Sinusitis some scientific points

[Sujatha]

Sinusitis

Acute rhinitis is the usual manifestation of a common cold.

Acute sinusitis is usually initiated by an acute respiratory tract infection of viral etiology.

Nearly all cases of acute sinusitis and most cases of chronic sinusitis respond well to antibiotic therapy.

The complications of acute and chronic sinusitis often require surgical therapy, as does unresponsive chronic sinusitis. Complications of maxillary sinusitis are rare. Ethmoid sinusitis is frequently complicated in children by orbital cellulitis and abscess.

Eighty percent of all cases of orbital cellulitis are secondary to ethmoid sinusitis.

In a patient who presents with erythema and swelling of the eyelids, proptosis, and displacement of the globe laterally and inferiorly, the source of the infection is sought by inspection of the nose for mucopus in the middle meatus and by CT scanning of the paranasal sinuses for ethmoid sinusitis. CT scanning of the orbits may allow differentiation of orbital cellulitis from orbital abscess.

Ethmoid sinusitis and orbital cellulitis respond well to systemic antibiotic therapy.

If the proptosis fails to subside or progresses, incision and drainage of the abscess, which is between the lamina papyracea and the orbital periosteum, is performed through a Killian incision that extends from the lateral aspect of the nose to the eyebrow. The orbital periosteum is elevated from the medial wall of the orbit so that the abscess cavity can be reached. The optic nerve tolerates 11 to 14 mm. of proptosis. The point at which extraocular motion is lost is also the limit of stretch of the optic nerve. Therefore, incision and drainage of an orbital abscess are performed prior to complete loss of extraocular motion to prevent permanent blindness.

Frontal sinusitis may cause intracranial complications such as meningitis, epidural abscess, subdural empyema, and brain abscess. In severe acute frontal sinusitis that fails to respond promptly to systemic antibiotic therapy, the floor of the frontal sinus is trephined through an incision just inferior to the medial part of the eyebrow. An opening of approximately 7 to 8 mm. is made, and a catheter is placed in the sinus to maintain drainage. Trephination is performed in an attempt to prevent the intracranial complications of frontal sinusitis.

Fractures of the frontal sinus lead to the development of mucoceles. Mucoceles follow duplication of the mucous membrane. They gradually enlarge and destroy the floor of the frontal sinus; as they expand into the orbital cavity, they produce proptosis and inferior and lateral displacement of the eye. Mucoceles and other forms of chronic frontal sinusitis that do not respond to medical management or endoscopic sinus surgery can be managed surgically by an osteoplastic flap approach for obliteration of the frontal sinus (Fig. 39–11 Fig. 39–11). The incision in the bone is made at the periphery of the frontal sinus, and the anterior wall is rotated inferiorly on the hinge of periosteum at the floor of the sinus. Infected mucous membrane is removed with a gas-driven burr under microscopic control, and the cavity of the frontal sinus is obliterated by the implantation of fat taken from the abdominal wall.

Approximately 25% of cases of chronic maxillary sinusitis are secondary to a dental infection.

In chronic maxillary sinusitis, radiographs of the apices of the teeth should be obtained to exclude the possibility of a periapical abscess.

Infection and allergy can lead to hyperplastic tissue in the confluence of the ostia of the maxillary, anterior ethmoid, and frontal sinuses in the middle meatus, which produces obstruction of the ostia of these sinuses. Inflammation in the ostiomeatal complex is thought to account for a great deal of subacute and chronic maxillary, ethmoid, and frontal sinusitis. Endoscopic excision of inflammatory tissue in the ostiomeatal complex is credited with resolution of chronic sinusitis without open operative procedures.

Chronic maxillary sinusitis that does not respond to medical management or endoscopic sinus surgery may be controlled with the Caldwell-Luc operation, which is a maxillary sinusotomy performed through an incision in the canine fossa.

The bone of the anterior wall of the maxillary sinus is resected to permit access to the interior of the sinus for removal of infected mucous membrane, cysts, and epithelial debris. Drainage of the maxillary sinus is improved by creating a nasoantral window in the inferior meatus.

Chronic ethmoid sinusitis is often associated with allergic rhinitis and the formation of nasal polyps. In those individuals in whom the formation of nasal polyps and the symptoms of ethmoid sinusitis cannot be controlled adequately with medical management, including topical corticosteroid therapy and immunotherapy, an ethmoidectomy is indicated. Ethmoidectomy is performed intranasally with endoscopic guidance and through an external approach utilizing a Killian incision.

In the external ethmoidectomy, the orbital periosteum is elevated, and the lamina papyracea is removed for the purpose of giving access to the ethmoid air cells. Infected mucous membrane, polypoid tissue, and epithelial debris are removed. The anterior half of the middle turbinate is excised for creation of a large opening between the ethmoid air cells and the nasal cavity. In essence, an ethmoidectomy incorporates the ethmoid air cell area into the nasal cavity.

Chronic sphenoid sinusitis that does not respond to medical management may be controlled by an operation in which the sphenoid sinus is approached with endoscopic guidance or through an external ethmoidectomy. After an ethmoidectomy has been accomplished, the anterior wall of the sphenoid sinus is resected to remove infected mucous membrane, polypoid tissue, and epithelial debris. The anterior and inferior walls of the sphenoid sinus are removed. In this way, the interior of the sphenoid sinus is incorporated in the posterior part of the nasal cavity and the nasopharynx, and, in essence, the sphenoid sinus is eliminated as a separate entity.

