Chronic Sinusitis

Sinusitis

• Defined as disease lasting more than three months
• Usually due to inadequately treated acute or subacute disease
• Considered irreversible by medical therapy alone
• Oxygenation of the sinuses through opening of the ostia is the primary treatment

Signs and Symptoms of Sinusitis

• Headache
• Pain and tenderness
• Nasal obstruction
• Nasal discharge
• Heavy feeling when bending
• Nasal congestion
• Fever and malaise

Radiographic Picture of Sinusitis

• Sinus opacity
• Horizontal fluid level (usually unilateral sinus opacity if of dental cause)

Treatment of Sinusitis

• Rest and fluid intake
• Antibiotics for 5-7 days
• Analgesics and antihistamines
• Decongestant and nasal drops to shrink mucosa lining and drainage
• Local treatment: daily irrigation of sinus with warm saline or steam inhalation (especially if oro-antral fistula present)

Chronic Sinusitis

• Result of prolonged low-grade inflammation in antral mucosa following acute phase or recurrence of acute sinusitis
• Antral mucosa is thickened with edema and sometimes accompanied by creation of polyp
• Signs and symptoms:
  • Dull pain and intermittent headache
  • Posterior nasal discharge
  • Nasal congestion
  • Repeated attacks of acute mucopurulent rhinitis
  • Toothache during chewing
• Radiographic picture:
  • Sinus opacity with horizontal fluid level
  • Sinus lining thickening
  • Sinus polyps are also present

Function of Sinuses

• Lighten the weight of the skull
• Warm the air
• Resonance of voice
• Act as a shock absorber
• Regulation of intranasal pressure

Clinical Examination of Sinusitis

• Tapping on the lateral wall of the sinus extraorally and palpation intraorally
• Transillumination (old method)
• Sinoscope (recent method)

Radiographic Examination of Sinusitis

• Waters view: best view for sinus examination
• Panoramic view: provides a good overview of both maxillary sinuses
• Intraoral views (Occlusal & Periapical views): demonstrates the relation of root apices to the floor of the sinus
• Submento-vertex view: demonstrates the posterior wall of the maxillary sinus
• Occipito-frontal view: shows all the paranasal sinuses, useful to exclude pansinusitis
• Lateral sinus projection: confirms the presence of fluid or cyst or foreign body in the sinus
• Computerized tomography (CT): detection of neoplasms and bony wall erosions within the sinus

Maxillary Sinusitis

• Acute sinusitis: suppurative or non-suppurative inflammation of the mucosal lining of the sinus
• Causes:
  • Infection from dental abscess
  • Infection from cystic lesion of related teeth
  • Dental material pushed into sinus
  • Tooth pushed into sinus
  • Oro-antral fistula
  • Facial fracture involving sinus

Pathophysiology of Sinusitis

• Acute sinusitis: disease lasting less than one month
• Subacute sinusitis: disease lasting 1 to 3 months

Treatment of Acute Sinusitis

• Analgesics: to relieve pain
• Antibiotics: to control and overcome infection
• Decongestants: to decrease congestion of the nasal mucosa and relieve nasal obstruction
• Surgery: surgical removal of polyps and thickened lining if present, through Functional Endoscope Assisted Sinus Surgery (FEASS)

Complications of Maxillary Sinusitis

• Orbital abscess and orbital cellulitis
• Intracranial abscesses
• Meningitis
• Cavernous sinus thrombosis
• Spread of infection to neighboring sinuses, structures, and organs
• Osteomyelitis
• Gastrointestinal disturbances

Oroantral Communication (OAC)

• Abnormal connection between the oral cavity and the maxillary sinus
• Etiology:
  • Extraction or instrumentation around maxillary teeth
  • Facial trauma
  • Surgical procedure
  • Malignant neoplasms
  • Other causes (osteomyelitis and syphilitic gamma of the palate)

Why OAC is a Problem

• Allows the flow of food and fluids from the mouth into the nose, leading to invasion of bacteria into the sinus and causing sinusitis

Signs and Symptoms of OAC

• Recent OAC:
  • Escape of fluids from the mouth into the nose
  • Unilateral epistaxis
  • Inability to blow out the cheeks due to escape of air from the mouth to the nose
  • Bubbles of blood from the socket