Chronic Maxillary Sinusitis

Sinus infection lasting for months or years is called
chronic sinusitis. Most important cause of chronic sinusitis
is failure of acute infection to resolve.
Pathophysiology
Acute infection destroys normal ciliated epithelium
impairing drainage from the sinus. Pooling and stagnation
of secretions in the sinus invites infection.
Persistence of infection causes mucosal changes, such as
loss of cilia, oedema and polyp formation, thus continuing
the vicious cycle
Pathology
In chronic infections, process of destruction and
attempts at healing proceed simultaneously. Sinus
mucosa becomes thick and polypoidal (hypertrophic
sinusitis) or undergoes atrophy (atrophic sinusitis).
urface epithelium may show desquamation, regeneration
or metaplasia. Submucosa is infiltrated with lymphocytes
and plasma cells and may show microabscesses,
granulations, fibrosis or polyp formation.
Bacteriology
Mixed aerobic and anaerobic organisms are often
present.
Clinical Features
Clinical features are often vague and similar to those
of acute sinusitis but of lesser severity. Purulent nasal
discharge is the commonest complaint. Foul-smelling
discharge suggests anaerobic infection. Local pain and
headache are often not marked except in acute exacerbations.
Some patients complain of nasal stuffiness and
anosmia.
Diagnosis
1. X-ray of the involved sinus may show mucosal
thickening or opacity.
2. X-rays after injection of contrast material may show
soft tissue changes in the sinus mucosa.
3. CT scan is particularly useful in ethmoid and sphenoid
sinus infections and has replaced studies with
contrast materials.
4. Aspiration and irrigation: Finding of pus in the sinus
is confirmatory.
Treatment
It is essential to search for underlying aetiological factors
which obstruct sinus drainage and ventilation. A workup
for nasal allergy may be required. Culture and sensitivity
of sinus discharge helps in the proper selection of
an antibiotic.
Initial treatment of chronic sinusitis is conservative,
including antibiotics, decongestants, antihistaminics and
sinus irrigations. More often, some form of surgery is
required either to provide free drainage and ventilation
or radical surgery to remove all irreversible diseases so as
to provide wide drainage or to obliterate the sinus.
Recently, endoscopic sinus surgery is replacing radical
operations on the sinuses and provides good drainage
and ventilation. It also avoids external incisions.
Surgeries For Chronic Maxillary Sinusitis:
1. Antral puncture and irrigation. Sinus cavity is irrigated
with a cannula passed through the inferior
meatus. Removal of pus and exudates helps the sinus
mucosa to revert to normal.
2. Intranasal antrostomy. It is indicated if sinus irrigations
fail to resolve infection. A window is created
in the inferior meatus to provide aeration to the
sinus and its free drainage.
3. Caldwell-Luc operation. In this operation, antrum is
entered through its anterior wall by a sublabial incision.
All irreversible diseases are removed and a
window is created between the antrum and inferior
meatus.