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Table of Contents

HIDUNG 2 ANATOMI 2

Dinding Lateral Hidung 3 Kompleks Osteomeatal 3

PATHOLOGY 4

PARANASAL SINUS 4 ANATOMY 5ANATOMY amp PHYSIOLOGY 6STRUCTURE AND FUNCTION OF PARANASAL SINUSES 6BASIC PHYSIOLOGY OF THE NASAL CAVITY AND PARANASAL SINUSES 7PATHOPHYSIOLOGY 7DIFFERENTIAL DIAGNOSIS 16WORKUP 17BLOOD STUDIES 17TESTS FOR IMMUNODEFICIENCY 17NASAL CYTOLOGY 17SWEAT CHLORIDE TEST 17CULTURES OF NASAL SECRETIONS 17COMPUTED TOMOGRAPHY 17

HIDUNG 2 ANATOMI 2

Dinding Lateral Hidung 3 Kompleks Osteomeatal 3

PATHOLOGY 4

PARANASAL SINUS 4 ANATOMY 5ANATOMY amp PHYSIOLOGY 6STRUCTURE AND FUNCTION OF PARANASAL SINUSES 6BASIC PHYSIOLOGY OF THE NASAL CAVITY AND PARANASAL SINUSES 7PATHOPHYSIOLOGY 7DIFFERENTIAL DIAGNOSIS 16WORKUP 17BLOOD STUDIES 17TESTS FOR IMMUNODEFICIENCY 17NASAL CYTOLOGY 17SWEAT CHLORIDE TEST 17CULTURES OF NASAL SECRETIONS 17COMPUTED TOMOGRAPHY 17



Hidung

Anatomi

Nasal septum

Muara sinus



Dinding Lateral Hidung

Kompleks Osteomeatal



Anterior ( A) and lateral (B) views of the paranasal sinuses C Coronal section of the skull revealing the cranial orbital and nasalcavities and their relationships to the paranasal sinuses

Pathology

Patients present to primary care providers with a variety of nasal com- plaints ranging from rhinorrhea and postnasal drainage toobstruction and pain Rhinorrhea and postnasal drainage can result from allergic rhinitis nonallergic rhinitis vasomotor rhinitisand acute and chronic rhinosinusitis Nasal obstruction can be caused by anatomic deformities (including septal and external nasaldeviation nasal valve compromise turbinate hypertrophy nasal polyps) and inflammatory changes resulting in mucosal edemaSuccessful treatment of the varying causes of rhinorrhea and obstruction is based on an accurate diagnosis of the underlying cause

The ldquoCommon Coldrdquo

Acute viral rhinosinusitis is frequently attributed to one of a multitude of rhinoviruses and results in symptoms we refer to as theldquocommon coldrdquoe pathophysiology involves infection inammation mucosal swelling and increased mucus production Low-grade fever facial discomfort and purulent nasal drainage are also common symptoms Treatment is symptomatic withantipyretics hydration analgesics and decongestants rec- ommended as needed Spontaneous resolution occurs in 7 ndash10 daysAntibiotic treatment of the common cold is discouraged but unfortunate- ly patients often request (or demand) antibiotics early inthe course of viral illness When spontaneous recovery occurs they assume that the antibiotics were responsible is is a majorcause of excessive antibiotic use and has contributed to the surge in antibiotic resistance

Paranasal Sinus

The paranasal sinuses are hollow cavities within the ethmoid frontal maxillary and sphenoid bones They help to decrease the

weight of the skull resonate sound produced through speech and produce mucus The paranasal cavities communicate with thenasal cavity where mucus is drained Branches of CN V provide general sensory innervation



The paranasal sinuses are easily recognizable on an x-ray because the sinuses are filled with air and thus appear as darker shadows

on the radiograph

Anatomy

Ethmoidal Sinus

Unlike the frontal maxillary and sphenoid paranasal sinuses the ethmoidal sinus consists of numerous small cavities (air cells)

within the bone as opposed to one or two large sinuses The subdivisions of the ethmoidal air cells (anterior middle andposterior)communicate with the nasal cavity

Anterior ethmoidal air cells Drain through tiny openings in the hiatus semilunaris of the middle meatus

Middle ethmoidal air cells Drain through the ethmoidal bulla of the middle meatus



Posterior ethmoidal air cells Drain through openings in the superior meatus

The posterior ethmoidal nerve (CN V-1) provides general sensory innervation for the ethmoidal air cells

Frontal Sinus

The frontal sinus is located in the frontal bone and opens into the anterior part of the middle meatus via the frontonasal duct Thesupraorbital nerve (CN V-1) provides general sensory innervation for the frontal sinus

Maxillary Sinus

The maxillary sinus is the largest of the paranasal sinuses and is located in the maxilla lateral to the nasal cavity and inferior to theorbit The maxillary sinus opens into the posterior aspect of the hiatus semilunaris in the middle meatus The infraorbital nerve

(CN V-2) primarily innervates the maxillary sinus

Maxillary sinusitis results from inflammation of the mucous membrane lining the maxillary sinus and is a common infectionbecause of its pattern of drainage The maxillary sinus drains into the nasal cavity through the hiatus semilunaris which is locatedsuperiorly in the sinus As a result infection has to move against gravity to drain Infection from the frontal sinus and the ethmoidalair cells potentially can pass into the maxillary sinus compounding the problem In addition the maxillary molars are separatedfrom the maxillary sinus only by a thin layer of bone Therefore if an infecting organism erodes the bone infection from an infectedtooth can potentially spread into the sinus The infraorbital nerve (CN V-2) innervates the maxillary teeth and sinus therefore

pain originating from a tooth or the sinus may be difficult to differentiate

Sphenoid Sinus

The sphenoid sinus is contained within the body of the sphenoid bone and is inferior to the sella turcica The sphenoid sinus opensinto the sphenoethmoidal recess of the nasal cavity The posterior ethmoidal nerve (CN V-1) and branches from CN V-2 providegeneral sensory innervation of the sphenoid sinus

The pituitary gland is located in the roof of the sphenoid bone The gland is important for the production and release of hormonestargeting the gonads adrenals thyroid kidney uterus and the mammary glands Tumors of the pituitary gland can cause anoverproduction of these hormones or may affect vision by compressing CN II Surgery may be necessary to remove the tumor Thesphenoid sinus is separated from the nasal cavity by a thin layer of bone Therefore the pituitary gland can be approached surgicallyby going through the nasal cavity into the sphenoid sinus and finally through the superior aspect of the sphenoid sinus into the sella

turcica where the pituitary gland is located (transsphenoidal hypophysectomy)

Anatomy amp Physiology

The nose and paranasal sinuses serve to warm filter and humidify inspired air modulate vocalizations and speech and providefor the sense of smell The external nose consists of soft tissue and skin resting on a largely cartilaginous framework The internalnose (nasal cavity) begins at the nasal vestibule anteriorly and extends posteriorly to the choana (which forms the boundarybetween the nasal cavity and the nasopharynx)

The nasal cavity is divided in the sagittal plane into largely symmetric halves by the nasal septum These cavities are partially filledby the three turbinates (superior middle and inferior) and occasionally by a fourth supreme turbinate which arise from the lateralnasal wall The spaces below each turbinate are called meatus (superior meatus middle meatus inferior meatus) These meatus areimportant for localizing the outflow tracts of the various paranasal sinuses which drain in a characteristic pattern Thenasolacrimal duct drains into the inferior meatus The maxillary frontal and anterior ethmoid sinuses all drain into the middlemeatus The sphenoid sinus and posterior ethmoids drain into the superior meatus Additionally the olfactory nerve endings (theend organ for the sense of smell) are located on the superior nasal septum and superior turbinate mucosa

