Paranasal Sinuses – Anatomy

What are Sinuses?

Sinuses air-filled cavities हैं जो skull bones में स्थित हैं और nasal cavity के around होती हैं। ये mucosa से lined होती हैं और छोटे openings (ostia) के through nose से connected हैं।

Four Pairs of Sinuses:

1. Maxillary Sinuses (सबसे बड़ी)

• Cheekbones में located
• Most commonly affected
• Ostium high पर है → poor drainage
• Tooth roots close proximity (dental infections spread कर सकते हैं)

2. Ethmoid Sinuses

• Eyes के बीच में
• Multiple small air cells (10-15)
• Key role in chronic sinusitis
• FESS में usually first approach

3. Frontal Sinuses

• Forehead में, eyes के ऊपर
• Drainage through frontal recess (narrow channel)
• Blockage causes severe frontal headache

4. Sphenoid Sinuses

• Skull के center में, deep location
• Close to optic nerve, carotid artery, pituitary gland
• Isolated sphenoid sinusitis rare but serious

Normal Sinus Function:

• Mucociliary Clearance: Cilia beat in coordinated fashion → mucus moves to ostia → drains into nose
• Air Conditioning: Warm and humidify inhaled air
• Voice Resonance
• Immune Defense: Mucus traps bacteria, viruses
• Lighten Skull Weight

Sinusitis Classification

Based on Duration:

1. Acute Rhinosinusitis (ARS)

Duration: < 4 weeks

Causes:

• Viral (90%): Common cold → sinus involvement
  • Rhinovirus, Coronavirus, Influenza
  • Self-limiting, 7-10 days
• Bacterial (5-10%): Secondary infection after viral URI
  • S. pneumoniae, H. influenzae, M. catarrhalis
  • Suspect if: Symptoms worsen after 5 days, persist >10 days, या severe onset

Symptoms:

• Facial pain, pressure (increases on bending forward)
• Purulent nasal discharge (yellow/green)
• Nasal congestion
• Decreased smell
• Fever (if bacterial)
• Dental pain (maxillary sinusitis)

2. Chronic Rhinosinusitis (CRS)

Duration: ≥ 12 weeks with persistent symptoms

This is NOT just prolonged acute sinusitis – it’s a different disease entity with chronic inflammation।

Two Subtypes:

A. CRS without Nasal Polyps (CRSsNP)

• More common
• Bacterial biofilms contribute
• Often unilateral या asymmetric
• Structural abnormalities common (DNS, concha bullosa)

B. CRS with Nasal Polyps (CRSwNP)

• Polyps = soft, painless, grape-like masses
• Usually bilateral
• Type 2 inflammation (eosinophilic)
• Associated with asthma, aspirin sensitivity (Samter’s triad)
• High recurrence rate even after surgery

3. Recurrent Acute Rhinosinusitis (RARS)

• ≥ 4 episodes per year
• Each episode <4 weeks duration
• Complete resolution between episodes
• Usually underlying predisposing factor

Causes and Risk Factors

1. Anatomical Factors

• Deviated Nasal Septum (DNS): Blocks sinus drainage
• Concha Bullosa: Air cell in turbinate
• Agger Nasi Cell: Blocks frontal sinus drainage
• Narrow Infundibulum: Maxillary sinus drainage pathway

2. Inflammatory

• Allergic Rhinitis: Major predisposing factor
  • Chronic inflammation
  • Mucosal edema → ostial blockage
• Nasal Polyps
• Aspirin Sensitivity

3. Environmental

• Pollution, Dust: Irritate mucosa
• Smoking: Impairs mucociliary clearance
• Occupational Exposure: Chemicals, fumes

4. Medical Conditions

• Immunodeficiency: Recurrent infections
• Cystic Fibrosis: Thick mucus
• Primary Ciliary Dyskinesia: Defective cilia
• Diabetes: Increases infection risk
• GERD: May contribute

5. Dental

• Odontogenic sinusitis (tooth infection spreading to maxillary sinus)
• Oro-antral fistula (after tooth extraction)

Diagnosis at Prime ENT Center

1. Clinical History

Key Questions:

• Duration: Acute या chronic?
• Symptoms: Major criteria (see below)
• Previous Episodes: Recurrent?
• Previous Treatment: Multiple antibiotic courses?
• Associated Conditions: Asthma, allergies?
• Triggers: Seasonal pattern?

Diagnostic Criteria for CRS (Need ≥2, one must be major):

Major Criteria:

• Facial pain/pressure
• Facial congestion/fullness
• Nasal obstruction/blockage
• Nasal discharge/purulence या postnasal drip
• Hyposmia/anosmia (decreased/lost smell)

Minor Criteria:

• Headache
• Fever
• Halitosis (bad breath)
• Fatigue
• Dental pain
• Cough
• Ear pain/pressure

2. Nasal Endoscopy – Essential

Diagnostic nasal endoscopy सबसे important investigation है – Dr. Harshita Singh perform करती हैं।

Procedure:

• Topical decongestant और anesthesia spray
• Rigid या flexible endoscope
• Complete visualization of nasal cavity, sinuses openings
• High-definition camera recording

Findings in CRS:

• Mucosal edema, inflammation
• Purulent discharge from middle meatus
• Nasal polyps (if present)
• Anatomical variations
• Sinus ostia visualization

3. CT Scan Paranasal Sinuses

Gold Standard for diagnosis and surgical planning

When Indicated:

• CRS not responding to medical treatment
• Planning for FESS surgery
• Suspected complications
• Recurrent acute sinusitis

What CT Shows:

• Extent of disease – which sinuses affected
• Anatomical variations
• Ostiomeatal complex patency
• Polyps
• Bone erosion (if present)
• Complications (orbital, intracranial)

