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Section 2 Inammatory Nasal Conditions92
A
Figs. 5.18A and B: Pneumosinus dilatans in a case of Crouzon Syndrome. (A) Large air
lled ethmoid sinuses (arrow) with mid-face hypoplasia; (B) Small sphenoid bone (asterisk).
A
Figs. 5.19A and B: Pneumosinus dilatans in acromegaly. (A) Abnormally expanded
air-lled frontal and ethmoid sinuses (arrow); and (B) Heterogenously enhancing large sellar
mass s/o pituitary macroadenoma (asterisk).
B
B
of normal thickness. Initially used for frontal sinus but any sinus may
be aected (Figs. 5.18 and 5.19).
• Pneumocele: Abnormal expansion with thinning/demineralization of
the walls of the sinus.
■ Complications:
• Rupture of such sinus can result in pneumocephalus.
• Compression of the optic nerve in the optic canal can result in
diminution of vision.
■ Causes:
• Acromegaly
• Anterior skull base meningioma
• Anterior skull base arachnoid cyst
• Fibrous dysplasia.
■ Management: If symptomatic, endoscopic decompression is required.
CONCLUSION
Polyps and mucoceles are common expansile masses of the sinonasal cavity.
In case of mucoceles, imaging evaluation should be done to look for an
underlying cause.
REFERENCES
1. Mafee MF, Tran BH, Chapa AR. Imaging of rhinosinusitis and its complications:
plain lm, CT, and MRI. Clin Rev Allergy Immun. 2006;30:165-86.
2. Joshi VM, Sansi R. Imaging in sinonasal inammatory disease. Neuroimag Clin N
Am. 2015;25:549-68.
3. Broderick DF. e opacied paranasal sinus: approach and dierential. Appl
Radiol. 2015;44:9-17.
4. Whyte A, Chapeikin G. Opaque maxillary antrum: a pictorial review. Australas
Radiol. 2005;49:203-13.
5. Zou J, Man F, Deng K, et al. CT and MR imaging ndings of sinonasal angiomatous
polyps. Eur J Radiol. 2014;83:545-51.
6. Urken ML, Som PM, Lawson W, et al. Abnormally large frontal sinus. II.
Nomenclature, pathology, and symptoms. Laryngoscope. 1987;97:606-11.
93Chapter 5 Imaging in Polyps and Mucoceles
6
CHAPTER
Chronic Rhinosinusitis:
Clinical Aspects
Arvind Kumar Kairo, Hitesh Verma
• Introduction
• Allergic Rhinosinusitis
– Diagnosis
– Treatment
• Infectious Rhinosinusitis
INTRODUCTION
Rhinosinusitis (RS) is dened as inammation of the mucosa of nose and
paranasal sinuses.
Rhinosinusitis is broadly classied into allergic, infectious, and other
groups (such as hormonal, occupational, drug, food related and
emotional).
ALLERGIC RHINOSINUSITIS
e prevalence of allergic rhinosinusitis is between 10% and 20% of
population with a male predominance and it is more common in young
adults. It is frequently associated with other allergic conditions such as
asthma, conjunctivitis as a part of the “allergic march”.
If the symptoms last for less than 4 days a week, for less than 4 weeks, RS
is called “intermittent”.
If the symptoms last for more than 4 days a week and for more than 4
weeks, RS is called “persistent”.
Diagnosis
Diagnostic provocative tests:
• Allergy testing: Skin prick test (SPT), serum specic immunoglobulin
E (IgE) [as radioallergosorbent test (RAST)]
• Allergen, lysine aspirin and methacholine nasal challenge test
Radiology
Nasal airway can be assessed by rhinomanometry or acoustic rhinometry.
Chronic Infectious Rhinosinusitis
▪ Treatment
– Polyposis
▪ Diagnosis
▪ Treatment
Treatment
Primary prevention is by restriction of allergen exposure.
Pharmacotherapy:
• Antihistaminics: ese helps in relieving symptoms in the initial hours
of exposure such as running of nose, itching, and sneezing.
• Topical glucocorticosteroids: e onset of action is slow and starts after
6–12 hours, reaches its maximum level after a few days. It is the most
eective treatment for allergic rhinosinusitis. It acts on all the forms
of symptoms.
• Topical nasal decongestants: ese act by reducing nasal obstruction.
Persistent use for more than 3 to 7 days (J Investig Allergol Clin
Immunol 2006; Vol. 16(3): 148-155) can cause rhinitis medicamentosa.
• Spray form of sodium cromoglycate and ipratropium bromide are also
useful but have limited compliance.
• Systemic corticosteroids: Tapering dose of oral steroids is indicated in
patients with severe symptoms not responding to above medications.
• Immunotherapy: Immune tolerance is created by repeated exposure
to the allergen extract. Immunotherapy may be considered in patients
with limited spectrum of allergies, with severe disease and failure to
response to usual treatment as it can cause serious systemic reaction,
and the treatment is cumbersome.
• Surgical indication in allergic rhinosinusitis is the presence of gross
septal deviation and thick turbinates which can aect use of topical
medication.
