Schematic diagram of motion of a single cilium during the rapid forward
Schematic diagram of motion of a single cilium during the rapid forward
beat
beat
and the slower recovery phase.
and the slower recovery phase.
Schematic diagram of motion of a single cilium during the rapid forward
Schematic diagram of motion of a single cilium during the rapid forward
beat
beat
and the slower recovery phase.
and the slower recovery phase.
Change in host
Change in host
milieu creates
milieu creates
culture
culture
medium for
medium for
bacterial
bacterial
growth in closed
growth in closed
cavity
cavity
Change in host
Change in host
milieu creates
milieu creates
culture
culture
medium for
medium for
bacterial
bacterial
growth in closed
growth in closed
cavity
cavity
Mucosal congestion or anatomic
Mucosal congestion or anatomic
obstruction blocs airflow and drainage
obstruction blocs airflow and drainage
OSTIUM IS CLOSED
OSTIUM IS CLOSED
Mucosal congestion or anatomic
Mucosal congestion or anatomic
obstruction blocs airflow and drainage
obstruction blocs airflow and drainage
OSTIUM IS CLOSED
OSTIUM IS CLOSED
Secretions
Secretions
stagnate
stagnate
Secretions
Secretions
stagnate
stagnate
Mucosal thickening creates
Mucosal thickening creates
further blockage
further blockage
Mucosal thickening creates
Mucosal thickening creates
further blockage
further blockage
Cycle of events that leads to chronic rhinosinusitis
Cycle of events that leads to chronic rhinosinusitis
begins with ostial blockage
begins with ostial blockage
Cycle of events that leads to chronic rhinosinusitis
Cycle of events that leads to chronic rhinosinusitis
begins with ostial blockage
begins with ostial blockage
Secretions thicken;
Secretions thicken;
pH changes
pH changes
Secretions thicken;
Secretions thicken;
pH changes
pH changes
Mucosal gas
Mucosal gas
metabolism changes
metabolism changes
Mucosal gas
Mucosal gas
metabolism changes
metabolism changes
Cilia and epithelium
Cilia and epithelium
are damaged
are damaged
Cilia and epithelium
Cilia and epithelium
are damaged
are damaged
Bacterial infection develops in
Bacterial infection develops in
the sinus cavity
the sinus cavity
Bacterial infection develops in
Bacterial infection develops in
the sinus cavity
the sinus cavity
Retained secretions
Retained secretions
cause tissue
cause tissue
inflammation
inflammation
Retained secretions
Retained secretions
cause tissue
cause tissue
inflammation
inflammation
The expression
The expression
sinusitis
sinusitis
describes an
describes an
inflammatory process present in the paranasal
inflammatory process present in the paranasal
sinuses mucous membrane, due to disturbances
sinuses mucous membrane, due to disturbances
of drainage and ventilation, as a result of
of drainage and ventilation, as a result of
infection, allergy or anatomical variations of the
infection, allergy or anatomical variations of the
lateral nasal wall. This term refers to
lateral nasal wall. This term refers to
pathological changes present both in one sinus
pathological changes present both in one sinus
e. g.
e. g.
maxillary sinusitis
maxillary sinusitis
and also in several
and also in several
paranasal sinuses
paranasal sinuses
(hemipansinusitis,
(hemipansinusitis,
pansinusitis)
pansinusitis)
.
.
The expression
The expression
sinusitis
sinusitis
describes an
describes an
inflammatory process present in the paranasal
inflammatory process present in the paranasal
sinuses mucous membrane, due to disturbances
sinuses mucous membrane, due to disturbances
of drainage and ventilation, as a result of
of drainage and ventilation, as a result of
infection, allergy or anatomical variations of the
infection, allergy or anatomical variations of the
lateral nasal wall. This term refers to
lateral nasal wall. This term refers to
pathological changes present both in one sinus
pathological changes present both in one sinus
e. g.
e. g.
maxillary sinusitis
maxillary sinusitis
and also in several
and also in several
paranasal sinuses
paranasal sinuses
(hemipansinusitis,
(hemipansinusitis,
pansinusitis)
pansinusitis)
.
.
For practical reasons in the daily clinical work both
For practical reasons in the daily clinical work both
terms -
terms -
sinusitis
sinusitis
and
and
rhinosinusitis
rhinosinusitis
are equivalent.
are equivalent.
