Rhinosinusitis: clinical features and diagnosis

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1 Rhinosinusitis: clinical features and diagnosis
Dr. Krishna Koirala

2 Definitions Rhino-sinusitis: inflammation of lining mucosa of nose & paranasal sinuses Acute: infection lasting < 4 weeks Sub acute: infection lasting 4 to 12 weeks Chronic: infection lasting > 12 weeks Recurrent acute (RARS): > 3 episodes of rhinosinusitis in 6 months or > 4 episodes in a year, each episode lasting for 7-10 days, without persistent symptoms in between

3 Types of sinusitis Acute / sub acute / chronic / recurrent
Open / Closed (depending on its drainage) Unilateral / bilateral Maxillary / frontal / ethmoidal / sphenoidal Single / multi / pan-sinusitis Anterior / posterior group Suppurative / hypertrophic Bacterial / fungal / allergic / occupational

4 Etiology Rhinogenic: commonest (85%), following any form of rhinitis
Dental: maxillary sinusitis, root abscess, dental procedures Trauma: R.T.A., swimming, diving, F.B., barotrauma Iatrogenic: nasal packing, septal surgery Hematogenous : rare

5 Predisposing factors Mucosal edema: viral, bacterial, allergic, irritant, vasomotor, barotrauma Mechanical obstruction: DNS with spur, polyp, hypertrophic turbinate, concha bullosa, paradoxical middle turbinate, Haller cell, large bulla ethmoidalis, agger nasi, uncinate anomaly, nasal tumours, foreign body, nasal packing

6 Mucous abnormality: Young’s syndrome, cystic fibrosis, mucoviscidosis, dehydration
Mucociliary dysfunction: Kartagener’s syndrome, viral, bacterial, allergic, smoking, pollutants, hypoxia, dry air, extremes of temperature, synechiae Miscellaneous: Poor health, immunodeficiency, diabetes, nutritional deficiency

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9 Bacteriology Chronic sinusitis Acute sinusitis Staph. Aureus
Streptococcus H. influenzae Bacteroides Pseudomonas Acute sinusitis Streptococcus pneumoniae Hemophilus influenzae Moraxella catarrhalis Staphylococcus aureus Neisseria

10 Progress Severity and resolution depends on Open / closed
Virulence of the organism Host resistance Treatment received

11 Ostio-meatal complex is key area for causation of infection in anterior group of sinuses
Pathological variants of ostio - meatal complex play a major role in causation of sinusitis due to reduced ventilation and drainage of sinuses

12 Clinical features of Rhinosinusitis
Symptoms Nasal discharge : mucoid / purulent / blood-stained Nasal obstruction with hyposmia / anosmia Headache and facial pain Cheek / eyelid congestion and swelling Hawking, sore throat, dry irritating cough Earache: associated Eustachian tube dysfunction Constitutional: fever, malaise, body ache

13 Location of facial pain in Rhinosinusitis
Maxillary sinusitis Cheek, upper jaw, forehead that increases on bending forward Frontal sinusitis Forehead that increases during morning and decreases by late afternoon (office headache) Anterior Ethmoid: nasal bridge and peri-orbital, more on eye movement Posterior Ethmoid : deep seated retro-orbital Sphenoid : vertex, occipital, retro-orbital pain

14 Signs of Rhinosinusitis
Congested and edematous nasal mucosa Nasal discharge (anterior and posterior rhinoscopy) Middle meatus: frontal, maxillary, anterior ethmoid Superior meatus: posterior ethmoid, sphenoid Tenderness over the paranasal sinuses Postnasal drip, granular pharyngitis Cheek swelling in maxillary sinusitis Lid edema in ethmoid & frontal sinusitis

15 Palpation to elicit paranasal sinus tenderness
Maxillary: over the canine fossa Anterior ethmoid: medial to medial canthus Frontal: Floor of sinus at the superomedial aspect of the orbit or tap over its anterior wall on the forehead

