SINUSITIS

Anatomy • Paranasal Sinuses

Sinuses

• The sinuses are hollow air-filled

sacs lined by mucous membrane.
The ethmoid and maxillary
sinuses are present at birth. The
frontal sinus develops during the
2nd year of life and the sphenoid
sinus develops during the 3rd year.
Sinuses – types

Four pairs of paranasal sinuses

– Frontal-above eyes in forehead bone

– Maxillary-in cheekbones, under eyes

– Ethmoid-between eyes and nose

– Sphenoid-in center of skull, behind

nose and eyes
• Sinuses have small orifices (ostia)
which open into recesses (meatus)
of the nasal cavities.
• Meatus are covered by turbinates
(conchae).
• Turbinates consist of bony shelves
• There are 3 turbinates and 3 meati in
each nasal cavity (superior, middle,
and inferior).
Sinusitis
• Inflammation of the mucosal lining
of paranasal sinuses
• An acute inflammatory process
involving one or more of the
paranasal sinuses.
• Occurs when the ostia from the
sinuses are narrowed or blocked
by inflammation or hypertrophy of
the mucosa
• Maxillary and ethmoid sinuses are
most frequently involved.
Causes
• Bacterial sinusitis – streptococcus
pneumoniae, hemophilus influenzae,
beta hemolytic streptococci,
klebsiella, pneumoniae

• Viral sinusitis – rhinovirus, influenza

virus, adenovirus

• Fungal sinusitis – aspergillus and

candida
Risk factors
• Allergies, nasal deformities, cystic
fibrosis, nasal polyps, and HIV
infection.
• Respiratory tract infection
• Cold weather
• Day care attendance
• Smoking in the home
Pathopysiology
• Usually follows rhinitis, which may be viral
or allergic.

• May also result from abrupt pressure

changes ( diving) or dental extractions or
infections.

• Inflammation and edema of mucous

membranes lining -the sinuses leads to
obstruction of the sinuses
• With inflammation, the mucosal lining
of the sinuses produce mucoid
drainage. Bacteria invade and pus
accumulates inside the sinus cavities.

• If the sinus orifices are blocked by

swollen mucosal lining, the pus cannot
enter the nose and builds up pressure
inside the sinus cavities.

• Signs and symptoms

Classification
• Acute Sinusitis – respiratory
symptoms last up to four weeks
• Subacute sinusitis – respiratory
symptoms last between 4 to 12
weeks
• Chronic sinusitis – respiratory
symptoms last more than 12
weeks .
Complications of Sinusitis

• Cellulitis or abscess
• Meningitis
• Brain abscess
• Wheezing in children with asthma
Signs and symptoms -Sinusitis
• Pressure, pain, or tenderness over sinuses
• Low-grade temperature, Malaise
• Persistent nasal discharge, often purulent
• Postnasal drip- upper airway cough syndrome
• Cough, worsens at night
• Mouthing breathing, snoring
• Sore throat, bad breath
• Headache
• Nasal congestion, nasal obstruction
• Acute sinusitis – hyperemic and edematous
mucosa, discolored purulent nasal drainage and
enlarged turbinates
Diagnostic Tests
• History collection
• Physical examination
• X ray
• Sinus CT, MRI
• Nasal endoscopy – to examine the
sinuses, obtain drainage for
culture and restore normal
drainage
• Rhinoscopy – fiberoptic
examination of the nose
Management
Antibiotics-treat for 10-14 days,
depending upon severity, with one
of the following:
• Amoxicillin:20-40mg/kg/d in 3
divided doses(>20kg, 250mg tid)
• Augmentin:25-45mg/kg/d in 2
divided doses(>20kg, 400mg bid)
• Biaxin (clarithromycin):15mg/kg/d in
2 divided doses