Sinonasal anatomy In this coronal plane CT scan several key sinonasal landmarks can be seen Mmaxillary sinus IT inferior turbinate MT middle turbinate im inferior meatus mm middlemeatus arrowhead indicates nasal septum

Structure and function of paranasal sinuses

The paranasal sinuses are air-filled bony cavities that extend from the skull base to the alveolarprocess and laterally from the nasal cavity to the inferomedial aspect of the orbit and the zygomaThe sinus cavities are lined with pseudostratified ciliated columnar epithelium that is contiguousvia ostia with the lining of the nasal cavity This epithelium contains a number of mucus-

producing goblet cells These goblet cells in the epithelium and the submucosal seromucous glands contribute to the airway surfaceliquid[4] which is 5-100 μm thick and covers the epithelium

Anterior and posterior ethmoid sinuses are composed of multiple air cells separated by thin bony partitions Each cell is drained byan independent ostium that measures only 1-2 mm in diameter These small openings are readily clogged by secretions or are



occluded by swelling of the nasal mucosa The sphenoid sinuses sit immediately anterior to the pituitary fossa and just behind theposterior ethmoid

The arterial supply of the paranasal sinuses is from branches of the internal and external carotid arteries while the venous andlymphatic drainage path is through the sinus ostia into the nasal cavity plexus In addition venous drainage occurs through valvelessvessels corresponding to the arterial supply

All sinus ostia drain into the nares at locations beneath the middle and superior turbinates The posterior ethmoid and sphenoidsinuses drain into the superior meatus below the superior turbinate The ostia of the maxillary anterior ethmoid and frontal sinusesshare a common site of drainage within the middle meatus This region is called the ostiomeatal complex and can be visualized bycoronal CT scan The common drainage pathway of the frontal maxillary and anterior ethmoid sinuses within the middle meatusallows relatively localized mucosal infection processes to promote infection in all these sinuses

The successful maintenance of sinus drainage represents a complicated interaction between ciliary action mucus viscosity size ofsinus ostia and orientation of body structures Ciliary beat at the rate of 8-15 Hz is continuously moved by the cilia at a speed of 6mmmin The ciliary action can be affected due to local factors such as infection and local hypoxia that is associated with completeocclusion of sinus ostia The sinus mucosa has less secretory and vasomotor function than the nasal cavity does Cilia areconcentrated near and beat toward the natural sinus ostia Blockage of the ostium results in stasis of mucous flow which can lead todevelopment of disease

The exact function of the paranasal sinuses is not well understood The possible roles of the sinuses may include reducing the weightof the skull dampening pressure humidifying and warming inspired air absorbing heat and insulating the brain aiding in soundresonance providing mechanical rigidity and increasing the olfactory surface area

BASIC PHYSIOLOGY OF THE NASAL CAVITY AND PARANASAL SINUSESThe nasal cavity serves to warm and humidify inhaled air There are a variety of theories on the function of the paranasal sinusesProposed functions include (1) acting as resonating chambers for the voice (2) providing protection to the brain and orbit fromtrauma (3) moisturizing and humidifying ambient air and (4) lightening the weight of the facial skeleton

The sinonasal mucosa is lined by pseudostratified columnar ciliated epithelium This respiratory epithelium is made up of a variablenumber of ciliated cells (75) mucus-secreting goblet cells (20) and basal cells (5) There are approximately 50ndash200 cilia on theapical surface of epithelial cells that beat in a coordinated fashion Under normal conditions the entire mucus blanket of the nose orsinus is cleared in 10 minutes Ciliary beat frequency can vary in response to chemical thermal mechanical and hormonal stimuliAdditionally changes in pH have a profound impact on ciliary beat frequency Impairment of mucociliary clearance may result inmucus stasis which under the proper conditions can support bacterial growth and infection

The mucus secreted by goblet cells is comprised of primarily of water glycoproteins immunoglobulins leukocytes salts andneurotransmitters The mucus consists of 2 layers the superficial gel phase and the inner sol phase Aerosolized pathogens and

particles larger than 05ndash1 m are trapped in the mucus gel layer and eventually transported posteriorly to the nasopharynx andoropharynx to be swallowed Within the sinuses the mucus blanket is transported toward the natural sinus ostia despite thepresence of accessory ostia Mucus also plays a critical role in olfaction Airborne olfactants must dissolve in the nasal mucosaoverlying the olfactory epithelium before the olfactory response is initiated Surgical antrostomies that do not include the true sinusommNstium can result in mucus recirculation which can be a source of persistent postoperative symptoms

The paranasal sinuses consist of hollow cavities that derive from pneumatization into the frontal ethmoid sphenoid and maxillarybones of the craniofacial skeleton They are lined with respiratory epithelium (pseudostratified ciliated columnar epithelium) whichserves to circulate and drain mucous along with entrapped particulate matter They are normally air filled but can become fluid filledif the ostia becomes obstructed by inflammation anatomic problems or disease process

Pathophysiology

The sinuses are normally sterile under physiologic conditions Secretions produced in the sinuses flow by ciliary action through theostia and drain into the nasal cavity In the healthy individual flow of sinus secretions is always unidirectional (ie toward the ostia)

which prevents back contamination of the sinuses In most individuals the maxillary sinus has a single ostium (25 mm in diameter5 mm2 in cross-sectional area) serving as the only outflow tract for drainage This slender conduit sits high on the medial wall of thesinus cavity in a nondependent position Most likely the edema of the mucosa at these 1- to 3-mm openings becomes congested bysome means (eg allergy viruses chemical irritation) that causes obstruction of the outflow tract stasis of secretions with negativepressure leading to infection by bacteria

Retained mucus when infected leads to sinusitis Another mechanism hypothesizes that because the sinuses are continuous with thenasal cavity colonized bacteria in the nasopharynx may contaminate the otherwise sterile sinuses These bacteria are usuallyremoved by mucociliary clearance thus if mucociliary clearance is altered bacteria may be inoculated and infection may occurleading to sinusitis[5 2]

Data are available that support the fact that healthy sinuses are colonized The bacterial flora of noninflamed sinuses were studiedfor aerobic and anaerobic bacteria in 12 adults who underwent corrective surgery for septal deviation [6]Organisms were recoveredfrom all aspirates with an average of 4 isolates per sinus aspirate The predominant anaerobic isolates were Prevotella

Porphyromonas Fusobacterium and Peptostreptococcus species The most common aerobic bacteria were S pyogenes S aureus S pneumonia and H influenzae In another study specimens were processed for aerobic bacteria only and Staphylococcus species andalpha-hemolytic streptococci were isolated[7]Organisms were recovered in 20 of maxillary sinuses of patients who underwentsurgical repositioning of the maxilla



In contrast another report of aspirates of 12 volunteers with no sinus disease showed no bacterial growth [8] Jiang et al evaluated thebacteriology of maxillary sinuses with normal endoscopic findings[9] Organisms were recovered from 14 (47) of 30 swabspecimens and 7 (41) of 17 of mucosal specimens Gordts et al reported the microbiology of the middle meatus in normal adultsand children[10] This study noted in 52 patients that 75 had bacterial isolates present most commonly coagulase-negativestaphylococci (CNS) (35)Corynebacterium species (23) and S aureus (8) in adults Low numbers of these species were presentIn children the most common organisms were H influenzae (40) M catarrhalis (34) and S pneumoniae (50) a markeddifference from findings in adults Nonhemolytic streptococci and Moraxellaspecies were absent in adults

