Sinusitis affects all age groups, and is a common diagnosis. Satisfactory outcomes result when acute and chronic sinusitis is treated early with aggressive medical management. Endoscopic sinus surgery restores sinus health with complete or moderate relief of symptoms in 80-90% of patients with recurrent or medically unresponsive sinusitis.
The 4 pairs of paranasal sinuses drain through their ostia and the nasal cavity which is usually colonized with bacteria. Sinuses are typically sterile. Secretions, for a number of different reasons, may form inside the sinuses and these are predisposed to microbial infections (bacterial or fungal).
Acute sinusitis presents with fever and unilateral facial pain, purulent nasal discharge, pain during eating, anosmia (reduction in the sense of smell), headache, fever and tooth ache.
Chronic Sinusitis mostly develops in patients who have acute sinusitis that does not respond to treatment, or in those who have not received treatment.
Chronic Sinusitis usually presents with nasal stuffiness, nasal discharge, postnasal drip, facial fullness, discomfort, headache, chronic unproductive cough, anosmia, sore throat, halitosis, (bad breath) general malaise, exacerbation of asthma, visual disturbances, sneezing, stuffy ears, unpleasant taste and fever of unknown origin.
The predisposing / risk factors in chronic sinusitis are:
- Structural - septal deviation, congenital abnormality, tumour, nasogastric intubation
- Inflammatory - allergic rhinitis, non allergic rhinitis, nasal polyps, recurrent upper respiratory tract infections, dental
- Environmental - smoking, pollution
- Ciliary Dysfunction - Cystic Fibrosis, Primary Ciliary Dyskinesia, Kartagener Syndrome
- Systemic diseases - Diabetes, Wegener Granulomatosis, Immunologic Disorders (eg, Common Variable Immunodeficiency, Immunoglobulin A Deficiency, Immunoglobulin G Subclass Deficiency, AIDS)
Investigations:
- CT Scan - is the most useful and indicated after failure of medical therapy and before surgery.
- MRI is rarely used unless neoplasms, orbital and intracranial complications, and fungal sinusitis are suspected.
- Plain X-Rays and nasal swabs are of limited value.
- Specimens Cultures can be obtained from sinus openings through an endoscope or during endoscopic sinus surgery.
- Routine blood cell counts and sedimentation rates are generally unhelpful; however, these may be elevated in patients with fever.
- Allergy testing is useful for atopic patients.
- Associated chronic diseases require specific tests - Cystic Fibrosis, Immune Deficiency and Ciliary Dysmotility Syndrome.
Treatments
Medical: Acute sinusitis - Symptomatic treatment and antibiotics (Amoxycillin and Clavulanate, Clarithromycin, Cephalexin) 10 - 14 days usually resolve most episodes. Up to 6 weeks may be required in some severe cases. Symptomatic measures include topical or oral decongestants (5 days only), topical or oral steroids, steam inhalations and nasal saline douches. Cases with severe pain, sepsis, or other complications may require surgical intervention.
Chronic sinusitis - Medical therapy is often considered as an adjunct to surgical treatment and is directed towards controlling predisposing factors and infections. When diagnosed early and if intensively treated with oral antibiotics, topical nasal steroids, short courses of oral steroids and decongestants, and saline nasal sprays, significant numbers of patients have relief from symptoms, and many can be cured.
Medications:
- Antibiotics: Amoxycillin and Clavulanate, Clarithromycin, Cephalexin, Doxycycline
- Topical Decongestants (short term less than 5 days only)
- Topical Corticosteroids - usually more than 3 months
- Others - immunotherapy
Surgical
When medical therapy is unsuccessful patients are referred for surgical evaluation. Functional
Endoscopic Sinus Surgery (ESS) is the surgical procedure of choice for the treatment of chronic sinusitis. ESS facilitates the removal of disease in key areas and restores adequate aeration and drainage of the sinuses. ESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. In children, surgical management is not as well established and should be reserved for complicated cases. Open sinus surgery is rarely used.
Indications for Endoscopic Sinus / Nasal Surgery
- Sinusitis - failed medical therapy, fungal, polyposis, antrochoanal polyps
- Epistaxis management - cautery, sphenopalatine artery ligation
- Cerebrospinal fluid (CSF) leak management
- Sinonasal neoplasia
- Congenital
- Endoscopic reduction of fractures
- Endoscopic decompression
- Endoscopic dacryocystorhinostomy (DCR)
- Sphenoidotomy and assisted pituitary surgery
Fungal Sinusitis
Fungal sinusitis can manifest in different ways.
- Acute Invasive Fungal Sinusitis is observed in immunosuppressed patients and diabetics and requires urgent and aggressive medical and surgical therapy. Mortality rates are very high.
- Chronic Fungal Sinusitis and Mycetomas or fungus balls. Surgical debridement is the preferred treatment.
- Allergic Fungal Sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens. Treatment consists of systemic steroids and surgical removal of polyps and mucinous secretions.
Fig 1. Endoscopic view of mucopus discharge from sinus ostia
Fig 2. Gross sinonasal polyposis
Fig 3. CT - sinusitis
Fig 4. Diagrammatic outcome of ESS
Fees & Insurance
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