Tag: Acute Sinusitis

Acute Sinusitis

Acute Sinusitis


ACUTE SINUSITIS.

  • Acute inflammation of the paranasal sinuses.

ETIOLOGY OF ACUTE SINUSITIS

  • Acute Rhinitis:causing spread of infection to the sinuses by way of their natural ostia from the nasal cavities
  • Pharyngeal infection
  • Dental infection
  • Trauma
  • Predisposing factors:
  • Obstruction:Anatomical,Infective,Allergy,Tumours

INFECTING ORGANISM CAUSING ACUTE SINUSITIS

  • Viral:Rhinovirus,parainfluenza virus,respiratory synctial virus.

Bacteria:

  • S. pneumoniae and nontypable Haemophilus influenzae are the most common pathogens, accounting for 50-60% of cases.
  • Moraxella catarrhalis causes disease in a signigicant percentage (20%) of children but less often in adults
  • Fungi-Aspergillosis
  • Tuberculosis,syphilis-rare.

CLINICAL FEATURES OF ACUTE SINUSITIS

  • The clinical symptoms of acute sinusitis have been classified into major and minor.

Major

  • Facial pain or pressure
  • Purulent nasal discharge
  • Fever
  • Nasal congestion
  • Nasal obstruction
  • Hyposmia or Anosmia
  • Facial congestion or fullness

Minor

  • Headache
  • Cough
  • Fatigue
  • Halitosis
  • Dental pain
  • Ear pain or pressure.

Characteristic findings of Acute Sinusitis

Sphenoid sinus:

  • Headache – usually localized to the occiput or vertex. Pain may also be referred to the mastoid region.
  • Isolated involvement of sphenoid sinus is rare. It is often a part of pansinusitis or is associated with infection of posterior ethmoidal sinus.
  • The reason for sphenoid sinus to be least affected is that it opens high up in the sphero ethmoid recess which is not affected by most of the conditions of nose

Maxillary sinus :

  • Along the infraorbital margin and referred to upper teeth or gums on affected side (along the distribution of superior orbital nerve).
  • Pain is aggravated on stooping or coughing.
  • Most common sinusitis in adults is Maxillary.
  • On rhinoscopy :pus or mucopus in in the middle meatus.
  • Tenderness is elicited at canine fossa.

Frontal sinus :

  • Pain localized over forehead.
  • It has a characteristic periodicity-Office headache
  • Tenderness elicited above the medial canthus.

Ethmoid sinus :

  • Pain localized over the nasal bridge, inner canthus and behind the ear.
  • Most common sinusitis in children is Ethmoid.  
INVESTIGATIONS IN A CASE OF ACUTE SINUSITIS
  • Radiology:May show Mucosal thickening,opacity of sinuses or Air-fluid level in case of Sinusitis.

Caldwell view is also known as occipitofrontal view or nose-forehead position. Structures seen are:

  • Frontal sinuses (seen best)
  • Ethmoid sinuses
  • Maxillary sinuses
  • Frontal process of zygoma and zygomatic process of frontal bone
  • Superior margin of orbit and lamina papyracea
  • Superior orbital fissure
  • Foramen rotundum (inferolateral to superior orbital fissure) 

Water’s view(occipitomental view or nose-chin position).Structures seen are:

  • Maxillary sinuses (seen best)
  • Frontal sinuses
  • Sphenoid sinus (if the film is taken with open mouth)
  • Zygoma
  • Zygomatic arch
  • Nasal bone
  • Frontal process of maxilla
  • Superior orbital fissure

Bacteriological:examination if the sinusitis does not respond to antibiotic treatment.

Diagnostic Antral Puncture

Nasal Sinus Endoscopy: Most definitive diagnosis of Sinusitis.

TREATMENT OF ACUTE SINUSITIS

  • It is generally medical treatment
  • Antibiotics,Local Decongestants,Analgesic with Anti-inflammatory,Antihistaminic,Steam inhalation.

Surgical :

  • Antral puncture
  • FESS.
  • Trephination of frontal sinus: indicated for frontal sinustis because of persistence or exacerbation of pain or pyrexia in spite of medical treatment for 48 hours.

