AIR SINUSES

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Topics covered
What is sinus? Classification History Development Classification PNS Functions MAXILLARY SINUS FRONTAL SINUS ETHMOID SINUS SPHENOID SINUS Blood supply Lymphatic drainage Nerve supply Microcsopic anatomy Osteomeatal complex Drainage of sinus

Sinusitis Predisposing factors Causes Types Pathology C/F Routes of spread Complications Diagnosis Surgical intervention D/D Prevention

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What is a sinus?
a hollow, cavity, recess, or pocket ,such as airfilled cavity in a dense portion of a skull bone a large channel containing blood a tract or fistula leading to a cavity which may be filled with pus a channel permitting the passage of blood or lymph that is not a blood vessel or lymphatic vessel, such as the sinuses of the placenta.
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Classification
Blood filled Sinus Air filled

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 Air sinus is an air containing space within a bone

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PARANASAL SINUSES

4 paired sets of air-filled cavities of cranio-facial complex surrounding the eyes and nose & are lined with mucusproducing membranes.

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PARANASAL SINUSES
Each sinus is named after the bone it resides in Frontal Ethmoidal Maxillary Sphenoidal

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 Galen (2oo) described the presence of the ethmoid air cells. descriptions of the maxillary sinuses by Leonardo da Vinci (1489) the sphenoid sinuses by Giacomo Berengario da Carpi (1521) the frontal sinuses by Coiter (16th century) The first modern and accurate descriptions by Austrian anatomist Emil Zuckerkandl.

History

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NORMAL DEVELOPMENT
Mesenchyme Tissue Ethmoidoturbinal -> middle, superior, and supreme turbinates Maxilloturbinal outgrowth -> inferior turbinate

development of - agger nasi cells uncinate process ethmoid infundibulum sinuses then begin to develop

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NORMAL DEVELOPMENT
Sinuses start as small sacs around nasal meatus and ressesses Grow -> invading bone -> forming air sinuses & cells

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Maxillary Frontal Sphenoids Ethmoids

At birth -> 3 yrs 2 - 9 yrs 6 7 yrs At birth -> puberty

All fully developed by age 17-18

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AIR SINUS

ANTERIOR

POSTERIOR

FRONTAL

MAXILLARY

ANT. ETHMOIDAL

SPHENOIDAL

POST . ETHMOIDAL

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Functions of para nasal sinuses

Not definitely known! but speculated:

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Functions of para nasal sinuses

Lightening the skull. Add resonance to speech Humidifying and warming inspired air Regulation of intranasal pressure Increasing surface area of olfaction Contribute to facial growth Act as airbags in trauma - Absorbing shock Possibly controls immune system?

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MAXILLARY SINUS
Largest PNS Paired Pyramidal in shape Capacity 30 ml

Base pointing to lateral wall of nose Apex laterally in zygomatic process

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Relations Maxillary sinus

Ant facial surface of maxilla Post infratemporal & pterygopalatine fossa Medial- middle & inferior meatus

Floor- alveolar& palatine process Roof- floor of orbit

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Important to dentist .bc of proximity of teeth and their

associated structures

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FRONTAL SINUS
Resides in frontal bone 2 nd largest Assymmetrical Usually pairedsometimes 1, 3 or none!

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Relations Frontal sinus

Ant- skin over the forehead Inf- orbits & its contents Post- meningeal and frontal lobe of brain

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Ethmoid sinus
within the ethmoidal labyrinth of the lateral mass of ethmoid bone divided into 1. Anterior 2. Middle 3. Posterior groups according to the area of drainage

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Ethmoid sinus - Relation

lies b/w the upper part of nasal cavity & orbits (2) and is separated from the orbit by a thin orbital plate of ethmoid laterally. Below is the part of maxillary airsinus(4) and superiorly is the anterior part of frontal sinus (1)
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Sphenoid Sinus
Resides in body of sphenoid May be single or paired Assymmetrical Not present at birth Lies below to sella tursica Related to optic tract, chiasma, internal carotid artery
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Sphenoid Sinus - Relation

