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.