The pathophysiology of rhinosinusitis is related to 3 factors

Obstruction of sinus drainage pathways (sinus ostia)

Ciliary impairment

Altered mucus quantity and quality

Obstruction of sinus drainage

Obstruction of the natural sinus ostia prevents normal mucus drainage The ostia can be blocked by mucosal swelling or local causes(eg trauma rhinitis) as well as by certain inflammation-associated systemic disorders and immune disorders Systemic diseasesthat result in decreased mucociliary clearance including cystic fibrosis respiratory allergies and primary ciliary dyskinesia(Kartagener syndrome) can be predisposing factors for acute sinusitis in rare cases Patients with immunodeficiencies (egagammaglobulinemia combined variable immunodeficiency and immunodeficiency with reduced immunoglobulin G [IgG]ndash andimmunoglobulin A [IgA]ndashbearing cells) are also at increased risk of developing acute sinusitis

Mechanical obstruction because of nasal polyps foreign bodies deviated septa or tumors can also lead to ostial blockage Inparticular anatomical variations that narrow the ostiomeatal complex including septal deviation paradoxical middle turbinates andHaller cells make this area more sensitive to obstruction from mucosal inflammation Usually the margins of the edematous mucosahave a scalloped appearance but in severe cases mucus may completely fill a sinus making it difficult to distinguish an allergicprocess from infectious sinusitis Characteristically all of the paranasal sinuses are affected and the adjacent nasal turbinates areswollen Air-fluid levels and bone erosion are not features of uncomplicated allergic sinusitis however swollen mucosa in a poorlydraining sinus is more susceptible to secondary bacterial infection

Hypoxia within the obstructed sinus is thought to cause ciliary dysfunction and alterations in mucus production further impairingthe normal mechanism for mucus clearance

Impaired ciliary function

Contrary to earlier models of sinus physiology the drainage patterns of the paranasal sinuses depend not on gravity but on themucociliary transport mechanism The metachronous coordination of the ciliated columnar epithelial cells propels the sinuscontents toward the natural sinus ostia Any disruption of the ciliary function results in fluid accumulation within the sinus Poorciliary function can result from the loss of ciliated epithelial cells high airflow viral bacterial or environmental ciliotoxinsinflammatory mediators contact between 2 mucosal surfaces scars and Kartagener syndrome[11]

Ciliary action can be affected by genetic factors such as Kartagener syndrome Kartagener syndrome is associated with immobilecilia and hence the retention of secretions and predisposition to sinus infection Ciliary function is also reduced in the presence oflow pH anoxia cigarette smoke chemical toxins dehydration and drugs (eg anticholinergic medications and antihistamines)

Exposure to bacterial toxins can also reduce ciliary function Approximately 10 of cases of acute sinusitis result from directinoculation of the sinus with a large amount of bacteria Dental abscesses or procedures that result in communication between theoral cavity and sinus can produce sinusitis by this mechanism Additionally ciliary action can be affected after certain viral infections

Several other factors can lead to impaired ciliary function Cold air is said to stun the ciliary epithelium leading to impaired ciliarymovement and retention of secretions in the sinus cavities On the contrary inhaling dry air desiccates the sinus mucous coatleading to reduced secretions Any mass lesion with the nasal air passages and sinuses such as polyps foreign bodies tumors andmucosal swelling from rhinitis may block the ostia and predispose to retained secretions and subsequent infection Facial trauma orlarge inoculations from swimming can produce sinusitis as well Drinking alcohol can also cause nasal and sinus mucosa to swell andcause impairment of mucous drainage

Altered quality and quantity of mucus

Sinonasal secretions play an important role in the pathophysiology of rhinosinusitis The mucous blanket that lines the paranasalsinuses contains mucoglycoproteins immunoglobulins and inflammatory cells It consists of 2 layers (1) an inner serous layer (iesol phase) in which cilia recover from their active beat and (2) an outer more viscous layer (ie gel phase) which is transported bythe ciliary beat Proper balance between the inner sol phase and outer gel phase is of critical importance for normal mucociliaryclearance

If the composition of mucus is changed so that the mucus produced is more viscous (eg as in cystic fibrosis) transport toward theostia considerably slows and the gel layer becomes demonstrably thicker This results in a collection of thick mucus that is retainedin the sinus for varying periods In the presence of a lack of secretions or a loss of humidity at the surface that cannot becompensated for by mucous glands or goblet cells the mucus becomes increasingly viscous and the sol phase may become



extremely thin thus allowing the gel phase to have intense contact with the cilia and impede their action Overproduction of mucuscan overwhelm the mucociliary clearance system resulting in retained secretions within the sinuses

Acute sinusitis in the intensive care setting

Acute sinusitis in the intensive care population is a distinct entity occurring in 18-32 of patients with prolonged periods ofintubation and is usually diagnosed during the evaluation of unexplained fever Cases in which the cause is obstruction are usuallyevident and can include the presence of prolonged nasogastric or nasotracheal intubation Moreover patients in an intensive caresetting are generally debilitated predisposing them to septic complications including sinusitis Finally sinusitis in intensive caresettings is associated with nasal catheter placement

Acute Bacterial Rhinosinusitis

Prolonged mucosal edema from whatever etiology causes sinus obstruction and retention of secretions may lead to acute bacterialrhinosinusitis Patients may exhibit several of the major symptoms (facial pressure pain facial congestionfullness purulent nasaldischarge nasal obstruction anosmia) and one or more of the minor symptoms (headache fever fatigue cough toothachehalitosis ear fullnesspressure) Radiographic studies (plain films or CT scans) do not di_erentiate acute bacterial rhi- nosinusitisfrom a viral upper respiratory infection (URI) More than 80 percent of patients with a viral URI also have an abnormal sinus CT scanTime will usually di_erentiate a bacterial from a viral infection It usually takes 7ndash10 days for a viral infection to resolve Symptomslasting beyond 7ndash10 days or worsening aer 5 days suggest that bacterial infection is being established Thee organismsresponsible are similar to the organisms that cause acute otitis media and include Streptococcus pneumoniae Haemophilusinfluenzae and Moraxella catarrhalis By definition acute rhinosinusitis persists less than one

month and subacute rhinosinusitis lasts more than one month but less than three months Chronic sinusitis is designed by

symptoms that persist more than three months and usually has a di_erent underlying microbiology with increased numbers ofanaer- obic organisms

The treatment of choice for acute rhinosinusitis (as well as acute otitis media) has been a 10-day course of either amoxicillin ortrimethoprim sulfamethoxazole Resistance to amoxicillin has prompted some physi- cians to consider using amoxicillinclavulanate or a second-generation cephalosporin or macrolide or a qui- nolone instead of amoxicillin as the first-line therapy Morerecently the appearance of penicillin resistance in S pneumoniae infection (which has a di_erent resistance mechanism than beta-lactamase production) has resulted in the recommendation that higher doses of amoxicillin be used routinely Drugs that do notadequately cover H influenzae are inappro- priate treatment for either otitis media or rhinosinusitis Adjunctive

measures may include topical decongestants (oxymetazoline) for three days mucolytics (guaifenisen) and oral decongestantsSevere or recurrent cases may require systemic steroids Antihistamines and topical steroids are not usually indicated unlessallergy is also a major concern Patients with sinusitis should be referred to an otolaryngologist if they have three to four infectionsper year an infection that does not respond to two three-week courses of antibiotics nasal polyps on exam or any complications of

sinusitis

Several types of acute sinusitis merit further mention Acute frontal ethmoid and sphenoid sinusitis that are not appropriatelytreated or do not respond to therapy can have serious consequences

