Sinusitis may be of various types. Description of a few are given here under:
ACUTE MAXILLARY SINUSITIS
Aetiology : Most commonly, it is viral rhinitis which spreads to involve the sinus mucosa. This is followed by bacterial invasion.
□ Diving and swimming in contaminated water.
□ Dental infections are important source of maxillary sinusitis. Roots of premolar and molar teeth are related to the floor of sinus and may be separated only by a thin layer of mucosal covering. Periapical dental abscess may burst into the sinus; or the root of a tooth, during extraction, may be pushed into the sinus. In case of oroantral fistula, following tooth extraction, bacteria from oral cavity enter the maxillary sinus.
□ Trauma to the sinus such as compound fractures, penetrating injuries or gun shot wounds may be followed by sinusitis.
Predisposing factors : One or more of the predisposing factors enumerated for sinusitis in general may be responsible for acute or recurrent infection.
CLINICAL FEATURES
Clinical features depend on (a) severity of inflammatory process and (b) efficiency of ostium to drain the exudates. Closed ostium sinusitis is of greater severity and leads more often to complications.
□ Constitutional symptoms consist of fever, general malaise and bodyache. They are the result of toxaemia.
□ Headache. Usually, this is confined to forehead and may thus be confused with frontal sinusitis.
□ Pain. Typically, it is situated over the upper jaw, but may be referred to the gums or teeth. For this reason patient may primarily consult a dentist. Pain is aggravated by stooping, coughing or chewing. Occasionally, pain is referred to the ipsilateral supraorbital region and thus may simulate frontal sinus infection.
□ Tenderness. Pressure or tapping over the anterior wall of antrum produces pain.
□ Redness and oedema of cheek. Commonly seen in children. The lower eyelid may become puffy.
□ Nasal discharge. Anterior rhinoscopy shows pus or mucosa in the middle meatus. Mucosa of the middle meatus and turbinate may appear red and swollen.
Postural test : If no pus seen in the middle meatus, it is decongested with a pledget of cotton soaked with a vasoconstrictor and the patient is made to sit with the affected sinus turned up. Examination after 10-15 minutes may show discharge in the middle meatus.
□ Post nasal discharge. Pus may be seen on the upper soft palate on posterior rhinoscopy.
DIAGNOSIS
Transillumination test. Affected sinus will be found opaque. X-rays. Waters’ view will show either an opacity or a fluid level in the involved sinus.
TREATMENT
Medical: Antimicrobial drugs. Ampicillin and amoxicillin are quite effective and cover a wide range of organisms. Erythromycin or doxycycline or cotrimoxazole are equally effective and can be given to those who are sensitive to penicillin. Sparfloxacin is also effective, and has the advantage of single daily dose.
□ Nasal decongestant drops. 1% ephedrine or 0.1% oxymetazoline are used as nasal drops or sprays to decongest sinus ostium and encourage drainage.
□ Steam inhalation. Steam alone or medicated with menthol provides symptomatic relief and encourages sinus drainage. Inhalation should be given 15 to 20 minutes after nasal decongestion for better penetration.
□ Analgesics. Paracetamol or any other suitable analgesic should be given for relief of pain and headache.
□ Hot fomentation. Local heat to the affected sinus is often soothing and helps in the resolution of inflammation.
SURGICAL
Antral lavage : Most cases of acute maxillary sinusitis respond to medical treatment. Lavage is rarely necessary. It is done only when medical treatment has failed and that too only under cover of antibodies.
COMPLICATIONS
□ Acute maxillary sinusitis may change to subacute or chronic sinusitis.
□ Frontal sinusitis. Frontonasal duct which opens in middle meatus is obstructed due to inflammatory oedema.
□ Osteitis or osteomyelitis of the maxilla.
□ Orbital cellulitis or abscess. Infection spreads to the orbit either directly, from the roof of maxillary sinus or indirectly, after involvement of ethmoid sinuses.
ACUTE FRONTAL SINUSITIS
Aetiology : Usually follows viral infections of upper respiratory tract followed later by bacterial invasion.
□ Entry of water into the sinus during diving or swimming.
□ External trauma to the sinus, e.g. fractures or penetrating injuries.
□ Oedema of middle meatus, secondary to associated ipsilateral maxillary or ethmoid sinus infection.
Predisposing factors, pathology and bacteriology are the same as in acute sinusitis in general.
CLINICAL FEATURES
□ Frontal headache. Usually severe and localised over the affected sinus. It shows characteristic periodicity, i.e. comes upon waking, gradually increases and reaches its peak by about mid day and then starts subsiding. It is also called ‘office headache’ because of its presence only during the office hours.
