The signs and symptoms of acute sinusitis frequently include a thick, yellow or greenish discharge that drains from the nose or down the back of the throat, difficulty breathing through the nose owing to a nasal obstruction or congestion, and pain, tenderness, swelling, and pressure in the eye, cheek, nose, or forehead region that becomes more intense when the patient bends over.[1]
The maxillary sinus is a pyramidal cavity, the base of which lies lateral to the nasal cavity. In adults, the dimensions of the sinus are approximately 33 mm in height, 23-25 mm in width, and 34 mm in the anteroposterior axis; the volume is approximately 15 mL. Maxillary sinus size may be asymmetrical within the same individual.[2]
The focal point of sinus drainage is the ostiomeatal complex, which comprises the maxillary, frontal, and anterior ethmoid ostia and is located in the middle meatus. The posterior ethmoid sinuses empty into the superior meatus, and the sphenoid sinuses empty into the sphenoethmoidal recess.
While superior location of the maxillary sinus ostia can lead to drainage complications and maxillary sinus disease, a study by Butaric et al indicated that the position of these ostia relative to the floor of the maxillary sinuses is significantly influenced by the size and height of the maxillary sinus. A correlation was found between a larger, taller maxillary sinus and superior placement of the ostia relative to the sinus floor.[3]
(A study by Tomomatsu et al suggested that the aperture width of the ostiomeatal complex influences whether initial treatment of odontogenic maxillary sinusitis,[4] using either antibiotic therapy or treatment of the causative tooth, are effective. Of the 39 patients in the study, the aperture tended to be significantly narrower in the 19 patients in whom the initial treatment was unsuccessful.[5] )
The sinus mucosa has less secretory and vasomotor function than the nasal cavity. Cilia are concentrated near the natural sinus ostia and beat toward them. Ostium blockage results in stasis of mucus flow, which can result in development of disease. (See the image below.)[6, 7]
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Surgical treatment of acute maxillary sinusitis. The left orbital subperiosteal abscess is displacing the medial rectus muscle.
Sinus puncture and irrigation techniques allow for a surgical means of removal of thick, purulent sinus secretions. Use a surgical means of sinus drainage when appropriate medical therapy has failed to control the infection, resulting in prolonged or slowly resolving symptoms, or when the patient has complications of sinusitis.[8, 9]
Another indication for sinus puncture is to provide culture material to guide antibiotic selection when empiric therapy has failed or when antibiotic choices are limited. This is particularly important in patients who are immunocompromised or under intensive care, in whom sinusitis can be a prominent source of sepsis.
Preoperative imaging is necessary to document the presence of acute sinusitis and to guide surgical planning.
In addition to surgical management, manage complications of acute sinusitis with a course of intravenous antibiotics. Third-generation cephalosporins (eg, cefotaxime, ceftriaxone), in combination with vancomycin, provide adequate intracranial penetration, making them a good first-line choice.[10, 11, 12]
A retrospective study by Troeltzsch et al of 174 patients who required surgical treatment for symptomatic unilateral maxillary sinusitis found that the majority of cases (75%) had an odontogenic etiology, including 83 cases that occurred following dentoalveolar surgical procedures.[13]
Similarly, a retrospective study by McCarty et al of 84 patients with acute maxillary sinusitis found a high prevalence of potential odontogenic sources, with no difference in such prevalence between immunocompetent and immunocompromised patients. However, immunocompromised patients had a greater frequency of bilateral sinusitis than those who were immunocompetent (67% vs 33%, respectively). Out of all patients, oroantral fistula was found in 1%, periapical lucencies in 16%, and projecting tooth roots in 71%.[14]
Maxillary sinus mucoceles or cysts are usually found incidentally on sinus radiography and are of little significance in the absence of symptomatology or infection. Surgical treatment is not usually necessary, and these lesions often regress spontaneously over time. If surgery is indicated, endonasal sinus techniques should be the standard approach.[15]
Conversely, frontoethmoidal and sphenoethmoidal mucoceles tend to be symptomatic and have a high potential for bony erosion. Frontoethmoidal mucoceles should be completely removed and the sinus obliterated. Sphenoethmoidal mucoceles should be widely opened into the nasal cavity. An ethmoidal mucocele appears in the image below.
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Surgical treatment of acute maxillary sinusitis. The left ethmoidal mucocele is complicating chronic sinusitis: note the proptosis of the left eye.
Orbital complications
Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins.
Surgical drainage of the infected sinuses and the orbit is advocated for Chandler classifications III-V if orbital cellulitis progresses or fails to improve despite medical therapy or if loss of visual acuity occurs.
Intracranial complications
Schlemmer and Naidoo (2013) published a retrospective study from South Africa on complicated sinusitis.[16] They described 138 patients with orbital complications only and 82 with intracranial complications.
A high index of suspicion must be maintained in detecting intracranial extension of the disease. Appropriate referral for management prevents high rates of morbidity and mortality. Management of intracranial complications of sinusitis is surgical—drainage of the affected sinus and the cranial abscess.
Al-Radadi and Alnoury (2011) reported on a patient with optic chiasma compression.[17] This is a very rare complication of allergic fungal rhinosinusitis. Immediate medical and surgical management is important.
