Sinusitis

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Sinusitis

• DR Rajesh
• 02/04/2008

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Anatomy

• MAXILLARY
• ANT ETHMOID
• FRONTAL
• POST ETHMOID
• SPHENOID
• LACRIMAL DUCTS

MIDDLE MEATUS
SUPERIOR MEATUS
INFERIOR MEATUS
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Development

• Maxillary Sinus
• first to develop at day 65 of gestation
• seen on plain films at 4-5 months
• slow expansion until 18 years
• Ethmoid Sinus
• develop in third month of gestation
• ethmoids seen on radiographs at one year
• enlarges to reach adult size at age 12
• Sphenoid Sinus
• originates in fourth gestational month from
  posterior part of nasal cavity
• pneumatization begins at age 3
• rapid growth to reach sella by age 7 and adult
  size at age 18
• Frontal Sinus
• begins in fourth month of gestation from superior
  ethmoid cells
• seen on radiographs at age 5-6
• grows slowly to adult size by adolescence

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Physiology

• THREE KEY ELEMENTS
• PATENCY OF THE OSTIA
• FUNCTION OF THE CILIARY APPARATUS
• QUALITY OF SECRETIONS

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Factors Predisposing To Obstruction Of Sinus
Drainage.
A. MUCOSAL SWELLING Systemic disorder Viral
URI Allergic inflammation Cystic
fibrosis Immune disorder Immotile cilia Local
insult Facial trauma Swimming, diving Rhinitis
medicamentosa
B. MECHANICALOBSTRUCTION Choanal
atresia Deviated septum Nasal polyp Foreign
body Tumor Ethmoid bullae C. MUCUS
ABNORMALITIES Viral URI Allergic
inflammation Cystic fibrosis
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Pathogenesis

• Ostia obstruction creates increasingly hypoxic
  environment within sinus
• Retention of secretion results in inflammation
  and bacterial infection
• Secretion stagnate, obstruction increases, cilia
  and epithelial damage become more pronounced
• Most common inciting event is viral URI

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Definitions

• Acute symptoms often inseparable from URI and
  include rhinorrhea, daytime cough, nasal
  congestion, infrequent low-grade fever, otitis
  media, irritability and headache. Key in
  diagnosis of sinusitis is persistence beyond 7-10
  days or worsening of symptoms at around 7 days
• Severe Acute Sinusitis purulent rhinorrhea, high
  fever, periorbital edema
• Recurrent complete resolution between episodes
  and 3 or more episodes in six months or more than
  4 episodes in one year
• Subacute signs and symptoms lasting three weeks
  to three months
• Chronic signs and symptoms lasting longer than
  three months

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Epidemiology

• Occurs during viral respiratory season
• Attendance at Day Care Center
• School-age siblings in the household

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Symptoms And Signs

• PERSISTENT URI
• gt10 DAYS
• No appreciable improvement
• Nasal discharge of any quality
• Cough(must be present during day)
• Malodorous breath
• Facial Pain and headache are rare
• If fever then low grade
• May not appear very ill

• SEVERE URI
• High fever gt 39 C
• And
• Purulent nasal discharge
• Present for atleast 3-4 days
• Headaches may be present
• Periorbital swelling occasionally

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Subacute Sinusitis

• 30 days to 3 months
• Mild to moderate and often intermittent symptoms
• Nasal discharge of any quality
• Cough often worse at night
• Low-grade fever may be periodic usually not
  prominent

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Chronic Sinusitis

• Extremely protracted nasal symptoms
• Discharge or congestion
• or Cough
• or both
• Some cases rhinorhhea minimal or absent
• Nasal congestion-mouth breathing-sore throat

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Chronic Sinusitis

• Chronic headache usually on awakening
• Intermittent fever
• Malodorous breath
• Secondary affects
• fatigue, impaired sleep
• decreased appetite
• irritability

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Physical Findings

• Mucopurulent discharge in nose or posterior
  pharynx
• Nasal mucosa- erythematous
• Throat- moderate injection
• Ears- acute otitis or otitis with effusion
• Paranasal sinus tenderness- occasionally
• Periorbital edema-occasionally
• Malodorous breath

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Differential Diagnosis- Purulent Nasal Discharge

• Uncomplicated viral URI
• Group A Strep infection
• Adenoiditis
• Nasal foreign body

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Differential Diagnosis- Nasal Symptoms

• Persistent clear nasal discharge or nasal
  congestion
• Allergic rhinitis- nasal discharge, congestion,
  sneezing, itchiness of eyes, nose, other mucous
  membranes, pale boggy mucosa, transverse crease
  on bridge of nose, headaches

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Differential Diagnosis- Nasal Symptoms

