------------------------------------------------------------------------------
TITLE:   SINUSITIS AND NON-ENDOSCOPIC SINUS SURGERY
SOURCE:  Dept. of Otolaryngology, UTMB, Grand Rounds
DATE:    4 May 1990
RESIDENT PHYSICIAN:      Mark C. Littlejohn, M.D.      
FACULTY:                 Charles M. Stiernberg, M.D.    
DATABASE ADMINISTRATOR:  Melinda McCracken, M.S.
------------------------------------------------------------------------------

"This material was prepared by resident physicians in partial fulfillment of 
educational requirements established for the Postgraduate Training Program of 
the UTMB Department of Otolaryngology/Head and Neck Surgery and was not 
intended for clinical use in its present form.  It was prepared for the purpose
of stimulating group discussion in a conference setting.  No warranties, either
express or implied, are made with respect to its accuracy, completeness, or 
timeliness.  The material does not necessarily reflect the current or past 
opinions of members of the UTMB faculty and should not be used for purposes of
diagnosis or treatment without consulting appropriate literature sources and 
informed professional opinion." 


I. DEFINITION: an inflammation involving the lining membrane of any
sinus.

II. PATHOGENESIS
 
 A. Development of Sinuses
  1. ethmoids- evident at birth
  2. maxillary- pneumatized between birth and 2 years of age
  3. sphenoid- evident radiologically by 3 years
  4. frontal- become distinct from the ethmoids by 6 years

 B. Anatomy
  1. All sinuses drain through ostia into the nasal cavity. The
functional diameter of the maxillary ostium is approximately 2-4 mm,
that of the ethmoid air cells 1-2 mm diameter. 
  2. Osteomeatal complex- middle meatus/anterior ethmoid complex,
stenotic area most often involved in inflammatory disease, anterior end
of the middle turbinate receives the brunt of inspiratory airflow and is
the primary site of particulate deposition.

 C. Factors
  1. patency of the ostia- most important factor. Ostium size varies
with body position, decreasing with recumbency. Mucosal inflammation and
anatomic abnormalities obviously adversely affect ostial size, as can
trauma, neoplasms, allergic polyps, and vasomotor rhinitis.
  2. oxygen exchange- When the ostia is obstructed, maxillary sinus PO2
falls from 117.6 mm Hg to 80.7 mm Hg with a concommitant rise in PCO2=>
favors anaerobic and facultative anaerobic growth.
  3. mucociliary transport- The mucus is normally propelled toward the
ostia. Impairment may be induced by viral infections (with resultant
decreased transport for up to one month), cold or dry air, chemicals,
drugs (ex.- afrin), alterations in mucus (cystic fibrosis), immotile
cilia syndrome, or two opposing mucosal layers coming in contact.
Prolonged or repeated infections can lead to irreversible mucosal damage
with pseudostratified columnar ciliated epithelium being replaced by
stratified squamous epithelium (i.e., metaplasia).
  4. mucosal blood flow

 D. Sites 
  1. maxillary- most common when a single sinus is involved, origin-
  nasal 90%, traumatic 4%, dental 4%, systemic 2%.
  2. frontal- associated with infection of the homolateral ethmoid and
  maxillary sinuses, frontonasal duct is tortuous and easily obstructed.
  3. sphenoid- frequently part of pansinusitis, especially with ethmoid
  involvement.
  4. all sinuses may become individually infected if locally
  obstructed.

III. ETIOLOGY 

 A. Normal flora vs. sterile sinus?- In a study by Brooks of
asymptomatic patients, anaerobic isolates included predominantly
Bacteroides, anaerobic gram positive cocci and Fusobacterium. Aerobic
isolates included beta and alpha hemolytic strep, Strep. pneumonia, H.
influenza, and Staph. aureus. (The sinuses were previously thought to be
sterile- still controversial.)

 B. Cultures- Only direct sinus aspirate provides reliable data. There
is a strong correlation between WBC count >5000/mm cubed and bacterial
titers > 1000 cfu/mm cubed. Nasal swabs and irrigation correlate with
sinus aspiration <65% of the time. Purulent nasal secretions usually
merely over-represent staphylococcus species.

