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Sinus Anatomy
Sinus Anatomy Amy Anstead, MD Director, Rhinology and Endoscopic Skull Base Surgery Virginia Mason Medical Center Seattle, WA Location of the sinuses Sinus anatomy pictorial representation F - Frontal sinuses, E - Ethmoid sinuses, M - Maxillary sinuses, O - Maxillary sinus ostium, STSuperior turbinate, T - Middle turbinate, IT- Inferior turbinate, SM- Superior meatus, MM- Middle meatus, S-Septum Hypoplastic Frontal Sinus Nasal Valve Vertical Lamella MT Infraorbital nerve Orbital Apex Inferior Orbital Fissure Optic N. Canal Carotid Anterior Clinoid Foramen Rotundum Sinus anatomy CT scan + - border of maxillary sinus, * - maxillary sinus ostium, U - uncinate process, E ethmoid sinuses, IT- inferior turbinate, MT- middle turbinate, S - septum, C - concha bullosa. CT scans of normal and infected sinuses Normal Infected */O - maxillary sinus ostium, U - uncinate process, E - ethmoid sinuses, ITinferior turbinate, MT- middle turbinate, S - septum, C - concha bullosa, P polyp Axial Cuts 1 Incisive Foramen 1 Greater Palatine Foramen 2 Lateral Pterygoid Muscle 5 Torus Tubarius 3 Medial Pterygoid Muscle 4 Fossa of Rosenmuller 1 Infraorbital Nerve (V2) 2 Nasolacrimal Duct 4 3 Coronoid Process Pterygopalatine Fossa Middle Turbinate (head) 2 1 Nasal Bone 3 Nasolacrimal Duct Natural Os – maxillary (leads to OMC) 4 5 Sphenopalatine Foramen 6 Foramen Ovale (V3) 7 Foramen Spinosum 8 ICA Inferior Orbital Fissure 1 4 9 cm (distance to columella) ICA 2 3 Clivus Cribriform Plate 1 Planum Sphenoidale 3 Pituitary Gland in Sella Turcica 4 (hypophyseal fossa) Posterior Clinoid Process 5 2 Optic Nerve (in optic canal) 6 Opticocarotid Recess Coronal Cuts Superior 1 Sagittal Sinus 2 3 Columella Intersinus Septum (frontal sinus) 1 Internal Valve 2 Superior Oblique Muscle Lacrimal Gland 1 Agger Nasi Nasal Spine 2 3 Crista Galli 1 Middle Turbinate 2 3 Lacrimal Sac 4 Inferior Oblique Muscle 5 Nasal Crest 1 Fovea Ethmoidalis Olfactory Fossa & 2 Cribriform Plate 3 Lamina Papyracea 4 Uncinate Process 5 Infraorbital Nerve (V2) 6 Hasner’s Valve 7 Incisive Foramen 8 Olfactory Cleft Anterior Ethmoid Artery 1 2 Levator Palpebrae Superioris 3 Superior Rectus Ethmoid Bulla 6 4 Medial Rectus 5 Inferior Rectus Natural Os – maxillary (leads to OMC) 7 2 Posterior Ethmoids Optic Nerve 1 3 Basal Lamella of the Middle Turbinate 1 Optic Nerve Superior Orbital 2 Fissure 3 Sphenopalatine Foramen 4 Greater Palatine Canal (pterygopalatine canal) 1 Optic Nerve / Chiasm 2 7 cm 1 Anterior Clinoid Process Foramen Rotundum (V2) 3 2 Intersinus Septum (sphenoid) Vidian Canal 4 Pharyngeal Canal 7 Rostrum Sphenoidale 5 6 Choanae Pituitary Gland in Sella Turcica (hypophyseal fossa) 1 2 Posterior Clinoid Process 3 4 Eustachian tube Medial & Lateral Pterygoid Plates 1 ICA Sagittal Cuts Anterior & Posterior Ethmoid Arteries (12 mm) 1 1 Anterior Ethmoid Artery (in roof of most superior subrabullar) 2 Hiatus Semilunaris 1 Crista Galli 2 Perpendicular Plate of Ethmoid 3 Vomer Anterior Arch of Atlas (C1) 4 Odontoid Process (Dens) of Axis (C2) 5 Abnormal CT Sinuses Lateralized Middle Turbinate Mucus retention cysts • Prior ESS; Right side clear rhinorrhea . . . Ethmoid Mucocele Sinusitis – Medical Management? CRS - Maximal Medical Therapy Survey (N= 308 ARS members) CRS - Maximal Medical Therapy • Which CRS therapies must fail before you recommend sinus % who use this almost surgery? always (>90% of time) 1. Oral antibiotics 2. Nasal steroids 3. Nasal saline irrigation 4. Oral steroids 5. Allergy testing 81% 74% 43% 29% 22% CRS - Maximal Medical Therapy • Length of oral antibiotic therapy? ▫ • 2 – 4 weeks (67% used this length) Length of oral steroid therapy? ▫ ▫ 6 – 14 days (67% used this length) High dose (tapered to off) CRS - Maximal Medical Therapy • Other therapies SOMETIMES used (10-50%) ▫ ▫ ▫ • Antihistamines Mucolytics Leukotriene inhibitors Therapies Rarely or Never used (0-10%) ▫ Antifungals ▫ Oral / spray / nebulizer Antibiotic IV / spray / nebulizers CRS - Maximal Medical Therapy • Failure of medical therapy ▫ Persistence of BOTH Radiographic disease AND Symptoms Sinusitis – Diagnosis & Treatment 31 pages Review Diagnosis & Treatment of . . . 