4. Acute Infection
Destroys normal ciliated epithelium
Impairs drainage from sinus
Pooling and stagnation of secretions
Persistence of infection
Mucosal changes – loss of cilia , edema
,polyp formation
5. Destruction of mucosa and healing occurs
simultaneously
Thickening of mucosa
Polypoidal Atrophy
[ hypertrophic sinusitis] [ atrophic sinusitis]
Surface epithelium – Desquamation
Regeneration/ Metaplasia
Submucosa – lymphocytic , plasma cells infiltration
with /without micro abscesses, granulations , fibrosis
or polyp formation
12. Identify the etiology which obstruct sinus
drainage and ventilation
Work up for Nasal allergy may be required
Culture and sensitivity – Antibiotic selection
Initial treatment – Conservative [ Antibiotics,
decongestants, antihistaminics, and sinus
irrigations]
SURGERIES – for free drainage and ventilation
14. CHRONIC MAXILLARY
SINUSITIS
Antral puncture and Irrigation
Intranasal antrostomy – when sinus
irrigation fails to resolve infection.
Caldwell – Luc Operation
15. CHRONIC FRONTAL SINUSITIS
Intranasal drainage operations
[ Correction of DNS, removal of a polyp or Iintranasal
ethmoidectomy, provide drainage through the
frontonasal duct.]
External frontoethmoidectomy
Trephination of frontal sinus
Osteoplastic flap operation
16. CHRONIC ETHMOID SINUSITIS
Intranasal ethmoidectomy
- ethmoid air cells & the diseased tissue is
removed between the middle turbinate
and the medial wall of orbit by intranasal
route.
External ethmoidectomy – Medial orbital
incision
17. CHRONIC SPHENOID SINUSITIS
Sphenoidotomy
Sinus entered through anterior wall
Usually asso with ethmoid disease , hence
external ethmoidectomy is also done
21. Fungal ball
Due to implantation of fungus in otherwise
healthy sinus
CT – hyper dense area with no evidence of
bone erosion or expansion.
Maxillary > Sphenoid> Ethmoid> Frontal
Surgical removal of fungal ball & adequate
drainage of sinus.
22. Allergic Fungal Sinusitis
Allergic reaction to causative fungus
Presents with Sinu- nasal polyposis & Mucin
[ Eosinophils, CL crystals, fungal hyphae]
CT - Mucosal thickening with hyperdense areas
- Bone erosion
- Expansion of sinus but no fungal invasion into
mucosa.
Treatment – endoscopic surgical clearance , drainage
ventilation + pre- & post-operative steroids
23. CHRONIC INVASIVE SINUSITIS
Fungal invasion into sinus mucosa
Presents with chronic rhinosinusitis, may present
with intracranial or intraorbital invasion.
CT – mucosal thickening, opacification of sinus,
bone erosion, expansion.
Histopatho – submucosal fungal invasion +
granulomatous reaction with multinucleated giant
cells.
24. Treatment – Surgical removal of involved
mucosa, bone and soft tissues followed by
IV Amphotericin B upto 2-3g followed by
Itraconazole for 12 months or more
monitored by serial CT/MRI scans.
25. Fulminant Fungal Sinusitis
Acute presentation
Immunocompromisation /Diabetes
Mucor , Aspergillus
Mucor – Rhinocerebral disease
- Due to invasion of BV ischemic necrosis
black eschar involving inf. Turbinate , palate or
sinus.
- Spreads to face , eyes, skull base and brain
Treatment – Surgical debridement of necrotic
tissue and IV Amphotericin B
Aspergillus – no eschar
26.
27. Minimally invasive
Does not require skin incisions / removal
of intervening bone to access the disease.
Ventilation and drainage of the sinuses is
established preventing the nasal and sinus
mucosa & its mucociliary clearance
function.
28. INDICATIONS
1. Chronic bacterial sinusitis unresponsive to medical
treatment
2. Recurrent acute bacterial sinusitis.
3. Polypoid rhinosinusitis
4. Fungal sinusitis with fungal ball/nasal polypi.
5. Antrochoanal polyp.
6. Mucocoele of frontoethmoid/ sphenoid sinus……
29. CONTRAINDIATIONS
1. Inexperience and lack of proper
instrumentation.
2. Endoscopy inaccessible diseases [ lateral
frontal sinus disease]
3. Osteomyelitis.
4. Threatened intracranial or intraorbital
complication.
30. ANAESTHESIA
GENERAL ANAESTHESIA Preferred.
LOCAL anaesthesia with IV sedation can
be used when limited work is to be done.
31. POSITION
Patient lies flat in supine postion with head
resting on a ring or head rest.
32. TECHNIQUES
Stammberger’s Technique[ Anterior to
posterior]
- Starts from uncinate process proceed
backwards to sphenoid sinus.
Wigand’s Technique[ Posterior to Anterior]
- Starts at sphenoid sinus and proceeds
anteriorly along the base of skull and
medial orbital wall.
33. Steps Of Operation…
1. Remove the pledgets of cotton kept for
nasal decongestion and topical
anaesthesia.
2. Inspect the nose with 4mm 0degree
endoscope .
3. Inject submucosally 1% lignocaine with
1:100000 adrenaline under endoscopic
control.