 C. Antral Puncture Specimens 
  1. Acute- Strep. pneumonia and unencapsulated H. influenza represent
>50% of the isolates obtained. Anaerobes are isolated in at least 10% of
cases. Predominant anaerobes include Bacteroides, Strep. pyogenes,
Branhamella catarrhalis, Gram negative bacteria are less frequently
encountered. (In children, Strep. pneumonia and H. influenza again
predominate. Anaerobes are less frequently identified. However,
Branhamella catarrhalis accounts for up to 20% of acute sinusitis in
children.)  
  2. Chronic- Anaerobes present in 40-50% of isolates. Predominant
anaerobes included Bacteroides, anaerobic gram-positive cocci, and
Fusobacterium. With aerobes, alpha-hemolytic strep, Haemophilus species,
Staph. aureus predominate.
  3. Dental Source- Usually anaerobes, esp. Bacteroides and anaerobic
gram-positive streptococci.
  4. Nosocomial- Gram-negative bacteria predominate, esp. Pseudomonas
aeroginosa, Klebsiella pneumonia, Enterobacter, Proteus mirabilis, and
E. coli.
  5. Viral- Isolated in 15%, usually in conjunction with or preceding bacterial
infection. Most common- rhinovirus. 
  6. Fungal- rare. Most common- Aspergillus: noninvasive form called
mycetoma or allergic aspergillosis. Mycetoma usually unilateral,
resistant to Abx=> may spread to orbit; invasive form occurs in
leukopenic, immunocompromised hosts=> rapidly progressive
mucoperiostitis, vascular invasion, and bony destruction. Rhinocerebral
mucormycosis is similar to invasive aspergillus. Mucor presents with
fever, black nasal discharge and turbinates, cranial nerve involvement,
and altered mental status. Candida albicans can cause noninvasive
sinusitis in patients receiving prior Abx therapy or with diabetes
mellitus.
  7. Other- Cystic fibrosis, immotile cilia syndrome usually affected by
Pseudomonas, Staph. aureus. AIDS- usually H. infuluenza, pneumococcus,
Pseudallescheria boydii (fungus).

IV. DIAGNOSIS

 A. History and Physical Examination
  1. Symptoms- 60% with purulent nasal discharge and facial pain (worse
when bending over), also disorders of smell, pain with mastication,
nasal congestion, cough, Hx of recent URI, fever in <50%. In children,
cough, nasal symptoms, and fever are the most common presenting
symptoms.
  2. Signs- tenderness (mostly frontal, maxillary), purulent discharge,
swelling (especially children), fever.
  3. S/S by location
maxillary sinusitis of dental origin- gum disease, halitosis, dental
caries.
sphenoid sinusitis- headache.
ethmoid sinusitis- excessive tearing and edema of the eyelids.
  4. Chronic sinusitis- Usually purulent nasal discharge, protracted
nasal congestion, facial pain.
  5. Fungal sinusitis  
mucor- fever, debility, altered mental status, black discoloration of
palate or septum, black nasal discharge, CNS findings.
invasive aspergillosis- presentation similar to mucor.
fungal mycetomas (Candida or Aspergillus)- usually only one sinus, nasal
congestion, facial pain.
allergic aspergillus sinusitis- asthma, recurrent pansinusitis, nasal
polyposis, thick inspissated mucus.