1. Acute Sinusitis 2. Recurrent Acute Sinusitis 3. Chronic Sinusitis ACUTE Rhinosinusitis • Acute = less than 4 weeks • 3 Cardinal Symptoms of ARS: ▫ Purulent drainage ↑ sensitivity ▫ Nasal obstruction ▫ Facial pain-pressure-fullness • GOAL - Distinguish bacterial from viral/noninfectious • Bacterial - (if signs/symptoms . . .) ▫ 10 days or more ▫ Initial improvement then worsen w/in 10 days (double worsening) Acute Rhinosinusitis • Only PE finding (to have diagnostic value for ARS) ▫ Purulence (nasal or posterior pharynx) • Sputum color is not determined bacteria! • Sputum color determined by? ▫ Neutrophils (not bacteria) ▫ Generally, allergies and viral ARS have clear mucus Acute Bacterial How to Treat? • Mild to moderate pain ▫ acetaminophen or NSAIDS (alone or c opioid) • Symptomatic relief ▫ Topical steroids, PO/topical Decongestants, Saline irrigation, and Mucolytics (in order of evidence). • Observation (no antibiotics) ▫ Mild, uncomplictd (mild pain & <101°F) & good f/u ▫ Start Abx if no improve (p 7 days from Diagnosis) • Antibiotics ▫ Severe, complic sinusitis, immune deficiency, prior sinus surgery, or coexisting bacterial illness. ▫ CONSIDER age, health, cardiopulmonary / comorbid Acute Bacterial • After 7-14 days Placebo = __% improve & __% cure 70% improve & 35% cure !!!! ▫ Abx improve outcomes (rate difference) 15% ▫ PCP setting & exclude severe/persistent Dz ▫ ↑objective dx = ↑ antibiotic benefit (+) imaging, (+) culture, Validated algorithm • 1st line therapy = ___(Abx)____ Amoxicillin ▫ Which Abx has been proven to have significant better outcomes? NONE (no signif outcome difference among antibiotics!!) Amoxicillin, Augmentin, Cephalospn, or Macrolides ▫ Amoxil slightly better than placebo ▫ PCN allergy should use? Bactrim (cheap) or macrolide (Z-pak) Acute Bacterial • How long to treat with Abx? ▫ No relation btw Abx duration & outcome (8 RCTs!) ▫ Most trials use 10 days ▫ ↑ Abx = ↑ side effects & ↑resistance • Top 3 organisms? ▫ #1 Strep pneumo, #2 H. flu, #3 M. cat ▫ Amoxil resistance for each? 25%, 80%, & 30% (respectively) Acute Bacterial Failure Define treatment failure • Worsen or no improve p 7 days from diagnosis • now, what to do with this patient? 1. Exclude other causes 2. R/o complications 3. Start or change antibiotics • Why 7days? . . . 73% improve c placebo & 85% Abx ▫ ▫ NOT severe, complic sinusitis, immune deficiency, prior sinus surgery, or coexisting bacterial illness. CONSIDER age, health, cardiopulmonary / comorbid Acute Bacterial Failure • Cultures (of Abx failure) show ↑resistance to original Abx (amoxil) • What are 2nd line Abx? ▫ Augmentin or fluoroquinolone (broad) ▫ Cephalosporins or macrolides (narrower) Chronic vs Recurrent Acute Define Chronic • >12 weeks • Signs/Sx (at least 2 of 4): ▫ ▫ ▫ ▫ Mucopurulent drainage Nasal congestion Facial pain-pressure-fullness Decreased smell • AND inflammation (at least 1 of 3) ▫ Purulent mucus or edema (middle meatus) ▫ Polyps ▫ Radiographic imaging c inflammation Chronic vs Recurrent Acute Define Recurrent Acute 1.4 or more per year 2.Between episodes no signs/symptoms • Why 4? ▫ Avg adult has 2 colds/yr (1.4-2.3) ▫ REALITY – hard to meet ABRS criteria 4 times/yr • (for recurrent acute) When get culture? or CT? ▫ Culture (acute) and CT (between episodes) CRS Differential Diagnosis • Allergic rhinitis • Nonallergic rhinitis ▫ vasomotor rhinitis, eosinophilic nonallergic rhinitis, etc. • Septal deviation / turbinate hypertrophy • Neoplasm • Neurologic facial pain ▫ Vascular headaches, migraine, trigeminal neuralgia, etc. Chronic & Recurrent Acute • 5 predisposing factors / diseases: ▫ Allergic rhinitis Very associated with CRS ▫ ▫ ▫ ▫ Cystic fibrosis Ciliary dyskinesia Immunocompromised state Anatomic variation Poor evidence Chronic & Recurrent Acute • 3 tests to perform/order: ▫ Nasal endoscopy See inflammation, obstruction, masses Obtain culture ▫ Radiographic imaging See inflammation, obstruction, masses ▫ Allergy/immune testing Chronic & Recurrent Acute • Gold standard radiologic test? ▫ CT scan • How well does CT correlate c symptoms or QOL? ▫ Very poor correlation Chronic & Recurrent Acute Immunocompromised state ▫ Examples: IgA deficiency, common variable immunodeficiency, hypogammaglobulinemia, ↓ pneumo vaccine response, or HIV ▫ Usually have other infections (bronchitis, acute OM) ▫ Labs Quantitative IgG, IgA, and IgM Specific Ab responses to tetanus & pneumo vaccine (pre&post) T-cell number and function Delayed hypersensitivity skin tests Flow cytometric enumeration of T cells Prevention • Educate patients about control measures ▫ ▫ ▫ ▫ Hand hygiene (prevent viral ARS) Tobacco use (↓ sinusitis) Nasal saline GERD? If they fail medical treatment?