CLINICAL CONDITIONS ASSOCIATED WITH SINUSITIS

  • Kartegenr’s Syndrome:presents with recurrent sinusitis ,recurrent chest infections ,infertility and Chest X-ray revealing dextrocardia and situs invertus
  • Isolated IgA Deficiency:may suffer from chronic otitis and sinusitis, low serum IgA level and may suffer an anaphylactic reaction following the administration of blood products
Exam Question
 
  • Most common sinus involved in infant and children is Ethmoid sinus.
  • Frontal Sinusitis- Pain shows periodicity,Tenderness is present just above the medial canthus of eye,Pain is referred to as office headache.
  • Pathognomonic feature of Maxillary sinusitis is Mucopus in the middle meatus.
  • Most definitive diagnosis of sinusitis is Sinoscopy.
  • Sphenoid sinusitis pain is referred most commonly to Occiput.
  • Common organisms causing sinusitis:S. pneumoniae and nontypable Haemophilus influenzae are the most common pathogens, accounting for 50-60% of cases. Moraxella catarrhalis causes disease in a signigicant percentage (20%) of children but less often in adults. 
  • Sinus least involved in sinusitis is Sphenoid.
  • Probable diagnosis in a male patient presenting with recurrent sinusitis ,recurrent chest infections ,infertility and Chest X-ray revealing dextrocardia and situs invertus is Kartagener’s syndrome.
  • Caldwell view of the X-ray is the best to show frontal sinus in a patient with recurrent frontal sinusitis.
  • Trephination is indicated for frontal sinustis because of persistence or exacerbation of pain or pyrexia in spite of medical treatment for 48 hours.
Don’t Forget to Solve all the previous Year Question asked on Acute Sinusitis

Acute Sinusitis

Acute Sinusitis

Q. 1

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Q. 1

A 30-year-old,lady, with a history of chronic otitis and sinusitis is found to have a low serum IgA level. All other immunoglobulin classes are found to be normal. Which of the following statements is correct?

 A

She may suffer an anaphylactic reaction following the administration of blood products

 B

Not associated with other autoimmune disorders

 C

Intravenous immunoglobulin (IVIG) is the treatment of choice

 D

All of the above

Ans. A

Explanation:

The patient is suffering from isolated IgA deficiency.

 
IgA deficiency is the most common PID.
It is asymptomatic in most cases; however, individuals may present with increased numbers of acute and chronic respiratory infections that may lead to bronchiectasis.
In addition, over their lifetime, these patients experience an increased susceptibility to drug allergies, atopic disorders, and autoimmune diseases.
Serum antibodies to IgA are reported in as many as 44% of patients with selective IgA deficiency.
If these antibodies are of the IgE isotype, they can cause severe or fatal anaphylactic reactions after intravenous administration of blood products containing IgA.
 
Administration of intravenous immunoglobulin (IVIG), which is >99% IgG, is not indicated because most IgA-deficient patients make IgG antibodies normally. Many IVIG preparations contain sufficient IgA to cause anaphylactic reactions.

Q. 2

A couple presents to a clinic for the work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Q. 2

A couple presents to a clinic for the work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Ans. C

Explanation:

The husband is suffering from Kartagener’s syndrome, an autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis, and bronchiectasis. The underlying cause of these varied manifestations are defects in the dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive tract. Since sperm motility is dependent on the functioning of cilia, infertility frequently accompanies this disorder.

Situs inversus occurs because ciliary function is necessary for cell migration during embryonic development.

Azoospermia is not a feature of Kartagener’s syndrome, as sperm production or survival is not affected in this disorder.

Germinal cell aplasia, also known as Sertoli only syndrome, is characterized by oligospermia or azoospermia.

Isolated gonadotropin deficiency is characterized by delayed or incomplete pubertal maturation.


Q. 3

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Q. 3

A couple presents to a clinic for work-up of infertility after 5 years of unprotected intercourse. The wife denies any medical problems and notes regular menstrual cycles. The husband states that he has had chronic sinusitis and lower respiratory tract infections. Physical examination of the woman is unremarkable. Examination of the man is remarkable for dextrocardia. Further work-up of the husband will most likely reveal?

 A

Azoospermia

 B

Germinal cell aplasia

 C

Immotile sperm

 D

Isolated gonadotropin deficiency

Ans. C

Explanation:

The husband is suffering from Kartagener’s syndrome, an autosomal recessive disorder characterized by infertility, situs inversus, chronic sinusitis, and bronchiectasis.

The underlying cause of these varied manifestations are defects in the dynein arms, spokes of microtubule doublets of cilia in the airways and the reproductive tract.