□ Tenderness. Pressure upwards on the floor of frontal sinus, just above the medial canthus, causes exquisite pain. It can also be elicited by tapping over the anterior wall of frontal sinus in the medial part of supraorbital region.
□ Oedema of upper eye lid with suffused conjunctiva and photophobia.
□ Nasal discharge. A vertical streak of mucopus is seen high up in the anterior part of the middle meatus. This may be absent if the ostium is closed with no drainage. Nasal mucosa is inflamed in the middle meatus.
X-rays Opacity of the affected sinus or fluid level can be seen. Both Waters’ and lateral views should be taken.
TREATMENT
Medical : This is same as for acute maxillary sinusitis, i.e. antimicrobials, decongestion of the sinus ostium for drainage and analgesics. A combination of antihistaminic with an oral nasal decongestant (pseudoephedrine or phenylephrine hydrochloride) are useful. Placing a pledget of cotton soaked in a vasoconstrictor in the middle meatus, once or twice daily, helps to relieve ostial oedema and promotes sinus drainage and ventilation. If patient shows response to medical treatment and pain is relieved, treatment is continued for full 10 days to two weeks.
SURGICAL
□ Trephination of frontal sinus. If there is persistence or exacerbation of pain or pyrexia inspite of medical treatment for 48 hours, or if the lid swelling is increasing and threatening orbital cellulitis, frontal sinus is drained externally. A 2 cm long horizontal incision is made in the superomedial aspect of the orbit below the eyebrow. Floor of frontal sinus is exposed and a hole drilled with a burr. Pus is taken for culture and sensitivity, and a plastic tube inserted and fixed. Sinus can now be irrigated with normal saline two or three times daily until frontonasal duct becomes patent. This can be determined by adding a few drops of methylene blue to the irrigating fluid and its exit seen through the nose. Drainage tube is removed when frontonasal duct becomes patent.
□ Antral lavage. Co-existent maxillary sinusitis may require antral lavage. This will encourage frontal sinus drainage by relieving oedema of the middle meatus.
COMPLICATIONS
□ Orbital cellulitis.
□ Osteomyelitis of frontal bone and fistula formation.
□ Meningitis, extradural abscess or frontal lobe abscess, if infection breaks through the posterior wall of the sinus. Chronic frontal sinusitis, if the acute infection is neglected or improperly treated.
ACUTE ETHMOID SINUSITIS
Aetiology: Acute ethmoiditis is often associated with infection of other sinuses. Ethmoid sinuses are more often involved in infants and young children.
CLINICAL FEATURES
□ Pain. It is localised over the bridge of the nose, medial and deep to the eye. It is aggravated by movements of the eye ball.
□ Oedema of lids. Both eyelids become puffy and swollen. There is increased lacrimation. Orbital cellulitis is an early complication in such cases.
□ Nasal discharge. On anterior rhinoscopy, pus may be seen in middle or superior meatus depending on the involvement of anterior or posterior group of ethmoid sinuses.
□ Swelling of the middle turbinate.
TREATMENT
Medical treatment is the same as for acute maxillary sinusitis.
Visual deterioration and exophthalmos indicate abscess in the posterior orbit and may require drainage of the ethmoid sinuses into the nose through an external ethmoidectomy incision.
COMPLICATIONS
□ Orbital cellulitis and abscess.
□ Visual deterioration and blindness due to involvement of optic nerve.
□ Cavernous sinus thrombosis.
□ Extradural abscess, meningitis or brain abscess.
ACUTE SPHENOID SINUSITIS
Aetiology : Isolated involvement of sphenoid sinus is rare. It is often a part of pansinusitis or is associated with infection of posterior ethmoid sinuses.
CLINICAL FEATURES
□ Headache. Usually localised to the occiput or vertex. Pain may also be referred to the mastoid region.
□ Postnasal discharge. It can only be seen on posterior rhinoscopy. A streak of pus maybe seen on the roof and posterior wall of nasopharynx or above the posterior end of middle turbinate.
□ X-rays. Opacity or fluid level may be seen in the sphenoid sinus. Lateral view of the sphenoid sinus is taken in supine or prone position and is helpful to demonstrate the fluid level.
DIFFERENTIAL DIAGNOSIS
Mucocele of the sphenoid sinus or its neoplasms may clinically simulate features or acute infection of sphenoid sinus and should always be excluded in any case of isolated sphenoid sinus involvement.
Treatment is the same as for acute infection.