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Vincent’s S.C.A.N.S 
Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
Sinusitis  Rhinosinusitis - Acute & Chronic EDUCATION
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
Last update:  26/12/14 
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
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The two congested mucosal layers come into contact resulting in reduced mucociliary clearance, retention of secretions, and decreased sinus ventilation  Mucosal layers of the nose and sinus (in pink)  The two normal mucosal layers over the sinus opening (ostium) remain apart resulting in good sinus clearance (yellow curved line) and ventilation with no retention of secretions.  normal maxillary sinus   infectedmaxillary sinus  pus
To   read   from   Sinustis   Part   1   -   What   ?   How? Who ? Am I the one ?
How is sinusitis diagnosed ? How is sinusitis diagnosed ? A combination of : History -based on the information you have given and the relevant questions asked by the  doctor. Clinical examination - Nasal endoscopy- Viewing the sinuses through a fiberoptic scope (called nasal endoscopy or rhinoscopy-whether rigid or flexible scope) may help diagnose sinusitis. Allergy testing, whether by blood specific IgE or skin prick test can help to identify the underlying trigger factors (allergen) If you test positive for allergies, your doctor can advise on appropriate measures and/or prescribe medications to control them, thereby reducing the risk of developing a sinus infection. A CT scan of the sinuses Is currently considered the gold standard for imaging sinus disease. However, reliance on CT alone can be misleading, and CT data must be interpreted in light of clinical and endoscopic findings The primary role of CT is : to aid diagnosis of recurrent acute or chronic sinus disease to define the anatomy before anticipated surgery. It is not used in the routine evaluation of acute sinusitis. If sinusitis is thought to involve a tumor or fungal infection, an MRI of the sinuses may be necessary. Regular x-rays of the sinuses are not very accurate for diagnosing sinusitis (though still performed by some practitioners). Haziness in the sinus field may indicate underlying sinus infection What is the treatment? Treatment for acute and chronic rhinosinusitis differs. In acute rhinosinusitis, treatment attempts to facilitate drainage of the sinus and nasal passages and relieve sneezing, coughing, and systemic symptoms. Medication can include: 1.  Antibiotics The mainstay of treatment for presumed bacterial sinusitis is antimicrobial therapy, combined with adjunctive symptomatic therapy Indications also include: Children with nasal discharge, possibly with a cough, that is not getting better after 2 - 3 weeks Fever higher than 102.2° Fahrenheit (39° Celsius) Headache or pain in the face Severe swelling around the eyes Acute bacterial sinusitis should be treated with appropriate antibiotics for 10 - 14 days Early treatment reduces the risk of developing complications. 2. Decongestants i.e vasoconstrictors that reduce the thickness of the nasal mucosa. Oral decongestants : o offer the theoretical advantage over topical decongestants of reducing congestion in deeper tissues. Nasal spray decongestants: o may provide immediate symptomatic relief. o prolonged and too-frequent use of topical agents may cause rhinitis medicamentosa i.e rebound vasodilation, irritation, and reactive hyperemia. o They may help at first, but using them for more than about 1 week can actually worsen nasal congestion. 3. Painkillers for sinus pain or pressure eg. paracetamol, Non-steroidal anti-inflammatory drugs(NSAIDS) (eg.voltaren, naproxen, ibuprofen) 4. Topical or systemic steroids have been reported to reduce local sinus osteal inflammation, 5. Mucus thinners, eg guaifenesin, acetylcystein, bromhexine-theoretical grounds to thin secretions and aid drainage, but efficacy inconsistent. 6. Saline lavage/douching of the nasal cavities with normal saline several times per day. You can see here for more info. 7. Steam inhalation - Inhale steam 2 - 4 times per day (for example, sitting in the bathroom with the shower running). Menthol can be added to the steam inhalation. Antihistamines generally not recommended for acute sinusitis - concerns of drying of mucous membranes and impeding clearance of secretions. The exception is sinusitis in allergic patients during the allergy season. Other measures include: Drinking plenty of water also help to thin the mucus and clear secretions. Use a humidifier. Avoid flying when you are congested. Avoid temperature extremes, sudden changes in temperature, and bending forward with your head down. Apply a warm, moist washcloth to your face several times a day. For those with underlying allergy