For practical reasons in the daily clinical work both
For practical reasons in the daily clinical work both
terms -
terms -
sinusitis
sinusitis
and
and
rhinosinusitis
rhinosinusitis
are equivalent.
are equivalent.
Two classifications of chronic rhinosinusitis are currently proposed
Two classifications of chronic rhinosinusitis are currently proposed
in rhinological literature. The classification introduced by Kern in
in rhinological literature. The classification introduced by Kern in
1984 is based on the duration of the disease process and
1984 is based on the duration of the disease process and
corresponding morphological changes in the mucosa of the
corresponding morphological changes in the mucosa of the
sinuses:
sinuses:
Acute purulent rhinosinusitis
Acute purulent rhinosinusitis
- lasting up to 3 weeks, with one or
- lasting up to 3 weeks, with one or
several sinuses involved.
several sinuses involved.
Subacute purulent rhinosinusitis
Subacute purulent rhinosinusitis
- lasting up to 3 weeks to 3
- lasting up to 3 weeks to 3
months.
months.
Morphological changes in the mucosa which occur within
Morphological changes in the mucosa which occur within
that time are usually reversible.
that time are usually reversible.
Chronic purulent rhinosinusitis
Chronic purulent rhinosinusitis
- lasting over 3 months. This form
- lasting over 3 months. This form
of
of
the disease process is thought to be a result of untreated or
the disease process is thought to be a result of untreated or
improperly treated acute inflammation. Surgery to remove
improperly treated acute inflammation. Surgery to remove
irreversibly changed mucosa is recommended.
irreversibly changed mucosa is recommended.
Two classifications of chronic rhinosinusitis are currently proposed
Two classifications of chronic rhinosinusitis are currently proposed
in rhinological literature. The classification introduced by Kern in
in rhinological literature. The classification introduced by Kern in
1984 is based on the duration of the disease process and
1984 is based on the duration of the disease process and
corresponding morphological changes in the mucosa of the
corresponding morphological changes in the mucosa of the
sinuses:
sinuses:
Acute purulent rhinosinusitis
Acute purulent rhinosinusitis
- lasting up to 3 weeks, with one or
- lasting up to 3 weeks, with one or
several sinuses involved.
several sinuses involved.
Subacute purulent rhinosinusitis
Subacute purulent rhinosinusitis
- lasting up to 3 weeks to 3
- lasting up to 3 weeks to 3
months.
months.
Morphological changes in the mucosa which occur within
Morphological changes in the mucosa which occur within
that time are usually reversible.
that time are usually reversible.
Chronic purulent rhinosinusitis
Chronic purulent rhinosinusitis
- lasting over 3 months. This form
- lasting over 3 months. This form
of
of
the disease process is thought to be a result of untreated or
the disease process is thought to be a result of untreated or
improperly treated acute inflammation. Surgery to remove
improperly treated acute inflammation. Surgery to remove
irreversibly changed mucosa is recommended.
irreversibly changed mucosa is recommended.
The 1995 International Conference on Sinus Disease classification
The 1995 International Conference on Sinus Disease classification
of rhinosinusitis is based on an assessment of the extent of
of rhinosinusitis is based on an assessment of the extent of
pathophysiological processes involving the mucosa of the
pathophysiological processes involving the mucosa of the
sinuses and the nasal cavity:
sinuses and the nasal cavity:
Acute rhinosinusitis is defined as an episodic inflammatory
Acute rhinosinusitis is defined as an episodic inflammatory
process which does not leave any significant persistent damage
process which does not leave any significant persistent damage
of
of
the mucosa after conservative treatment.
the mucosa after conservative treatment.
Acute recurrent rhinosinusitis refers to repeated episodes of
Acute recurrent rhinosinusitis refers to repeated episodes of
acute
acute
inflammation with complete recovery after conservative
inflammation with complete recovery after conservative
treatment, causing no persistent damage of the mucosa.
treatment, causing no persistent damage of the mucosa.
Chronic rhinosinusitis is defined as persistent inflammation which
Chronic rhinosinusitis is defined as persistent inflammation which
cannot be cured with conservative treatment.
cannot be cured with conservative treatment.