Several techniques have been described for drainage of the maxillary sinus. The inferior meatus and canine fossae are optimal drainage sites because of their ease of accessibility and relatively thin, well-vascularized bone.
Place conscious patients in the sitting position to allow for drainage of the sinus contents into a provided basin. Protect the airway and suction the oropharynx during sinus puncture performed on unconscious patients. In patients in the intensive care unit, catheterization of the sinus may be undertaken with puncture to ensure continued adequate drainage.
Inferior meatal puncture
Use topical anesthesia (eg, cocaine, tetracaine, lidocaine 4%) and a local anesthetic/vasoconstrictor (eg, lidocaine 1% with epinephrine 1:100,000) to infiltrate the inferior meatal mucosa.
Placement of a curved trocar through the mucosa and bone 1 cm above the floor of the nose, one third of the way toward the posterior choana with an upward angle, allows for optimal penetration of the sinus. A curved trocar is preferred to the straight type to minimize risk of orbital injury caused by misdirected force. Advance the trocar until the sinus mucosa is penetrated, then remove the introducer.
Aspirate a sterile sample with a 10-mL syringe for Gram stain, culture, and sensitivities.
Irrigation of the sinus with 50-100 mL of isotonic sodium chloride solution allows flow of purulent secretions through the natural ostium. Irrigation should commence only after the position of the trocar is confirmed to be in the antrum by aspiration of air or purulent fluid.
The procedure is complete when secretions passing through the natural ostium are clear. Remove the trocar and have the patient rest for 15 minutes to prevent vasovagal episodes.
Canine fossa puncture
Use topical anesthesia (eg, cocaine, tetracaine, lidocaine 4%) and a local anesthetic/vasoconstrictor (eg, lidocaine 1% with epinephrine 1:100,000) to infiltrate the superior gingivolabial groove at the level of the canine fossa.
Placement of a straight trocar through the mucosa and bone superior to the root of the canine tooth, inferior to the infraorbital foramen, medial to the zygomatic buttress, and lateral to the piriform aperture, allows for optimal penetration of the sinus. Advance the trocar until the sinus mucosa is penetrated, and then remove the introducer.
Aspirate a sterile sample with a 10-mL syringe for Gram stain, culture, and sensitivities.
Irrigate the sinus with 50-100 mL of isotonic sodium chloride solution, which allows flow of purulent secretions through the natural ostium. Irrigation should commence only after the position of the trocar is confirmed to be in the antrum by aspiration of air or purulent fluid.
The procedure is complete when the secretions passing through the natural ostium are clear. Remove the trocar and have the patient rest for 15 minutes to prevent vasovagal episodes.
Endoscopic techniques
Endoscopic techniques of sinus drainage may be useful if multiple sinuses are infected or to decompress the orbit in patients with complications.
Using a 0° or 30° telescope, the nasal cavities are inspected bilaterally. The condition of the mucosa, turbinates, septum, and airway are noted, as is the presence of purulent secretions. On the side of the maxillary sinus infection, the middle turbinate and uncinate process are infiltrated with 1-2% lidocaine with 1:100,000 epinephrine. The nose is then packed with 0.25-inch gauze for 5 minutes, allowing time for optimal decongestion.
Using a freer elevator or a backbiting instrument, the uncinate process is removed, exposing the maxillary sinus ostium. The maxillary sinus is entered using a curved suction, and secretions are sent for culture. The ostium is opened widely to allow for optimal sinus drainage. If the patient has concurrent ethmoid disease, an ethmoidectomy is performed.
No absolute contraindications for maxillary sinus drainage exist; however, prudent evaluation is necessary in patients at high risk of bleeding (eg, low platelet count) or with anatomic variations that increase the risk of injury to adjacent structures (eg, hypoplastic maxillary sinus).
Complications of nonendoscopic drainage procedures can be minor or severe. The most common complication is failure to enter the sinus because of improper positioning of the trocar, incomplete penetration of the sinus mucosa, or the presence of a hypoplastic antrum. Epistaxis may occur because of laceration of the nasal mucosa or preexisting coagulopathies necessitating packing. Severe complications include orbital injury, air embolism, and death secondary to injection of air into the sinus.
Ted L Tewfik, MD, Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA, Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .
Acknowledgements
Stephen G Batuello, MD Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.
Hassan H Ramadan, MD, MSc Professor and Vice-Chair, Department of Otolaryngology-Head and Neck Surgery, Professor, Department of Pediatrics, West Virginia University School of Medicine
Hassan H Ramadan, MD, MSc is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and American Rhinologic Society
Disclosure: Nothing to disclose.
Melvin D Schloss, MD, FRCSC Director of Pediatric Otolaryngology, Professor, Department of Otolaryngology, McGill University Faculty of Medicine, Canada
Melvin D Schloss, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.
Steven E Sobol, MD, FRCSC, MSc, FAAP Assistant Professor, Director of Pediatric Otolaryngology, Department of Otolaryngology Head and Neck Surgery, Emory University School of Medicine; Otolaryngologist-In-Chief, Children's Healthcare of Atlanta at Egleston
Steven E Sobol, MD, FRCSC, MSc, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
References
Mayo Clinic. Acute sinusitis. Available at https://www.mayoclinic.org/diseases-conditions/acute-sinusitis/symptoms-causes/syc-20351671. Accessed: Jun 18, 2019.
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