Since sperm motility is dependent on the functioning of cilia, infertility frequently accompanies this disorder.

Situs inversus occurs because ciliary function is necessary for cell migration during embryonic development.

Azoospermia is not a feature of Kartagener’s syndrome, as sperm production or survival is not affected in this disorder.

Germinal cell aplasia, also known as Sertoli only syndrome, is characterized by oligospermia or azoospermia.

Isolated gonadotropin deficiency is characterized by delayed or incomplete pubertal maturation.

Ref: Federico M.J., Stillwell P., Deterding R.R., Baker C.D., Balasubramaniam V., Zemanick E.T., Sagel S.D., Halbower A., Burg C.J., Kerby G.S. (2012). Chapter 19. Respiratory Tract & Mediastinum. In W.W. Hay, Jr., M.J. Levin, R.R. Deterding, J.J. Ross, J.M. Sondheimer (Eds), CURRENT Diagnosis & Treatment: Pediatrics, 21e.


Q. 4

A patient presented with history of recurrent frontal sinusitis. Which of the following view of the X-ray is the best to show frontal sinus in this patient?

 A

Towne’s view

 B

Water’s view

 C

Caldwell’s view

 D

Schuller’s view

Q. 4

A patient presented with history of recurrent frontal sinusitis. Which of the following view of the X-ray is the best to show frontal sinus in this patient?

 A

Towne’s view

 B

Water’s view

 C

Caldwell’s view

 D

Schuller’s view

Ans. C

Explanation:

Caldwell view is also known as occipitofrontal view or nose-forehead position. Structures seen are:

  • Frontal sinuses (seen best)
  • Ethmoid sinuses
  • Maxillary sinuses
  • Frontal process of zygoma and zygomatic process of frontal bone
  • Superior margin of orbit and lamina papyracea
  • Superior orbital fissure
  • Foramen rotundum (inferolateral to superior orbital fissure)
 
Structures seen in Water’s view (occipitomental view or nose-chin position):
  • Maxillary sinuses (seen best)
  • Frontal sinuses
  • Sphenoid sinus (if the film is taken with open mouth)
  • Zygoma
  • Zygomatic arch
  • Nasal bone
  • Frontal process of maxilla
  • Superior orbital fissure
Structures seen in Towne’s view:
  • Arcuate eminence and superior semicircular canal
  • Mastoid antrum
  • Internal auditory canal
  • Tympanic cavity
  • Cochlea
  • External auditory canal
  • Both petrous pyramids
Structures seen in Schuller’s view:
  • External canal superimposed on internal canal
  • Mastoid air cells
  • Tegmen
  • Lateral sinus plate
  • Condyle of mandible
  • Sino-dural angle
  • Antrum and upper part of attic
 

Q. 5

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Q. 5

Kartagener’s syndrome includes –

 A

Situs inversus

 B

Bronchiectasis Sinusitis

 C

Male infertility

 D

All

Ans. D

Explanation:

Ans. is ‘a’ i.e., Situs inversus; ‘b’ Bronchiectasis, Sinusitis’ `c’ Male infertility

o Kartagener’s syndrome is a subgroup of primary ciliary dyskinesia. [Ref Bobbin’s r/e p. 692 & 71h/e p. 727] Primary ciliary dyskinesia ‑

o It is an antosomal recessive syndrome.

o It is characterized by poorly functioning cilia. There is absence or shortening of Dynein arms that are responsible for the coordinated bending of cilia.

o Approximately half of the patients with primary ciliary dyskinesia have kartagener’s syndrome.

Kartagener’s syndrome

Poor functioning of cilia contribute to retention of secretions and recurrent infections

Sinusitis              –>

Lack of ciliary activity interferes with bacterial clearance, predisposing sinuses to infection

 Situs inversus       —>       Due to ineffective cell motility during embryogenesis

Infertility                           Due to ineffective mobility of sperm


Q. 6

A child present with recurrent sinusitis and recurrent chest infections. Chest X-ray reveals dextrocardia and situs invertus. The diagnosis is ‑

 A

Kartagener’s syndrome

 B

Good-pasture’s syndrome

 C

Ehlers-Danlos syndrome

 D

William Campbell syndrome

Q. 6

A child present with recurrent sinusitis and recurrent chest infections. Chest X-ray reveals dextrocardia and situs invertus. The diagnosis is ‑

 A

Kartagener’s syndrome

 B

Good-pasture’s syndrome

 C

Ehlers-Danlos syndrome

 D

William Campbell syndrome

Ans. A

Explanation:

Ans is ‘a’ i.e., Kartagener’s syndrome

o Kartagener’s syndrome is a subgroup of primary ciliary dyskinesia.