 B.Investigations
  1. Transillumination- for maxillary, frontal sinusitis (less helpful
in chronic sinusitis).
  2. Sinus films- Waters: maxillary, Caldwell: ethmoid and frontal,
Submental vertex and lateral: sphenoid. Look for air-fluid levels,
mucosal thickening, opacification of sinus. (Presence of any of these
findings with appropriate Hx. is predictive of a positive aspirate in
70-80%. Normal x-ray correlates with a normal aspirate in >80%. When the
width of the sinus mucosa is greater than or equal to 5 mm in adults or
4 mm in children, likelihood of pus is high.
  3. CT- Best performed when patient is medically optimized. Especially
good for the osteomeatal complex. Use coronal views with the head
hyperextended with soft tissue windows.
  4. MRI- Better than CT according to some.
  5. Ultrasonography- Controversial. Recent studies find it no better
than plain films.
  6. Nasal endoscopy- Initial exam along the floor with a view of the
inferior meatus and the nasopharynx. Second pass between the middle
and inferior turbinates with a view of the osteomeatal complex.
  7. Diagnostic antral puncture- Below the inferior turbinate, with
1 cc of normalsaline instilled and aspirated if no frank pus. Send
for aerobes,anaerobes, and fungi.

 C. Differential Diagnosis 
  1. Dental pain- worse with chewing, thermal stimulation, experience
chronic, intense, recurring pain, worse at night.
  2. Migraine headache- throbbing, boring, aching pain, associated with
nausea, vomiting, auras, and parasthesias.
  3. Trigeminal neuralgia- always unilateral over anatomic distribution,
severe, agonizing intense pain lasting seconds to minutes, precipitated
by stimulation of trigger zone, no other associated signs.
  4. Neoplasms- SCCA most common, pain late, usually involving maxillary
branch of V, associated with bloody discharge, unilateral obstruction,
may have swelling of the cheek, alveolus, nasal bridge, or palate,
unilateral proptosis, parasthesias, ulcer of the palate, trismus.
  5. Facial cellulitis- normal sinus films, red, swollen over face,
adenopathy.
  6. Temporal arteritis- intense, boring, throbbing pain over the
temples, frontal, and occipital areas, exquisite tenderness of the
overlying scalp with erythema and swelling, may be associated with
papilledema and loss of vision, Dx. by biopsy.
  7. Angioneurotic edema- usually single lesion, but may be multiple,
tense, nonpitting swelling, nontender, NOT hot/red/or pruritic
  8. Insect bites- erythema, warmth, pruritus, swelling.

V. TREATMENT

 A. Medical
  1. Antibiotics- Directed against the most common pathogens: Strep.
pneumonia, H. influenza, Branhamella catarrhalis.

ampicillin 500 mg po q6hrs x 2 weeks
amoxicillin 500 mg po q8hrs x 2 weeks
amoxicillin/clavulanate 500 mg po q8hrs x 2 weeks
cefaclor 500 mg po q8hrs x 2 weeks
cefuroxime axetil 250 mg po q12hrs x 2 weeks
trimethoprim-sulfamethoxazole (160/800 mg) 1 po q12hrs x 2 weeks

children:
amoxicillin 40 mg/kg/day in 3 divided doses
erythromycin/sulfisoxazole 50/150 mg/kg/day in 4 divided doses
trimethoprim/sulfamethoxazole 8/40 mg/kg/day in 2 divided doses
cefaclor 40 mg/kg/day in 3 divided doses
amoxicillin/clavulanate 40/10 mg/kg/day in 3 divided doses

If no improvement or worsening in 48 hrs, clinically re-evaluate. If
improved but not completely recovered in 2 weeks, continue same
treatment for one more week.
  2. Symptomatic therapy- Topical decongestants x 3 days, oral
decongestants (controversial- pediatric literature does not recommend),
antihistamines (may thicken fluid and impair drainage, do not use
unless allergic component), analgesics, bed rest.
  3. Chronic sinusitis- If no improvement in 2 weeks, some recommend
sinus aspiration. Change Abx- 2nd or 3rd generation cephalosporin,
clindamycin for anaerobes, Abx with beta-lactamase coverage. Treat for
2-4 more weeks. Topical steroids- controversial. If nosocomial, consider
gram-negative coverage.
  4. Fungal sinusitis- Usually require surgery.

