Rhinosinusitis: clinical features and diagnosis kk

1. Rhinosinusitis: clinical
features and diagnosis
Dr. Krishna Koirala
2020-05-25

2. Definitions
Rhino-sinusitis: inflammation of lining mucosa of nose &
paranasal sinuses
Acute: infection lasting < 4 weeks
Sub acute: infection lasting 4 to 12 weeks
Chronic: infection lasting > 12 weeks
Recurrent acute (RARS): > 3 episodes of rhinosinusitis in 6
months or > 4 episodes in a year, each episode lasting for 7-
10 days, without persistent symptoms in between

3. Types of
sinusitis
Acute / sub acute / chronic / recurrent
Open / Closed (depending on its drainage)
Unilateral / bilateral
Maxillary / frontal / ethmoidal / sphenoidal
Single / multi / pan-sinusitis
Anterior / posterior group
Suppurative / hypertrophic
Bacterial / fungal / allergic / occupational

4. Etiology
Rhinogenic: commonest (85%), following any
form of rhinitis
Dental: maxillary sinusitis, root abscess,
dental procedures
Trauma:
• R.T.A., swimming, diving, F.B., barotrauma
• Iatrogenic: nasal packing, septal surgery
Hematogenous : rare

5. Predisposing
factors
Mucosal edema: viral, bacterial, allergic,
irritant, vasomotor, barotrauma
Mechanical obstruction: DNS with spur, polyp,
hypertrophic turbinate, concha bullosa,
paradoxical middle turbinate, Haller cell, large
bulla ethmoidalis, agger nasi, uncinate
anomaly, nasal tumours, foreign body, nasal
packing

6. Mucous abnormality: Young’s syndrome,
cystic fibrosis, mucoviscidosis, dehydration
Mucociliary dysfunction: Kartagener’s
syndrome, viral, bacterial, allergic, smoking,
pollutants, hypoxia, dry air, extremes of
temperature, synechiae
Miscellaneous: Poor health,
immunodeficiency, diabetes, nutritional
deficiency

9. Bacteriology • Acute sinusitis
− Streptococcus
pneumoniae
− Hemophilus
influenzae
− Moraxella catarrhalis
− Staphylococcus
aureus
− Neisseria
• Chronic sinusitis
− Staph. Aureus
− Streptococcus
− H. influenzae
− Bacteroides
− Pseudomonas

10. Progress
• Severity and resolution depends on
– Open / closed
– Virulence of the organism
– Host resistance
– Treatment received

11. • Ostio-meatal complex is key
area for causation of infection
in anterior group of sinuses
• Pathological variants of ostio -
meatal complex play a major
role in causation of sinusitis
due to reduced ventilation and
drainage of sinuses

12. Clinical
features of
Rhinosinusitis
• Symptoms
− Nasal discharge : mucoid / purulent /
blood-stained
− Nasal obstruction with hyposmia /
anosmia
− Headache and facial pain
− Cheek / eyelid congestion and swelling
− Hawking, sore throat, dry irritating cough
− Earache: associated Eustachian tube
dysfunction
− Constitutional: fever, malaise, body ache

13. Location of
facial pain in
Rhinosinusitis
Maxillary sinusitis
• Cheek, upper jaw, forehead
that increases on bending
forward
Frontal sinusitis
• Forehead that increases
during morning and
decreases by late afternoon
(office headache)
Anterior Ethmoid: nasal
bridge and peri-orbital,
more on eye movement
Posterior Ethmoid:
deep seated retro-
orbital
Sphenoid : vertex,
occipital, retro-orbital
pain

14. Signs of
Rhinosinusitis
Congested and edematous nasal mucosa
Nasal discharge (anterior
and posterior rhinoscopy)
Middle meatus: frontal, maxillary,
anterior ethmoid
Superior meatus: posterior ethmoid,
sphenoid
Tenderness over the paranasal sinuses
Postnasal drip, granular pharyngitis
Cheek swelling in maxillary sinusitis
Lid edema in ethmoid & frontal sinusitis

15. Palpation to elicit paranasal
sinus tenderness
• Maxillary: over the canine fossa
• Anterior ethmoid: medial to medial canthus
• Frontal: Floor of sinus at the superomedial
aspect of the orbit or tap over its anterior
wall on the forehead