The 1995 International Conference on Sinus Disease classification
The 1995 International Conference on Sinus Disease classification
of rhinosinusitis is based on an assessment of the extent of
of rhinosinusitis is based on an assessment of the extent of
pathophysiological processes involving the mucosa of the
pathophysiological processes involving the mucosa of the
sinuses and the nasal cavity:
sinuses and the nasal cavity:
Acute rhinosinusitis is defined as an episodic inflammatory
Acute rhinosinusitis is defined as an episodic inflammatory
process which does not leave any significant persistent damage
process which does not leave any significant persistent damage
of
of
the mucosa after conservative treatment.
the mucosa after conservative treatment.
Acute recurrent rhinosinusitis refers to repeated episodes of
Acute recurrent rhinosinusitis refers to repeated episodes of
acute
acute
inflammation with complete recovery after conservative
inflammation with complete recovery after conservative
treatment, causing no persistent damage of the mucosa.
treatment, causing no persistent damage of the mucosa.
Chronic rhinosinusitis is defined as persistent inflammation which
Chronic rhinosinusitis is defined as persistent inflammation which
cannot be cured with conservative treatment.
cannot be cured with conservative treatment.
The patient may complain
The patient may complain
of:
of:
The patient may complain
The patient may complain
of:
of:
nasal blockage or congestion;
nasal blockage or congestion;
nasal discharge - serous, seropurulent,
nasal discharge - serous, seropurulent,
purulent;
purulent;
postnasal discharge;
postnasal discharge;
pain or pressure in the orbital region, pain
pain or pressure in the orbital region, pain
or
or
pressure in the region of the sinus
pressure in the region of the sinus
affected by
affected by
inflammation;
inflammation;
headache;
headache;
toothache.
toothache.
nasal blockage or congestion;
nasal blockage or congestion;
nasal discharge - serous, seropurulent,
nasal discharge - serous, seropurulent,
purulent;
purulent;
postnasal discharge;
postnasal discharge;
pain or pressure in the orbital region, pain
pain or pressure in the orbital region, pain
or
or
pressure in the region of the sinus
pressure in the region of the sinus
affected by
affected by
inflammation;
inflammation;
headache;
headache;
toothache.
toothache.
Physical examination reveals:
Physical examination reveals:
Physical examination reveals:
Physical examination reveals:
oedema and reddening of the nasal cavities mucosa;
oedema and reddening of the nasal cavities mucosa;
oedema of the skin in the region of the root of the nose and
oedema of the skin in the region of the root of the nose and
in
in
the region of the palpebras;
the region of the palpebras;
mucous, mucopurulent or purulent secretion in the nasal
mucous, mucopurulent or purulent secretion in the nasal
cavities;
cavities;
mucous or purulent secretion in the nasopharynx;
mucous or purulent secretion in the nasopharynx;
purulent secretion on the lateral wall of the nasal cavity;
purulent secretion on the lateral wall of the nasal cavity;
painfulness of the cheek when exerting pressure on the
painfulness of the cheek when exerting pressure on the
canine
canine
fossa (in the maxillary sinusitis) and when exerting
fossa (in the maxillary sinusitis) and when exerting
pressure on
pressure on
the upper wall of the orbit (in the frontal
the upper wall of the orbit (in the frontal
sinusitis).
sinusitis).
oedema and reddening of the nasal cavities mucosa;
oedema and reddening of the nasal cavities mucosa;
oedema of the skin in the region of the root of the nose and
oedema of the skin in the region of the root of the nose and
in
in
the region of the palpebras;
the region of the palpebras;
mucous, mucopurulent or purulent secretion in the nasal
mucous, mucopurulent or purulent secretion in the nasal
cavities;
cavities;
mucous or purulent secretion in the nasopharynx;
mucous or purulent secretion in the nasopharynx;
purulent secretion on the lateral wall of the nasal cavity;
purulent secretion on the lateral wall of the nasal cavity;
painfulness of the cheek when exerting pressure on the
painfulness of the cheek when exerting pressure on the
canine
canine
fossa (in the maxillary sinusitis) and when exerting
fossa (in the maxillary sinusitis) and when exerting
pressure on
pressure on
the upper wall of the orbit (in the frontal
the upper wall of the orbit (in the frontal
sinusitis).
sinusitis).
