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Chronic Sinusitis causes, predisposing factors, symptoms, treatment

Definition: Chronic (more than 3 months duration) inflammation of the mucoperiosteal lining of the paranasal sinuses, usually rhinosinusitis.

Etiology
The anterior ethmoid is the source of infection and reinfection of the other paranasal sinuses. Blockage at the ostiomeatal complex [OMC] leads to secondary maxillary and/or frontal sinusitis and the most common causative organisms are Streptococcus Pneumoniae, Moraxella Catarrhalis and Hemophilus Influenza in addition to anaerobic organisms.
chronic-sinusitis

Predisposing factors:
1. Nasal blockage due to:
  • Nasal allergy
  • Nasal polyps
  • Deviated septum
  • Large middle turbinate
  • Adenoids

2. Low resistance of the patient, high virulence of the organism and/or inefficient medical treatment in acute sinusitis [sensitivity, dose, form, route and/or duration of the antibiotics].

Age: adults more than children.
Sex: equal.
Incidence: common.
Sinus affected: Most common are the ethmoids followed by the maxillary then frontal and the sphenoid sinus are the least common.

Pathology: Hypertrophic sinusitis with macrophages.

Symptoms of Chronic Sinusitis:

Local:

  • Postnasal discharge: thick, and purulent with cough.
  • Anterior nasal discharge: unilateral or bilateral according to the side affected, thick, mucoid and/or purulent.
  • Nasal obstruction: unilateral or bilateral, partial or complete
  • Headache: mainly in-between eyes may be below or above the eye according to the sinus affected. It is deep, dull and increases on straining. It may be periodic in frontal sinusitis.


N.B. Sinusitis of dental origin is usually associated with bad odorous nasal discharge.


Systemic:

  • Septic focus: Low-grade fever, headache, ill health, rapid fatigue and anorexia. May lead to optic neuritis, iritis, rheumatic heart disease, prostatitis, oophoritis, arthritis and osteomyelitis.
  • Spread of infection: e.g. otitis media, pharyngitis, laryngitis and/or chest infection.
  • Complications: Extra-cranial, cranial, intra-cranial and/or orbital.

Signs:

  • Purulent discharge: mainly from the middle meatus.
  • Congestion of the nasal mucosa: usually localized around the middle meatus.
  • Polyps: few, pink, soft and arising mainly from the middle meatus.

N.B. Kartagnar's syndrome [immotile cilia syndrome]: Sinusitis, bronchiectasis and sterility.

Investigations:

  1. Nasal endoscopy: polyps, pus and congested mucosa around the middle meatus.
  2. CT: opacity at the ostiomeatal complex area (OMC) and affected sinus/es.
  3. Culture and sensitivity of the purulent discharge.
  4. Trans-illumination: The affected sinus is opaque in comparison to the other side.

N.B. Plain X-ray, lipiodol study and proof puncture are not used anymore after the introduction of diagnostic nasal endoscopy and computed tomography.

Treatment of Chronic Sinusitis:

a. Medical:
  • Antibiotics.
  • Analgesics.
  • Decongestant nasal drops.
  • Mucolytic.
  • Saline nasal lotion

b. Surgical:
  • Indicated only after failure of aggressive medical therapy as documented by endoscopy and CT.
  • Functional endoscopic sinus surgery (FESS) is the treatment of choice.

FESS includes:
  1. Polypectomy using the shaver.
  2. Anterior and posterior ethmoidectomy.
  3. Middle meatal antrostomy: widening the maxillary ostium.
  4. Frontal recess clearance: removal of polyps and diseased mucosa.
  5. Sphenoid sinusotomy: widening of the ostium

  • Treatment of the predisposing factors is important.
treatment-chronic-sinusitis

N.B. In chronic sinusitis: puncture and lavage, intranasal antrostomy and radical antrum, external ethmoidectomy and external frontal operations procedures were performed before the introduction of functional endoscopic sinus surgery.
  • Puncture and lavage is not advised any more, as it does not remove the blockage at the ostiomeatal area and leads to recurrence.
  •  Inferior meatal antrostomy is not advised, as the mucociliary clearance system of the maxillary sinus drains mucous by ciliary movements towards the natural maxillary ostium bypassing the artificial inferior meatal antrostomy.
  •  Radical antrum procedure is not advised, as it removes the natural maxillary sinus mucosa and leads to replacement by fibrosis lacking the mucociliary activity leading to recurrent and persistent symptoms.
  •  External ethmoidectomy and external frontal operations are not advised (except in selected cases ) due to external facial incision and scar, insult to the bony skeleton of the nose and sinuses and inability to take care of all the sinuses in one sitting.

Key points:

Chronic sinusitis results from malmanagement of acute rhinosinusitis leading to persistent blockage at the OMC. -Nasal endoscopy and CT are used recently for the diagnosis of chronic sinusitis. -Medical therapy is the mainstay in management of chronic rhinosinusitis. -FESS is the state of the art in management of persistent chronic rhinosinusitis after failure of comprehensive medical therapy.

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