eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Ethmoid, Acute, Surgical Treatment

Author: Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota
Coauthor(s): Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Staff and Partner, Myers Wyse Center for the Eye; Joseph P Mirante, MD, MBA, FACS, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of South Florida College of Medicine
Contributor Information and Disclosures

Updated: Aug 14, 2007

Introduction

Acute ethmoid sinusitis can be bilateral or unilateral. It can have a bacterial, viral, or allergic etiology. When it is unresponsive to medical therapy, surgical intervention is often warranted. Ethmoid sinusitis that affects the anterior air cells can lead to dysfunction of the middle meatus. Because other sinuses, such as the maxillary and frontal sinuses, drain into this area, disruption in the mucociliary secretions passage in this area can obstruct those sinuses, also, leading to more fulminant disease.

History of the Procedure

Ethmoid sinusitis was often underappreciated for its role as a major causative factor in sinus disease. However, various authors had realized the contributing effect ethmoidal disease has upon sinus disease. As early as 1882, Zukerlandl had recommended that antrostomies should be made in the middle meatus to offset this problem.

Endoscopes were first used by Hirschmann in 1903, but instrumental events in our current understanding of sinus disease were the development of the rigid endoscope by H H Hopkins and its use in maxillary sinus surgery, reported in 1989 by Hopkins and Kapang. With the use of the endoscope, an understanding of mucociliary clearance patterns from the sinuses was obtained. The anatomy of the sinuses and the ostia were also better visualized with the endoscope, and the relationships between the intranasal and paranasal structures were better understood.¹

Problem

Acute ethmoid sinusitis denotes inflammation of the mucosal lining of the sinus.

Etiology

Ethmoiditis is often a sequela of an upper respiratory tract infection such as a cold. The impairment of drainage from the ostia of the sinus can also be caused by other factors, including polyps, foreign bodies, anatomical abnormalities (such as a deviated septum or an enlarged turbinate), or tumors. Immunocompromise, trauma, placement of feeding tubes, and abnormalities in cilia motility can put a patient at greater risk for developing sinusitis.²

Alternatively, dentition can also be a source of the infective material. Hematogenous spread is a much less common source.

Acute ethmoidal sinusitis is often bacterial in nature. Historically, Streptococcus pneumoniae and Haemophilus influenzae accounted for more than 50% of the pathogens in all types of acute sinusitis. Other pathogens include Staphylococcus aureus and Streptococcus pyogenes.² However, with the advent of the S pneumoniae and H influenzae vaccines, this predominance may change. In chronic sinusitis, anaerobes can be a factor, and, in immunocompromised patients, fungal pathogens and gram-negative bacilli can be causes of the sinusitis.

Acute ethmoid sinusitis is usually not abrupt in onset (except in cases caused by diving or swimming where bacterial organisms gain entry to the paranasal structures).³

Pathophysiology

The inflammation of the sinus mucosa from a common cold, for example, results in edema of the mucosa and can cause blockage of the natural ostia of the sinus leading to impairment of mucociliary drainage. The secretions accumulate within the sinus, and infection can set in. The ostiomeatal complex is intimately involved in the drainage of the ethmoidal sinuses.

Presentation

In general, patients with acute ethmoid sinusitis usually present with mild-to-moderate degrees of malaise. A discharge from the nares may be present, the nasal mucosa and turbinates may be edematous and hyperemic, and a purulent discharge may be present. Erythema of the nasopharynx and oropharynx can be present. Patients will often develop a low-grade fever and possibly a headache. The WBC count is usually not elevated unless a systemic cause for the sinusitis is involved. As the sinusitis progresses, pain usually increases over the ethmoidal area; however, the pain can be referred to the medial orbital and eye area and brow areas.

More severe cases of acute ethmoid sinusitis, especially in immunocompromised patients, can rapidly progress and present in an emergent way with facial cellulitis, orbital cellulitis, and meningitis.

Indications

The typical case of acute ethmoidal sinusitis is treated with medical therapy. Medical treatment can reduce the inflammation and edema of the mucosa, alleviate the pain, combat the infection, open the ostia of the sinuses, and restore normal mucociliary secretions. However, surgery is indicated in the following instances:

• Sinusitis not responsive to medical management
• Rapidly progressing sinusitis
• Sinusitis that creates an abscess either in the sinus or adjacent areas such as the orbit or brain
• Sinusitis that compromises the survival of the patient

Relevant Anatomy

In infancy, the ethmoidal sinuses are developed, and they expand during early childhood.⁴ The sinuses are paired and are divided into anterior and posterior ethmoidal air cells. This division is provided by the basal lamella of the middle turbinate. In an adult, the average length of the sinus is 4-5 cm. The height is approximately 3 cm. The sinus widens from anterior to posterior, expanding from 0.5 cm anteriorly to 1.5 cm posteriorly.

The frontal, lacrimal, palatine, sphenoid, and maxillary bones contribute to the walls of the ethmoid sinus.⁵ Medially, the ethmoid sinus is demarcated by the lamina papyracea, which forms the medial wall of the orbit and the lateral nasal wall. Superiorly, it is demarcated by the fovea ethmoidalis.^6,7 The infundibulum of the ethmoid represents a cleft that is demarcated by the uncinate process on its medial side and the lamina papyracea on its lateral side.⁷ It connects the inferior aspect of the hiatus semilunaris with the superomedial aspect of the maxillary sinus.

The uncinate process is a bony curved prominence extending from the lateral nasal wall superiorly to the inferior turbinate. The ostiomeatal complex denotes the ultimate pathway for the secretions from the anterior ethmoidal air cells. Inferiorly, the hiatus semilunaris is the shortest distance from the free posterior margin of the uncinate process to the anterior aspect of the bulla ethmoidalis. Superiorly, it is a space between the lateral aspect of the middle turbinate and the superior aspect of the bulla ethmoidalis.⁷ The anterior air cells drain into the middle meatus, and the posterior air cells drain into the superior meatus.

Contraindications

Surgical intervention for acute ethmoid sinusitis is contraindicated in poor surgical candidates who are unable to undergo the risks of anesthesia.

Most often the surgery is performed under general anesthesia. The desire to perform the surgery under local anesthesia with monitored anesthesia sedation must be carefully considered because hemorrhage in a partially sedated patient with no protection of the airway can be difficult to manage. However, the surgical method chosen, degree of surgery required, and experience of the surgeon are all qualifying factors.

Bleeding dyscrasias may also be a relative contraindication to surgery.

In 1994, Lawson stated that patients with a defect in the lamina papyracea, fovea ethmoidalis, or the cribriform plate should not have an ethmoidectomy from the intranasal approach.⁸ However, not all surgeons would agree.

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