Pituitary gland lies above the sphenoid sinus Optic nerve and internal carotid arteries traverse its lateral wall The nerve of pterygoid canal lie in the floor of the sinus
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Blood supply
Ethmoid Sphenopalatine art Ant & posterior ethmoidal artery Maxillary facial, infra orbital, greater palatine art

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Blood supply
Sphenoid sinus post ethmoidal art Frontal Supra orbital art ant ethmoidal

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Lymphatic drainage
ANTERIOR Maxillary Frontal Ethmoid- ant,middle

submandibular nodes
SUBMANDIBULAR

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Lymphatic drainage
POSTERIOR

Post ethmoid Sphenoid

retropharyngeal nodes

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NERVE SUPPLY
Maxillary- infra orbital
alveolar nerves (ant, middle, post sup)

Frontal - Supra orbital nerve traversing the floor of

the sinus

Ethmoid - Ant and post ethmoidal nerves.

Orbital br of pterygopalatine ganglion

Sphenoid - post ethmoidal nerve

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MICROSCOPIC ANATOMY

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 Lined by mucus membrane Ciliated columnar epithelium Goblet cells secretes mucus Cilia are marked near ostia

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Cilia 9+2

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epithelial lining has a cilium - relatively long structure -> push sinus mucus.

mucociliary clearance is programmed , so mucus moves along in a specific pattern.

(About ltr per 24 hr !)

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The sinus doesnot drain by gravity - it is an active process.

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Ostiomeatal complex
All sinus open into middle meatus except post ethmoid & sphenoid sinus The openings of the sinus ostia into the middle meatus are close together and form the ostio-meatal complex Functional reln between the space and the ostia that drain into it
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This is a key area because pathology in this region can interfere with ventilation and mucociliary clearance of the sinuses. Prolonged obstruction of these ostia during prolonged nasotracheal intubation can lead on to chronic sinusitis
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 Ostium: opening within the maxillary sinus Uncinate process: sickle shaped bone extension of the medial wall Infundibulum: the canal like structure Hiatus semilunaris: slit like air space Bulla ethmoidalis: largest ethmoidal bulla Middle meatus: where hiatus semilunaris opens
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BE

infundibulum

ostium

DRAINAGE OF SINUSES
1) SS sphenoethmoid recess
FS

2) FS infundibulum of middle 3) Ant ES / infundibular infundibulum of middle 4) middle ES / Bullar sinus ethmoid bulla of middle
SS

ES

5) MS middle meatus (posterior ethmoid cells superior)

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One other structure empties into the nasal cavity and the is the nasolacrimal duct. This duct carries away extra tears. when the drainage pores are closed off due to irritation, they fill up and cause pressure which can then cause headaches (sinus headaches).

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APPLIED ANATOMY

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Paranasal sinuses are joined to nasal cavity via small orifices called Ostia

Ostia easily blocked -> drainage of mucus is disrupted Sinusitis may result Latin word SINUO = bend, wind, curve

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SINUSITIS

It is a condition of infection or inflammation of PNS, which may or may not be a result of infection, from bacterial, viral, fungal, allergic or autoimmune issues.

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Maxillary > ethmoid > frontal > sphenoid

All sinuses affected

Pansinusitis
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Predisposing factors
Allergies Asthma DNS Small sinus ostia Smoking Nasal polyps Cystic fibrosis -thick mucus

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Mallus.
River bath Oil bath Change of weather Humid climate

Sea air Pollution Two wheeler Allergies from pets

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SINUSITIS
Cause of a/c sinusitis Virus Bacteria Fungus Nose blowing Scuba diving Foreign body Medications Dental infections Trauma Adenoids & tonsillitis DNS , polypi , beneign tumours Cause of c/c sinusitis Allergies Fungus Unresolved a/c sinusitis Asthma Temp & humidity Narrow sinuses Defective m m Dehydration Poor air quality Weak immune system Hormones & stress Polyps & tumours