Primary ciliary dyskinesia:

o It is an autosomal recessive syndrome.

o It is characterized by poorly functioning cilia. There is absence or shortening of Dynein arms that are responsible for the coordinated bending of cilia.

o Approximately half of the patients with primary ciliary dyskinesia have kartagener’s syndrome.


Q. 7

Features associated with DNS include all of the following except:

 A

Epistaxis

 B

Atrophy of turbinate

 C

Hypertrophy of turbinate

 D

Recurrent sinusitis

Q. 7

Features associated with DNS include all of the following except:

 A

Epistaxis

 B

Atrophy of turbinate

 C

Hypertrophy of turbinate

 D

Recurrent sinusitis

Ans. B

Explanation:

Q. 8

DNS may be associated with all the following except:

 A

Recurrent sphenoiditis

 B

Acute otitis media

 C

Hypertrophy of the inferior turbinate

 D

Recurrent maxillary sinusitis

Q. 8

DNS may be associated with all the following except:

 A

Recurrent sphenoiditis

 B

Acute otitis media

 C

Hypertrophy of the inferior turbinate

 D

Recurrent maxillary sinusitis

Ans. A

Explanation:

 

  • In deviated nasal septum, the nasal chamber on the concave side of the nasal septum is wide and shows compensatory hypertrophy of turbinates and not atrophy.
  • The sphenoid sinus opens in the sphenoethmoid recess near the roof of nasal cavity and this opening is not affected by DNS.



Q. 9

In acute sinusitis, the sinus most often involved in chil­dren is:

 A

Maxillary

 B

Sphenoid

 C

Ethmoid

 D

Frontal

Q. 9

In acute sinusitis, the sinus most often involved in chil­dren is:

 A

Maxillary

 B

Sphenoid

 C

Ethmoid

 D

Frontal

Ans. C

Explanation:

 

Most common sinusitis in children is Ethmoid. Most common sinusitis in adults is Maxillary.


Q. 10

Sinus least involved in sinusitis is:

 A

Maxillary

 B

Ethmoid

 C

Frontal

 D

Sphenoid

Q. 10

Sinus least involved in sinusitis is:

 A

Maxillary

 B

Ethmoid

 C

Frontal

 D

Sphenoid

Ans. D

Explanation:

 

Isolated involvement of sphenoid sinus is rare. It is often a part of pansinusitis or is associated with infection of posterior ethmoidal sinus.                                                                                                                                              

The sphenoid sinus is rarely affected on its own —Turner 10th/ed p 48

The reason for sphenoid sinus to be least affected is that it opens high up in the sphero ethmoid recess which is not affected by most of the conditions of nose


Q. 11

Common organisms causing sinusitis:

 A

Pseudomonas

 B

Moraxella catarrhalis

 C

Streptococcus pnenumoniae

 D

b and c

Q. 11

Common organisms causing sinusitis:

 A

Pseudomonas

 B

Moraxella catarrhalis

 C

Streptococcus pnenumoniae

 D

b and c

Ans. D

Explanation:

 

 

Among community-acquired cases, S. pneumoniae and nontypable Haemophilus influenzae are the most common pathogens, accounting for 50-60% of cases. Moraxella catarrhalis causes disease in a signigicant percentage (20%) of children but less often in adults. Other streptococcal species and Staphylococcus aureus cause only a small percentage of cases, although there . is increasing concern about community strains of methicillin – resistant S. aureus (MRSA) as an emerging cause. -Harrison 17th/ed

 

The bacterial pathogens causing acute bacterial sinusitis in children and adolescents include Streptococcus pneumoniae (= 30%), nontypable Haerrophilus influenzae (=20%). – Nelson 18th/ed

 

M/C Organism causing sinusitis in adults is also Streptococcus pneumoniae followed by H. influenza. – scotts Brown 7th/ed

In children:

M/C is Streptococcus pneumoniae (30-43%) followed by both H. influenza and Moraxella catarrhalis (20-28% each)


Q. 12

Sphenoid sinusitis pain is referred most commonly to:

 A

Occiput

 B

Cost of nose

 C

Frontal

 D

Temporal region

Q. 12

Sphenoid sinusitis pain is referred most commonly to:

 A

Occiput

 B

Cost of nose

 C

Frontal

 D

Temporal region

Ans. A

Explanation:

 

Acute sphenoditis: Headache – usually localized to the occiput or vertex. Pain may also be referred to the mastoid region.