disorder, further treatment include: Nasal corticosteroid sprays and antihistamines to decrease swelling, especially if there are nasal polyps or allergies Avoiding allergy triggers -can be identified from blood specific IgE testing or skin prick test Immunotherapy to help prevent the disease from returning However, in Chronic Rhinosinusitis, chronic sinusitis symptoms can be difficult to treat even with a long regimen of antibiotics and thte other adjunctive treatemnts mentioned above. When antibiotic treatment fails, allergy testing, desensitization, and/or surgery may be recommended as the most effective means for treating chronic sinusitis. Research studies suggest that the vast majority of people who undergo surgery have fewer symptoms and better quality of life. Surgery to clean and drain the sinuses -Functional Endoscopic Sinus Surgery (FESS)  remains the gold standard of treatment to overcome this problem of CRS, especially in patients whose symptoms fail to go away after 3 months, despite medical treatment, or in patients who have more than two or three episodes of acute sinusitis each year. Using endoscopic technologies, various precision surgical instruments are used to removed diseased tissue in the sinuses and ventilate the paranasal sinuses. Other coexistent conditions like a deviated nasal septum or nasal polyps usually require surgery. Most fungal sinus infections require surgery. Of late, new technologies have emerged as adjuncts/aids to surgeons (only in selective cases) : Image Guided Surgery -i.e Using the existing FESS instruments and incorporating 3D imaging system to precisely localise the area of disease (imagine the GPS system in the sinuses) so that more precise surgery can be performed and injury to important neighbouring structures can be reduced/avoided, although it may add to the cost of the surgical setup. Balloon Sinuplasty - i.e using medical-grade balloon to dilate narrowed sinus openings to ventilate the diseased paranasal sinus. In addition, while the advantage over FESS to maintain patency of the sinuses and its long term effectiveness has not been conclusively established, it may result in reduced bleeding and less post-procedure discomfort. This procedure can be safely combined with FESS whenever the condition dictates. Expectations (prognosis) Sinus infections are usually curable with self-care measures and medical treatment. If you are having recurrent attacks, you should be checked for underlying causes such as nasal polyps or other problems, such as allergies. Complications Close proximity of the paranasal sinuses to the eyes (orbit) and the brain makes spread of infection to  these organs and the neighbouring soft tissue or bony structures likely but fortunately rare. Children generally are more susceptible than adults. Neglected or suboptimal treatment of sinusitis predisposes one to these complications. Patients who have compromised immune defence mechanism are susceptible as well. Having said that, occasionally one can present with these complications at the first presentation as the underlying sinusitis symptoms were very subtle therefore may be ignored or missed by the patient or doctor. Although very rare, complications may include: Brain infection o Meningitis (infection of the lining of the brain) o Abscess in the brain o Cavernous sinus thrombosis (severe infection involving  the cavernous sinus in the brain) Eye or orbit infection o Skin infection around the eye (orbital cellulitis) o Abscess collection of varying severity involving the orbit Bone infection (osteomyelitis) of the frontal bone (the bone over the forehead) Mucocele formation (Mucoceles are chronic, cystic lesions of the sinuses) Calling your health care provider Please consult your doctor if: Your upper respiratory tract infection (URTI) symptoms last longer than 10 - 14 days Your cold/flu gets worse after 7 days You have a severe headache, unrelieved by over-the-counter pain medicine You have high fever You still have symptoms after taking all of your antibiotics properly You have any changes in your vision or surrounding eye region during a sinus infection A green or yellow discharge does not necessarily indicate a sinus infection or the need for antibiotics. Prevention The best way to prevent sinusitis is to avoid or quickly treat flus and colds: Take decongestants during an URTI Other tips for preventing sinusitis: Treat allergies quickly and appropriately. Avoid smoke and pollutants. Drink plenty of fluids to increase moisture in your body. Eat healthily i.e plenty of fruits and vegetables, which are rich in antioxidants and other chemicals that could boost your immune system and help your body resist infection. Get an influenza vaccine each year. Reduce stress. Wash your hands often to reduce transmission of germs.
