Sinusitis

Sinusitis is a better defined clinical condition. The pathogenesis of sinusitis is better understood nowadays after the importance of mucous transportation is realized. Sinusitis is usually unilaterally its symptoms are better appreciated in four levels:

1. Primary (Level 1) symptoms of sinusitis are unusual as the sinuses have no specific function. However if the involved sinus becomes totally blocked, local pain and tenderness may occur as tension develops within the sinus.

2. Secondary (Level 2) symptoms develop as entrapped and frequently infected secretion overflows from the involved sinus. The patient may then present with mucopurulent rhinorrhoea.

3. Tertiary (Level 3) symptoms develop as the mucopus collects around the Eustachian tube causing middle ear dysfunction.

4. Quaternary (Level 4) symptoms develop if a totally obstructed sinus also becomes infected or develops into a mucocele. Under these situations, progressive tension will develop and may decompress itself along line of weakness. Patients may then present with orbital or intracra-nial complications.

Acute sinusitis

This commonly follows an URTI and presents acutely with fever local pain and tenderness over the involved sinus. Nasal symptoms may not be prominent. Nasal endoscopy reveals local congestion and pus may be seen streaming down from the diseased sinus. A pus swab should be taken for microbiological work-up and meanwhile the patient should be treated symptomatically with an analgesic and antipyretic. A 2-week course antibiotic with coverage for Gram-positive and Gramnegative organisms should be started immediately. The regime may need to be revised if clinical progress is slow or as determined by culture and sensitivity results. Most acute sinusitis resolves with conservative treatment.

Chronic sinusitis

This usually present with chronic nasal congestion and recurrent mucopurulent rhinorrhoea (Level 2 symptoms). There is usually an underlying cause such as nasal polyposis, a septal deviation, an abnormal middle turbinate, etc. The presence of any condition which obstructs mucous transportation out of the sinus will lead to recurrent infection and sinusitis becomes chronic. Therefore, surgery is frequently required as a definitive procedure. Functional endoscopic sinus surgery (FESS) which aims at re-establishing normal

Figure 20.5. Nasendoscopic picture of the nose showing a solitary nasal polyp coming out of the middle meatus.

mucous transportation is now a well-established operation for this condition. When considering any patient for FESS, coronal CT scanning of the sinuses must be done so that the full extent of disease and any variation in sinus anatomy are known to the surgeon.

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