Frontal Sinusitis

The frontal sinus lining has veins that penetrate the posterior sinus wall and go directly to the dura on the opposite side These veinscan quite easily transmit organisms or become pathways for propagation of an infected clot This can quickly lead to meningitis andeven brain abscess In fact the most common cause of frontal lobe abscess is frontal sinusitis

Therefore the diagnosis of acute frontal sinusitis with an air-fluid level requires aggressive antibiotic therapy The key to frontalsinusitis is to cover S pneumoniae and H inuenzae as well as get good cerebrospinal fluid penetration Pain is severe and patientsusually require hospital admission for treatment and close observation Topical vasoconstriction to shrink the swollen mucosa

around the nasofrontal duct and restore natural drainage into the nose should begin in the clinic and continue throughout thehospital stay Systemic steroids may also be considered to decrease swelling If frontal sinusitis does not greatly improve within 24hours the frontal sinus should be surgically drained to prevent serious intracranial infections

Ethmoid Sinusitis

Severe ethmoid sinusitis can result in orbital cellulitis or abscess These patients present with eyelid swelling proptosis and doublevision While one might assume the double vision is due to the involvement of the nerves of the cavernous sinus it can also be causedby an abscess located in the orbit A CT scan will generally show the presence (or absence) of an abscess which is alwaysaccompanied by ethmoid sinusitis If an abscess is present it will require surgical drainage as soon as possible so the patient shouldbe referred to an otolaryngologist

However if the condition is severe ethmoid sinusitis without abscess it may be treated with intravenous antibiotics and nasalflushes with decongestant nose drops Severe ethmoid sinusitis will often resolve with nonoperative therapy but i f the patientrsquoscondition worsens then surgery is indicated

Sphenoid Sinusitis

Sphenoid sinusitis can cause ophthalmoplegia meningitis and even cavernous sinus thrombosis Cavernous sinus thrombosis is acomplication with even more grave implications than meningitis or brain abscess and it carries a mortality of approximately 50



percent The veins of the face that drain the sinuses do not have valves and they may drain posteriorly into the cavernous sinusInfectious venous thrombophlebitis can spread into the cavernous sinus from a source on the face or in the sinus The most commoncause of this serious infection is rhinosinusitis The nerves that run through the cavernous sinus are the oculomotor (III) trochlear(IV) and first and second divi- sions of the trigeminal (V) and the abducens (VI) A patient who has double vision and rhinosinusitisshould be assumed to have cavernous sinus thrombosis until it is ruled out by a CT andor MRI scan The preferred treatment ishigh-dose intravenous antibiotics and surgical drainage of the paranasal sinuses Anticoagulation is also a consideration in the treat-ment regimen

Fungal Sinusitis

Although fungal elements are commonly found in the nasal cavity of normal patients some patients develop a sensitivity orimmunoreactivity to fungi resulting in allergic fungal sinusitis This allergic disorder to fungi can result in severe symptoms ofchronic sinusitis and significant inflammation in the sinonasal mucosa due to a preponderance of eosinophils Effective treatmentrequires surgery to remove the o_ending fungal mucin Fungal spores can also get trapped in a sinus where they germi- nate and allthe sinus with debris forming a ldquofungal ballrdquo or mycetoma Typically mycetomas do not cause a significant inflammatory responseand they are easily cured by surgical removal If a patient is immuno-compromised or has diabetes certain fungal infections (egmucormycosis) can become ldquoinvasiverdquo resulting in destruction of the sinus with erosion into the orbit or brain These invasivefungal infections constitute an ENT emergency since they are life threatening and can advance quite rap- idly

ESSENTIALS OF DIAGNOSIS

The vast majority of cases of acute rhinosinusitis are self-limiting viral events

Chronic rhinosinusitis is an inflammatory disease whose causes are often multifactorial

In chronic rhinosinusitis nasal endoscopy andor CT scan may be necessary to make the diagnosis if symptoms do notcorrelate well with findings

GENERAL CONSIDERATIONS

Rhinosinusitis is one of the most commonly diagnosed medical conditions in the United States affecting an estimated 16 of theadult population annually Direct health care costs are significant estimated to be over $58 billion per year According to the recent2007 data from the National Health Interview Survey rhinosinusitis continues to be one of the top 10 leading diagnoses of officevisits in the United States Of all antibiotics prescribed in 2002 9 of pediatric prescriptions and 18 of adult prescriptions werewritten for a diagnosis of acute sinusitis

RHINOSINUSITIS CLASSIFICATION AND DIAGNOSIS

Rhinosinusitis is broadly defined as symptomatic inflammation of the paranasal sinuses and nasal cavity The term rhinosinusitis isused because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa There have been a number ofiterations of the actual definition that are described in this section The Rhinosinusitis Task Force in 1997 classified rhinosinusitisbased on both symptom duration and by history A history suggestive of rhinosinusitis includes two or more major factors or onemajor and two minor factors (Table 15ndash1) In 2003 another task force that included the American Academy of Otolaryngology ndash Head and Neck Surgery (AAO-HNS) proposed revised guidelines that required physical exam findings for the diagnosis of chronicrhinosinusitis (CRS) Findings on nasal endoscopy or anterior rhinoscopy should include one or more of the following purulentdrainage polyps polypoid changes in the mucosa and edema or erythema of the middle meatus These guidelines also suggest thatCT scans can be a helpful to confirm the diagnosis of symptomatic patients with equivocal physical exam findings In 2004 amultidisciplinary panel further classified CRS as CRS with nasal polyps CRS without nasal polyps and allergic fungal

rhinosinusitis (AFS) to better guide clinical research and patient care

Table 15ndash1 Major and Minor Factors in the Diagnosis of Rhinosinusitis (1997 Task Force)

Major factors

Facial pain or pressure

Facial congestion or fullness

Nasal obstruction or blockage

Nasal discharge purulence or discolored postnasal drainage

Hyposmia or anosmia

Purulence in nasal cavity

Fever (in acute rhinosinusitis only)

Factors



Headache

Fever (in chronic sinusitis)

Halitosis

Fatigue

Dental pain

Cough

Ear pain pressure or fullness

Acute rhinosinusitis 4 weeks

Subacute rhinosinusitis Duration of 4ndash12 weeks

CRS 12 weeks

Recurrent acute rhinosinusitis Greater than four or more episodes of acute rhinosinusitis per year with each episodelasting 7ndash10 days with symptom resolution between episodes

Acute exacerbations of CRS are a sudden worsening of CRS with a return to baseline after treatment

Most recently in 2007 new clinical practice guidelines were developed to improve and update the diagnosis of rhinosinusitis CRS isnow defined as 12 weeks or longer of two or more of the following symptoms

Mucopurulent drainage (anterior posterior or both)

Nasal obstruction (congestion)

Facial pain-pressure-fullness

Decreased sense of smell

And inflammation as seen by one or more of the following

Purulent mucus or edema in the middle meatus or ethmoid region

Polyps in the nasal cavity or the middle meatus

Radiographic imaging showing inflammation of the paranasal sinuses

PATHOGENESIS amp CLINICAL FEATURES

Acute Rhinosinusitis

Acute rhinosinusitis in contrast to CRS is most often caused by an infectious agent Acute rhinosinusitis is defined as up to 4 weeksof purulent nasal drainage accompanied by nasal obstruction facial pain facial pressure or fullness The clinician must thendistinguish between viral rhinosinusitis (VRS) and acute bacterial rhinosinusitis (ABRS) This distinction is made based on illnesspattern and duration

