RHINOSINUSITIS AND COMPLICATIONS—-DANIEL TODD, MD
RHINOSINUSITIS—REALLY CANNOT HAVE SINUSITIS WITHOUT RHINITIS
Dx BASED ON 5 MAJOR Sx: FACIAL PAIN OR PRESSURE, NAO (CONGESTION), ANT OR  PND, HYPOSMIA, COUGH NOT DUE TO ASTHMA IN CHILDREN
7 MINOR Sx: FEVER(58%), HEADACHE(42%), FATIGUE, DENTAL PAIN, HALITOSIS, COUGH IN ADULTS, ETD
PARSON’S-SEVEN CARDINAL FINDINGS: CHRONIC NAO, PURELENT NASAL D/C, PND, HORIZONTAL COUGH, HALITOSIS, HA’S (MIDFACE CEPHALALGIA EXASERBATED BY BENDING OVER), BEHAVOIRAL CHANGES
TEMPORAL NOMENCLATURE:
0-4 WKS = ACUTE
4-12 WKS = SUBACUTE
>12 WKS = CHRONIC
> 4 EPISODES/YEAR = RECURRENT
Dx CAN BE MADE OBJECTIVELY BY PURULENCE IN THE NOSE OR BY PERSISTENT SYMPTOMS—-2 OR MORE MAJOR OR 2 OR MORE MINOR WITH 1 MAJOR LASTING LONGER THAN 4 WEEKS
PE: ANT RHINOSCOPY, DNE +/- MMA CULTURES(85% ACCURATE), NASAL CYTOLOGY (EOSINOPHILS VS PMNS), I-CAP FOR PTS WITH ALLERGY HX, CT SCAN—DO NOT OPERATE WITH A SCREENING CT SCAN ONLY—SOME SAY YOU NEED BOTH CORONALS AND AXIALS—-MIGHT WANT TO CONTRAST TO SEE THE CAVERNOUS SINUS IN COMPLICATED CASES
-PURULENCE=GREEN=VERDOPEROXIDASE PRODUCED BY DEAD PMN’S
Rx: P.O HYDRATION, HUMIDIFIED AIR, HTSI, MUCOLYTICS (SSKI OR GUAIFENESIN—-2,400MG Q DAY), P.O. DECONGESTANTS (PSUEDOPHED), 4 DAYS OF AFRIN TID, NASAL STEROID—-CONSEDER SYSTEMIC STEROID BURST WITH TAPER, POSSIBLE NONSEDATING ANTIHISTAMINE IF ALLERGIC ETIOLOGY
AMOXACILLIN IS NO LONGER THE RECOMMENDED 1ST LINE TREATMENT—-TMP/SMX, AUGMENTIN, LORCARBEF, FLOROQUINOLONES, NEW MACROLIDES
POST FESS RHINOSINUSITIS—-HIGH PSEUDOMONAS AND LOW INCIDENCE OF ANAEROBES—USE CIPRO OR LEVOQUIN—(ONLY PO ABX AGAINST PSEUDOMONAS)
ABX—2 WEEKS MINIMUM FOR ACUTE, 4 WEEKS FOR CHRONIC, 6 WEEKS FOR KIDS
STREP PNEUMO AND H. INF ARE ENCAPSULATED—-NEED A T-CELL LYMPHOCYTE RESPONCE
CHRONIC SINUSITIS—-STAPH > ANAEROBES
ACUTE RHINOSINUSITIS—STREP PNEUMO>H.INF>MCAT
CAVEATES:
5 MAJOR ETIOLOGIES—-ALLERGY, RECURRENT VIRAL ILLNESS, TOBACCO, ADENOID HYPERTROPHY, ?GERD
KEFLEX IS A POOR CHOICE WITH POOR COVERAGE OF H INF AND MCAT
CONCHA BULLOSA CORRELATES 30% WITH CHRONIC RHINOSINUSITIS
HALLER CELLS AND PARADOXICAL TURBS DO NOT CORRELATE WITH SINUSITIS
PROBABLY SHOULD NOT DISCHARGE AN OPAQUE PARANASAL SINUS WITHOUT DOCUMENTING ITS RESOLUTION
LUND-MACKAY CT GRADING SYSTEM—-0-2—-0=CLEAR AND 2 =TOTALLY OPACIFIED
GRADE EACH SINUS AND THE OMC
OLFACTORY ASSESMENT
ANOSMIA—ABSENCE OF OLFACTION—- ACUTELY IS USUALLY DUE TO OBST AND CONGESTION DUE TO INFXN
CHRONIC CAUSE IS POST VIRAL SEQUELAE
ONLY 35% OF PTS WITH CHRONIC OBST ANOSMIA WILL C/O NAO
ONLY 45%OF PTS WITH CHRONIC OBST ANOSMIA WILL REPORT FLUCTUATION OF Sx
-3% DISABILITY
