OtoRhinoLaryngology Portal

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Sinus Disease

Acute Rhinosinusitis with Discharging Mucopus

    

Acute rhinusitis presents with fever, facial pain and headache usually following viral infection.  Nasal examination reveals congested turbinates, oedematous mucosa, and discharging mucopus around middle turbinate or in postnasal space.

 

Watch video of draining mucopus from middle meatus @ YouTube

 Watch video of draining mucopus from sphenoethmoid recess @ YouTube

Watch video of endoscopic-assisted antral washout @ YouTube

 

 

Coakley antrum trocar commonly used to perform antral puncture and the subsequent washouts.  

Sphenoid Sinusitis: Mucopus Drainage

Isolated left-sided sphenoid sinusitis presenting as severe central and occipital headache in a 16 weeks pregnant patient.  Endoscopy revealed thick mucopus draining along left sphenoethmoid recess (dotted line) resulting in postnasal drip.  [A - remnant of adenoids, V - vomerine part of nasal septum, IT - tail of inferior turbinate].

Similar mucopurulent postnasal drip in another patient as seen from right nasal cavity.  (IT - tail of inferior turbinate, V - vomer)

 

Copious mucopus postnasal drip.  (arrow - Eustachian tube opening) 

 Copious mucopus postnasal drip.  (arrow - Eustachian tube opening}
 Copious mucopus postnasal drip.  (arrow - Eustachian tube opening}

Postnasal Drip

 

Turbid tenacious mucous.

Frank mucopus postnasal drip in bilateral pansinusitis

as seen by using transoral nasopharyngoscopy technique.

 

Watch video of tracking mucopus trail towards its source @ YouTube

Postnasal Reactive Lymphoid Hyperplasia in Prolonged Postnasal Drip

Chronic Sinusitis

                   Figure A                                                       Figure B

                       Figure C                                                 Figure D

 

These figures represent a chronic unilateral sinusitis involving primarily the maxillary sinus.  Fungal sinusitis need to be ruled out with necessary investigations.

 

Figure A - coronal cut slice of paranasal sinuses CT-scan showing right maxillary sinus involvement.

Figure B - right middle meatus appearance showing osteomeatal complex narrowing and lateral wall mucosal oedema   Brownish materials covered by mucopus seen (arrow).

Figure C - exposed slate-brown materials filling the maxillary sinus prior to removal (arrows).

Figure D - antral mucosa hypertrophy before biopsy taken and remaining diseased mucosa removed.

 

Watch video of recalcitrant chronic rhinosinusitis @ YouTube

Watch video of endoscopic sinus surgery to cure cacosmia @ YouTube

Allergic Fungal Sinusitis

Opthalmic Complications of Sinusitis

Figures show an example of sinusitis complication. Conjunctival chemosis, corneal haziness, proptosis, limited eye movements, and impaired visual acuity can occur.  Endoscopic examination showed presence of mucopus over the left middle meatus region. 

CT-scan in axial view showing periorbital abscess formation (arrow) complicating left-sided acute ethmoiditis. E - eyeball. 

 

Pus drained (P) after lamina papyracea and mediao orbital periosteum opened.  EB - ethmoid bulla, MT middle turbinate (medialized).

 

Chandler classification [orbital complication of sinusitis] includes:

 

Group I - Inflammatory edema (preseptal cellulitis); normal visual acuity and extraocular movement.

 

Group II - Orbital cellulitis with diffuse orbital edema; no discrete abscess.

Group III - Subperiosteal abscess of the lamina papyracea with downward and lateral globe displacement.

Group IV - Orbital abscess with chemosis, ophthalmoplegia, and decreased visual acuity.

Group V - Cavernous sinus thrombosis with progressive bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity, along with possible meningeal signs and high fever.

Pulmonary Complications of Sinusitis

                   Chronic Sinusitis                                     Bronchiectasis.

Maxillary Antrum Views:Intraoperative

Left antrum seen via meatotomy. 

    

                     Pre-suction                                        Post-suction

M- Mucopus, arrow- infraorbital nerve

 

Trans-ostial view of right maxillary antrum by using 30 degree rigid endoscope facing laterally in a patient who had nasal polyps.  Punctate submucosal patechial haemorrhagic spots noted without other mucosal changes.  The sinus ostium

was naturally enlarged and meatotomy was unnecessary. 

[Stars- posterior edge of maxillary sinus ostium,

arrow- infraorbital nerve traversing maxillary bone]

 

Watch video of infraorbital nerve course in the maxillary sinus @ YouTube

Inferior Meatal Antrostomy

This figure shows a wide inferior meatal antrostomy opening.  It was previously a popular surgical management of chronic maxillary sinusitis.  However, the normal ciliary direction is towards the natural sinus ostium which is sited higher.

 

Dotted circle- antrostomy opening, IT- inferior turbinate,

MT- middle turbinate, S- nasal septum, N- nasopharynx.

 

 

Video clip of left inferior meatus antrostomy.

 

Endoscopic findings of right inferior meatal antrostomy and turbinectomy

which was performed for chronic sinusitis with nasal polyposis. 

[Stars- antral polyps, arrow- nasolacrimal duct openng, S- nasal septum, MT- middle turbinate, N- nasopharynx]

 

Watch video of inferior meatal antrostomy with antral polyps @ YouTube

Frontal Sinus

Left figure shows transillumination of frontal sinus

with the endoscope light intoduced into the nasal cavity leading to its ostium. 

Right figure shows the frontal sinus view intraoperatively

with stars indicate midline.

 

Watch video of frontal sinus endoscopy and transillumination @ YouTube

Concha Bullosa Surgery

Figures depict surgery of left concha bullosa.  Its lateral-half was excised which showed hyperplastic mucosa (+) as it was involved by chronic infection.  Uncinectomy, middle meatotomy, and ethmoidectomy was performed as well as part of the conventional functional endoscopic sinus surgery.  [S - nasal septum, MT - middle turbinate, E - uncapped ethmoid sinus air cells, arrow - middle meatotomy]

Middle Meatus Appearance after Functional Endoscopic Sinus Surgery (FESS)

This image shows the appearance of the left middle meatus in a patient

who had functional endoscopic sinus surgery performed. 

The ethmoids air cells were uncapped and the mucosa had healed. 

Frontal recess heading towards the sinus ostium can be seen superiorly.

 

Watch video of nasal cavity appearance after FESS @ YouTube

Middle Turbinate Adhesion Post-FESS

This image shows an adhesion in the right middle meatus involving middle turbinate and lateral nasal wall complicating sinusitis management.  It was left alone as there was no significant effect caused.

 Another example of mucosal synechiae (+).  

[S -nasal septum. MT - middle turbinate]

A similar synechiae on left side.

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