• Cefzil:15mg/kg/d in 2 divided doses

• Lorabid (loracarbef): 30mg/kg/d in 2

divided doses
• Codeine (antitussive) – for severe
pain and cough
• Rhinocort nasal spray – 2 sprays
in each nostril every 12 hours for
children over 6 years of age.
• Acetaminophen or ibuprofen to
relieve pain
• Decongestants – relieve nasal
congestion
• Antihistamines
Non-pharmacological treatment
• Humidifier to relieve the drying of mucous
membranes associated with mouth
breathing, steam inhalation
• Increase oral fluid intake 6 to 8 glass of
water
• Saline irrigation of the nostrils
• Moist heat over affected sinus
• Prolonged warm shower to promote
drainage
• Do not smoke or avoid exposure to smoke
• Saline solution can be prepared at
home
• 1/4 tsp of salt dissolved in 8 oz of
tap water . A pinch of baking soda
may be added
• 3 times daily
Surgical management
Functional endoscopic sinus surgery (FESS)
• Uses Fiberoptic endoscope
• Diseased tissue which is located by CT scan will be
dissected
• If surgery is doing with local anesthesia, patient is
only kept for 2-3 hours postoperatively and then
discharged
• This will promote sinus drainage and ventilation and
remove diseased tissue and also opens ostia
• This can be also used for the removal of polys,
foreign bodies
CALDWELL – LUC sinus operation
• Also known as radical antrum operation - It is a
radical operation to the maxillary sinus performed
through the oral vestibule
• Incision under the upper lip
• Surgeon removes part of anterior bony wall of the
maxillary sinus, producing a permanent window
• The diseased tissues are dissected and drained.
• Antrum or cavity may be packed to prevent bleeding
• Packing removed after 24 to 48 hours after surgery
• As the maxillary sinus heals, the exposed bone is
covered by mucosa
Ethmoidecotmy
• Removal of enthmoid air cells
• Diseased mucosa, nasal polyps or
mucocele are removed
• Mucocele – mucous cyst that
leads to repeated infection
• Ethmoidectomy is performed in 3
ways – transnasal, transantral and
external
Sphenoid sinus surgery
• Endoscopic technique
• External or transantral approach
• Removes ethmoid sinus and
opens the anterior wall of the
sphenoid sinus
• Diseased tissue is removed along
with mucus membrane lining the
sinus.
Frontal sinusectomy
• OSTEOPLASTIC FLAP OPERATION
• Complete removal of diseased
mucosa of the frontal sinus and for
obliteration of the sinus so that it is
no longer functional or continuous
with the inner nose.
• Obliteration is done with
subcutaneous fat obtained from the
left lower abdominal quadrant
Nursing management
Pre operative teaching
• NPO for 6-8 hours before surgery
• Explain that the patient will:
• receive a sedative , feel pressure not
pain during surgery
• Have a nasal pack for 24 to 48 hours
after surgery
• Have a mustache dressing after surgery
• Have black eyes and swelling around
nose and eyes for 1 to 2 weeks
• Feel pressure, not pain during surgery
Post operative teaching
Precautions for the first week
• After general anesthesia, position the
patinet in side line.
• Do not blow nose atleast 3 to 5 days after
surgery
• After caldwell luc operation do not blow
nose for 2 weeks
• Tell the patinent to expectorate secretion
instead of swallow
• Try not to sneeze, Do not bent over
• Avoid constipation, Maintain Oral hygiene
• Encourage mid fowlers position
when fully awake to promote
drainage and decrease edema
• Apply ice compresses over nose
• Encourage liberal fluid intake
Managing pain – acetaminophen
Taking care of drainage – bright red
bleeding is expected for a week
• Change the pad several time each day
depending on the amount of drainage
• After initial bloody drainage stops, a
thicker, yellowish green drainage may
continue for several weeks
Breathing difficulties
• Keep the head elevated
• Sleep with an extra pillow- more
comfort, decrease edema and
allow better drainage
• Cool mist humidifier usage
Rest and activity
• Avoid strenuous activities
• After a week swimming, jogging are
permitted
• If bleeding occurs, stop activity
• Avoid heavy lifting
Self monitoring
• Report signs of infections
• Expect ecchymosis for 1 – 2 weeks
• Expect tarry stools from swallowed blood
for a few days
• Avoid aspirin which can cause bleeding