 B. Surgical
  1. Maxillary sinus
   a. Irrigation- Puncture inferior meatus/canine fossa with 16 guage
spinal needle. Catheter inserted for repeated irrigations. Anesthesia:
topical or local. Risks: trauma to tooth buds or orbit.
   b. Intranasal Antrostomy- (nasal-antral window), For infection of
short duration which is unresponsive to Abx and irrigation or when a
tissue Dx. is needed. May be effective for patients with ciliary
dyskinesia (i.e., Kartagener's). Less effective for those with normal
ciliary beating toward natural ostia.
   c. Sublabial Antrostomy/Caldwell-Luc- Usually performed for chronic
maxillary sinusitis, removal of benign tumors, staging of maxillary
cancer, removal of foreign bodies, to gain access to the ethmoid and
sphenoid sinuses, the orbit for decompression, and the pterygomaxillary
space.
   d. Obliteration- For chronic infection associated with respiratory
disease. Fat usually used.
  2. Ethmoid sinus
   a. Transantral Ethmoidectomy- Performed for inflammatory and
hyperplastic disease of both antrum and ethmoid air cells, orbital
decompression (however, only inferior and medial orbital walls may be
taken down).
   b. External Ethmoidectomy- Performed for acute ethmoiditis with
resultant orbital or periosteal abscess, biopsy or resection of ethmoid
and orbital neoplasms, and frontal and ethmoid disease requiring access
to both. May be combined with lateral rhinotomy or used alone for repair
of CSF leak.
   c. Lateral Rhinotomy Approach- Provides excellent exposure with
acceptable cosmetic and functional results. Versatile. Performed for
removal of nasal and paranasal sinus tumors, including juvenile
angiofibroma and inverting papilloma. Procedure: Incision slightly
anterior to the nasofrontal line, extending from just anterior to the
medial canthus, inferiorly to the lateral border of the nasal ala in the
alar groove. May be extended upward into the eyebrow or across the nose
into the opposite brow superiorly. Inferiorly may be joined with a
similar incision on the opposite side by curving anteriorly across the
columella. The incision is carried down to the periosteum of the frontal
process of the maxilla. Following ligation of angular vessels,
osteotomies on the frontal process are performed, and the lateral wall
of the nose reflected. The incision may be carried inferiorly, providing
exposure of the maxillary antrum. En bloc resection of the ethmoid cells
and median maxillectomy can be performed. If the incision is extended
laterally from the area of the medial canthus and eyebrow, total
maxillectomy with or without orbital exenteration may be carried out. A
lateral craniotomy incision may also be added. Complications-
nasocutaneous fistula in the medial canthal region, intermittent
epiphora, chronic dacrocystitis.
  3. Frontal sinus
   a. Trephination- For severe acute sinusitis, air-fluid levels or
inflammation unresponsive to Abx. Catheter may be inserted for
irrigation.
   b. Lynch External Frontoethmoidectomy- Performed for acute
inflammatory disease of the frontal and ethmoid sinuses with extension
into the orbit, for chronic frontal and ethmoid sinusitis of extremely
large or very small sinuses. Warning: failure to maintain a patent
nasofrontal duct may result in recurrent infection or mucocele formation
(occurs in 20-30% of cases). Procedure: Floor of frontal sinus and
ethmoids removed. Subsequently lined with split-thickness skin graft
with prolonged intubation of the duct. 
   c. Frontal Osteoplastic Flap with Sinus Obliteration- Indicated for
chronic frontal sinusitis unresponsive to medical therapy and is
complicated by persistent pain, orbital involvement, bone necrosis + or
- osteomyelitis, mucocele and pyocele formation, or intracranial
extension. Also performed for benign and malignant tumors of the frontal
sinus, posterior table fractures (especially with CSF leak or
pneumocephalus), and sinocutaneous fistula. Procedure: A 6 foot Caldwell
template is taken and is used to outline the frontal sinus prior to
incising the pericranium. The external incision is placed coronally
behind the hairline or low in the brow. (Brow incision preferable in
males.) All mucosal remnants are removed. The sinus is then obliterated.
(The type of obliteration and whether the nasofrontal duct need be
occluded is controversial.) Materials: fascia, muscle, bone, fat, blood
clot, synthetic collagen. Most agree autogenous fat plus nasofrontal
duct closure is the most successful form of obliteration.
   d. Riedel Procedure- Removes diseased anterior wall. Patient left
with defect that can later be rebuilt with methyl methacralate.
   e. Lothrop Procedure- Intersinus septum and ethmoids removed.
   f. Killian Procedure- Supraorbital rim preserved. Anterior wall,
floor of the frontal sinus and ethmoids are removed.
  4. Sphenoid sinus
   a. Access may be gained via the maxillary sinus, posterior
ethmoids,via external ethmoidectomy, or trans-septally. Antral and
ethmoid disease must be cleared as well.
   b. Intranasal Sphenoethmoidectomy- Indicated for chronic hyperplastic
rhinosinusitis, recurrent nasal polyps, acute and chronic pansinusitis,
polyps in asthmatics, and tight nasal valve syndrome. Procedure-
Submucus resection of septal deviation if present. Middle turbinate and
posterior ethmoids removed. The anterior wall of the sphenoid sinus is
taken down. The remainder of the ethmoid air cells are removed going
posteriorly to anteriorly.
 