Lund-Mackay Staging: CT scoring system (0-24) for disease severity

4. Allergy Testing

• If allergic rhinitis suspected as underlying cause
• Skin prick test available at Prime ENT Center

Treatment at Prime ENT Center

Medical Management – First Line

1. Nasal Saline Irrigation

Cornerstone of treatment – all patients should do

• Method:
  • Isotonic saline (normal saline)
  • Neti pot, squeeze bottle, या syringe
  • Head tilted, irrigate one nostril, flows out other side
• Benefits:
  • Washes out mucus, allergens, bacteria
  • Improves mucociliary function
  • Safe, no side effects
• Frequency: 2-3 times daily, especially during acute episodes

2. Intranasal Corticosteroids

Most effective medical treatment

• Mechanism: Reduce inflammation directly in nasal/sinus mucosa
• Usage: Daily, long-term (even if symptoms improve)
• Duration: At least 3 months for CRS
• Side Effects: Minimal (local dryness, occasional nosebleed)

3. Antibiotics

Acute Bacterial Sinusitis:

• Culture-directed if possible (endoscopic culture)
• Duration: 10-14 days typically
• Complete course important

Chronic Sinusitis:

• Controversial role
• Long-term low-dose (macrolides) – anti-inflammatory effect
• Consider if acute exacerbations

4. Oral Corticosteroids

• Short course (5-7 days)
• For severe CRS with polyps
• Acute exacerbations
• Can provide dramatic relief

5. Leukotriene Modifiers

• Especially useful if asthma coexists
• CRSwNP patients

6. Antihistamines

• If allergic component
• Not routine for all CRS

When Medical Treatment Fails – FESS Surgery

Indications for Surgery:

• CRS failing adequate medical therapy (3+ months)
• Recurrent acute sinusitis (≥4 episodes/year)
• Nasal polyps causing obstruction
• Fungal sinusitis
• Complications (orbital cellulitis, meningitis)
• Structural abnormalities (severe DNS with CRS)
• Suspected sinus tumor

FESS – Functional Endoscopic Sinus Surgery

Dr. Harshita Singh is specially trained in FESS with Fellowship in Rhinology

Concept:

FESS एक minimally invasive technique है जो nasal endoscope के through की जाती है – no external cuts। Goal है diseased tissue remove करना और sinus drainage pathways को widen करना ताकि sinuses properly drain हो सकें।

Procedure:

Pre-operative:

• CT scan study (surgeon uses for navigation)
• Anesthetic fitness
• Blood tests
• Informed consent

During Surgery:

• General anesthesia
• Endoscope inserted through nostril
• High-definition camera shows magnified view on monitor
• Micro-instruments used
• Steps (as needed based on disease):
  • Uncinectomy: Remove uncinate process
  • Maxillary Antrostomy: Widen maxillary sinus opening
  • Ethmoidectomy: Open ethmoid cells
  • Sphenoidotomy: Open sphenoid sinus
  • Frontal Sinusotomy: Clear frontal recess
  • Polyp Removal: If present
  • Septoplasty: If DNS contributing
  • Turbinate Reduction: If enlarged
• Nasal packing (dissolvable typically)
• Duration: 1-3 hours depending on extent

Advantages of FESS:

• Minimally invasive – through nose
• No facial scars
• Excellent visualization
• Preserves normal structures
• Quick recovery
• Day care या 1 night stay

Post-operative Care:

Hospital (Day 0-1):

• Pain management
• Nasal packing usually removed next day
• Discharge same day या day 1

First Week:

• Rest at home
• Head elevated while sleeping
• No nose blowing (first 7 days)
• Saline irrigation starts (gently)
• Avoid: Straining, bending, heavy lifting
• Mild nasal bleeding normal

Weeks 2-6:

• Regular Debridement: Very important!
  • Dr. Harshita Singh removes crusts, clots endoscopically
  • Usually weekly for 3-4 visits
  • Essential for healing
• Continue nasal saline, steroid sprays
• Gradual return to activities

Long-term:

• Regular follow-up (3 months, 6 months, 1 year)
• Maintenance nasal steroids (long-term)
• Saline irrigation (can continue indefinitely)

Success Rate:

• 80-90% patients significantly improve
• Symptoms relief, quality of life improvement
• Polyps can recur (especially if aspirin sensitivity) – may need revision

Complications (Rare with experienced surgeon):

• Bleeding (minor common, major rare)
• Infection
• Orbital injury (very rare – <1%)
• CSF leak (very rare – <0.5%)
• Anosmia (smell loss)

Prevention and Maintenance

After Medical Treatment या Surgery:

• Daily Nasal Saline: Lifelong habit
• Nasal Steroid Sprays: Long-term especially post-FESS
• Avoid Triggers:
  • Smoking cessation
  • Control allergies
  • Avoid pollution when possible
• Treat URTIs Promptly: Don’t let cold progress to sinusitis
• Humidification: Especially in dry environments
• Stay Hydrated: Keeps mucus thin
• Regular Follow-ups: Early detection of recurrence

Complications of Untreated Chronic Sinusitis

Local:

• Nasal polyps
• Mucocele (mucus-filled sinus)
• Osteomyelitis (bone infection)

Orbital (Eye) Complications:

• Preseptal cellulitis
• Orbital cellulitis
• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Can cause vision loss if not treated urgently

Intracranial (Brain) Complications:

• Meningitis
• Epidural abscess
• Subdural abscess
• Brain abscess
• Life-threatening – need urgent treatment

⚠️ Warning Signs (See ENT Immediately):

• Severe headache with vomiting
• Eye swelling, redness, pain
• Vision changes
• High fever with confusion
• Facial swelling
• Neurological symptoms