a large pupil is common Optic nerve involvement is manifested by congestion of the optic disc, field cuts, or complete less of vision  In a responsive patient, sensation in volving the first division of V nerve maybe diminished of lacking  Treatment consists of intensive antibiotic therapy, drainage of the contiguous, infected ethmoidal and sphenoidal sinuses and anti coagulation

30. 1. Bacteria pseudomonas, S.aurens (penicillin resistant) 2. This is aparticulary important consideration for patients with cystic fibrosis. 3.Sinus infections in ill patient or in the patient in ICU are precipitated by foreign objects placed through the nose, N.G Tube nasopharyngeal airway tube, and packing 4. Treatment a: removal of nasal tube b: administration of IV antibiotics c: especially in life- threatening sinus- drainage Nasocomial sinus infections

31. Fungal sinus infection A. Non opportunistic infection 1. Aspergillus fumigatus is the most common cousative agent 2. In nonivasive fungal sinusitis, fungus lives saprophytically as a, small mycetoma on the mucosa of the sinus floor  Treatment is the removal of the fungus and improved sinus ventilation  This disease often begins as a dental infection or follows an oroantral fistula

32. Fungal sinus infection 3. Allergic aspergillus sinusitis: The disease, which often affects young adult, is characterized by recurrent polyoid rhinosinusitis, a history of asthma, and pansinusitis documented by Xray  The diagnosis is made histologically byexamination of mucinous material for eosinophils, septate hyphae, and charcot.Leyden crystals and by immunologic Testing for an lgG - mediated positive skin test or by antigen specific serumIgE- elevation There is no tissue invasion by the fungi  Treatment: a: surgical extirpation and earation b: long- term oral steroid therapy

33. Fungal sinus infection B. Opportunistic infections 1. Invasive fungal infections occurs under diabetic keto acidosis, immune alteration secondary to antibiotic and steroid therapy and profound granulocytopenia 2. The earliest clinical presentation: a: Unexplained fever b: A slight cloudy rhinorea c: Facial tenderness 3. Xray film: the patients impaired inflammatory response dose note produce sign of sinusitis on Xray films until the disease is advanced

34. 4. Nasal examination: gray non sensate areas may represent early tissue invasion and infarction 5. Biopsy a: Nonseptate hyphaetissue mucormycosis b: septate hyphae with branching at 45 degrees aspergillosis c: other opportunistic infections include candida, herpes simplex, and pseudomona 6. Treatment: Surgical excision should be performed as quickly advance rapidly  Amphoteripcin -B is administers  The best hope for survival is an improved granulocyte count Fungal sinus infection

35. 1. It is a fluminant opportunistic infection usually caused by Rhizopus oryzae 2. The infection, by fever and increased obtundation, usually arises in the nose and ethmoidal sinus, however, it can arise in the lung or bowel 3. If uncontrolled, it is fatal in a period of days to weeks. 4.Clinical presentation a: headache b: nasal blockage c: sero sanguinous nasal discharge d: invading and penetrating the walls and causing thrombosis and necrosis e: panophthalmoplegia and proptosis f: extend intracranially seizure, coma, death Mucor Mycoses

36. Mucor Mycoses 5. The prognosis is grave 6. The diagnosis by biopsy demonstrates non septate, branching hyphae 7. Treatment: a: Amphoteripcin-B should be initiated as soon as possible intravenously b: surgical debridment of infected tissue

37. Aspergillosis 1. Although aspergillosis occurs most commonly as a chronic pulmonary disease, it may also be a chronic granulomatous infection of M.E,E.A.c, nose and paranasal sinuses 2. The fungus may be part of the normal orophryngeal flora, but, in debilitated or mmunosuppressed patients, acute aspergillosis may become a very aggressive nasal and sinus infection 3. Extension from the nose and oaranasal sinuses can quickly involve the orbit and C.N.S

38. Aspergillosis 4. Diagnosis: by biopsy, culture and exmination of nasal secretions for mycelial forms 5. Treatment: a: In chronic form, It is not life threatning and shold be treated by debridment and local therapy b: In acute form, it is life threatening disease, prompt debridemnt is requred  systemic amphotericin- B therapyy is occasionally effective

39. 1. History 2. Physical examination 3. X-ray film 4. C.T.Scan 5. Biopsy & culture Waters Caldwell Diagnostic Evaluation

40. Management of sinusitis (duration) 1- clinical improvemement usually occurs within 48 to 72 hours of inltiation of antimicrobial therapy 2- the antibiotic therapy should be continued for a minimum of 7days afer the symproms have disappeared 3- the average duration of treatment should be 10 days and often 2 weeks

41. Surgical Managment A. Maxillary sinus 1. Antral irrigation 2. Fenestration (inf. Meatus) 3. Caldwell-Luc 4. F.E.S.S (antrostomy of M.M)

42. Surgical Managment B. Frontal sinus a: acute frontal sinusitis 1. Trephination b: chronic frontal sinusitis 1. Lynch 2. Reidel 3. Killian 4. Lothrop 5. Osteoplastic 6. F.E.S.S

43. c: Ethmoidal sinus 1. Intranasal ethmoidectomy 2. External ethmoidectomy 3. F.E.S.S d: Sphenoid sinus 1. Transseptal sphenoidectomy 2. Trans ethmoidal sphenoidectomy 3.F.E.S.S Ant. Ethmoidectomy Post. ethmoidectomy Spheno ethmoidal yecess Trans ethmoidal Surgical Managment

44. Indication for external ethmoidectomy 1. Extensive polypoid sinus and nasal disease 2. Chronic ethmoid sinus infection 3. Approach to tumor of the frontal, ethmoidal and sphenoidal sinuses 4. Searching for and repairing C.S.F leaks in the cribriform, ethmoidal and sphenoidal regions 5. Extracranial approach in hypophhysectomy 6. Orbital decompression