SAFETY ISSUES—RANCID FOOD, SMOKE, CHAMICALS, TOXINS
TASTE (90%)—MOST PTS WILL COMPLAIN OF HYPOGEUSIA—MUST QUESTION THEM SPECIFICALLY ABOUT 4 PRIMARY TASTES (SWEET, SOUR, BITTER AND SALTY)
THERE IS A DOMINANT SIDE LIKE HANDEDNESS
POST TRAUMIC ACUTE ANOSMIA—ACOUNTS FOR ONLY ABOUT 10% OF ALL ANOSMIA—-USUALLY CRIBRIFORM SHEAR—ONLY 33% RECOVERY AT BEST
ENDOSCOPY
AST (ALCOHOL SNIFF TEST) AND UPSIT STANDARDIZED TESTS OF OLFACTION
DO OPTHO EXAM AND DNE
IF OBST POLYPS/DISEASED MUCOSA—TRY A SYSTEMIC STEROID BURST WITH TOPICAL STEROIDS
IF ACUTE AND NO OBST SEEN TRY –NASAL STEROIDS X 4-8 WEEKS
IF NORETURN TO FUNCTION—-THIN CUT CT SCAN / CORONAL
PAROSMIA = PHANTOSMIA = CHANGES
DYSOSMIA = UNPLEASANT CHANGES—–CONSIDER TEMPORAL LOBE NEOPLASM
CACOSMIA (KAKOSMIA) = FECAL SMELL WHEN NONE IS PRESENT
Rx:
MEDICAL
DECONGESTANTS—TOPICAL
IRRIGATIONS—PROETZ
MOST EFFECTIVE IN THE “MECCA” POSITION
PIMA=KI 5 GRS/5ML—GIVE 5-10ML TO ADULT—TITRATE TO RHINORRHEA
SSKI DROPS FOR INFANTS AND CHILDREN
ADD CODEINE (OFTEN ROBITUSSIN C) TO ALLEVIATE COUGH
P.O.—GUAIFENESIN—NEED HIGH DOSES TO ACHEIVE THERAPEUTIC LEVELS—OFTEN CAUSE N/V
ANTIHISTAMINES MAY EXASERBATE RHINOSINUSITIS VIA DESSICATION
TOPICAL NASAL STEROIDS CAN DO WONDERS—–AIM AWAY FROM THE SEPTUM TO AVOID EPISTAXIS
NO EVIDENCE THAT NASAL STEROIDS CAUSE OR EXASERBATE GLAUCOMA
TOPICAL ANTIHISTAMINES MAY BE HELPFUL
CHLORPHENIRAMINE MALEATE—4MG
ABX— PROBABLY NEED TO TREAT FOR 3-4 WEEKS!
RHINOGENIC HEAD ACHE—-IF IT AINT BAROMETRIC I DONT UNDERSTAND IT
WHEN YOU OPERATE FOR PAIN—-YOU GET PAIN (TEN TIMES WORSE)
ORBITAL COMPLICATIONS—(CHANDLER STAGING)——MOST COMMON
USUALLY BETA HEMOLYTIC STREP > H inf (PREVELENT IN PEDS) > PNEUMOCOCCUS > DIPLOCOCCUS
STAGE I—-PRESEPTAL (PERIORBITAL) CELLULITIS—ANT TO THE SEPTUM—-NO FLUCTUANCE—–USUALLY ONLY ONE EYE (92%)—BOTH MAY BE INVOLVED—NO PROBLEMS WITH VISUAL ACUITY OR EOM’S
STAGE II—-SUBPERIOSTEAL ABSCESS—-PRESEPTAL CELLULITYS PRESENT AS WELL AS AN ABSCESS—USUALLY FROM THE ETHMOIDS DISPLACING THE PERIORBITA—-CHEMOSIS, ASYMETRIC PROPTOSIS, EOM RESTRICTION, AND POSSIBLY DECREASED VISION
STAGE III—-ORBITAL CELLULITIS—–INFLAMMATION WITHIN THE RETROBULBAR CONTENTS OF THE ORBIT–BUT COMPLETELY ENCLOSED BY THE PERIORBITA—SPIKING FEVERS, MARKED PRESEPTAL CELLULITIS, CHEMOSIS, PROPTOSIS(AXIAL), OPHTHALMPLEGIA, AND DECREASED VISION
STAGE IV—-ORBITAL ABSCESS—–WITHIN THE CONE OF THE PERIORBITA—INCLUDES RETROBULBAR ABSCESS—SEVERE PROPTOSIS AND VISUAL LOSS
STAGE V—-CAVERNOUS SINUS THROMBOSIS—-(COAG + S. a IS MOST COMMON)-WITH ORBITAL CELLULITIS—OFTEN BILATERAL OR WILL BECOME BILATERAL—-CN 3, 4, AND 6 PALSEYS—EPISCLERAL VENOUS DILATION AND PROPENSITY FOR EPISTAXIS AS HIGH VENOUS PRESSURES EXIST—MENINGITIS OR BLINDNESS MAY OCCUR