Viral Rhinosinusitis

Symptoms of acute rhinosinusitis are present less than 10 days

Symptoms are not worsening


Signs or symptoms of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratorysymptoms

Signs or symptoms of acute rhinosinusitis worsen within 10 days after an initial improvement

In most cases bacterial sinusitis is preceded by a viral upper respiratory infection Other common conditions that can predispose apatient to acute sinusitis are cigarette smoke anatomical factors such as nasal septum deformities concha bullosa and allergies



More than 200 different viruses are known to cause the symptoms of the common cold The most frequently detected viruses includerhinovirus respiratory syncytial virus influenza virus and parainfluenza virus Approximately 2 of VRS progresses to bacterialrhinosinusitis in adults

Three cardinal symptoms have been found to have high sensitivity and specificity for ABRS These include purulent rhinorrhea facialpainpressure and nasal obstruction Secondary symptoms that support the diagnosis include anosmia fever aural fullness coughand headache Another finding suggestive of ABRS is if patients worsen after an initial improvement in symptoms The most commonorganisms responsible for ABRS include Streptococcus pneumoniae Haemophilus influenzae and Moraxella catarrhalis

Chronic Rhinosinusitis

CRS is defined as an inflammatory condition of the nasal cavity and paranasal sinuses lasting for longer than 12 weeks Thepathophysiology of CRS remains incompletely understood but it is believed to be multifactorial resulting from interactions betweenhost anatomy genetics and the environment A simplified way to approach CRS is illustrated in Table 15ndash2 CRS can be thought offirst resulting from mucosal inflammation causing swelling and obstruction at the sinus ostium This can lead to mucus stasis whichcan then lead to bacterial superinfection The signs and symptoms of CRS often vary in severity and prevalence Nasal obstruction(81ndash95) is the most common symptom followed by facial congestion-pressure-fullness (70ndash85) discolored nasal discharge(51ndash83) and hyposmia (61ndash69) High fevers are usually absent although fatigue and myalgias are common (Table 15ndash1)

Unlike in acute rhinosinusitis which is usually caused by aninfectious agent there is no one causative factor that accountsfor CRS There is evidence of numerous factors contributing to

CRS including

Biofilms

Osteitis

Allergy

Superantigens from Staphylococcus aureus

Fungi

General Host Factors

Infectious

GENERAL HOST FACTORS

Genetic factors and immune deficiency can significantly increase the potential for patients to develop CRS These general host factors

can lead to diffuse inflammation of the sinonasal mucosa This inflammation can cause obstruction at the sinus ostium that can

trigger a cascade of impaired mucociliary clearance mucus stasis and subsequent bacterial overgrowth Systemic diseases include

autoimmunegranulomatous diseases such as Wegeners granulomatosis aspirin sensitivity triad (Samters Triad) cystic fibrosis

immunodeficiency and primary ciliary dyskinesia Patients with these conditions are at a high risk for failing conventional medical

and surgical management for CRS

STAGING SYSTEMS

Many staging systems have been used to stratify patients with CRS according to objective levels of disease Two commonly usedstaging systems found in the literature will be described briefly in this section

LundndashMackay Staging

The LundndashMackay staging system is widely used in radiologic assessment of CRS The scoring system is based on CT scan findingsthat are obtained after an adequate trial of medical treatment Each sinus group is then assigned a numeric grade 0 = noabnormality 1 = partial opacification and 2 = total opacification The sinus groups include the maxillary frontal sphenoidal anteriorethmoidal and posterior ethmoidal sinuses The ostiomeatal complex is scored only as 0 (not obstructed) or 2 (obstructed) Thus atotal score of 0ndash24 is possible and each side can be considered separately (0ndash12)

Lundndash

Kennedy Endoscopic Scores

In this staging system the endoscopic appearances of the nose are also quantified for the presence of polyps (0 = none 1 = confinedto middle meatus 2 = beyond middle meatus) discharge (0 = none 1 = clear and thin 2 = thick and purulent) and edema scarring oradhesions and crusting (for each 0 = absent 1 = mild 2 = severe)



DIAGNOSTIC MODALITIES

Physical Examination

A complete head and neck exam with anterior rhinoscopy is essential in all patients suspected of having rhinosinusitis Findings ofmucopurulence edema septal deflection and polyps should be noted The middle meatus is often well visualized after appropriatedecongestion

Endoscopic Evaluation

Rigid endoscopy or flexible fiberoptic endoscopy are useful to better evaluate the nasal cavity sinuses and nasopharynx Findingsthat should be noted in the examination are septal deviations edema of the turbinates and the presence of mucus pus polyps orerythema Two critical areas to examine are the osteomeatal complex lateral to the middle turbinate and the sphenoethmoidalrecess Endoscopically guided cultures should be taken of any purulence in the nasal cavity or sinuses and sent for aerobicanaerobic fungal and acid-fast bacilli cultures

Imaging Studies

Computed tomography (CT) scanning is currently the method of choice for sinus imaging Because a viral upper respiratory infectionmay cause abnormalities on CT that are indistinguishable from rhinosinusitis imaging in ABRS has limited usefulness except whencomplications are suspected On the other hand symptoms of CRS do not correlate well with findings Therefore CT andor nasalendoscopy is necessary to make the diagnosis In addition to providing excellent visualization of mucosal thickening air fluid levelsand bony structures coronal scans give optimal visualization of the osteomeatal complex and are conveniently oriented for thesurgeon in terms of surgical planning Sagittal views can help delineate frontal sinus anatomy and confirm the presence of Onodi

cells

Coronal CT scan in a patient with chronic rhinosinusitis and allergic rhinitis Notethe left concha bullosa

When compared to CT scans MRI of the sinuses provides better soft tissue contrast resolution and tissue characterization MRIoffers better differentiation of benign obstructed secretions from tumor and can be a helpful modality with suspected orbital orintracranial extension For these reasons MRI scanning should be the imaging method of choice in the evaluation of soft tissuemasses complicated sinus inflammatory diseases and intracranial or intraorbital extension of sinus pathology

Historically standard radiographs were used to evaluate the sinuses The conventional paranasal sinus evaluation included thefollowing views Caldwell (to visualize the frontal and ethmoid sinuses) Waters (for the maxillary sinuses) lateral (for the anteriorand superior walls of the frontal maxillary and sphenoid sinuses) and submental vertex views (for the ethmoid and sphenoidsinuses)

Laboratory Tests

Laboratory tests and immunologic studies may be helpful for patients who fail to improve with conventional medical and surgicaltreatments A variety of conditions such as Wegener granulomatosis ChurgndashStrauss syndrome and sarcoidosis can be causes ofrecurrent sinusitis Nasal crusting can occur secondary to dryness of the mucosa in Sjogren syndrome Some common laboratorytests for these conditions include cytoplasmic-antineutrophil cytoplasmic antibody perinuclear-antineutrophil cytoplasmic antibodyIgE erythrocyte sedimentation rate c-reactive protein rheumatoid factor and antinuclear antibody Testing for HIV and IgG levelsshould be also considered in refractory patients