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Viral Rhinosinusitis
Most URTI are viral Short lived, lasts less than 10 days Sinus mucosa & nasal mucosa is involved

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Classification of Bacterial Sinusitis

a/c < 4 weeks Resolve completely Resolves completely

Sub a/c

4 - 12 weeks

c/c

> 12 weeks

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Chronic Sinusitis
Symptoms present longer than 8 weeks in adults or 12 weeks in children Eosinophilic inflammation or chronic infection Associated with positive CT scans

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Bacteria Involved in Chronic Sinusitis

Role of Viruses is Unknown Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria

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Fungal sinusitis
Patients with Diabetes or immune defeciencies Aspergillus - temperate climate mouldy work atmosphere Mucor species

Life threatening

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Paediatric sinusitis
R/c cold , allergy Intake of cold food Foreign bodies in nose Influenza Measles Adenoids Living in congested area, unhygeinic env
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PATHOLOGY
Mucus membrane affected Secretions -> purulent Increased ciliary movement -> ineffective -> destruction Proliferation of mm Thickening of memb -> polyps Infection -> submucus layer -> bone Fibrous tissue, new bone formation
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CLINICAL FEATURES
a/c sinusitis
Vacuum headache Systemic malaise, bodyache, fever MM of nose red & oedematous Pus from corresponding outlets

c/c sinusitis
Headache Facial fullness < bending Fever Hoarseness Halitosis Nasal obstruction Nasal discharge - purulent PND Abnormalities of smell Epistaxis r/c sore throat

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Frontal

Above eyes < morning Deep behind eyes Localised to upper teeth < noon Deep seated central pain Vertex / occiput

Swelling of upper eyelid Medial canthus

Ethmoidal

Maxillary

Lower eyelid

Sphenoidal

55 www.similima.com Blockage of frontonasal duct -> air absorbed -> hyperaemia -> HA

Routes of spread
Dehiscences and weak bony barriers Floor of the frontal sinuses form the roof of the orbit (Infraorbital canal) Thrombophlebitis via diploic veins present in the frontal bone - veins of Breschet. Venous connections between the sinuses and the orbit donot have any valves The roots of the second premolar and the first upper molar are intimately related to the floor of the maxillary sinus.
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Predisposing factors for complications

Immunocompromised patient (e.g. HIV) Diabetes mellitus Irregular treatment for sinus infections

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ORBITAL COMPLICATIONS
Orbital cellulitis & abscess Blindness compression of optic canal Optic neuritis infection thru dural sheath of optic N

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INTRACRANIAL COMPLICATIONS
Meningitis thrombophlebitis Brain abscess Cavernus sinus thrombosis CSF rhinorrhoea from blowing nose Persisting HA Defects in memory, behaviour

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OTHER COMPLICATIONS
Osteomyelitis Pott's puffy tumor: oeteomyelitis of frontal bone Fractures Mucocoele Cysts Fistula Malignancies Tumours Kartageners syndrome
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DIAGNOSIS
Duration of s/s Diagnostic Nasal Endoscopy (DNE)congestion & mucopus CT scan Echosinography Diagnostic proof puncture Tissue sample for histology & culture Multiple biopsy Transillumination maxillary & frontal
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Radiographic positions for paranasal sinuses Occipito-mental view (Water's view) Occipital-frontal view (Caldwel view) Submento-vertical position (Hirtz position) Lateral view Oblique view 39 Degrees oblique (Rhese position)

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Waters View

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Waters view ( occipitomental )

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ELICITING SINUS TENDERNESS

Frontal sinuses by pressing the finger upward beneath the medial end of the superior orbital margin. Ethmoidal sinuses with the thumb in the inner canthus of one eye and the index finger in the other and pushing posteriorly, posterior to the lachrymal bone and squeezing. Maxillary sinus by pressing the finger against the ant wall of maxilla below the inf orbital margin
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Surgical intervention
Trephening of the frontal sinus for a/c sinusitis through floor of the frontal sinus above the inner canthus Antrum puncture Intra nasal antrostomy Caldwell-LUC operation Balloon catheter dilation of paranasal sinus for chronic sinusitis