COMPLICATIONS OF ANY OF THESE ENTITIES—OPHTHALMOPLEGIA—ORBITAL APEX SYNDROME—HIGH IOPS—CENTRAL RETINAL ARTERY OR VEIN OCCLUSION—OPTIC NEURITIS—ENDOPHTHALMITIS—MENINGITIS OR EVEN DEATH
CROSS OF DEATH IS WHEN THE TEMP FALLS AND THE PULSE QUICKENS—OMINOUS
Dx–CLINICALLY DOCUMENT VISUAL ACUITY AND IOPS AND EOMI
GET THIN CUT CT SCAN (CONTRASTED) OF THE SINUSES
Rx:CONSULT OPTHO— I&D (PREFERRABLY ENDOSCOPICALLY)—FOR A PERIORBITAL ABSCESS MOST PRACTIONERS WILL DO AN EXT ETHMOIDECTOMY VIA LYNCH—FOR AN ABSCESS WITHIN THE PERIORBITA GET OPHTHO INVOLVED
MOISTURE CHAMBER, LACRILUBE, SEDATIVES, ANALGESICS, TOPICAL ABX EYE DROPS, AFRIN, SYSTEMIC DECONGESTANTS, IV AVX (UNASYN AND CLEOCIN), WARM COMPRESSES
LOCAL COMPLICATIONS
MUCOSAL—MUCOCELES,  (MUCO)PYOCELES—–OFTEN PUSH, REMODEL AND EVENTUALLY THIN THE BONE
BONEY—-OSTEITIS—–OSTEOMYELITITS (PRIMARILY S.a)
FRONTAL SINUS (ANT TABLE)—-POTT’S PUFFY TUMOR—X-RAY FINDINGS LAG 7-10 DAYS
YOUNG ADULTS (OFTEN TRAUMA INDUCED)—FEMALE>MALE—-SOFT DOUGHY OVERLYING SKIN—SINOCUTANEOUS FISTULA MAY DEVELOPE
POST TABLE (CRYPTS OF BRESCHET) PREDISPOSE TO INTRACRANIAL COMPLICATIONS
MAXILARY SINUS—-ANT WALL—SWELLING OF THE CHEEK WITH LOCAL ERYTHEMA
BOTH MAXILLARY AND FRONTAL MAY DEVELOPE AND ADJACENT PNEUMOCELE (AIR IN THE FACE DUE TO POS PRESSURE)—-PNEUMOSINUS DILITANS (EXPANSIVE PNEUMOCELE OF THE SINUS—-ASSOC WITH ACROMEGALLY, LOCALIZED OSTEITIS, OR REGIONAL FRACTURES
FLOOR—-ORO-ANTRAL FISTULA—COMMON—MAY BE DIFFICULT TO SEE DIRECTLY
POST WALL—MAY INVOLVE THE PTERYGOID PROCESSES—-RESULANT TRISMUS
ASPERGILLUS FUMIGATUS (ASPERGILLOSIS)
O.E. OTOMYCOSIS = EXTERNA MYCOTICA (ASPERGILLUS ALBICANS AND NIGER)
H&N CAN BE ALLERGIC, NON-INVASIVE,  INVASIVE, OR MYCETOMA (FUNGAL BALL)=MYCETOMA, ASPERGILLOMA
ALLERGIC FUNGAL SINUSITIS = A TYPE I HYPERSENSITIVITY RXN—-ALSO POSIBLE TYPE III
RHINOCEREBRAL PHYCOMYCOSIS = SAPROPHYTIC FACIAL FUNGAL INFXN
LIFE THREATENING—PRIMARILY IMMUNOCOMPROMISED HOST OR DKA
RHIZOPUS, ABSIDIA, RHINOSPORIDIOSIS, MUCORMYCOSIS
RHINOSPORIDIUM SEEBERI (RHINOSPORIDIOSIS)
A PHYCOMECETES M/O
SRI LANKA AND SOUTHERN INDIA
NAO, EPISTAXIS, SNEEZING, RHINORRHEA
“STRAWBERRY”, INDOLENT, PAINLESS, WARTY, FRIABLE, POLYPOID, MUCOSAL MASS—FAIRLY VASCULAR
Rx = EXCISION AND AMPHO B
MUCORMYCOSIS
IMMUNOCOMPROMISED HOST(AIDS), NEUTROPENIA,  AND OR DKA(ACIDOSIS AND HYPOGLYCEMIA), DEFEROXIMINE
LOW GRADE FEVER, DULL SEVERE SINUS PAIN, EPISTAXIS, FACIAL HYPESTHESIA——DIPLOPIA, OBTUNDATION, FEVER, BLACK TURBINATES, PROPTOSIS, FACIAL SWELLING, BLINDNESS—-COMA—-DEATH
PAY SPECIAL ATTENTION TO THE MIDDLE TURBINATE!