17. Transillumination test for sinuses
• Performed in a dark room.
• High-intensity light source placed inside patient’s
mouth or against the cheek (for maxillary sinus) &
under medial aspect of supra-orbital ridge (for
frontal sinus)
• Trans-illumination normal : no sinusitis
• Trans-illumination absent : sinus filled with pus
• Trans-illumination dull : equivocal result

18. Postural tests
for sinusitis
Performed in acute sinusitis (active nasal discharge)
Pus cleaned in supine position & pt sits upright
Pus appears = frontal or ethmoid sinusitis
Pus appears on stooping forwards = sphenoid
sinusitis
No discharge  pt lies in lateral position with
affected side up
Pus appears = maxillary sinusitis

19. Rhinosinusitis Task Force Criteria
Major Minor
1. Facial pain / pressure 1. Headache
2. Nasal obstruction 2. Fever (non-acute sinusitis)
3. Nasal discharge or 3. Halitosis
discolored postnasal drip 4. Fatigue
4. Hyposmia / anosmia 5. Dental pain
5. Purulence on exam 6. Cough
6. Fever (acute sinusitis) 7. Ear pain / pressure / fullness
Presence of 2 major factors or 1 major + 2 minor factors: sinusitis

20. Investigations
Diagnostic nasal endoscopy (D.N.E.)
Maxillary Sinoscopy
X-ray of P.N.S.
U.S.G. of maxillary sinus (Rhinoscan)
C.T. scan of P.N.S.
M.R.I. of P.N.S is rarely done
Allergic tests
Proof puncture (antral wash): for maxillary sinus
Endoscopic microswab for culture & sensitivity
Fungal culture: of cheesy nasal discharge

21. Diagnostic Nasal Endoscopy

22. • Patients not responding to medical therapy
• Anatomic factor preventing adequate
examination by anterior rhinoscopy
• Collection of pus from hiatus semilunaris
for culture & sensitivity
• Objective monitoring of patients
• Peri-operative nasal inspection & cleaning
Indications for D.N.E.
Pus seen in middle meatus
on doing D.N.E.

23. Maxillary sinoscopy
• Anterior sinus wall perforated
directly through canine fossa
between roots of 3rd & 4th teeth
with maxillary sinus trocar &
cannula
• Trocar removed and sinoscope
introduced through cannula to see
inside the maxillary sinus

24. Plain X- ray of Paranasal sinuses
• Water’s view (Occipito -mental)  maxillary sinus
• Caldwell’s view (Occipito -frontal) and lateral view
frontal
• Rhese’s view (lateral oblique) and lateral view 
ethmoids
• Base skull view (Submento -vertical) and Pierre’s view
(Occipito -mental with mouth open)  sphenoid
− Air-fluid level seen in acute sinusitis
− Mucosal thickening seen in chronic sinusitis

25. Para-nasal sinus sonography
• Bony anterior wall is seen as hyper-echoic line
• Maxillary cavity filled with air appears as hyper-
echoic hence posterior sinus margin not seen
• Fluid in sinus, cyst & mucosal thickening are
hypoechoic, so posterior sinus margin is visible
• B mode sonogram differentiates between fluid in
sinus, cyst & mucosal thickening

26. C.T. scan of Nose and PNS
• Most reliable imaging modality for
sinusitis at present
• Plain axial, coronal and sagittal cuts of 3
mm
• Contrast for suspected vascular,
neoplastic, inflammatory lesions
• Helps to delineate the extent of disease,
define anatomical variants and study the
relationship of sinuses with
surrounding structures
• Indications:
• Recurrent acute/chronic sinusitis not
responding to medical treatment
• Before endoscopic sinus surgery
• Impending complications of sinusitis

27. Plain C.T. scan Nose and PNS: Maxillary and ethmoid sinusitis

28. C.T. scan: frontal sinusitis

29. C.T. scan: sphenoid sinusitis

30. M.R.I. of P.N.S.
• Indications
−To assess the intracranial extension of
sinonasal disease, brain abscess due to
sinusitis and meningocele or encephalocele
−Malignant neoplasms of sinonasal tract
−To evaluate the orbital complications of
sinusitis