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D/D
Allergic rhinitis Bronchitis Rhinoviral infections Upper respiratory infection Cystic fibrosis (especially in children with polyps) HIV infection Wegener's granulomatosis Tumors Mucor Mycosis Migraine
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Differentiating Sinusitis from Rhinitis

Sinusitis Nasal congestion Postnasal drip Headache Facial pain Anosmia Cough, fever Rhinitis Nasal congestion Runny nose Itching, red eyes Nasal crease Seasonal symptoms

Purulent rhinorrhea Rhinorrhea clear

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PREVENTION

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For sinus pain or pressure

Avoid flying when you are congested Avoid temperature extremes Avoid sudden changes in temperature Avoid bending your head down

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 Apply a warm, moist washcloth to your face several times a day Drink plenty of fluids to thin the mucus Inhale steam 2 - 4 times per day nasal saline several times per day Use a humidifier?

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 Saline rinse - one cup of warm water + 1/4 teaspoon of non-iodized salt + teaspoon of baking soda

Discontinue eating milk and cheese since dairy products contribute to mucus production in the body
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 Avoid substances that dehydrate the body - spicy foods, alcoholic beverages, tea and coffee Avoid excessive forceful nose-blowing Avoid swimming or diving, which can put undue pressure on the sinuses
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Frontal sinus
Supra orbital nerve referred pain over skin of forehead upto vertex Drains close to maxillary sinus orifice infection spreads easily Brain abscess in frontal lobe

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Maxillary sinus
Commonly involved aperture above floor of sinus & poor natural drainage Proximity of maxillary molar tooth Sup alveolar nerve sensation of toothache Infra orbital nerve referred pain to upper jaw & teeth

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Ethmoid sinus
Fragile medial wall of orbit blindness & optic neuritis Common in paediatric age group Common site of # - CSF Rhinorrhoea

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Sphenoid sinus
Spread upward in front of pituitary affects optic chiasma disturbed vision

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Other Diseases Affecting Sinuses

Mucocoele Cysts Oro antral fistula Tumours of the sinuses Barotrauma Fractures

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Mucoceles
c/c cystic lesions esp in the frontal & ethmoid result of obstruction of the sinus ostium accumulation of secretions into an expanding mass. Expansion and inflammation lead to remodeling and erosion of bone, which changes the bony architecture significantly. Usually contents of the mucocele are sterile If infected, then known as mucopyocele
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Cysts
more popularly known as nasal polyp soft and pearl-colored growths that develop in the lining of the sinuses. in singles or clustered together by prolonged inflammation of the nasal passages. Symptoms of allergies and asthma can also lead to polyp formation.
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Oro Antral Fistula

Abnormal cavity that connects oral cavity with maxillary sinus Usually caused after tooth extraction particularly premolars & molars

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Tumours of sinuses
BENIGN Transitional cell papilloma - Localised ivory osteoma - Cancellous osteoma MALIGNANT - Squamous cell carcinoma

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Kartageners syndrome
cilia are unable to move rare genetic birth defect Autosomal recessive Triad Dextrocardia Bronchiectasis Sinusitis Primary ciliary dyskinesia /Immotile ciliary syndrome Afzelius syndrome /Zivert's syndrome
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HOMOEOPATHY

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MIASMATIC DIAGNOSIS
Early stage psora R/c infection of sinus tubercular & sycosis

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PSORA
Rhinitis

SYCOSIS
Sinusitis DNS, adenoids Moist snuffles with purulent dge < damp weather > Abn dge

SYPHILIS
Deg & ulcerative condn Clinkers with offensiveness < nght warmth > Abn dge