In order to pack the posterior part of the nasal cavity, the choana is obstructed with the balloon of a Foley catheter (Fig. 39–12 Fig. 39–12) or a postnasal pack (Fig. 39–13 Fig. 39–13). Although the Foley catheter is easier to insert, the gauze postnasal pack is more secure. The postnasal pack is made by folding and rolling 4- by 4-inch gauze squares into a tight pack and tying the pack with two strands of no. 2 black silk. The ends of one tie are oriented inferiorly, and the ends of the other tie are oriented superiorly. After topical anesthesia of the nose, nasopharynx, and pharynx has been induced, a catheter is introduced through the nasal cavity on the side of the bleeding and brought out through the mouth. The superiorly oriented ends of the tie are tied to the catheter, and the catheter is withdrawn from the nose as the pack is placed posterior to the soft palate into the nasopharynx. The inferiorly oriented ends of the tie are trimmed below the level of the soft palate so that they can be utilized in removing the pack. The superiorly oriented strands are held taut while the nasal cavity is firmly packed with petrolatum gauze. If the bleeding point is in the inferior meatus, this area is packed tightly. The superiorly oriented strands are tied over a roll of a 4- by 4-inch gauze square. The packing is left in place for 4 days. Prophylactic antibiotic therapy is indicated to prevent sinusitis and otitis media. Patients requiring postnasal packing generally have serious systemic vascular diseases. They have a low arterial PO 2 while the packing is in place and should be given supplemental humidified oxygen by mask.

Persistent nasal obstruction due to adenoid hypertrophy is a problem in which the age of the patient is considered as well as the severity, since lymphoid tissue reaches a relative and absolute maximum at puberty. Persistent and recurrent purulent rhinorrhea despite adequate antibiotic therapy is occasionally encountered in association with adenoid hypertrophy and chronic adenoiditis. Chronic sinusitis in children without an underlying immune or other defense mechanism defect such as agammaglobulinemia or hypogammaglobulinemia, cystic fibrosis, or Kartagener's syndrome is relatively rare but is rather regularly improved or eliminated by adenoidectomy.

A cranial bone may be the site of hematogenous spread of a bacterial infection from another area of the body, but more often it becomes involved by adjacent spread from an infected paranasal sinus, by a penetrating wound, or by an operative infection involving a craniotomy flap. Pott's puffy tumor is such a frontal osteomyelitis, with marked overlying soft tissue swelling that is secondary to frontal sinusitis.

Treatment consists of the surgical removal of the infected bone, with simultaneous treatment of any coexisting sinusitis. Appropriate systemic antibiotics are administered, and an adequate margin of normal bone is removed with the specimen to minimize the risk of recurrent infection. A cranioplasty may be performed later for cosmetic and protective reasons, but at least a year should be allowed to pass, during which time there is no evidence of inflammation in the area, before the plate is inserted. Otherwise, this large foreign body can serve as a focus for a further inflammatory response.

An epidural infection is usually a well-confined bacterial abscess associated with one or more of the previously mentioned infections, and it is drained at the same time the coexisting osteomyelitis or sinusitis is treated. A subdural infection, however, is usually a more widespread empyema rather than a localized abscess, since the developing infection easily dissects open the subdural space to cover the surface of an entire cerebral hemisphere. Subdural empyema may begin by the extension of infection through the dura mater from without or through the arachnoid from within, or it may result from the operative infection of a subdural hematoma. In any event, subdural empyema is usually treated by immediate evacuation through multiple trephine openings or a craniotomy flap in order to avert death or serious neurologic morbidity. Drains are usually left in the subdural space for several days, until all drainage has ceased.

1. Extension of an infection through the meninges. In this way, mastoiditis may lead to an abscess in the ipsilateral temporal lobe or cerebellar hemisphere, or frontal sinusitis may produce a frontal lobe abscess.

Although congenital bronchiectasis is unusual, several congenital disorders may produce bronchiectasis in up to 58% of children with bronchiectasis. 15 Congenital cystic bronchiectasis, with incomplete terminal airways, lack of alveolar tissue, and saccular bronchi, is now considered to be rare and the only truly congenital form of bronchiectasis. In Williams-Campbell syndrome, annular bronchial cartilage is congenitally absent, leading to bronchomalacia and bronchiectasis. Genetic abnormalities in Ehlers-Danlos and Mounier-Kuhn syndromes may contribute to tracheobronchomegaly and tracheobronchiectasis. Primary ciliary dysmotility with impaired mucociliary transport can produce bronchiectasis as an isolated abnormality or as part of Kartagener's syndrome (bronchiectasis, situs inversus, and sinusitis). 4, 15 In either partial or severe alpha 1-antitrypsin deficiency, enzyme deficiency may impair clearance of sputum elastase, producing airway damage and bronchiectasis in approximately 10% of patients. Patients with cystic fibrosis have abnormally viscid bronchial secretions and may be predisposed to bronchiectasis due to impaired clearance of bronchial airways. Intralobar bronchopulmonary sequestration may occasionally be complicated by bronchiectasis. Patients with panhypogammaglobulinemia have a clear predisposition to bronchiectasis, as may patients with human immunodeficiency virus infection or other forms of immunodeficiency. 8, 15

An additional diagnostic procedure of potential use in bronchiectasis is sinus radiography, which can be used to look for evidence of sinusitis that may require treatment. Although pulmonary function tests in bronchiectasis generally do not demonstrate more than mild airway obstruction, 5 spirometry should be performed in surgical candidates to evaluate tolerance for lung resection. Lung ventilation and perfusion scans often show areas of relatively normal perfusion but impaired ventilation and may have some use for screening, particularly in children. 12 Quantitative immunoglobulins or sweat chloride determination may be obtained if immunodeficiency or cystic fibrosis is suspected.

[solosynergy]

woow great stuff but then all i ended up was with a cereberal pausititis