 

Maxillary sinus     Along the infraorbital margin and referred to upper teeth or gums on affected side (along the distribution of superior orbital nerve) Pain is aggravated on stooping or coughing.

Frontal sinus        Pain localized over forehead. It has a characteristic periodicity

Ethmoid sinus      Pain localized over the nasal bridge, inner canthus and behind the ear.



Q. 13

Most definitive diagnosis of sinusitis is:

 A

X-ray PNS

 B

Proof puncture

 C

Sinoscopy

 D

Transillumination test

Q. 13

Most definitive diagnosis of sinusitis is:

 A

X-ray PNS

 B

Proof puncture

 C

Sinoscopy

 D

Transillumination test

Ans. C

Explanation:

Q. 14

Pathognomonic feature of Maxillary sinusitis is:

 A

Mucopus in the middle meatus

 B

Inferior turbinate hypertrophy

 C

Purulent nasal discharge

 D

Atrophic sinusitis

Q. 14

Pathognomonic feature of Maxillary sinusitis is:

 A

Mucopus in the middle meatus

 B

Inferior turbinate hypertrophy

 C

Purulent nasal discharge

 D

Atrophic sinusitis

Ans. A

Explanation:

  • Characteristic finding of maxillary sinusitis on Rhinoscopy is pus or mucopus in in the middle meatus.
  • Mucosa and turbinates may appear red and swollen.

Q. 15

Kartagener’s syndrome includes all of the following, Except :

 A

Sites inversus

 B

Bronchiectasis

 C

Sinusitis

 D

Cystic fibrosis

Q. 15

Kartagener’s syndrome includes all of the following, Except :

 A

Sites inversus

 B

Bronchiectasis

 C

Sinusitis

 D

Cystic fibrosis

Ans. D

Explanation:

Answer is D (Cystic fibrosis):

Note : 

Situs inversus refers to perfect mirror image of normal physiologic position of visceral organs with preservation of their A-P relationship. Situs inversus is usually associated with dextrocardia (Heart on Right Side of chest).


Q. 16

Sinusitis in children is commoner in which sinus:

 A

Frontal

 B

Maxillary

 C

Ethmoid

 D

Sphenoid

Q. 16

Sinusitis in children is commoner in which sinus:

 A

Frontal

 B

Maxillary

 C

Ethmoid

 D

Sphenoid

Ans. C

Explanation:

Q. 17

Which of the following is false regarding frontal sinusitis ‑

 A

Pain shows periodicity

 B

Most common sinus involved in infants and children

 C

Pain is referred to as office headache

 D

Tenderness is present just above the medial canthus of eye

Q. 17

Which of the following is false regarding frontal sinusitis ‑

 A

Pain shows periodicity

 B

Most common sinus involved in infants and children

 C

Pain is referred to as office headache

 D

Tenderness is present just above the medial canthus of eye

Ans. B

Explanation:

Ans. is ‘b’ i.e., Most common sinus involved in infants and children

Most common sinus involved in infant and children is Ethmoid sinus.

Clinical features of acute sinusitis

Most common presenting patient’s compliant is persistent nasal discharge which can be of any quality (thin, thick, clear, or purulent). Nasal discharge from a sinus infection can be blood – tinged from excessive nose blowing and irritation. The clinical symptoms of acute sinusitis have been classified into major and minor.


Q. 18

A minor symptom of sinusitis is 

 A

Nasal blockage

 B

Facial congestion

 C

Nasal congestion

 D

Halitosis

Q. 18

A minor symptom of sinusitis is 

 A

Nasal blockage

 B

Facial congestion

 C

Nasal congestion

 D

Halitosis

Ans. D

Explanation:

 

The clinical symptoms of acute sinusitis have been classified into major and minor.

Major

  • Facial pain or pressure
  • Purulent nasal discharge
  • Fever
  • Nasal congestion
  • Nasal obstruction
  • Hyposmia or Anosmia
  • Facial congestion or fullness

Minor

  • Headache
  • Cough
  • Fatigue
  • Halitosis
  • Dental pain
  • Ear pain or pressure


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