TUBERCULA R
Epistaxis Nasal polyps Narrow nostrils r/c & c/c Epistaxis PND < closed room > Open air > epistaxis

a/c symp Thin watery < morning cold > Natural Dge

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MURPHYS REPERTORY
Children - CATARRH, infants - sinuses, of Constitutions - INFANTS, constitutions catarrh - sinuses, of Diseases - SINUSITIS, infection, nose Emergency - HEADACHES, severe, migraines - sinus, headache
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BBCR NOSE - Internal sinuses PHATHAK N - Nose - sinuses S - Sinus affections, of BOERICKE NOSE - Pain in - Pressing - in frontal sinuses NOSE - Sinuses NOSE - Sinuses - Catarrh of frontal sinuses
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COMPLETE REPERTORY
GENERALITIES - INFLAMMATION chronic - sinusitis

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SYNTHESIS
GENERALS - HISTORY; personal sinusitis; of recurrent GENERALS - INFLAMMATION - Sinuses; of GENERALS - INFLAMMATION - Sinuses; of - recurrent GENERALS - SINUSITIS GENERALS - SUPPRESSED COMPLAINTS; ailments from - sinusitis
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Rare remedies
Luffa operculata Abroma augusta folia Cassia sophera Granatum Erigeron Q Mucor mucido Distemberinum vaccinum Oscillococcinum Justisia adhatoda Berrylium mur Oxygenium Gallium sulph Tungstenium Cotyledon sinusitisinum

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 Purulent sinusitis Frontal and occipital headache Acute or chronic inflammation of the mucous membranes in the nasal cavities Hypertrophy or atrophy of the nasal mucous membranes Violent headaches going from the forehead towards the nape of the neck Pain in the occipital region Frontal pains , with vertigo and muscae volitantes. Head cold , with pale or yellow nasal secretion , especially in the morning. Extreme hunger with emasciation Dryness of the nasal mucus, with sticky scab formations. < dry air in the closed room. > fresh air outdoors.

Luffa operculata

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Abroma augusta folia

Vertigo with empty feeling of head Dull frontal headache with heaviness < sun > motion > open air , pressure Dryness of mouth with thirst Thirst for large quantity of cold water Bitter taste in mouth Dryness of tongue
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Cassia sophera
Dull pain in temporal and frontal regions < heat > Cold application bandage Desire for curd and pickles Desire for warm food and drinks eggs, sweet Appetite, diminished Weakness
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 Granatum (pomgranate)
vermifuge

vertigo

Oscillococcinium

Especially indicated in cases of INFLUENZA in persons where there is a carcinomatous background in the familyanamnesis, somewhat identical to Carcinosinum. Inflammatory reactions

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Berryllium mur
These people are very unsure of themselves. They don't know how to stand up for themselves, especially because they think that the other person will leave them if they do. So they tend to ignore their own needs to please others; they come across as being kind and very easy going.
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Chest radiography showing dextrocardia with aortic arch lying on right side of trachea with cystic bronchiectatic changes

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Sinus polyp

Oroantral fistula

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Frontal sinus mucocele

Girl with displacement of right eye

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Fungal sinusitis

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Role of NO in host defence

In nasal airways, continuous production of NO - indicated by presence of gas in nasally derived air - In Kartagener's syndrome, pts lack NO in nasal air & have severe problems with recurrent airway infection epithelium in paranasal sinuses is a major site of NO production and suggest a role for airway-derived NO in primary host defence

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Structural theory:
Fallopio's theory: (1600) - Reducing the load on neck musculature which supports the head maintenance of equilibrium and the positioning of the head Proetz theory: remodelling of facial bones

Evolutionary theory:
Evolutionary response of anthropomorphic monkeys to shift from terrestrial environment to the aquatic one By Hardy. Necessity to cross large stretches of water enabled them to develop these air filled sinus cavities
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Functional theories:
Bartholini's theory:
As organs of resonance which added quality and resonance to the voice

Cloquet's theory:
Paranasal sinuses contained olfactory epithelium aiding in the function of smell.

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Sinuses improves nasal function:

Embryological and histological continuity with the nasal mucosa Additional secretion of lytic enzymes and immunoglobulins.

Ventilatory function:
Gaseous exchange There is a pressure gradiant between the nasal cavity and para nasal sinuses causing airflow in to the sinus cavities
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Transillumination of sinus

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