DIFFERENTIAL DIAGNOSIS

The differential diagnoses of acute and chronic sinusitis are many and include the following the common cold temporomandibularjoint (TMJ) pain headache (including migraine) trigeminal pain and sinus neoplasms Allergic and odontogenic causes of symptoms

should also be excluded The symptoms of facial pressure and pain purulent nasal discharge nasal congestion hyposmia tooth painand a poor response to nasal decongestants can help differentiate these entities

Sinus neoplasms are relatively uncommon but are critical to exclude A history of unilateral nasal obstruction and epistaxis warrantsfurther workup including CT scan and nasal endoscopy Changes in vision and cranial nerve deficits particularly in the distributionof the infraorbital nerve should also cause suspicion Palatal numbness or dry eyes can also be due to lesions in the pterygopalatine



fossa

TREATMENT OF CHRONIC RHINOSINUSITIS

Medical management of CRS can be simplified into three groups antimicrobial anti-inflammatory and mechanical It is helpful tobreak down treatments from each group and combine them when appropriate into a comprehensive treatment plan Also it isimportant at this time to consider the side effects of each therapy and weigh them with the patients symptom severity and othermedical conditions In general medical management of CRS should include 3ndash4 weeks of culture directed (or broad spectrum)antibiotics a nasal steroid spray and nasal saline irrigation Strong consideration should be given to a tapered course of oral steroidsunless contraindicated

Benninger MS Ferguson BJ Hadley JA Adult chronic rhinosinusitis definitions diagnosis epidemiology andpathophysiology Otolaryngol Head Neck Surg 2003 Sep129(3 Suppl)S1ndash32

Lund VJ Maximal medical therapy for chronic rhinosinusitis Otolaryngol Clin North Am 2005 Dec38(6)1301ndash1310 (Well-writtenreview of the current medical treatments of chronic sinusitis)

Antibiotics

Antimicrobial medications are best given for patients with CRS after cultures have been performed After the correct antibiotic ischosen there are multiple ways to deliver it including oral intravenous or topical Oral antibiotics are the mainstay of treatment inthe management of CRS to clear infection and to treat exacerbations of CRS In contrast to antibiotic therapy for acute sinusitisantibiotics should be used for at least 3ndash4 weeks Ideally antibiotic therapy should be culture-directed particularly after failure ofprior antibiotic use

Topical antibiotics have the theoretical advantage of high local levels of drug with minimal systemic absorption lower costs anddecreased morbidity when compared to IV antibiotics A study by Vaughn and Carvalho showed that after a 3-week course of culturedirected nebulized antibiotics patients demonstrated improvements in posterior nasal discharge and facial painpressure Thesepatients also had a longer infection-free period and improved endoscopic exams There were no major side effects to treatment andminor side effects were usually benign and self-limiting

Antifungal therapy for CRS is still controversial at this time Recent double-blind placebo controlled trials have not shownsubstantial improvement in CRS based on objective and subjective criteria after treatment with amphotericin B Nonetheless somepatients with CRS treated with oral antifungals do benefit

Steroid Nasal Sprays and Oral Steroids

Mucosal inflammation and polyposis which can lead to the obstruction of sinus ostia are critical in the pathogenesis of most cases of

CRS Nasal steroid sprays directly address this problem by reducing mucosal inflammation and the site of polyps thereby limitingpostoperative recurrence Common adverse effects with nasal steroids include nasal irritation mucosal bleeding and crustingSystemic side effects are uncommon and therefore nasal steroids are often prescribed for maintenance therapy in those with CRSFor better frontal sinus penetration an eyedropper can be used to instill standard nasal steroid spray solution Placement of drops athome can be done by the patient kneeling and then placing the forehead on the floor (Moffits position) or with the head hanging offthe bed (Myginds position)

Systemic steroids are highly effective at reducing mucosal inflammation and nasal polyp bulk in CRS Oral steroids decrease whiteblood cell migration production of inflammatory mediators antibody production histamine release and swelling through a varietyof mechanisms However a thorough discussion with patients regarding the risks of systemic steroid administration is mandatory Atapered regimen may be given during severe CRS flare-ups and in the postoperative period but their use should be limited andcarefully monitored

Nasal Irrigation and Other Mechanical Treatments

Nasal saline irrigation is an important component in the treatment of CRS Frequent rinsing prevents the accumulation of nasalcrusts and promotes mucociliary clearance Hypertonic saline may increase the rate of clearance in certain cases Nasal irrigation iswell tolerated by patients without any evidence of significant harmful side effects Work by the senior author has demonstrated theefficacy of 1 baby shampoo nasal irrigations for patients with CRS recalcitrant to surgery and isotonic saline irrigations Patientswith CRS were treated with twice-a-day sinus irrigation with 1 baby shampoo which led to improvement in SNOT-22 scores fornearly 50 of patients who remained symptomatic despite surgical and conventional medical management Greatest improvementswere in reducing thickened nasal secretions and postnasal drainage Baby shampoo nasal irrigation has promise as an inexpensivewell-tolerated adjuvant therapy to conventional medical therapies for symptomatic patients after FESS

Decongestants and Leukotriene Antagonists and Other Therapies

Systemic decongestants and mucolytic agents such as guaifenesin may provide some symptomatic relief Given the favorable sideeffects of these agents they are often added to the therapeutic regimen Leukotriene receptor antagonists (montelukast zafirlukast ) and macrolide antibiotics which have anti-inflammatory effects may also prove to be useful therapeutics

Budesonide is used for the maintenance treatment of asthma and as prophylactic therapy in children aged 12 months to 8 yearsWhile not FDA approved for use in CRS use of budesonide respules (Pulmicort Respules AstraZeneca LP Wilmington Delaware) forpatients with nasal polyps or significant mucosal edema has been gaining popularity in the United States A recent study for patientswith chronic sinusitis found that use of budesonide 025 mg once a day for 30 days improved SNOT-20 scores without suppression of



the hypothalamicndashpituitaryndashadrenal axis Budesonide can be used both in nasal irrigation or can be applied directly from respules

Oxymetazoline hydrochloride and other topical nasal decongestant sprays cause intense vasoconstriction of the nasal mucosaRebound swelling (rhinitis medicomentosa) may incite a vicious cycle leading to complete nasal obstruction and subsequent sinusdiseaseOxymetazoline spray may be used for very short periods of time (less than 3 days) for symptomatic relief usually in ABRS oracute exacerbations of CRS

Allergy Management

For patients with documented allergic disease ongoing allergy management is beneficial Environmental avoidance topical nasal

steroids and immunotherapy may prevent exacerbations of allergic rhinitis Immunotherapy is most effective for pollen dust moldsand pet dander allergies Traditionally treatments are via a subcutaneous route but more recently sublingual immunotherapy hasbeen gaining popularity especially in Europe There is also a potentially beneficial role in aspirin desensitization for those patientswith aspirin-exacerbated respiratory disease and Samters triad

Sinus Surgery

Maximal medical therapy for CRS is typically defined as 4ndash6 weeks of broad spectrum or culture-directed antibiotics nasal steroidsnasal irrigation allergy management and a short course of oral steroids Surgical therapy may be necessary if the patient remainssymptomatic and there is evidence of persistent mucosal disease or sinus obstruction on CT scan or endoscopic evaluation Patientswith clear anatomic abnormalities large sinonasal polyps or allergic fungal sinusitis may be better candidates for primary surgicaltherapy

Patients should be strongly encouraged to stop smoking prior to considering sinus surgery Current tobacco use is associated with

worse outcomes after endoscopic sinus surgery when compared to nonsmokers Work by Senior et al demonstrated active smokershave higher rates of disease relapse after sinus surgery requiring more revision surgeries than nonsmokers In this study 100 ofpatients with severe disease required a revision operation for persistent symptoms

