0:00

Frankly, it's pretty uncommon to have the evaluation

0:05

for acute sinusitis by anything other than CT scan.

0:09

These days. Used to be that people would employ plain films,

0:13

but with the advent of CT scanning, we know

0:16

that we could see so much more on CT that is not obvious

0:20

or not apparent on the plain film examination.

0:24

So the evaluation for acute sinusitis is a clinical one, uh,

0:28

but if they do ask for any imaging, it would be done

0:32

by uh, CT scanning.

0:35

So what are the criteria

0:36

by which we would make the diagnosis of acute sinus?

0:40

Assuming the patient doesn't have a nasal gastric tube

0:43

or endotracheal tube or has not been instrumented?

0:47

The presence of an air fluid level is one

0:49

of our strongest indicators that there is acute sinus

0:53

as opposed to chronic sinusitis, which just leads

0:57

to mucosal thickening.

0:59

If you have complete opacification of the paranasal sinuses,

1:03

that also is likely to be representative of acute sinusitis.

1:08

Understanding that some patients

1:10

with chronic sinusitis may also pacify their sinuses if you

1:13

see a little bubbly layer on the top of secretions,

1:18

those bubbles also would suggest

1:21

that this is an acute infection as opposed

1:23

to chronic infection.

1:25

The most useful way to make the diagnosis

1:28

of acute sinusitis, and this happens a lot

1:30

of times in the hospital where patients who are at risk

1:33

for infection

1:35

and we're having a fever will have serial CT scans,

1:38

is when you find new findings.

1:40

So if you have new mucosal thickening

1:42

or new fluid level

1:44

that was not there on a CT scan three days earlier

1:47

and the patient is continuing to have a fever

1:49

of unknown origin, we would assume that that would

1:52

represent acute sinusitis.

1:54

But in the end, I think the

1:57

gold standard is still endoscopy, where you see

2:01

purulent material coming out of the maxillary, uh,

2:04

the sinus osteo or into the nasal cavity.

2:07

That is sort of what we would say is the,

2:10

the best indicator is by endoscopy.

2:13

So what do I mean by these little bubbles?

2:16

So here on the top left image, you see this appearance

2:20

of not just the meniscus,

2:22

but these little bubbles within the sinus inflammation.

2:26

That seems to be a pretty good indicator

2:28

of acute sinusitis when you combine that

2:31

or if you have an air fluid level, which you see here again

2:34

with meniscus, that would also indicate the presence

2:38

of an acute infection as opposed to chronic infection.

2:42

This type of mucosal thickening anteriorly within the

2:45

maxillary science, well that may be chronic infection

2:49

and the patient may have acute

2:51

on chronic inflammation in the left maxillary sinus,

2:56

this thickening of the mucosa that

2:58

Can last, you know, months, weeks, even potentially years

3:03

where you see that on serial scanning.

3:05

And we can't really rely on just mucosal thickening

3:08

to suggest acute sinusitis

3:11

unless it was not there on a scan just a

3:14

few weeks earlier.

3:17

Just a normal variation.

3:18

You notice that this maxillary science is smaller than the

3:21

contralateral maxillary science.

3:22

So a little hypoplastic, right? Maxillary antrum.

3:25

This is another case

3:27

where you have this wispy stuff within the

3:30

cy nasal secretions that is analogous to the little bubbles.

3:35

And this also would be a finding

3:37

that would suggest acute sinusitis.

3:40

Once we have the acute sinusitis, we will look at the

3:43

sinus anatomy in order to identify whether

3:46

or not there is obstruction of the maxillary sinus ote.

3:49

Not sure exactly where the fibular is in this patient,

3:52

but I would probably call it obstructed on the

3:55

left side, the right side.

3:56

We see it a little bit better

3:58

with the uncinate process here.

4:00

Small little max ethmoidal howler cell.

4:04

Let's move on to this slide.

4:06

This is from a, uh, publication looking at the

4:11

maxillary air density measurement for differentiating acute

4:15

and chronic rhinosinusitis.

4:18

And you can see that the mean air density in the acute sinus

4:23

cases was in point of fact below that,

4:26

within the chronic sinusitis

4:29

and the standard deviation of the areas is seen here.

4:33

But this is one potential quantitative measure of looking

4:38

for acute versus chronic rhinosinusitis.