• Nonallergic rhinitis -resemble allergic
  rhinitis children -specific allergens cannot be
  demonstrated, IgE levels normal,
  radioallergosorbent test negative
• Rhinitis Medicamentosa
• Vasomotor Rhinitis

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Differential Diagnosis-Cough

• Reactive airway disease
• GER
• Pertussis
• Mycoplasma bronchitis
• TB

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Diagnosis- Sinus Aspiration

• Indications
• failure to respond to multiple antibiotics
• severe facial pain
• orbital or intracranial complications
• evaluation of an immunoincompetent host
• Material should be sent for quantitative aerobic
  and anaerobic cultures
• Density of atleast 104 colony-forming units/ml
  represents true infection

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Diagnosis-Imaging

• Standard views
• Anterioposterior
• Lateral
• Occipitomental
• When children older than 1 have neither
  respiratory signs nor symptoms, their sinus
  radiographs are almost normal
• Findings
• acute-diffuse opacification,mucosal thickening of
  atleast 4 mm, or an air-fluid level
• Significantly abnormal in 88 of children younger
  than 6

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Diagnosis- CT Scans

• Frequent abnormalities are found in patients with
  a fresh common cold
• Indications
• complicated sinus disease (either orbital or CNS
  complications)
• numerous recurrences
• protracted or nonresponsive symptoms(surgery is
  being contemplated)

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Microbiology

• Streptococcus pneumoniae 30-40
• Haemophilus influenzae 20
• Moraxella catarrhalis 20
• Strep pyogenes 4
• Respiratory viral isolates 10
• adenovirus
• parainfluenzae
• influenzae
• rhinovirus
• Other rarer isolates- group A strep, group C
  strep, viridians strep, peptostrep, Moraxella
  species, Eikenella corrodens

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Treatment goals

• The goal in treating these children is to combine
  
• antibiotic therapy
• with treatment of associated conditions
• for a time sufficient to allow resolution of
  symptoms
• with return of normal sinus physiology and
  mucociliary clearance.

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Medical Treatment

• Acute Sinusitis
• Young children with mild to moderate ARS,
  amoxicillin at normal or high dose
• Amoxy-allergic patients, treat with a
  cephalosporinsevere allergy, treat with
  macrolide
• Nonresponders, more severe initial disease, those
  at high-risk for resistant strep, treat with high
  dose amoxy/clavulanate
• Parenteral ceftriaxone for children not
  tolerating oral medicines
• Duration of therapy is usually 10-21 days or
  until symptoms resolve plus 10 days

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Medical Treatment

• Chronic Rhinosinusitis
• 4 to 6 week course of beta lactam stable
  antibiotic
• Adjuvant therapy with nasal steroids commonly
  employed
• Antihistamines especially if underlying allergic
  condition suspected
• Mucolytics may thin secretions

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Refractory Rhinosinusitis

• Consider associated conditions
• Allergy
• Immune deficiency
• Asthma
• Gastroesophageal reflux disease
• Cystic Fibrosis
• Primary Ciliary Dyskinesia (Immotile Cilia
  Syndrome)
• Allergic Fungal Sinusitis

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Allergy

• Major contributing factor in rhinosinusitis
• Similar pathogenesis as viral etiology with
  obstruction -- mucostasis --hypoxia
  colonization
• Itching mucous membranes, clear rhinorrhea,
  eczema, food intolerance, nasal congestion,
  stuffiness, fluctuating rhinorrhea, sneezing,
  cough, behavioral changes, headaches, facial
  pressure
• Avoidance
• clean, allergy proof house, filter, no pets, air
  conditioning
• Pharmacotherapy
• antihistamines, nasal steroids, mast cell
  stabilizers
• Immunotherapy

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Immune Deficiency

• History of frequent otitis media, pneumonia and
  sinusitis may suggest a primary or secondary
  immunodeficiency state
• Serum immunoglobulins and IgG subclasses should
  be checked as well as ability to respond to
  capsular antigens of S. pneumoniae and H.
  influenzae
• Must have laboratory with age-appropriate norms
• Chronic pediatric sinusitis associated with IgG2
  deficiency
• Consistent low total immunoglobulin defines
  common variable hypoglobulinemia
• Treatment in primarily medical
• Patients may benefit from IVIG therapy
• Genetic counseling for patient and family may be
  appropriate

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Asthma

• Sinusitis and asthma frequently associated same
  underlying disease process or causal
  relationship?
• Treatment of sinusitis whether medical or
  surgical reduces use of bronchodilators, improves
  pulmonary symptoms

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Gastroesophageal Reflux Disease