Functional Endoscopic Sinus Surgery (FESS)

Indications

Kennedy coined the term functional endoscopic sinus surgery to emphasize that surgery should aim at restoring normal sinusfunction and ventilation without excessive removal of potentially reversibly diseased tissue Functional endoscopic sinus surgery isbased on several key observations (1) widely patent antrostomies in nonanatomic positions may fail to drain sinuses due to thedirectionality of mucociliary flow (2) the ostiomeatal unit is anatomically constricted and (3) the stripping of sinus mucosa leads todelayed healing and the loss of normal ciliary function Thus a conservative endoscopic technique has been developed The keys tothe technique are the use of through-cutting instruments that preserve sinonasal mucosa and the excellent visualization made

possible with modern telescopes Mucosal polyps can be carefully deacutebrided the natural ostia enlarged and the ethmoid sinusesunroofed which opens them to the nasal cavity The improvement in symptoms with FESS may be expected in more than 90 ofpatients

Relationship with Other Treatments

Sinus surgery should be considered as only a part of the treatment plan Any underlying medical conditions such as diabetesmellitus immunodeficiency tobacco use and atopic disease must also be addressed if ultimate success in treatment is to beobtained Patients will require meticulous postoperative care including debridements and finally long-term medical maintenancetherapy

Complications

The complications of surgical therapy are related to the close anatomic proximity of the paranasal sinuses to the brain and orbits An

intimate knowledge of the patients individual anatomy is critical to reduce complications Serious morbidity is rare and includescerebrospinal fluid leak (CSF) leaks orbital injury and intracranial hemorrhage Injury to the medial wall of the orbit may cause theprolapse of orbital fat into the nasal cavity A violation of the orbital wall with subsequent hemorrhage and orbital hematoma maylead to compression of the optic nerve and blindness Damage to the cribriform plate region may lead to CSF leak herniation ofcranial contents meningitis or intracranial bleeding In one large meta-analysis of patients who underwent FESS the authors foundthe major complication rate was 085 with CSF leak being the most common complication Minor complications occurred in 69of patients with orbital penetration and middle turbinate adhesions being the most common

COMPLICATIONS OF RHINOSINUSITIS

Orbital Infection

Chandler divided the progression of sinonasal orbital infections into five stages (Table 15ndash3) The first stage is periorbital edemawhich presents with cellulitis of the eyelids without visual loss or ophthalmoplegia The second stage describes infection extendingthrough the orbital septum and is classified as orbital cellulitis These patients present with pain proptosis and chemosis With

orbital cellulitis there may be some degree of ophthalmoplegia related to edema of the extraocular muscles and a mild decrease invisual acuity related to corneal edema The third stage involves formation of a subperiosteal abscess The fourth stage is the formationof an orbital abscess Severe proptosis chemosis ophthalmoplegia and visual loss are usually present The fifth stage results fromretrograde thrombophlebitis of the valveless ophthalmic veins that can lead to cavernous sinus thrombosis



Potential Orbital Complications of Sinusitis

Periorbital edema

No limitation of extraocular movements and vision is normal

Infection is anterior to the orbital septum

Orbital cellulitis

Infection of the soft tissue posterior to the orbital septum

Subperiosteal abscess

Pus collection beneath the periosteum of the lamina papyracea

Globe is usually displaced in inferolateral direction

Orbital abscess

Pus collection in the orbit

Associated with limitation of extraocular movements exophthalmos and visual changes

Cavernous sinus thrombosis

Septic thrombosis of the cavernous sinuses

Fever ophthalmoplegia ptosis proptosis chemosis blindness meningitis

Periorbital edema can usually be treated in an outpatient setting with oral antibiotics and close follow-up in the absence of medicalcomorbidities such as uncontrolled diabetes Orbital cellulitis usually responds to intravenous antibiotics whereas subperiosteal andorbital abscesses require operative drainage of the abscess with concurrent sinus surgery Cavernous sinus thrombosis can truly belife-threatening Even in the post-antibiotic era the mortality rate of cavernous sinus thrombosis is 30 Intravenous antibiotictreatment should be instituted immediately and if indicated the involved sinuses should be surgically drained The role ofanticoagulation to prevent further thrombus formation and systemic steroid therapy is controversial The incidence of all orbitalcomplications is higher in the pediatric population than in adults

Intracranial Complications

In the antibiotic era intracranial complications of sinusitis have become less commonplace but nevertheless continue to occur andbe associated with significant morbidity and mortality Meningitis usually occurs by extension of infection from the ethmoid orsphenoid sinuses On examination patients with this complication may have a diminished sensorium or may be obtunded Thetypical signs of meningitis such as Kernig and Brudzinski signs may be present If meningitis secondary to sinus infection issuspected a high-resolution CT scan of the brain with contrast and a sinus CT scan should be obtained A CT scan of the brain iscritical both to rule out mass effect and to delineate any other intracranial complications Lumbar puncture is diagnostic andprovides material for culture The treatment for meningitis involves intravenous antibiotics and surgical drainage of the sinusesAnaerobic organisms are reported to be the most common pathogens in suppurative intracranial complications of sinusitis butaerobic and mixed infections are also common

An epidural abscess is a collection of purulent material between the bone of the skull and the dura typically in relation to frontalsinusitis The further spread of infection either by direct extension or by hematogenous seeding may lead to subdural empyema andeventually to brain abscess (Figure 15ndash3) Draining both the abscess and the offending sinuses is mandatory and long-termantibiotics are often necessary Regardless of the treatment morbidity is high particularly with subdural involvement and can resultin long-term neurologic sequela

Pott Puffy Tumor

Pott puffy tumor is an osteomyelitis of the frontal bone with the development of a subperiosteal abscess manifesting as a puffyswelling on the forehead or scalp It usually occurs as a complication of frontal sinusitis Treatment is prompt surgical drainage andinitiation of broad-spectrum antibiotics

Differential Diagnosis Allergic and Environmental

Asthma

Asthma

Bronchitis

Haemophilus InfluenzaeInfections

Headache Cluster

Headache Tension



Influenza

Migraine Headache

Moraxella CatarrhalisInfections

Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic

RhinocerebralMucormycosis

Rhinoviruses

Sinusitis Chronic

Staphylococcal Infections

Workup

Some authors have reported on the use of laboratory tests including sedimentation rate white blood cell counts and C-reactiveprotein levels to help diagnose acute sinusitis[32] These tests appear to add little to the predictive value of clinical findings in thediagnosis

According to the AAAAI 2005 practice parameter evaluation of acute chronic or recurrent sinusitis might include the followinglaboratory tests nasal cytology nasal-sinus biopsy or tests for immunodeficiency cystic fibrosis or ciliary dysfunction [12]

Imaging studies are not necessary when the probability of sinusitis is either high or low but may be useful when the diagnosis is indoubt based upon a thorough history and physical examination Plain sinus radiographs may demonstrate mucosal thickening air-fluid levels (see the image below) and sinus opacification

Limitations of plain films include interobserver variability inability to distinguish infection from a polyp or tumor disease and poordepiction of the ethmoid and sphenoid sinuses

Blood Studies

The erythrocyte sedimentation rate and C-reactive protein level may be elevated in rhinosinusitis but these findings are nonspecific

The findings of complete blood cell (CBC) count with differential may be within reference ranges

Tests for Immunodeficiency

Tests for immunodeficiency are indicated if history findings indicate recurrent infection to include the following