Factors predisposing recurrences of acute
Factors predisposing recurrences of acute
rhinosinusitis
rhinosinusitis
Factors predisposing recurrences of acute
Factors predisposing recurrences of acute
rhinosinusitis
rhinosinusitis
Anatomic:
Anatomic:
deviation of the nasal septum;
deviation of the nasal septum;
anatomical variations of the nasal lateral
anatomical variations of the nasal lateral
wall:
wall:
of the middle nasal concha,
of the middle nasal concha,
of the uncinate process,
of the uncinate process,
of the ridge of the nose,
of the ridge of the nose,
of the ethmoidal bulla,
of the ethmoidal bulla,
of the Haller’s cels;
of the Haller’s cels;
Morphological:
Morphological:
nasal polyps;
nasal polyps;
nasal tumours;
nasal tumours;
adenoids.
adenoids.
Anatomic:
Anatomic:
deviation of the nasal septum;
deviation of the nasal septum;
anatomical variations of the nasal lateral
anatomical variations of the nasal lateral
wall:
wall:
of the middle nasal concha,
of the middle nasal concha,
of the uncinate process,
of the uncinate process,
of the ridge of the nose,
of the ridge of the nose,
of the ethmoidal bulla,
of the ethmoidal bulla,
of the Haller’s cels;
of the Haller’s cels;
Morphological:
Morphological:
nasal polyps;
nasal polyps;
nasal tumours;
nasal tumours;
adenoids.
adenoids.
Oedemas of the mucosa:
infection;
allergy;
rhinitis vasomotorica;
rhinitis medicamentosa;
hormonal disturbances.
Traumas:
local traumas;
barotrauma;
foreign bodies;
iatrogenic.
Constitutional:
syndromes of ciliary disturbances;
cystic fibrosis;
immunological deficiencies.
Factors predisposing recurrences of acute
Factors predisposing recurrences of acute
rhinosinusitis
rhinosinusitis
Factors predisposing recurrences of acute
Factors predisposing recurrences of acute
rhinosinusitis
rhinosinusitis
The most often used antibiotics in the therapy of
The most often used antibiotics in the therapy of
rhinosiusitis
rhinosiusitis
The most often used antibiotics in the therapy of
The most often used antibiotics in the therapy of
rhinosiusitis
rhinosiusitis
Supplementary
Supplementary
treatment
treatment
Supplementary
Supplementary
treatment
treatment
1.
1.
Decongestants
Decongestants
should ensure restoration of the patency of
should ensure restoration of the patency of
the
the
ostio-meatal complex and thereby the sinuses ostia.
ostio-meatal complex and thereby the sinuses ostia.
2.
2.
Mucolytic drugs
Mucolytic drugs
act on the retained in the sinuses secretion
act on the retained in the sinuses secretion
in such
in such
a way that it becomes more liquid thus easier to
a way that it becomes more liquid thus easier to
move.
move.
3.
3.
Corticosteroids are recommended
Corticosteroids are recommended
first of all in the therapy
first of all in the therapy
of
of
chronic inflammation.
chronic inflammation.
4.
4.
Recommendation for the administration of
Recommendation for the administration of
antihistamines
antihistamines
requires
requires
comprehensive reasoning, because allergy plays a
comprehensive reasoning, because allergy plays a
far smaller role
far smaller role
in the pathogenesis of rhinosinusitis than it
in the pathogenesis of rhinosinusitis than it
is assumed.
is assumed.
1.
1.
Decongestants
Decongestants
should ensure restoration of the patency of
should ensure restoration of the patency of
the
the
ostio-meatal complex and thereby the sinuses ostia.
ostio-meatal complex and thereby the sinuses ostia.
2.
2.
Mucolytic drugs
Mucolytic drugs
act on the retained in the sinuses secretion
act on the retained in the sinuses secretion
in such
in such
a way that it becomes more liquid thus easier to
a way that it becomes more liquid thus easier to
move.
move.
3.
3.
Corticosteroids are recommended
Corticosteroids are recommended
first of all in the therapy
first of all in the therapy
of
of
chronic inflammation.
chronic inflammation.
4.
4.