• Many pediatric patients experience improvement in
  their chronic sinonasal symptoms after a trial of
  antireflux medicine
• GERD theorized to have direct effect on nasal
  mucosa, initiating inflammatory response with
  edema and impaired mucociliary clearance
• Phipps in 2000 reported a prospective trial in
  which 63 CRS patients were found to have
  esophageal reflux by pH probe 32 demonstrated
  nasopharyngeal reflux
• Bothwell in 1999 reported 89 of pediatric
  candidates for FESS avoided surgery with
  treatment for GERD

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Cystic Fibrosis

• Autosomal recessive disease
• Mutation of CFTR protein
• Patients develop chronic pulmonary disease in
  childhood also affected with sinusitis and nasal
  polyposis, pancreatic insufficiency and biliary
  cirrhosis
• If surgery contemplated, check coags
• Recent studies suggest heterozygous mutations in
  the CFTR gene are associated with chronic
  rhinosinusitis
• Raman found that 12.1 of CRS patients harbored
  CFTR mutations compared with the expected rate of
  3-4
• Wang found a 7 incidence of CFTR mutation in 123
  CRS patients compared to 2 in a control group

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Primary Ciliary Dyskinesia

• History of chronic otitis media, chronic
  sinusitis and chronic bronchitis or
  bronchiectasis
• Kartageners syndrome sinusitis, situs inversus,
  bronchiectasis and male infertility
• Diagnosis established with inferior or middle
  turbinate or tracheal biopsy

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Allergic Fungal Sinusitis

• Allergic reaction to aerosolized fungi,
• Treatment is surgical with perioperative oral
  steroid and post-operative topical steroids
• High recurrence rate, requires close follow up
• Findings in children different than adult
  findings
• Children more frequently have abnormalities of
  their facial skeleton
• More likely to have unilateral disease

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Complications

• Orbital
• Orbital complications more common in children
  than adults
• Most common is medial subperiosteal abscess
• Intracranial
• More common in adolescents/adults
• Include meningitis (most common), epidural
  abscess, subdural abscess, intracerebral abscess,
  cavernous sinus thrombosis

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Orbital Complications

• Classified by Chandler
• I. Preseptal cellulitis
• II. Orbital cellulitis
• III. Periorbital abscess
• IV. Orbital abscess
• V. Cavernous sinus thrombosis
• Spread by direct extension via osseous structures
  or indirectly via valveless venous plexuses
• CT scan with contrast if orbital involvement
  suspected

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Stage IPreseptal Cellulitis

• Eyelid edema, erythema and normal globe movement
• Stage I in children more likely due to cutaneous
  lesions or hematogenous seeding rather than
  sinusitis

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Stage IIOrbital Cellulitis

• Proptosis, Chemosis, Edema, Pain
• Dilated pupil
• Visual loss
• Ophthalmoplegia
• Afferent pupillary defect

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Stage IIIPeriorbital Abscess

• Proptosis with globe displacement
  inferolaterally, decreased EOM, vision decreased
• IV Ab with external or endoscopic drainage of
  abscess and involved sinus

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Stage IVOrbital Abscess

• orbital abscess
• severe proptosis and chemosis
• usually no globe displacement
• opthalmoplegia present
• Impaired visual acuity

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Stage VCavernous Sinus Thrombosis

• Progressive symptoms
• Proptosis and fixation
• CN II, IV, VI
• Meningitis
• High mortality
• High fever, bilateral symptoms

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Intracranial Complications

• Meningitis, Epidural Abscess, Intracerebral
  Abscess, Potts Puffy Tumor
• Neurosurgical Consultation, high-dose
  antimicrobial therapy, drainage of intracranial
  abscess planned in concert with drainage of
  affected sinus
• Frontal sinus is most implicated sinus venous
  drainage of the frontal sinus via small diploic
  veins extending through sinus wall these
  communicate with venous plexi of dura, periorbita
  and cranial periostuem

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Surgery

• Adenoidectomy With adenoidectomy alone, symptom
  improvement occurs for more than 50 of patients.
• Functional endoscopic sinus surgery Uncinate
  removal, anterior ethmoidectomy, and maxillary
  antrostomy overall success rate is approximately
  80.
• Maxillary sinus wash and intravenous antibiotics
  have not been universally accepted.
• Balloon sinuplasty

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Surgery

• Rarely required
• Consider if orbital or central nervous system
  complications or
• Failure of maximal medical therapy

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Absolute Indications for Surgery

• Causing brain abscess or meningitis,
  subperiosteal/orbital abscess, cavernous sinus
  thrombosis, another contiguous infection, or an
  impending complication (Potts tumor)
• Sinus mucocele or pyocele
• Fungal sinusitis
• Nasal polyps (massive )
• Neoplasm or suspected neoplasm

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Other Medications

• Antihistamines, decongestants, and
  anti-inflammatory agents have not systematically
  been studied in children
• May try these above agents