Immunoglobulin studies

HIV serologyNasal Cytology

Nasal cytology examinations may be useful to elucidate the following entities

Allergic rhinitis[33]

Eosinophilia

Nasal polyposis

Aspirin sensitivitySweat Chloride Test

Sweat chloride test screening should be performed if cystic fibrosis is suggested

Cultures of Nasal Secretions

Cultures of nasal secretions are of limited value because they are usually contaminated by normal flora Consequently cultures arenot routinely obtained in the evaluation of acute sinusitis however they should be obtained in a patient in intensive care or with

immunocompromise in children not responding to appropriate medical management and in patients with complications of sinusitis

Because the nose is colonized with multiple nonpathogenic species of bacteria care must be taken when evaluating culture results Aspecific organism is considered pathogenic when more than 104 colony-forming units of the species are grown on culture or whenpolymorph counts are greater than 5000 cellsmL Important to note is that this sample must be taken from the cavity of a paranasalsinus not nasal secretions cultures from which are considered useless Obtaining cultures endoscopically is useful

Aspiration of the sinus by direct antral puncture is the only accurate way to obtain a culture however this is reserved for those withlife-threatening illness or an immunocompromised status or those who have disease that is unresponsive to therapy However inadults if attainable cultures directed at the middle meatus more accurately reflect the contents of the sinuses themselves accordingto most studies This may not be useful in children because the meatus is usually colonized[34]

Computed Tomography

CT scanning is the preferred imaging method for rhinosinusitis A screening sinus CT scan is adequate for diagnosis and less

expensive than other methods but is necessary only in cases of treatment failure or chronic rhinosinusitis A complete sinus CT scanwith frontal and coronal planes is used if an alternative diagnosis (eg tumors) must be excluded CT scanning is characteristic inallergic fungal sinusitis and is one of the major criteria for diagnosis

The 2005 AAAAI practice parameter states that the optimal technique for evaluating the ethmoid sinuses and for preoperativeevaluation of the nose and paranasal sinuses including assessment of the ostiomeatal complex areas is CT[12]



CT scanning has poor specificity for the diagnosis of acute sinusitis demonstrating sinus air-fluid levels in 87 of individuals withsimple upper respiratory tract infections and 40 of asymptomatic individuals CT scanning is the modality of choice however inspecific circumstances such as in the evaluation of a patient in intensive care when complications are suspected or in thepreoperative evaluation of surgical candidates

According to the 2005 AAAAI practice parameter CT evidence of sinusitis is associated with viral upper respiratory infections 40-90 of the time Symptoms of viral upper respiratory tract infections do not differ between patients with CT abnormalities andpatients with no CT evidence of sinusitis and both groups appear to self-resolve without antibiotics within 21 days It isinappropriate to prescribe antibiotic treatment for uncomplicated viral upper respiratory tract infection Doing so is stronglydiscouraged[12]

CT scanning can provide valuable information regarding the anatomical and mechanical contributions in the development of acutesinusitis Coronal views with bone windows are the preferred sinus study for evaluating each of the sinuses as well as theostiomeatal complex CT scan findings may be used to differentiate orbital cellulitis from periorbital cellulitis as a complication or toevaluate extension into intracranial space

Delay CT scanning until antibiotics control acute exacerbation this practice allows correct diagnosis of chronic inflammationmucoperiosteal thickening soft tissue swelling and ethmoid osteitis

Because of concerns of radiation exposure use of limited sinus CT scanning (see the image below) is gaining wide acceptance as analternative to a single Waters view for evaluation of pediatric chronic sinusitis

Radiography

Basic radiographic examination includes 3 projections as follows

Waters view (occipitofrontal) - Primarily useful for evaluation of maxillary and frontal sinuses

Caldwell view (angled posteroanterior) - Only view that visualizes the ethmoid air cells

Lateral view - Primarily for adenoid andor nasopharyngeal size and sphenoid disease

Radiographic findings in patients with acute sinusitis include diffuse opacification mucosalthickening (gt4 mm) or an air fluid level These findings in conjunction with clinical features ofacute sinusitis are helpful in confirming the diagnosis

When plain film radiographs are compared with the criterion standard (CT scans)however a 75-80 disagreement occurs This means that plain film radiographyreveals disease in 40 of cases in which no disease is demonstrated on CT scanning



and that plain film radiographs appear normal in 35-40 of cases in which disease is found on CT scanning

See the main article Imaging in Sinusitis for more information

Magnetic Resonance Imaging

MRI is useful only if fungal infection or a tumor is suggested MRI is excellent for evaluating soft tissue disease within the sinuses butit is of little value in the diagnostic workup for acute sinusitis

This type of imaging may be too sensitive to define soft tissue structures MRI is not useful for detecting bone pathology MRI ismainly used to evaluate intracranial extension and can be used as an adjunct to CT scanning in defining allergic fungal sinusitis

To see complete information on Imaging in Sinusitis please go to the main article by clicking here

Ultrasonography

Ultrasonography is of limited use A-mode ultrasonography may be useful in screening for fluid in the maxillary sinus B-mode (grayscale) ultrasonography may be useful in detecting fluid in the cavity mucosal thickening or soft tissue mass in the maxillary sinus


Paranasal Biopsy

Paranasal biopsy is used to help exclude neoplasia fungal disease and granulomatous disease

Fiberoptic Sinus Endoscopy

Fiberoptic sinus endoscopy is used to visualize posterior sinonasal structures This test is useful to help exclude structural lesionsfungal disease and granulomatous diseases



Hidung

Anatomi

Nasal septum

Muara sinus








Pathology




Paranasal Sinus






on the radiograph

Anatomy

Ethmoidal Sinus









Frontal Sinus


Maxillary Sinus





Sphenoid Sinus
























Pathophysiology











Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy











Pathology




Paranasal Sinus






on the radiograph

Anatomy

Ethmoidal Sinus









Frontal Sinus


Maxillary Sinus





Sphenoid Sinus
























Pathophysiology











Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy







on the radiograph

Anatomy

Ethmoidal Sinus









Frontal Sinus


Maxillary Sinus





Sphenoid Sinus
























Pathophysiology











Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy








Frontal Sinus


Maxillary Sinus





Sphenoid Sinus
























Pathophysiology











Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy
















Pathophysiology











Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy









Ciliary impairment

























sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy















sinusitis


Frontal Sinusitis




Ethmoid Sinusitis



Sphenoid Sinusitis





Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy







Fungal Sinusitis












Major factors





Hyposmia or anosmia



Factors



Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy






Headache


Halitosis

Fatigue

Dental pain

Cough




CRS 12 weeks





























CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy











CRS including

Biofilms

Osteitis

Allergy


Fungi


Infectious








STAGING SYSTEMS




Lundndash










Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy











Imaging Studies


cells




Laboratory Tests








fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy






fossa





Antibiotics

















Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy








Allergy Management



Sinus Surgery





Indications





Complications




Orbital Infection






Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy







Periorbital edema



Orbital cellulitis





Orbital abscess










Pott Puffy Tumor



Asthma

Asthma

Bronchitis


Headache Cluster

Headache Tension



Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy






Influenza

Migraine Headache


Mucormycosis

Otitis Media

Parainfluenza Virus

Rhinitis Allergic


Rhinoviruses

Sinusitis Chronic


Workup





Blood Studies









Eosinophilia

Nasal polyposis








Computed Tomography











Radiography















Ultrasonography



Paranasal Biopsy











Radiography















Ultrasonography



Paranasal Biopsy












Ultrasonography



Paranasal Biopsy




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