95Chapter 6 Chronic Rhinosinusitis: Clinical Aspects
INFECTIOUS RHINOSINUSITIS
A variety of viruses can cause acute rhinitis. e sinus may be involved
by secondary bacterial infection. Streptococcus pneumoniae and Haemo-
philus inuenzae are the most common bacteria causing rhinosinusitis.
e fungi and bacteria causing RS are discussed in Chapter 4. Infectious
rhinosinusitis is further classied into four subtypes based on clinical
presentation.
1
• Acute infectious RS: e duration of symptoms is less than 12 weeks
with complete resolution of symptoms.
• Recurrent acute infectious RS: e number of acute episodes is less
than 4 per year, with 8 weeks symptom-free period without treatment.
• Chronic infectious RS: e duration of symptoms is more than 12 weeks,
or incomplete resolution on radiology for more than 4 weeks after
starting medical therapy.
• Acute exacerbations of chronic RS: e patient is presents with newer
symptoms or worsening of existing symptom.
Chronic Infectious Rhinosinusitis
Diagnosis of infectious rhinosinusitis is based on following criteria which
were given by the Rhinosinusitis Task Force of the American Academy of
Section 2 Inammatory Nasal Conditions96
Table 6.1: Diagnostic criteria of infectious rhinosinusitis.
Major criteria Minor criteria
Facial pain/pressure/fullness
Nasal obstruction/blockage
Nasal or postnasal discharge/purulence (by
history or physical examination)
Hyposmia/anosmia
Fever (in acute rhinosinusitis only)
Headaches
Fever (other than acute rhinosinusitis)
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
Fig. 6.1: 0
o
sinoscope.
Otolaryngology—Head and Neck Surgery in 1997. e symptoms are divided
into major and minor type to evaluate severity of disease.1 To diagnose RS,
patient must have two major, or one major with two minor criteria (Table 6.1).
Nasal endoscopy: It is indicated in patients with unreliable history or
sinusitis is not responding to medical management, postoperative
cavity care and in patients with unreliable history. e 0o, 30o, 45o
and 70o endoscopes with diameter of 4 mm (adult) (Fig. 6.1) and 2.7
mm (pediatric) are used to examine nasal cavity and sinus drainage
pathways. To facilitate examination, high intensity light source and light
cable is required. e prerequisites for nasal endoscopic examination are
consent, position, and application of local anesthetic with decongestants.
• e procedure is documented in the form of three passes:
1. First pass includes examination of oor of nasal cavity along with
inferior meatus and nasopharynx.
2. Second pass entails nding the space in between inferior and
middle meatus, and sphenoethmoidal recess is documented here.
3. ird pass: e examination of deeper part of middle meatus such
as uncinate process, ethmoidal infundibulum, hiatus semilunaris,
and bulla ethmoidalis are documented here.
Treatment
Hydration maintenance to maintain sol-gel ratio in mucous for proper
mucociliary clearance.
Antibiotics: e duration of treatment is from 7 to 14 days and rst-line
management for acute rhinosinusitis is beta lactam or uoroquinolone
groups. In non-responding cases with usual treatment, culture based
antibiotics are indicated.
A long course of macrolide group antibiotic is added along with topical
steroid to avoid relapse as both have anti-inammatory response.
In cases where medical management is not working, ostia of involved
sinus can be targeted with preservation of mucosa. Such endoscopic
sinus surgery is called Functional Endoscopic Sinus Surgery (FESS).
e goal of this procedure is to reestablish sinus ventilation and normal
function.
Nasal endoscopy is used to give post operative care.
Alkaline nasal douches—nasal douches are indicated in rhinitis patients
and as a part of postsurgery cavity management. It improves quality of
life to great extent.
Polyposis
Patients with nasal polyposis presents with gradually progressive nasal
obstruction along with all other symptoms of chronic rhinosinusitis.
It becomes persistent over a period of time with more viscous nasal
secretion.
Patients may have abnormality of sense of smell and taste when polyposis
covers the area of olfaction.
Diagnosis
Endoscopic staging system used for nasal polyposis is (e Lund and
Mackay staging system)
• Stage 1: No polyp
• Stage 2: Polyp conned to middle meatus
• Stage 3: Polyp extending below middle meatus
• Stage 4: Massive polyposis
ere are numerous secondary causes of polyposis which should be
suspected in presence of multiple and persistent polyps and excluded
(see Chapter 5).
2
Treatment
Intranasal and systemic corticosteroids are the rst-line management for
nasal polyposis. Other drugs have limited eect and can be prescribed in
addition.
Systemic steroids for 10–14 days can correct early stage polyposis. In
massive polyposis appropriate treatment is surgery and steroids can be
a part of treatment.
In cases of nasal polyposis with irreversible mucosal disease, the
treatment plan is FESS. It is a minimally invasive technique in which
paranasal sinus ostia are opened under direct visualization. Open surgery
is occasionally indicated for disease inaccessible through endoscopy.
Dierent surgeries used for chronic rhinosinusitis are mentioned in
Table 6.2.