VI. COMPLICATIONS OF SINUSITIS

 A. Spread
  1. directly through the bony wall (osteitis)
  2. veins from septic venous thrombosis
  3. retrograde thrombosis to dura (meningitis, thrombosis of sinuses,
cerebritis) 
  4. hematogenous
  5. lymphatics
  6. perineural spaces (olfactory nerve to subarachnoid space)

 B. Orbital
  1. Most common complication. Usually in children. Majority arise from
the ethmoids with some from the frontals. Staph. aureus is common if
abscess formation.
  2. Periorbital Cellulitis- Swelling and erythema of periorbital
tissues, EOMI, visual acuity unchanged. Rx: IV Abx.
  3. Orbital Cellulitis- Proptosis, chemosis, minimal decrease in
acuity, extraocular mobility may be limited. Rx: IV Abx.
  4. Subperiosteal Abscess- Proptosis, limited extraocular mobility,
impaired visual acuity. Rx: IV Abx, emergent drainage.
  5. Orbital Abscess- Proptosis, chemosis, complete opthalmoplegia,
rapid visual loss. Rx: IV Abx, emergent drainage.

 C. Bone
  1. Osteitis- Sclerosis of bone. Rx: IV Abx, drain sinus, remove
sequestrum.
  2. Osteomyelitis- Infection of bone, including marrow, especially with
the frontal sinus (Pott's puffy tumor), can involve the entire
calvarium. Rx: IV Abx x 6 weeks (for Staph. aureus, beta-hemolytic
strep, pneumococcus, anaerobic strep), removal of sequestrum if no/slow
improvement, hyperbaric oxygen, repair of surgical defect no earlier
than one year later.

 D. Mucocele
  1. Usually frontal sinus.
  2. Etiology- Obstruction of a duct secondary to inflammation, external
trauma, growth near the ostia, or expansion of an ethmoid cell.
  3. S/S- Dull pain or pressure over the sinus in 50%, proptosis,
diplopia, palpable expansion of the floor of the frontal sinus.
  4. Dx- X-ray: thinning of bone, sclerosis.
  5. Rx- Removal