Rx = EARLY DIAGNOSIS—SUSPICION, BIOPSY—BRANCHING(90 DEGREES) AT RIGHT ANGLES, THICK WALLED NON-SEPTATE HYPHAE “M”—DEBRIDE–RADICAL MAXILLECTOMY, ORBITAL EXENTERATION, AMPHO B LIPOSOMAL —IRRIGATIONS, SYSTEMIC AMPHO B AND HBO!
STAIN + WITH HMB-45 (MELANIN STAIN)
CONSIDER GRANULOCYTE STIM FACTOR—THEIR RESPONSE PARALLELS THEIR SURVIVAL
INTRACRANIAL COMPLICATIONS
MENINGITIS = THE MOST COMMON INTRACRANIAL COMPLICATION?
SPHENOID >>> ETHMOID > FRONTAL > MAXILLARY
EPIDURAL ABSCESS > SUBDURAL ABSCESS —-PRIMARILY FROM A THROMBOPHLEBITIS ESTENDING THROUGH THE CRYPTS OF BRESCHET IN THE POST TABLE OF THE FRONTAL SINUS (FRONTAL IS MOST COMMON SINUS FOR BOTH)
BRAIN ABSCESS (MOST COMMON IS A FRONTAL LOBE ABSCESS FROM THE FRONTAL SINUS)—–40% MORTALITY—-OF THOSE WHO LIVE 40% PERMANENT DISABILITY—THE MOST COMMON INTRACRANIAL COMPLICATION
ATROPHIC RHINITIS/OZENA (PUTREFACTION/PUTINASKA)
KLEBSIELLA OZENA
PRIMARY (IDIOPATHIC)
SECONDARY (TRAUMA/SURGERY/VIDIAN NEURECTOMY)
ENDEMIC IN SUBTROPICAL CLIMATES
+FH
BLACKS/ASIANS/LATINOS>OTHERS
POOR HYGEINE
MALES>FEMALES
ABNL AIRFLOW—-CILIOSTASIS–MUCOSAL CHANGES—-CRUSTING—SUPERINFXN
TURB ATROPHY
SUPERINFXN WITH KLEBSIELLA OZENA
OZENA = FOUL ODOR = A STENCH
EPISTAXIS, CRUSTS, INSP PAIN, NAO, HA, EPISTAXIS, ANOSMIA, HALITOSIS, FETOR ORIS, OFFENSIVE ODOR
Rx: CLEANING, ESTROGEN, VITAMIN A!—SEEMS TO BE IMPORTANT, ABX, VACCINE, PILOCARPINE, ACETOCHOLINE
SURGERY—IMPLANTS, CAVITY NARROWING, DENERVATION(SYMPATHECTOMY)
TSS = TOXIC SHOCK SYNDROME
A SYNDROME FIRST DESCRIBED BY TODD IN 1978—RELATED TO TAMPONS
A PHAGE GROUP I STAPH AUREUS EXOTOXIN (TSST 1)
CAN ALSO BE RELATED TO INTRANASAL PACKING OR EVEN STENTS
35% OF PTS CARRY STAPH AUREUS IN THE NOSE (7% CARRY TSST 1 PRODUCING STAPH)
Dx: TEMP OF 39 OR HIGHER, HYPOTN, N/V/D, OLIGURIA, MYALGIAS, DIC, AND MUCOUS MEMBRANE INFLAMATION AND ERYTHEMA—-PHARYNGITIS ECT…
CLASSICALLY A SCARLITINIFORM RASH (DIFFUSE OR PALMAR ERYTHRODERMA) WITH DESQUAMATION OF THE PALMS OR SOLES 1-2 WEEKS LATER
Rx: PULL PACKS, IVF (COLLOID AND CRYSTALLOID)—ABX CAN PREVENT BUT NOT TREAT TSS