97Chapter 6 Chronic Rhinosinusitis: Clinical Aspects
Section 2 Inammatory Nasal Conditions98
Table 6.2: Surgeries for chronic rhinosinusitis.
Surgeries with
Endoscopic surgeries
Draf I to III
Middle meatal
Antrostomy
Endonasal drainage
Uncinectomy
Ethmoidectomy
invisible incision Open surgeries
Antral washout
Caldwell–Luc
Intranasal antrostomy
Trephination (of the frontal
sinus)
Transantral ethmoidectomy
Frontoethmosphenoidectomy
Lothrop
Osteoplastic ap
Cranialization (of the frontal sinus)
REFERENCES
1. Hadley JA, Schaefer SD. Clinical evaluation of rhinosinusitis: history and physical
examination. Otolaryngol Head Neck Surg. 1997;117:S8-11.
2. Lund VJ, Mackay IS. Staging in rhinosinusitis. Rhinology. 1993;31:183-4.
7
CHAPTER
Imaging in Fungal Sinusitis
Ashu Seith Bhalla, Smita Manchanda
• Introduction
• Classication
– Noninvasive
– Invasive
• Imaging Modalities
– Computed Tomography
– Magnetic Resonance Imaging
INTRODUCTION
Fungal sinusitis is frequently encountered in Asia and has protean clinical and
radiological manifestations. e most frequent pathogen is the Aspergillus
species.
CLASSIFICATION
e classication of fungal sinusitis is based on histopathology. e
International Society for Human and Animal Mycology group classica tion1
divides fungal sinusitis into the following groups/forms.
Noninvasive
■ Allergic fungal sinusitis
■ Mycetoma
Invasive
■ Acute
■ Chronic (nongranulomatous and granulomatous)
• Types
– Noninvasive Forms
▪ Allergic Fungal Sinusitis
▪ Fungal Ball/Mycetoma
– Invasive Fungal Sinusitis
▪ Acute Invasive
▪ Chronic Invasive Fungal
Sinusitis
Section 2 Inammatory Nasal Conditions100
IMAGING MODALITIES
Noncontrast computed tomography (NCCT) is the initial imaging modality of
choice. Contrast-enhanced magnetic resonance imaging (CEMRI) is required
for extent of invasive disease.2
Computed Tomography
■ Initially when the secretions are watery, these appear low attenuation on
NCCT (similar to all forms of rhinosinusitis).
■ Over a period of time, the uid content of the secretions decreases and
calcium and magnesium salts get deposited. Iron, magnesium and
manganese accumulate in fungal sinusitis as these are thought to be
essential for amino acid metabolism of the fungus. is results in the
appearance of high attenuation on NCCT (Fig. 7.1).
Fig. 7.1: Noncontrast computed tomography (NCCT) allergic fungal sinusitis. Central
hyper dense contents (arrow) in expanded left maxillary and ethmoid sinuses; and nasal
cavity.
Magnetic Resonance Imaging
■ Signal intensity on MRI is governed by the viscosity of secretions, their
protein content (as in other forms of rhinosinusitis) and the deposition of
salts. Characteristic T2 hypointensity (Fig. 7.2) is seen due to the presence
of iron and magnesium salts.
TYPES
Noninvasive Forms
Allergic Fungal Sinusitis
■ Allergic fungal sinusitis (AFS) is the most common form and is an allergic
response to colonized fungi.
■ AFS is the commonest form and is an allergic response to colonized fungi.
■ It is seen in young, immunocompetent patients with history of atopy.
Fig. 7.2: Magnetic resonance imaging (MRI) rhino-orbito-cerebral mucormycosis.
Axial T2WI: markedly T2 hypointense soft tissue in right orbit (white arrow), orbital apex
(asterisk) and cavernous sinus (black arrow). Intermediate signal contents in bilateral
ethmoid sinuses (arrowhead).
101Chapter 7 Imaging in Fungal Sinusitis
Pathology:
■ Pathology is similar to allergic bronchopulmonary aspergillosis (ABPA).
■ Histopathology reveals mucus impaction, cellular debris, fungal
elements, inammatory response.
Imaging:
■ Involvement is unilateral; or if bilateral, it is then asymmetric.
■ Multiple sinuses are aected with maxillary and ethmoid sinuses being
the most frequent.
■ In about 30% patients AFS may erode the skull base.
3
■ NCCT (Figs. 7.3A and B):
• Central hyperdensity and peripheral hypodensity outlining in the
sinus wall (due to inamed mucosa)
• Expansion of sinuses, remodeling and thinning/erosion of bony sinus
walls.
■ MRI (Figs. 7.4A to C):
• Variable depending on the content of the secretions as has been
described in chronic rhinosinusitis (see Chapter 4)
• T1, T2 signal: Iso/hypointense or profoundly hypointense (signal void)
• Contrast-enhanced magnetic resonance (CEMR): Mucosal thickening
and enhancement. Minimal spread to extra sinus soft tissues.
• Pitfall: ere is underestimation of the extent of involvement on MRI,
and hence it should always be correlated with CT.
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