 E. Intracranial
  1. Meningitis- Most commonly from the ethmoids and sphenoid. Commonly
beta-hemolytic strep and pneumococcus; H. influenza in children; also
anaerobes. Dx: S/S, CT scan (R/O space-occupying lesion), LP-
leulocytosis, elevated protein, decreased glucose. Rx: IV Abx, drainage
of causative sinus.
  2. Cavernous Sinus Thrombosis- From orbital complications and/or
ethmoid/sphenoid/frontal sinus disease. Commonly Staph. aureus. S/S:
spiking picket-fence fevers, exopthalmos, chemosis, papilledema,
anesthesia of trigeminal nerve, headache, photophobia, opthalmoplegia,
visual loss. Dx: S/S, CT. Rx: IV Abx, anticoagulants (controversial).
  3. Epidural Abscess- Usually secondary to frontal sinusitis. Often
associated with osteomyelitis of the posterior table. S/S: spiking
fevers, headaches, personality changes. Dx: S/S, CT scan. Rx: IV Abx,
craniotomy.
  4. Subdural Abscess- Most dangerous intracranial complication.
Commonly from the frontal sinus. S/S: fulminant course, sepsis,
headache, reduced consciousness, possibly severe neurologic
involvement (hemiparesis, hemiplegia, seizures). Dx: S/S, CT, LP.
Usually Staphylococcus. Rx: IV Abx, emergent craniotomy and sinus
obliteration.
  5. Brain Abscess- Usually secondary to frontal sinusitis. Commonly
Staph., Strep., also gram-negative rods, and anaerobes. S/S: vary from
mild headaches and subtle personality changes to partial paralysis and
complete obtundation. Dx: CT, (LP dangerous). Rx: IV Abx, mannitol,
steroids, surgery- combined, anterior osteoplastic flap or radical
sinusectomy.
  6. Note: Most authors recommend IV cefuroxime plus metronidazole; or
penicillinase-resistant PCN plus chloramphenicol or metronidazole.
Follow-CT is recommended for intracranial and orbital abscesses. In
contrast to previous reports, a recent study by Maniglia et al found
anaerobes to be the most common cause of intracranial abscesses.

------------------------------------------------------------------------------
                           BIBLIOGRAPHY

Blitzer, A. et al. Surgery of the Paranasal Sinuses, 1985, pg. 123, 130,
141, 148-150, 184-186, 199, 330, 332, 336.

Daley, C.L. and Sande, M. The Runny Nose, Infection of the Paranasal
Sinuses, Infectious Disease Clinics of North America, Vol. 2, #1, March
1988, pg. 131-145.

Friday, G.A. and Fireman, P. Sinusitis and Asthma, Clinics in Chest
Medicine, Vol. 9, #4, December 1988, pg. 449-452.

Friedman, W.H. and Katsantonis, G.P. The Role of Standard Technique in
Modern Sinus Surgery, Otolaryngology Clinics of North America, Vol. 22,
#4, August 1989, pg. 759-775.

Friedman, W.H. and Rosenblum, B.N. Paranasal Sinus Etiology of Headaches
and Facial Pain, Otolaryngology Clinics of North America, Vol. 22, #6,
December 1989, pg. 1217-1228.

Goodwin, W.J., Orbital Complications of Ethmoiditis, Otolaryngology
Clinics of North America, Vol. 18, #1, February 1985, pg. 139-147.

Lusk, R.P. et al, The Diagnosis and Treatment of Recurrent and Chronic
Sinusitis in Children, Pediatric Clinics of North America, Vol. 36, #6,
December 1989, pg. 1411-1419.

Malow, J.B. and Creticos, C.M., Nonsurgical Treatment of Sinusitis,
Otolaryngology Clinics of North America, Vol. 22, #4, August 1989, pg.
809-817.

Maniglia, A.J. et al, Intracranial Abscesses Secondary to Nasal, Sinus,
and Orbital Infections in Adults and Children, Archives of
Otolaryngology-Head and Neck Surgery, Vol. 115, December 1989, pg.
1424-1429.

Parker, G.S. et al, Intracranial Complications of Sinusitis, Southern
Medical Journal, Vol. 82, #5, pg. 563-568.

Parnes, L.S. et al, Mycotic Sinusitis: A Management Protocol, Journal of
Otolaryngology, Vol. 18, #4, 1989, pg. 176-179.

Ramsey, P.G. and Weymuller, E.A., Complications of Bacterial Infection
of the Ears, Paranasal Sinuses, and Oropharynx in Adults, Emergency
Medicine Clinics of North America, Vol. 3, #1, February 1985, pg.
143-154.

Wald, E.R., Diagnosis and Management of Acute Sinusitis, Pediatric
Annals, 17:10, October 1988, pg. 625-638.

Wald, E.R., Management of Sinusitis in Infants and Children, Pediatric
Infectious Disease Journal, Vol. 7, #6, June 1988, pg. 449-452.
--------------------------------END-------------------------------------------