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17 Transillumination test for sinuses
Performed in a dark room. High-intensity light source placed inside patient’s mouth or against the cheek (for maxillary sinus) & under medial aspect of supra-orbital ridge (for frontal sinus) Trans-illumination normal : no sinusitis Trans-illumination absent : sinus filled with pus Trans-illumination dull : equivocal result

18 Postural tests for sinusitis
Performed in acute sinusitis (active nasal discharge) Pus cleaned in supine position & pt sits upright Pus appears = frontal or ethmoid sinusitis Pus appears on stooping forwards = sphenoid sinusitis No discharge  pt lies in lateral position with affected side up Pus appears = maxillary sinusitis

19 Rhinosinusitis Task Force Criteria
Major Minor 1. Facial pain / pressure Headache 2. Nasal obstruction Fever (non-acute sinusitis) 3. Nasal discharge or Halitosis discolored postnasal drip Fatigue 4. Hyposmia / anosmia Dental pain 5. Purulence on exam Cough 6. Fever (acute sinusitis) Ear pain / pressure / fullness Presence of 2 major factors or 1 major + 2 minor factors = sinusitis

20 Investigations Diagnostic nasal endoscopy (D.N.E.) Maxillary Sinoscopy
X-ray of P.N.S. U.S.G. of maxillary sinus (Rhinoscan) C.T. scan of P.N.S. M.R.I. of P.N.S.: rarely done Allergic tests Proof puncture (antral wash): for maxillary sinus Endoscopic microswab for culture & sensitivity Fungal culture: of cheesy nasal discharge

21 Diagnostic Nasal Endoscopy

22 Pus seen in middle meatus on doing D.N.E.
Indications for D.N.E. Patients not responding to medical therapy Anatomic factor preventing adequate examination by anterior rhinoscopy Collection of pus from hiatus semilunaris for culture & sensitivity Objective monitoring of patients Peri-operative nasal inspection & cleaning Pus seen in middle meatus on doing D.N.E.

23 Maxillary sinoscopy Anterior sinus wall perforated directly through canine fossa between roots of 3rd & 4th teeth with maxillary sinus trocar & cannula Trocar removed and sinoscope introduced through cannula to see inside the maxillary sinus

24 Plain X- ray of Paranasal sinuses
Water’s view (Occipito -mental)  maxillary sinus Caldwell’s view (Occipito -frontal) and lateral view frontal Rhese’s view (lateral oblique) and lateral view  ethmoids Base skull view (Submento -vertical) and Pierre’s view (Occipito -mental with mouth open)  sphenoid Air-fluid level seen in acute sinusitis Mucosal thickening seen in chronic sinusitis

25 Para-nasal sinus sonography
Bony anterior wall is seen as hyper-echoic line Maxillary cavity filled with air appears as hyper-echoic hence posterior sinus margin not seen Fluid in sinus, cyst & mucosal thickening are hypoechoic, so posterior sinus margin is visible B mode sonogram differentiates between fluid in sinus, cyst & mucosal thickening

26 C.T. scan of Nose and PNS Most reliable imaging modality for sinusitis at present Plain axial, coronal and sagittal cuts of 3 mm Contrast for suspected vascular, neoplastic, inflammatory lesions Helps to delineate the extent of disease, define anatomical variants and study the relationship of sinuses with surrounding  structures Indications: Recurrent acute/chronic sinusitis not responding to medical treatment Before endoscopic sinus surgery Impending complications of sinusitis

27 Plain C.T. scan Nose and PNS: Maxillary and ethmoid sinusitis

28 C.T. scan: frontal sinusitis

29 C.T. scan: sphenoid sinusitis

30 M.R.I. of P.N.S. Indications To assess the intracranial extension of sinonasal disease, brain abscess due to sinusitis and meningocele or encephalocele Malignant neoplasms of sinonasal tract To evaluate the orbital complications of sinusitis