Recommendation for the administration of
Recommendation for the administration of
antihistamines
antihistamines
requires
requires
comprehensive reasoning, because allergy plays a
comprehensive reasoning, because allergy plays a
far smaller role
far smaller role
in the pathogenesis of rhinosinusitis than it
in the pathogenesis of rhinosinusitis than it
is assumed.
is assumed.
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
In adults
In adults
8 weeks of persistent symptoms and sings
8 weeks of persistent symptoms and sings
or
or
Four episodes per year of recurrent acute sinusitis,
Four episodes per year of recurrent acute sinusitis,
each
each
lasting at least 10 days
lasting at least 10 days
in association with
in association with
Persistent changes on computer tomography 4
Persistent changes on computer tomography 4
weeks
weeks
after medical therapy without intervening acute
after medical therapy without intervening acute
infection
infection
In adults
In adults
8 weeks of persistent symptoms and sings
8 weeks of persistent symptoms and sings
or
or
Four episodes per year of recurrent acute sinusitis,
Four episodes per year of recurrent acute sinusitis,
each
each
lasting at least 10 days
lasting at least 10 days
in association with
in association with
Persistent changes on computer tomography 4
Persistent changes on computer tomography 4
weeks
weeks
after medical therapy without intervening acute
after medical therapy without intervening acute
infection
infection
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
In children
In children
12 weeks of persistent symptoms and sings
12 weeks of persistent symptoms and sings
or:
or:
Six episodes per year of recurrent acute sinusitis,
Six episodes per year of recurrent acute sinusitis,
each
each
lasting at least 10 days
lasting at least 10 days
in association with
in association with
Persistent changes on computer tomography 4
Persistent changes on computer tomography 4
weeks
weeks
after medical therapy without intervening acute
after medical therapy without intervening acute
infection
infection
In children
In children
12 weeks of persistent symptoms and sings
12 weeks of persistent symptoms and sings
or:
or:
Six episodes per year of recurrent acute sinusitis,
Six episodes per year of recurrent acute sinusitis,
each
each
lasting at least 10 days
lasting at least 10 days
in association with
in association with
Persistent changes on computer tomography 4
Persistent changes on computer tomography 4
weeks
weeks
after medical therapy without intervening acute
after medical therapy without intervening acute
infection
infection
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Criteria for chronic rhinosinusitis
Symptoms and sings
Symptoms and sings
Adults and children
Adults and children
Major
Major
Nasal congestion
Nasal congestion
Nasal discharge
Nasal discharge
Headache
Headache
Facial pain or pressure
Facial pain or pressure
Olfactory disturbance
Olfactory disturbance
Minor
Minor
Fever
Fever
Halitiosis
Halitiosis
Children only
Children only
Cough
Cough
Irritability
Irritability
Symptoms and sings
Symptoms and sings
Adults and children
Adults and children
Major
Major
Nasal congestion
Nasal congestion
Nasal discharge
Nasal discharge
Headache
Headache
Facial pain or pressure
Facial pain or pressure
Olfactory disturbance
Olfactory disturbance
Minor
Minor
Fever
Fever
Halitiosis
Halitiosis
Children only
Children only
Cough
Cough
Irritability
Irritability
The most often isolated microorganisms in
The most often isolated microorganisms in
rhinosiusitis
rhinosiusitis
Streptococcus pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Haemophilus influenzae
Streptococcus pyogenes
Streptococcus pyogenes
Staphylococcus aureus
Staphylococcus aureus
Anaerobes:
Anaerobes:
Bacteroides
Bacteroides
Fusobacterium
Fusobacterium
Peptostreptococcus
Peptostreptococcus
Alpha- and beta-haemolytic
Alpha- and beta-haemolytic
streptococci
streptococci
Other Gram-negative bacterias
Other Gram-negative bacterias
Streptococcus pneumoniae
Streptococcus pneumoniae
Haemophilus influenzae
Haemophilus influenzae
Streptococcus pyogenes
Streptococcus pyogenes
Staphylococcus aureus
Staphylococcus aureus
Anaerobes:
Anaerobes:
Bacteroides
Bacteroides
Fusobacterium
Fusobacterium
Peptostreptococcus
Peptostreptococcus
Alpha- and beta-haemolytic
Alpha- and beta-haemolytic
streptococci
streptococci
Other Gram-negative bacterias
Other Gram-negative bacterias
Surgical indications
Surgical indications
Surgical indications
Surgical indications
