Tuesday, December 28, 2010

Acute Maxillary Sinusitis

Aetiology
1. Most commonly, it is viral rhinitis which spreads to
involve the sinus mucosa. This is followed by bacterial
invasion.
2. Diving and swimming in contaminated water.
3. Dental infections are important source of maxillary
sinusitis. Roots of premolar and molar teeth are related
to the floor of sinus and may be separated only by a
thin layer of mucosal covering. Periapical dental
abscess may burst into the sinus; or the root of a tooth,
during extraction, may be pushed into the sinus. In
case of oroantral fistula, following tooth extraction,
bacteria from oral cavity enter the maxillary sinus.
4. Trauma to the sinus such as compound fractures, penetrating
injuries or gun shot wounds may be followed
by sinusitis.
Predisposing factors. One or more of the predisposing
factors enumerated for sinusitis in general may be
responsible for acute or recurrent infection.
Clinical Features
Clinical features depend on (a) severity of inflammatory
process and (b) efficiency of ostium to drain the exudates.
Closed ostium sinusitis is of greater severity and leads
more often to complications.
1. Constitutional symptoms consist of fever, general malaise
and body ache. They are the result of toxaemia.
2. . Headache. Usually, this is confined to forehead and
may thus be confused with frontal sinusitis.
3. Pain. Typically, it is situated over the upper jaw, but
may be referred to the gums or teeth. For this reason
patient may primarily consult a dentist. Pain is aggravated
by stooping, coughing or chewing. Occasionally,
pain is referred to the ipsilateral supraorbital region
and thus may simulate frontal sinus infection.
4. Tenderness. Pressure or tapping over the anterior
wall of antrum produces pain.
5. Redness and oedema of cheek. Commonly seen in
children. The lower eyelid may become puffy.
6. Nasal discharge. Anterior rhinoscopy shows pus or
mucopus in the middle meatus. Mucosa of the middle
meatus and turbinate may appear red and
swollen.
Postural test. If no pus seen in the middle meatus, it is
decongested with a pledget of cotton soaked with a
vasoconstrictor and the patient is made to sit with
the affected sinus turned up. Examination after 10-15
minutes may show discharge in the middle meatus.
7. Post nasal discharge. Pus may be seen on the upper
soft palate on posterior rhinoscopy.
Diagnosis
Transillumination test. Affected sinus will be found
opaque.
X-rays. Waters' view will show either an opacity or a
fluid level in the involved sinus.
Treatment
Medical
1. Antimicrobial drugs. Ampicillin and amoxicillin are
quite effective and cover a wide range of organisms.
Erythromycin or doxycycline or cotrimoxazole are
equally effective and can be given to those who are
sensitive to penicillin. f3-lactamase-producing strains
of H. inf/uenzae and M. catarrhalis may necessitate
the use of amoxicillin/clavllianic acid or cefllroxime
axetil. Sparfloxacin is also effective, and has the
advantage of single daily dose.
2. Nasal decongestant drops. 1 % ephedrine or 0.1 % xylo or
oxymetazoline are used as nasal drops or sprays to
decongest sinus ostium and encourage drainage.
3. Steam inhalation. Steam alone or medicated with
menthol or Tr. Benzoin Co. provides symptomatic
relief and encourages sinus drainage. Inhalation
should be given 15 to 20 minutes after nasal decongestion
for better penetration.
4. Analgesics. Paracetamol or any other suitable analgesic
should be given for relief of pain and headache.
S. Hot fomentation. Local heat to the affected sinus is
often soothing and helps in the resolution of inflammation.
Surgical
Antral lavage. Most cases of acute maxillary sinusitis
respond to medical treatment. Lavage is rarely necessary.
It is done only when medical treatment has failed and
that too only under cover of antibodies.
Complications
1. Acute maxillary sinusitis may change to subacute or
chronic sinusitis.
2. Frontal sinusitis. Frontonasal duct which opens in middle
meatus is obstructed due to inflammatory oedema.
3. Osteitis or osteomyelitis of the maxilla.
4. Orbital cellulitis Or abscess. Infection spreads to the
orbit either directly, from the roof of maxillary sinus
or indirectly, after involvement of ethmoid sinuses.

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