How is sinusitis diagnosed ? What is the treatment? Expectations (prognosis) Complications Calling your health care provider Prevention
CT scans of the paranasal sinuses (of 3 different patients):  Remember that air spaces looks black on the CT and normal paranasal sinus is filled with air, therefore looking black on CT  Figure A: Coronal view -i.e seen directly from the front: Mucosal thickening in the right maxillary sinus suggestive of sinusitis (blue asterisk) as compared to the normal air-filled left maxillary sinus (red asterisk).  Figure B: Sagittal view -i.e seen directly from the side of the head: CT scan image showing significant soft tissue density (grey colour) in the right frontal sinus (blue asterisk) and sphenoid sinus (blue cross) suggestive of sinusitis.   Figure C: Axial view -i.e seen directly from leg up to the head: CT scan image showing significant soft tissue density (grey colour) in the left maxillary sinus suggestive of sinusitis (blue asterisk) as compared to the normal air-filled right maxillary sinus (red asterisk).  * © Vincent Tan ENT A B C * * * right  eye left  eye Brain Spinal cord Spinal cord Right Ear Nose Right cheek  bone Tongue Brain * + Pituitary gland A skin prick test (SPT) in progress © Vincent Tan ENT An example of current CT scan machine.  Different models used in different facilities. (source of image: Siemens press pictures -www.siemens.com) Left: A rigid nasal endoscope and the direction of entry into the nose Right: Endoscopy of the nose using a rigid endoscope in the clinic. NASAL CAVITY ORAL CAVITY BRAIN BRAIN © Vincent Tan ENT Flexible endoscopy of the upper airway. The black tube represent the scope (source of unlabelled diagram: Netter Atlas of Anatomy) NASAL CAVITY TONGUE POSTNASAL SPACE BRAIN SOFT  PALATE HARD  PALATE BASE OF TONGUE EPIGLOTTIS WINDPIPE/TRACHEA TONSIL CERVICAL SPINE VOCAL CORDS LOWER JAW/ MANDIBLE POSTERIOR PHARYNGEAL WALL © Vincent Tan ENT Flexible endoscopy of the upper airway in a real ENT clinic setting. Top: Rigid nasal endoscopes at different viewing angles Bottom: A flexible endoscope © Vincent Tan ENT Acute rhinosinusitis: an endoscopic view of the nose showing yellowish pus draining from one of the sinuses (left picture) and into the throat (right picture). © Vincent Tan ENT
Left Figure : Skull X-ray showing increased haziness over the left maxillary sinus region (red arrow) suggestive of sinusitis. Right Figure : CT scan done while patient is lying down showing air- fluid level over the left maxillary sinus region (red line) and mucosal thickening in the right maxillary sinus (red asterisk) suggestive of sinusitis.
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© Vincent Tan ENT
It is important to differentiate between Allergic Rhinitis, Common Cold/Flu and sinusitis/rhinosinusitis Colds/flu and allergies are the main risk factors for developing sinusitis Although most cases resolve completely, sinusitis can, rarely, have serious complications, especially in children Acute sinusitis - mainstay of treatment : medical or non- surgical methods Chronic rhinosinusitis - mainstay of treatment : Surgical methods Early treatment reduces the risk of developing complications  
Chronic Rhinosinusitis Acute Rhinosinusitis COMPLICATIONS OF SINUSITIS Orbital cellultis: redness over the left upper and lower eyelids of a child after a prolonged ‘common cold’. His condition improved with prolonged course of antibiotics.  Orbital abcess: notice the gross swelling over the left eye in an adult. He did not have obvious sinusitis symptoms prior to this. He regained normal vision after surgical treatment with a prolonged course of antibiotics. Mucocele notice the swelling over the right eye. On closer inspection, the eye is displaced downwards and outwards. His condition improved after surgical treatment with prolonged course of antibiotics. Brain abscess: notice the swelling in the brain on the CT scan.  © Vincent Tan ENT
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To   read   from   Sinustis   Part   1   -   What   ? How? Who ? Am I the one ?
(source of unlabelled diagram: Schering-Plough. Addtional artwork and caption added) Graphic representation of balloon sinuplasty at work  (image copyright of Acclarent)
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In MOST cases of uncomplicated acute rhinosinusitis, surgery is NOT necessary as medications can effectively bring about resolution.
(Click for for larger image...) Image Guided Surgery (IGS): Precisely localising the disease in question combining andoscopic and radiological imaging views
© Vincent Tan ENT
Sinus Surgery with IGS In progress
CT scan showing differences of blocked and patent/unblocked sinus drainage pathway (osteomeatal complex OMC).
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Significance of thin mucosal lining of the sinuses ?   Incidental thin visible mucosal lining within the sinuses can be normal findings This should not form a basis for the diagnosis of Sinusitis without any other evidence of sinus disease. Neither is it a good indication for sinus surgery.
Talks about SINUSITIS on 21/2/14 (for educational purposes)
ENT
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Cert.in Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
+603-3377 7864  +6012-3760 728
ENTdrvincenttan@gmail.com